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EXAM 1 MED SURG
Respiratory
| Question | Answer |
|---|---|
| Community Acquired Pneumonia (CAP) | Pneumonia that occurs in the community or up to 48 hours after hospital admission or institutionalization of patients who do not meet health-care associated pneumonia criteria |
| Health Care Associated Pneumonia (HCAP) | Occurs in a no hospitalized patient with extensive health care contact and can be difficult to treat. |
| Health Care Associated Pneumonia (HCAP) Causes | Hospitalization for greater than 2 days in an acute care facility within 90 days of infection |
| Hospital Acquired Pneumonia (HAP) | Develops 48 hours or more after admission and does not appear to be incubating at the time of admission. |
| Aspiration Pneumonia | Pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway. Often from bacterial infection from aspiration of bacteria normally residing in upper airways. Can be community or hospital acquired. |
| Resonance (Percussion) | Loud, low-pitched, long, hollow sound produced in a normal lung that is filled with air |
| Tympany (Percussion) | Loud, low-pitched, long, hollow sound produced in a normal lung that is filled with air |
| Flatness (Percussion) | Soft, High-pitched, short dull sound produced by dense tissue such as muscle or bone |
| Dullness (Percussion) | Medium intensity and duration is moderate, thud like sound produced over dense tissue such as the liver, spleen, or heart |
| Hyperresonance (Percussion) | Abnormally very loud, very low, and very long, booming sound produced over an emphysematous lung |
| Assessing and prioritizing the patient's risk for aspiration pneumonia | Decreased LOC, Difficulty swallowing, NG tubes, Edema of Airway, Infections |
| When a patient is sitting straight up (high-fowlers position) we are draining | The upper lobes of the lungs |
| When a patient is lying on their left side with the right chest elevated we are draining | The Right upper lobe |
| When a patient is lying on their right side with the left chest elevated we are draining | The Left upper lobe |
| When a patient is lying on their stomach with their feet higher than their head (Prone Trendelenburg's Position) we are draining | The lower lobes of the lungs |
| Physical Examination | Fever, crackles, increased tactile fremitus, percussion dullness, bronchial breath sounds, positive egophony and whispered pectoriloquy. |
| Blood Cultures | To determine is bloodstream invasion such as bacteremia has occurred |
| Sputum Samples | Is often purulent but is not a reliable indicator of the etiologic agent. Rusty/Blood-tinged may be with Streptococcal, staphylococcal, and klebsiella pneumonia. Have the patient rinse their mouth with water, deeply breathe several times, cough deeply, and then expectorate the raised sputum into a sterile container |
| Thoracentesis | May be performed to remove the fluid from the lungs and sent to the lab for analysis |
| Nursing Diagnosis for patients with pneumonia | Ineffective airway clearance relation to tracheobronchial secretions, Fatigue and activity intolerance related to impaired respiratory function, Risk for deficient fluid volume related to fever and a rapid respiratory rate, Imbalanced nutrition, less than body requirements, Deficient knowledge about the treatment regimen and preventive measures |
| Interventions for patients with pneumonia | Hydration, antipyretics, antitussive, warm, moist inhalations for bronchial irritation, antihistamines, nasal decongestants, bed rest. More aggressively high concentrations of oxygen, endotracheal intubation, and mechanical ventilation |
| Focused assessment for patients with pneumonia | Monitor for signs of hypoxemia through pulse ox and ABGs - ABGs are used for baseline with pulse ox used continuously |
| CAP Pneumonia Patient Education | Rest, and avoid smoking, hydration, and adequate nutrition, and there may be a need of supplemental oxygen. Early mobilization is important to prevent DVT |
| Nursing interventions and rationales for patients with pneumonia | Maintain airway patency by removing secretions - secretions can interfere with gas exchange and may slow recovery, Encourage 2-3 L of hydration per day to loosen pulmonary secretions, Provide high-humidity facemasks that help liquefy secretions and relieves tracheobronchial irritation |
| Pneumonia Treatments | Bacterial pneumonia is treated with antibiotics. however, viral pneumonia does not respond to antibiotics |
| When is patient ready for discharge with CAP? | Vital signs have normalized, lung function & oxygenation have returned to baseline, blood culture is negative and blood cell count is lowered, and comorbid illnesses have stabilized |
| How do we know patient is responding to treatment? And if not, what happens next? | Typically, does occur within 2-3 days, but note that radiographic evidence of resolution lags behind clinical resolution. Symptoms of improvement are the same as other pneumonias such as decreased dyspnea, decreased cough, absence of crackles in the lungs, etc. |
| CAP patient not responding to treatment | May have a resistant or unsuspected pathogen, inadequate dosing or absorption of medication, or misdiagnosis. Information should be carefully reviewed with a repeat infection screening and considered alternative diagnosis. |
| CAP Treatment Plan | Antibiotics should be started promptly (ideally within 4 hours), and continued for 7-10 days for low-to-moderate forms. Pathogen-directed antibiotics should be used once known, and if it is Gram-Negative Bacteria, or suspected of, prolonged antibiotic treatment of up to 21 days may be needed. |
| Pneumococcal vaccination criteria for recommendations and contraindications | Acute febrile illness, immunosuppressive drug therapy, immunodeficiency states, hematologic cancers, generalized malignancy, pregnancy |
| PCV13 Vaccine | Protects against 13 types of pneumonia and is recommended for adults 65 years and older and adults 19 years or older with conditions that weaken the immune system. |
| PPSV23 Vaccine | New vaccine and protects against 23 types of Pneumonia. Recommended for all adults 65 and older and those 19-64 who smoke cigarettes, or have asthma. |
| Testing to confirm TB diagnosis | Sputum Culture positive for AFB |
| TB Transmission | A susceptible person inhales mycobacteria which are transmitted through the airways to the alveoli, where they are deposited and multiply. Also can be transported via the lymph system into the bloodstream to other parts of the body |
| Quantiferon-TB Gold in tube and T-Spot | TB blood tests. The results of the tests are available within 24-36 hours. Positive IGRA means the patient has been infected. |
| Plan of care for TB patients | Promoting airway clearance, advocating adherence to prescribed regimen, promoting activity and nutrition, and preventing transmission |
| Isolation precautions for TB | Airborne Use a private room with negative pressure in relation to the surrounding areas, and a minimum of six air changes per hour. - the air should be exhausted directly to the outside. Any entering the room should use disposable particulate respirators that fit snugly around the face. |
| Promoting Airway Clearance | Increasing fluid intake promotes systemic hydration and serves as an effective expectorant. The nurse should also instruct the patient about correct positioning |
| Promote Activity & Nutrition | Planning of progressive activity schedule that focuses on increasing activity tolerance, and muscle strength. Identify facilities that provide meals in the patient's neighborhood to ensure nutritious intake. Encourage the patient to have small, frequent meals, and possibly liquid nutritional supplements |
| Prevent Transmission | Hygiene measures, mouth care, proper disposal of tissues |
| Possible adverse effects of Rifampin for TB patients | GI upset, skin rashes, hepatotoxicity, and acute renal failure. Causes harmless red-orange discoloration of urine, tears, sweat, and other body fluids, main stain contact lenses. Prolonged use may result in bacterial or fungal superinfections, include C. Diff |
| Medications for prevention of TB for those exposed to positive patients | Bacillus Calmette-Guerin (BCG) vaccine has been shown to provide children with excellent protection. However, protecting is a variable especially in adults. Isoniazid is the preferred choice for prevention and latent forms of TB. It is mainly used to protect people |
| The term for TB prevention | Chemoprophylaxis |
| Risk factors for COPD | Smoking, secondhand smoke, air pollution, occupational exposure, infectious agents, allergens, age, and possible genetics. |
| Chronic Bronchitis | Disease of the airways, defined as the presence of cough and sputum production for at least three months in each of the two consecutive years. Increased mucus production causes mucus plugging of the airway and reduces ciliary function, bronchial walls become thickened, and further narrowing of the bronchial lumen occurs. |
| Emphysema | It is the abnormal distension of airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli, resulting in impaired oxygen and CO2 exchange and hypoxemia, high BP, and heart failure, edema, distended neck veins, or pain in the region of the liver. |
| Panlobular Emphysema | Destruction of the respiratory bronchiole, alveolar duct, and alveolus |
| Centrilobular Emphysema | Pathologic changes take place mainly in the center of the secondary lobule, preserving the peripheral portions of the acinus |
| Expected physical assessment findings in COPD patient | Barrel Chest, Musculoskeletal wasting, use of accessory muscles to breathe, weight loss, fatigue |
| Patient population that may require alpha1- antitrypsin testing for COPD | Caucasians |
| Clinical Manifestations in COPD | Chronic cough, sputum production, dyspnea, increased respiratory infections, metabolic syndrome, depression |
| Assessment and Diagnostic Findings in COPD | Spirometry to evaluation airflow obstruction, the patient has difficulty or cannot forcibly exhale air from lungs. Leaning forward, forcing shoulder girdle upward and causing the supraclavicular fossae to retract on inspiration. ABGs may be obtained to determine gas exchange and oxygenation status. |
| Risk factors to avoid for patient already diagnosed with COPD | Environmental exposure, smoking cessation, avoid secondhand smoke |
| Management of COPD Exacerbations | Roflumilast (Daliresp), Bronchodilators, corticosteroids, antibiotic agents, oxygen therapy |
| COPD symptom management | Bronchodilators are the key |
| COPD surgical interventions | Bullectomy, Thoracotomy, Lung Transplantation, Lung Volume Reductions |
| Bullectomy | Used in patients with bullous emphysema. Bullae compress areas of the lung and may impair gas exchange, so this procedure excises the bullae to help reduce dyspnea and improve lung function. Can be done via video-assisted thoracoscope or limited thoracotomy incision |
| Lung Transplantation | Shown to improve quality of life and functional capacity in selected groups. Limited not only by the shortage of donors, it is costly and often requires costly immunosuppressive medication regimens |
| Lung Volume Reductions | Treatment option for end-stage COPD (grade IV) with a primary emphysematous component. Involves the removal of a portion of the diseased lung parenchyma. Reduces hyperinflation and allows functional tissue to expand, resulting in improved elastic reoil of the lung and improved chest wall expansion. |
| Pulmonary Rehabilitation | Most widely accepted and used in treatment of COPD. Primary goals are to reduce symptoms, improve quality of life, ,and increase physical and emotion activity. Multidisciplinary process that includes assessment, education, smoking cessation, physical reconditioning, nutrition counseling, skills training and psychological support. |
| Patient Education | Breathing exercises, activity pacing, self-care activities, oxygen therapy, palliative care |
| Use of diaphragmatic breathing in COPD patients | Reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and helps patient control rate and depth of respiration. Also promotes relaxation, enabling the patient to gain control of dyspnea and reduce feelings of panic |
| Evaluating efficacy of administering bronchodilator for COPD patients | Measured improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing dyspnea and ensuring that it has lessened |
| Nursing Process for COPD | Assessment, Achieve Airway Clearance, Improve Breathing Patterns, Use of Diaphragmatic Breathing in COPD Patients pursed lip breathing |
| Bronchodilators | Inhaled therapy is preferred treatment for COPD. Can be PRN or scheduled. Relieve bronchospasms by improving expiratory flow through widening of the airways and promoting lung emptying with each breath |
| Corticosteroids | Improve symptoms of COPD but do not slow the decline in lung function. Long-term use is not recommended as it can lead to myopathy, muscle weakness, decreased ability to function, and in advances diseases, respiratory failure. Combination of beta2-agonists and corticosteroids may be appropriate |
| Signs and symptoms of asthma | Cough, dyspnea, wheezing, generalized chest tightness, |
| Patient education for preventing asthma attacks | The cause of asthma attacks should be assessed. Possible allergens, occupational exposure . |
| Use of peak flow meter monitoring for asthma | Measures the highest airflow during a forced expiration. Patient takes a deep breath and fill lungs completely - Places mouthpiece in the mouth, and closes lips around mouthpiece then the patient exhales hard and fast Repeat two more times |
| Signs and symptoms of status asthmaticus | An asthma exacerbation and can range from mild to severe with potential respiratory arrest. Symptoms include labored breathing, prolonged exhalation, engorged neck veins, and wheezing. When wheezing disappears, it may be a sign of respiratory failure |
| Patient education for asthma patients taking corticosteroids | Take on a regular schedule, at approx. the same time every day, not effective unless used every day. |
| Patient education for asthma attack medication regimen | Correct technique for metered-dose inhaler, monitoring peak flow, avoiding triggers, asthma action plan, signs of complications |
| Nurse’s priority for severe asthma attack patients | Unable to catch breath, Difficulty talking and concentrating, and walking, Cyanosis of skin, beginning around mouth and fingers, Nasal flaring, Normal PaCO2 during an asthma attack may be a signal of impending respiratory failure. |
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