Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
54 Cards in this Set
- Front
- Back
|
Which of the following assessment findings in the pt with pneumonia most indicates a need to remind the pt to cough & deep breathe?
a. The pt co of chest pain. b. The pt has removed her oxygen. c. The nurse auscultates wheezes & crackles. d. The nurse notes a fever of 101 F. |
c. The nurse auscultates wheezes & crackles.
|
|
|
The nurse is caring for a pt w/tuberculosis who puts his light on because he needs to use the bathroom. There are green surgical masks in the isolation cabinet outside his room. What should the nurse do?
a. Fit the mask firmly to his/her face before going into the room. b. Place two masks together & fit them firmly to the face. c. Ask the pt to put on a mask before entering the room. d. Ask the pt to wait while the nurse obtains a special high-efficiency mask. |
d. Ask the pt to wait while the nurse obtains a special high-efficiency mask.
|
|
|
Which of the following assessment findings does the nurse expect in the pt w/emphysema?
a. Purulent sputum b. Diminished breath sounds c. Generalized edema d. Dull chest pain |
b. Diminished breath sounds
|
|
|
Which of the following assessment findings in the pt w/pneumothorax does the nurse report immediately?
a. Positioning of the trachea toward the unaffected side b. Frequent dry cough c. Moderate pain at the chest tube site d. Diminished breath sounds over the affected area |
a. Positioning of the trachea toward the unaffected side
|
|
|
As the nurse enters Mr. Jones's room, he notes that the pt has become confused & combative over the past hour. Which of the following actions is appropriate first?
a. Assess Mr. Jones; check to see if his oxygen is flowing correctly. b. Page the physician stat. c. Put up Mr. Jones's side reails & apply soft restraints. d. Administer an oral sedative. |
a. Assess Mr. Jones; check to see if his oxygen is flowing correctly.
|
|
|
Which of the following interventions is most appropriate for the pt w/an ineffective breathing pattern?
a. Encourage the pt to cough & deep breathe. b. Encourage oral fluids. c. Teach the pt controlled diaphragmatic breathing. d. Allow the pt to rest between activities. |
c. Teach the pt controlled diaphragmatic breathing.
|
|
|
Mrs. Jackson had an abdominal hysterectomy yesterday. The nurse enters her room & finds her acutely short of breath, w/a look of panic in her eyes. Which of the following additional symptoms is most important as the nurse decides what to do?
a. Mrs. Jackson complained of pain in her left leg earlier this morning. b. Mrs. Jackson states that she also has a headache. c. Mrs. Jackson has a recent hx of an upper respiratory infection. d. Mrs. Jackson has not eaten in 24 hours. |
b. Mrs. Jackson states that she also has a headache.
|
|
|
bronchitis
|
inflammation of the bronchial tree
includes R & L bronchi, secondary bronchi, & bronchioles |
|
|
bronchiectasis
|
dilation of the bronchial airways (localized or spread through lungs)
usually secondary to another chronic respiratory dx S/S: excessive, purulent sputum pooling in airway - cough - inflamed airway - hemoptysis - dyspnea - wheezes & crackles - fever |
|
|
mucolytic agents
|
help thin respiratory tract secretions
|
|
|
pneumonia
|
infectious agent enters & multiplies in lungs of pt
infectious particles can come from cough of infected person, contaminated equipment, aspiration of bacteria from mouth/pharynx/stomach cause of >10% of hospital admission annually & most common cause of death from infection |
|
|
Six types of pneumonia are . . .
|
1. bacterial
2. viral 3. fungal 4. aspiration 5. hypostatic 6. chemical |
|
|
S/S of pneumonia include . . .
|
- fever
- chest pain - dyspnea - productive cough - sputum (purulent/blood tinged) - crackles & wheezes |
|
|
atelectasis
|
collapsed alveoli
can occur as a result of trapped secretions |
|
|
tuberculosis (TB)
|
dx primarily affects lungs (can affect kidneys, liver, brain, & bone)
caused by Mycobacterium tuberculosis bacteria spread by inhalation of infected droplets |
|
|
S/S of tuberculosis include . . .
|
- chronic, productive cough
- blood-tinged sputum - night sweats - pulmonary fibrosis - hemoptysis |
|
|
purified protein derivative (PPD) skin test
|
screening for TB
+ if raised are of induration occurs w/i 48-72 hours + result means person HAS been exposed to TB - but does NOT mean TB is active |
|
|
Antibiotics used in treatment of TB:
|
- Isoniazid
- Rifampin - Streptomycin - Ethambutol - Pyrazinamide (2 or 3 given simultaneously for 6-8 months) |
|
|
Impaired Gas Exchange Related to Decreased Ventilation or Perfusion
interventions: |
- assess lung sounds, rr, use of accessory muscles
- check skin & mucous membranes for cyanosis - assess degree of dyspnea (1-10 scale) - "good lung down" - monitor ABG values & pulse ox - obtain order for IV morphine sulfate (causes vasodilation - relieves pulmonary edema & anxiety) |
|
|
Ineffective Airway Clearance Related to Excessive Secretions
interventions: |
- assess lung sounds q4h
- monitor sputum - encourage fluids - use humidifier - encourage coughing & deep breathing hourly & prn - suction per orders |
|
|
Ineffective Breathing Pattern Related to Anxiety or Pain
interventions: |
- assess rr, depth, effort q4h
- monitor ABG & ox sat - place in Fowler's/semi-Fowler's position - teach pt to use diaphragmatic breathing (2 sec in - 4 sec out) |
|
|
compliance
|
elasticity of lungs or chest wall
|
|
|
pleurisy
|
membranes surround lungs become inflamed causing friction against tissue
usually related to another resp dx irritation causes increase in pleural fluid which can lead to pleural effusion |
|
|
S/S of pleurisy include . . .
|
- sharp chest pain on inspiration, coughing, or sneezing
- shallow, rapid breathing - fever - chills - elevated WBC - pleural friction rub heard on ausculatation |
|
|
pleural effusion
|
excess fluid collects in pleural space
condition causes increase in fluid production OR inadequate reabsorption by lymphatic system avg amount around each lung is 1-15 mL (>25 mL abnormal) |
|
|
empyema
|
collection of pus in the pleural space (infected pleural effusion)
usually complication of pneumonia, TB, or lung abscess S/S: similar to pleural effusion |
|
|
atelectasis
|
collapse of alveoli
areas of lungs not well aerated & become plugged w/mucus which prevents inflation of alveoli most common in postsurgical pts who don't cough & deep breathe effectively can be caused by anything causing hypoventilation |
|
|
chronic obstructive pulmonary disease (COPD)
|
group of pulmonary disorders characterized by difficulty exhaling due to narrowed/blocked airways
develops over at least 30 years before symptoms show smoking greatest risk factor |
|
|
emphysema
|
affects alveolar membranes causing destruction of alveolar walls & loss of elastic recoil
passive respiration impaired & air trapped in alveoli |
|
|
S/S of COPD include . . .
|
- prolonged expiration
- barrel-shaped chest - chronic productive cough - SOB - activity intolerance - crackles & wheezes |
|
|
bullae
|
large air spaces within lung tissue
similar to blisters that can rupture & cause lung collapse seen in COPD |
|
|
blebs
|
large air spaces adjacent to pleurae
similar to blisters that can rupture & cause lung collapse seen in COPD |
|
|
COPD treatment includes . . .
|
- cessation of smoking
- oxygen @ 1-2L for pt w/ox sat <88% (higher flow rates supress hypoxic drive) - meds: bronchodilators, expectorants, antibiotics, steroids - humidifier - chest physiotherapy - lung vol. reduction surgery (LVRS) |
|
|
asthma
|
inflammation of mucosal lining of bronchial tree & spasm of bronchial smooth muscles causing narrowed airways & air trapping
S/S: chest tightness - dyspnea - hypersensitive airways - increased rr - wheezing - prolonged expiration - cough |
|
|
status asthmaticus
|
bronchospasm is not controlled & symptoms are prolonged
pt increases rr due to narrowed airway causing excess carbon dioxide to be blown off = respiratory alkalosis |
|
|
asthma profolactics
|
- bronchodilator or mast cell in hibitor metered dose inhalor (MDI)
- indoor humidity between 40-50% to reduce mold growth - avoid ASA, NSAIDS & beta blockers |
|
|
asthma meds:
|
- adrenergic bronchodilators
albuterol Proventil Ventolin -mast cell inhibitor cromolyn sodium Intal nedocromil sodium Tilade -inhaled steroid Azmacort Beclovent -oral theophylline bronchodilators Theovent Theo-Dur -antileukotrienes -corticosteroids methylprednisolone prednisone |
|
|
cystic fibrosis (CF)
|
disorder of exocrine glands affecting primarily lungs, GI tract, & sweat glands
abnormal Na+ & chloride transport across cell membranes causing thick secretions (difficult to remove) which cause airway obstruction genetic dx - BOTH parents must be carriers |
|
|
S/S of cycstic fibrosis include . . .
|
- sweat high in sodium & chloride (not reabsorbed as they pass through sweat ducts)
- chronic sinusitis - thick sputum - frequent respiratory infections - finger clubbing - hemoptysis - loss of lung function - respiratory failure - foul-smelling stools due to lack of enzymes - inability to absorb fat-soluble vitamins |
|
|
treatment of cystic fibrosis includes . . .
|
- increased hydration for sputum removal
- exercise - nebulizer treatments - breathing exercises, incentive spirometry, & effective coughing techniques |
|
|
embolism
|
foreign object that travels through the bloodstream
may be blood clot, fat, or air |
|
|
S/S of pulmonary embolism include . . .
|
- sudden onset of dyspnea
- tachycardia - tachypnea - crackles or friction rub |
|
|
pulmonary hypertension
|
arteries that carry deoxygenated blood from the heart to the lungs become narrowed as a result of changes in vascular smooth muscle
results in elevated pressure in pulmonary arteries R ventricle works harder to push blood into ventricles & eventually fails most comming in women 20-40 yrs old & is hereditary |
|
|
pneumothorax
|
air in pleural space outside lungs
can be caused by bullae or blebs S/S: dyspnea - chest pain - tachypnea - asymetrical chest expansion - absent/diminished breath sounds |
|
|
hemothorax
|
presence of blood in the pleural space
can occur w/or w/o accompanying pneumothorax often due to trauma can be caused by lung cancer, pulmonary embolism & anticoagulants |
|
|
pleurodesis
|
creation of adhesions between visceral and parietal pleura to treat pneumothorax
painful procedure |
|
|
rib fractures
|
4th - 9th ribs most commonly affected
can lead to flail chest where affected part of chest collapses w/inspiration & bulges w/expiration |
|
|
paradoxical respiration
|
ineffective ventilation in which chest collapses w/inspiration & bulges w/expiration
can be caused by multiple rib fractures |
|
|
A drop in PaO2 of 10 to 1_____ mm Hg or a pH of less than 2____ with associated elevated PaCO2 indicates 3_____ failure.
|
1 15
2 7.30 3 respiratory |
|
|
acute respiratory distress (ARDS)
|
alveolocapillary membranes become inflamed & damaged either by direct contact w/an inhaled irritant or by chemical mediators that are released when systemic injury occurs
membranes become leaky so that proteins, blood cells, & fluid move from capillaries into interstitial space & the into alveoli surfactant is reduced atelectasis occurs & fibrotic changes take place causing lungs to become less compliant |
|
|
lung cancer
|
- leading cause of cancer death in US
- 169,500 new cases for 2001 - approx 28% of cancer deaths are from lung cancer |
|
|
types of lung cancer:
1. 2. 3. 4. |
1. small cell lung cancer (SCLC) - 20% of LC - caused by smoking - survival time of 9 to 10 months
2. large cell carcinoma - poor prognosis - 10% of LC - grows quickly 3. adenocarcinoma - more common in women - 40% of LC - slow growing - less closely linked w/smoking 4. squamous cell carcinoma - 30% of LC - originate near bronchi - due to smoking - prognosis OK |
|
|
thoracotomy
|
surgical incision made into chest wall
|
|
|
pneumonectomy
|
surgical removal of a lung
|
