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COMPLEX exam 2
| Question | Answer |
|---|---|
| Oxygenation/perfusion EARLY abnormal findings | -tachypnea -tachycardia -restlessness -pale skin and mucous membranes -elevated BP -nasal flaring, tracheal tugging, use of accessory muscles, adventitious lung sounds |
| Oxygenation/perfusion LATE abnormal findings | -confusion/stupor -cyanosis -bradypnea -bradycardia -hypotension -cardiac dysrhythmias |
| breathing patterns: Cheyne-Stokes | respirations gradually increase in depth, then become more shallow, followed by a period of apnea |
| breathing patterns: Biot's | - neurologic, highly irregular breathing pattern with abrupt pauses between efforts |
| breathing patterns: Kussmaul's | - Respirations faster and deeper without pauses |
| Breathing patterns: apneustic | - respirations prolonged, gasping, followed by extremely short, inefficient expiration |
| Oxygenation/perfusion: geriatric considerations | - elasticity decreases in alveoli -lung capacity decreases - restrictions in tidal volume -increased dead space in lungs -decreased respiratory ability -blood oxygen level decreases |
| Bronchoscopy vs thoracentesis | -Bronchoscopy: visualization of larynx, trachea, and bronchi with flexible bronchoscope - Thoracentesis: uses a large bore needle inserted into a pleural space to drain |
| Nursing Care for Bronchoscopy | -consent signed -assess use of anticoags -remove dentures -NPO - aspiration risk -Preprocedure meds: anxiolytic, lidocaine spray -position- sitting, supine -label specimens -monitors vitals/O2 - Assess GAG REFLEX -salt water/lozenge -sore throat |
| Nursing Care for Thoracentesis | -consent signed - gather supplies -obtain preprocedure xray to locate pleural effusion -Position pt sitting upright with arms/shoulders raised and supported on pillows or bedside table with feet/legs well supported -educate pt to remain still |
| Obtaining ABGs | - allens test to assess ulnar artery circulation for radial site stick -obtain heparinized syringe for sample -obtain sample -hold pressure at least 5mins, assess bleeding, loss of pulse, swelling, and changes in color or temperature to hand/fingers |
| ARDS (acute respiratory distress syndrome) Signs/symptoms | -tachypnea -dyspnea -retractions -hypoxia -tachycardia -decreased pulmonary compliance |
| ARDS pathophysiology (1/2) | -insult; systemic inflammatory response syndrome -release of inflammatory mediators leading to lung tissue inflammation -damage to alveolar -capillary membrane -alveoli injury -increased capillary permeability |
| ARDS pathophysiology (2/2) | - rapid onset of pulmonary edema (noncardiogenic) - rapid deterioration of ABGs to Hypoxemia, Hypoxia, and Respiratory failure. |
| ARDS: risk factors: Direct Insults | -pneumonia -aspiration of gastric contents -inhalation injuries -near drowing |
| ARDS: risk factors: indirect insults | -sepsis -major burns -drug overdoses -shock -blood transfusions -trauma |
| ARDS: clinical manifestations | -manifests 1-2 days after initial insult -baseline lab data help to identify change in pulmonary status - Dyspnea and Tachypnea are EARLY signs |
| ARDS: Manifestations as progressive respiratory distress develops (1/2) | -Increase RR, intercostal retractions, use of accessory muscles -tachypnea -rales (crackles), rhonchi; cyanosis unchanged with O2 -Xray shows interstitial changes, patchy infiltrates "ground glass" -pulse ox, abg levels show refractory hypoxemia |
| ARDS: what is refractory hypoxemia | - "stubborn" -in this state the pts lungs are failing to provide enough oxygen despite therapeutic oxygen supplementation |
| ARDS: Manifestations as progressive respiratory distress develops (2/2) | -agitation, confusion, lethargy |
| ARDS: Nursing Interventions | -Treat the cause -Mechanical Vent: pain, sedation, paralytic -positioning- prone -nutrition-enterally -decrease O2 demands -maintain fluid/electrolyte balance -psychosocial support |
| ARDS: COMPLICATIONS | -Multiple Organ Dysfunction syndrome(shock)- dysrhythmias, acidosis, vasoconstriction, hypoperfusion -DIC: widespread hypercoagulable state -pulmonary fibrosis: long term pulmonary scarring |
| Chest Trauma: Hemothorax: define, S/S, Treatment | -collection of blood in pleural space -decreased breath sounds, dullness in percussion, hypotension, respiratory distress -treat: chest tube |
| Chest Trauma: Pneumothorax: define, S/S, Treatment | - injury to chest allows air to enter pleural cavity without an escape route -severe respiratory distress, absence of breath sounds, chest pain, hypotension, tachycardia, tracheal deviation to unaffected side -treat: needle decompression, chest tube |
| Chest Trauma: Rib Fractures and Flail Chest: define, S/S, treatment | - 2 or more adjacent ribs broken in 2 or more places/floating ribs -paradoxical chest movement (asymmetrical), increase WOB, tachypnea, hypoxemia -treat: intubation/vent, prevent pneumonia, pain control |
| Chest Tube indications? | -Pneumothorax -Hemothorax -Post op chest drainage -pleural effusion -pulmonary empyema (infection, mucus, etc) |
| Chest tube management (chambers) | First chamber: drainage collection second chamber: water seal third chamber: suction control |
| Chest Tube: Nursing Care : Assessing Patient | -Assess breathing status, work of breathing -breath sounds -vitals -ABGs -Chest Xrays -insertion site: redness, pain, infection, crepitus (subcutaneous air) |
| Chest Tube: Nursing Care: Assessing System | -Check for kinks in the tubing -tape all connections between tube and drainage system -monitor for bubbling in air leak chamber -intermittent bubbling is okay, continuous bubbling indicates an air leak |
| Chest Tube: standard nursing care interventions | - keep drainage system below level of pts chest -encourage cough, deep breathing -admin pain meds -document drainage output, amount, color, consistency, changes -do NOT milk, strip, or clamp tubing, may cause tension pneumothorax |
| Chest Tube: What do you do if chest tube becomes dislodged from patient? | -apply petroleum/occlusive gauze to pts insertion site -notify provider |
| Chest tube: what do you do if drainage system gets knocked over? | -return to upright position promptly and note changes in the collection chamber |
| Chest Tube: what do you do if tube becomes dislodged from system? | -Submerge end of tube in 2 inches of sterile water until another system is supplied |
| Chest Tube: What do you do if tube is damaged? | - BRIEFLY clamp the tube, notify provider |
| Airway Management and Modalities | - positioning -Devices: -oral airway -nasopharyngeal airway -endotracheal airway |
| low flow oxygen | nasal cannula: 1-6L, FiO2 0.24-0.44 Simple face mask: 5-12:, FiO2 0.30-0.60 face masks with reserviors: 15L partial rebreather= 0.35-0.60 FiO2 15L nonrebreather = 0.60-0.80 FiO2 |
| High Flow oxygen | High flow nasal cannula: 15-40L, 0.60-0.90 FiO2 Venturi Mask: 4-12L, 0.24-0.60 |
| Complication: Oxygen Toxicity | -Symptoms: -nonproductive cough -substernal pain -nasal stuffiness -nausea/vomiting -fatigue -headache -sore throat -hypoventilation *only use the lowest level of oxygen to maintain prescribed O2 |
| Indications for Ventilation | -Hypoxemia: PaO2 <60mmhg on FiO2 >0.50 -Hypercapnia: PCO2 > 50mmhg with pH < 7.25 -progressive deterioration: increase RR and WOB, decreasing ventilation. - OR respiratory support during surgery/heavy sedation |
| Vent Settings : PEEP (there are more, you can look up if want, but dont have to memorize) | - Positive End-Expiratory Pressure -pressure at the end of expiration to keep alveoli open |
| Ventilator Modes | -Assist//Control: Ventilator is doing all the work -Synchronized intermittent mandatory ventilation: spontaneous breaths are possible between mandatory breaths -Continuous spontaneous: every breath is initiated by patient -vents also have CPAP/BiPAP |
| Care for Ventilated patient (1/2) | -secure/monitor ETT, preventing extubation -Assess skin to prevent breakdown -assess secretions and need for suction -maintain upright position HOB>35 -oral care Q 2hrs -ABG analysis -manage wrist restraints -communicate with patient and family |
| Care for Ventilated Patient (2/2) | -work collaboratively with respiratory therapy and physician -nutrition -**Goal is to avoid patient-ventilator desynchrony ("fighting the ventilator") |
| Ventilated patient: Medications: Sedatives/anesthetics | -enhances action of GABA in the CNS. Acts as CNS depressant -prevents dyssynchrony between pt & ventilator -ex: propofol, precedex, midazolom, brevital, diazepam, lorazepam |
| Ventilated patient: medications: paralytics | -paralyzes muscles (specifically diaphragm) -prevents dyssynchrony between pt-ventilator, must be used in conjunction with sedatives and analgesics -ex: Nimbex, pancuronium |
| Ventilated patient: Medication: Analgesics | -works on mu & kappa receptors to produce effects of sedation, euphoria and pain relief -pain relief and added sedation for the vented patient -ex: morphine, fentanyl |
| Ventilated patient: medication: ulcer-preventing agents | - famotidine , pantoprazole |
| Ventilated Patient: Complications | -barotrauma/volutrauma -fluid retention -oxygen toxicity -hemodynamic compromise -aspiration and VAP (vent associated pneuomia) -GI ulceration |
| Vent patient: Weaning/ ready for extubation? | Assess: -underlying cause resolved? -adequate oxygenation fiO2 <0.4-0.5 and peep 5 *Spontaneous breathing trial: -pt awake, participating -breathing pattern -gas exchange -hemodynamic stability -tolerate 120mins |
| ABGS: Normal Values | -pH: 7.35-7.45 (7.4) -CO2: 35-45 -HCO3: 22-26 -PaO2: 80-100 |
| Metabolic Acidosis | -pH low, HCO3 low -too much acid in body due to not enough bicarb -cause: DKA, Shock, renal failure, diarrhea, starvation, liver failure -S/S: weakness, fatigue, headache, dysrhythmias, kussmaul respirations |
| Metabolic alkalosis | -pH high, HCO3 high -too much bicarb in system causes: vomiting, hypokalemia, GI suctioning, TPN, Tums/antacids, blood transfusions S/S: dizziness, decreased respirations, decreased peripheral sensation |
| Respiratory Acidosis | -pH low, CO2 high -too much acid due to build up of CO2 -cause: respiratory failure, COPD exac, hypoventilation, sedatives, pneumonia, coma, asthma attack, thoracic injury, drug overdose -S/S: anxiety, confusion, headache, restless, blurry vision |
| Respiratory Alkalosis | -pH high, CO2 low -not enough CO2 -causes hyperventilation, anxiety, fear -s/s: dizziness, dry mouth, decreased peripheral sensation |
| Compensation (ABGs) | -look at pH -uncompensated: opposite system within normal range and pH out of range -FULLY: opposite system out of range, pH within normal range -PARTIAL: both system out of range, pH out of range |
| Organ Transplant Drugs: Corticosteroids: definition/examples | - switch off multiple inflammation pathways including cytokine expression -ex: prednisone, methylprednisone |
| Organ Transplant Drugs: Antiproliferative/Antimetabolites (Antirejection): definition/antimetabolites | -inhibit the proliferation of B and T lymphocytes that are responsible for activating the immune system -ex: azathioprine, mycophenolate mofetil, cyclophosphamide |
| Organ Transplant: Nursing Care | -posttransplant pts greater risk for infection due to immune suppression drugs -adhere to infection control precautions -protective isolation precautions -teach pt about hand hygiene - monitor for s/s of infection (fever may be only symptom ) |
| what is organ transplant rejection | - a complication manifested by an immune reaction and organ failure |
| what is guillain barre syndrome? | - demyelinating disorder of PNS - results from immune response -risk factors/causes: epstein barr virus, flu shot, HIV -can result in respiratory failure |
| Diabetes Insipidus: assessment findings | -insatiable thirst -polyuria -polydipsia -nocturia -fluid volume deficit -hypotension+tachycardia, weak pulse |
| Define diabetes Insipidus | -large volume of dilute urine excreted daily -either nephrogenic (lack of kidney response to ADH) or neurogenic ( lack of production of ADH) - |
| Diabetes insipidus pharm | Vasopressin : promotes reabsorption of water within the kidney through vasoconstriction considerations: water intoxications, myocardial ischemia due to vasoconstriction of coronary arteries |
| Diabetes insipidus labs | - increased hct, Na/K+ (concentrated blood) -decreased urine specific gravity and osmolality (dilute urine) |
| Define SIADH | - excessive release of ADH (vasopressin) from pituitary -renal reabsorption |
| SIADH causes | - malignant tumors, increased intrathoracic pressure (pos pressure vent), head injury, meningitis, Med: barbiturates, anesthetics, diuretics, chemo, TCAs, SSRIs, opioids, fluoroquinolone antibiotics |
| SIADH assessment findings | - decreased urine output, concentrated urine -hyponatremia -fatigue, headache, anorexia, weight gain w/o edema -change in LOC -weakness, tachycardia, tachypnea, bounding pulse, cerebral edema, intracranial pressure |
| SIADH labs | -diluted blood: decreased hct, hgb,Na, osmolarity -concentrated urine: increased urine specific gravity, osmolality, urine sodium |
Created by:
Katelynsw27