Capstone Med-Surg

Question 1

Angina Precipitating Factors: 4 E’s

Answer 1

Exertion: physical activity and exercise

Eating

Emotional distress

Extreme temperatures: hot or cold weather

Question 2

Arterial Occlusion: 4 P’s

Answer 2

Pain

Pulselessness or absent pulse

Pallor

Paresthesia

Question 3

Congestive Heart Failure Treatment: MADD DOG

Answer 3

• *M**orphine
• *A**minophylline
• *D**igoxin
• *D**opamine
• *D**iuretics
• *O**xygen
• *G**asses: Monitor arterial blood gasses

Question 4

Heart Murmur Causes: SPASM

Answer 4

• *S**tenosis of a valve
• *P**artial obstruction
• *A**neurysms
• *S**eptal defect
• *M**itral regurgitation

*murmur has a whooshing or swishing sound

Question 5

Heart Sounds: All People Enjoy the Movies

Answer 5

Aortic: 2nd right intercostal space

Pulmonic: 2nd left intercostal space

Erb’s Point: 3rd left intercostal space

Tricuspid: 4th left intercostal space

Mitral or Apex: 5th left intercostal space

Question 6

Hypertension Care: DIURETIC

Answer 6

• *D**aily weight
• *I**ntake and Output
• *U**rine output
• *R**esponse of blood pressure
• *E**lectrolytes
• *T**ake pulse
• *I**schemic episodes or TIAs
• *C**omplications: CVA, CAD, CHR, CRF

Question 7

Shortness of Breath (SOB) Causes: AAAPPP

Answer 7

Airway obstruction

Angina

Anxiety

Asthma

Pneumonia

Pneumothorax

Pulmonary Edema

Pulmonary Embolus

Question 8

Stroke Signs: FAST

Answer 8

Face

Arms

Speech

Time

Question 9

Compartment Syndrome Signs and Symptoms: 5 P’s

Answer 9

Pain

Pallor

Pulse declined or absent

Pressure increased

Paresthesia

Question 10

Shock Signs and Symptoms: CHORD ITEM

Answer 10

• *C**old, clammy skin
• *H**ypotension
• *O**liguria
• *R**apid, shallow breathing
• *D**rowsiness, confusion
• *I**rritability
• *T**achycardia
• *E**levated or reduced central venous pressure
• *M**ulti-organ damage

Question 11

Hypoglycemia Signs: TIRED

Answer 11

Tachycardia

Irritability

Restlessness

Excessive hunger

Depression and diaphoresis

** Cold and clammy, give them candy **

Question 12

Hypocalcaemia Signs and Symptoms: CATSS

Answer 12

Convulsions

Arrhythmias

Tetany (spasms)

Stridor and Spasms

Question 13

Hypokalemia Signs and Symptoms: 6 L’s

Answer 13

Lethargy

Leg cramps

Limp muscles

Low, shallow respirations

Lethal cardiac dysrhythmias

Lots of urine (polyuria)

Question 14

Hypertension Complications: The 4 C’s

Answer 14

Coronary artery disease (CAD)

Congestive heart failure (CHF)

Chronic renal failure (CRF)

Cardiovascular accident (CVA): Brain attack or stroke

Question 15

Traction Patient Care: TRACTION

Answer 15

Temperature of extremity is assessed for signs of infection

Ropes hang freely

Alignment of body and injured area

Circulation check (5 P’s)

Type and location of fracture

Increase fluid intake

Overhead trapeze

No weights on bed or floor

Question 16

Cancer Early Warning Signs: CAUTION UP

Answer 16

• *C**hange in bowel or bladder
• *A** lesion that does not heal
• *U**nusual bleeding or discharge
• *T**hickening or lump in breast or elsewhere
• *I**ndigestion or difficulty swallowing
• *O**bvious changes in wart or mole
• *N**agging cough or persistent hoarseness
• *U**nexplained weight loss
• *P**ernicious Anemia

Question 17

Leukemia Signs and Symptoms: ANT

Answer 17

Anemia and decreased hemoglobin

Neutropenia and increased risk of infection

Thrombocytopenia and increased risk of bleeding

Question 18

Clients Who Require Dialysis: AEIOU

Answer 18

Acid base imbalance

Electrolyte imbalances

Intoxication

Overload of fluids

Uremic symptoms

Question 19

Asthma Management: ASTHMA

Answer 19

Adrenergics: Albuterol and other bronchodilators

Steroids

Theophylline

Hydration: intravenous fluids

Mask: oxygen therapy

Antibiotics (for associated respiratory infections)

Question 20

Hypoxia:

RATT (signs of early)

BED (signs of late)

Answer 20

• *Early**
• *R**estlessness
• *A**nxiety
• *T**achycardia and Tachypnea
• *Late**
• *B**radycardia
• *E**xtreme restlessness
• *D**yspnea

Question 21

Pneumothorax Signs: P-THORAX

occurs when air leaks into the space between your lungs and chest wall

Answer 21

Pleuretic pain

Tracheal deviation

Hyperresonance

Onset sudden

Reduced breath sounds (& dyspnea)

Absent fremitus

X-ray shows collapsed lung

Question 22

Transient Incontinence Causes: DIAPERS

Answer 22

Delirium

Infection

Atrophic urethra

Pharmaceuticals and psychological

Excess urine output

Restricted mobility

Stool impaction

Question 23

Dealing with Dysphagia

Answer 23

• Clients with dysphagia are at an increased risk of aspiration. Place the client in an upright or high-Fowler’s position to facilitate swallowing.
• Provide oral care prior to eating to enhance the client’s sense of taste.
• Allow adequate time for eating, utilize adaptive eating devices, and encourage small bites and thorough chewing.
• Avoid thin liquids and sticky foods.

Question 24

Dumping Syndrome

Answer 24

• A complication of gastric surgeries that inhibits the ability of the pyloric sphincter to control the movement of food into the small intestine.
• This “dumping” results in nausea, distention, cramping pains, and diarrhea within 15 min after eating.
• Weakness, dizziness, a rapid heartbeat, and hypoglycemia may occur.
• Small, frequent meals are indicated.
• Consumption of protein and fat at each meal is indicated.
• Avoid concentrated sugars.
• Restrict lactose intake.
• Consume liquids 1 hr before or after eating instead of with meals (a dry diet).

Question 25

Gastroesophageal Reflux Disease (GERD):

Answer 25

• GERD leads to indigestion and heartburn from the backflow of acidic gastric juices onto the mucosa of the lower esophagus.
• Encourage weight loss for overweight clients.
• Avoid large meals and bedtime snacks.
• Avoid trigger foods such as citrus fruits and juices, spicy foods, and carbonated beverages.
• Avoid items that reduce lower esophageal sphincter (LES) pressure, such as alcohol, caffeine, chocolate, fatty foods, peppermint and spearmint flavors and cigarette smoking.

Question 26

Peptic Ulcer Disease (PUD)

Answer 26

• PUD is characterized by an erosion of the mucosal layer of the stomach or duodenum.
• This may be caused by a bacterial infection with Helicobacter pylori or the chronic use of non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen.
• Avoid eating frequent meals and snacks, as they promote increased gastric acid secretion.
• Avoid alcohol, cigarette smoking, aspirin and other NSAIDs, coffee, black pepper, spicy foods, and caffeine.

Question 27

Prioritization

Answer 27

1. Treat first any immediate threats to a patient’s survival or safety.
   
   • Ex. obstructed airway, loss of consciousness, psychological episode or anxiety attack
   • ABC’s.
2. Next, treat actual problems.
   
   • Ex. nausea, full bowel or bladder, comfort measures.
3. Then, treat relatively urgent actual or potential problems that the patient or family does not recognize.
   
   • Ex. Monitoring for post-op complications, anticipating teaching needs of a patient that may be unaware of side effects of meds.
4. Lastly, treat actual or potential problems where help may be needed in the future.
   
   • Ex Teaching for self-care in the home.

Question 28

Princples of Prioritization

Answer 28

• Systemic before local
• Acute before chronic
• Actual before potential
• Listen don’t assume
• Recognize first then apply clinical knowledge
• Maslow’s Hierarchy of Needs:

Question 29

Cholecystitis

Answer 29

• Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats.
• Fat intake should be limited to reduce stimulation of the gallbladder.
• Other foods that may cause problems include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods.
• Otherwise, the diet is individualized to the client’s needs and tolerance.

Question 30

Acute Renal Failure (ARF)

Answer 30

• ARF is an abrupt, rapid decline in renal function.
• It is usually caused by trauma, sepsis, poor perfusion, or medications.
• ARF can cause
  
  • hyponatremia,
  • hyperkalemia,
  • hypocalcemia, and
  • hyperphosphatemia.
• Diet therapy for ARF is dependent upon the phase of ARF and its underlying cause.

Question 31

Pre-End Stage Renal Disease (pre-ESRD)

Answer 31

• Diminished renal reserve/renal insufficiency
• Predialysis condition characterized by an increase in serum creatinine.
• Limit the intake of protein and phosphorus - protein restriction is key
  
  • ​Too little protein results in breakdown of body protein, so protein intake must be carefully determined.
  • Restricting phosphorus intake slows the progression of renal disease.
  • High levels of phosphorus contribute to calcium and phosphorus deposits in the kidneys.
• Control blood glucose levels and hypertension, which are both risk factors.
• Dietary recommendations for pre-ESRD:
  
  • Limit meat intake.
  • Limit dairy products to ½ cup per day.
  • Limit high-phosphorus foods (peanut butter, dried peas and beans, bran, cola, chocolate, beer, some whole grains).
  • Restrict sodium intake to maintain blood pressure.
  • Caution clients to use vitamin and mineral supplements ONLY when recommended by their provider.

Question 32

End Stage Renal Disease (ESRD) - Nutrition

Answer 32

• Occurs when the glomerular filtration rate (GFR) is less than 25 mL/min, the serum creatinine level steadily rises, or dialysis or transplantation is required.
• The goal of nutritional therapy is to maintain appropriate fluid status, blood pressure, and blood chemistries.
• A high-protein, low-phosphorus, low-potassium, low-sodium, fluid restricted diet is recommended.
  
  • Protein needs increase once dialysis is begun because protein and amino acids are lost in the dialysate.
  • Fifty percent of protein intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy).
• The high protein requirement leads to an increase in phosphorus intake.
  
  • Phosphorus must be restricted.
  • Phosphate binders must be taken with all meals and snacks.
• Adequate calories (35 cal/kg of body weight) should be consumed to maintain body protein stores.
• Calcium and vitamin D are nutrients of concern.

Question 33

ABCDE Princple

Answer 33

• Airway
• Breathing
• Circulation
• Disability
  
  • A – Alert
  • V – Responsive to voice
  • P – Responsive to pain
  • U – Unresponsive
• Exposure (complete physical assessment)

Question 34

CNS - Beta₁ Receptors

Answer 34

• Heart stimulation leads to
  
  • Increased heart rate,
  • Increased myocardial contractility, and
  • Increased rate of conduction through the atrioventricular (AV) node.
• Activation of receptors in the kidney leads to the release of renin.

Question 35

CNS - Beta₂ Receptors

Answer 35

• Activation of receptors in the arterioles of the heart, lungs, and skeletal muscles lead to vasodilation.
• Bronchial stimulation leads to bronchodilation.
• Activation of receptors in uterine smooth muscle causes relaxation.
• Activation of receptors in the liver cause glycogenolysis.
• Skeletal muscle receptor activation leads to muscle contraction.

Question 36

Extravasation

Answer 36

• Leakage of fluid from vascular space during IV infusion
• Can lead to tissue necrosis
• Treat with a local injection of an alpha-adrenergic blocking agent, such as phentolamine.

Question 37

Cerebral Angiogram

Answer 37

A cerebral angiogram provides visualization of the cerebral blood vessels.

• Digital subtraction angiography “subtracts” the bones and tissues from the images, providing x-rays with only the vessels apparent.
• The procedure detects defects, narrowing, or obstruction of arteries or blood vessels in brain.
• The procedure is performed within the radiology department because iodine-based contrast dye is injected into an artery during the procedure.

Question 38

CT Scan

Answer 38

• Provides cross-sectional images of the cranial cavity. A contrast media may be used to enhance the images.
• Can be used to identify tumors and infarctions, detect abnormalities, monitor response to treatment, and guide needles used for biopsies.

Question 39

Electroencephalography (EEG)

Answer 39

• This noninvasive procedure assesses the electrical activity of the brain and is used to determine if there are abnormalities in brain wave patterns.
• EEGs are most commonly performed to identify and determine seizure activity, but they are also useful for detecting sleep disorders and behavioral changes.

Question 40

Glasgow Coma Scale

Answer 40

Eye opening (E4)

• 4 = Eye opening occurs spontaneously.
• 3 = Eye opening occurs secondary to voice.
• 2 = Eye opening occurs secondary to pain.
• 1 = Eye opening does not occur.

Verbal (V5)

• 5 = Conversation is coherent and oriented.
• 4 = Conversation is incoherent and disoriented.
• 3 = Words are spoken, but inappropriately.
• 2 = Sounds are made, but no words.
• 1 = Vocalization does not occur.

Motor (M6)

• 6 = Commands are followed.
• 5 = Local reaction to pain occurs.
• 4 = There is a general withdrawal to pain.
• 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present.
• 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present.
• 1 = Motor response does not occur

** Best score is 15/15 **

• < 8 – severe head injury and coma
• 9 to 12 – moderate head injury
• > 13 – minor head trauma

Question 41

MRI

Answer 41

• Provides cross-sectional images of the cranial cavity. A contrast media may be used to enhance the images.
• Unlike CT scans, MRI images are obtained using magnets, thus the consequences associated with radiation are avoided. This makes this procedure safer for women who are pregnant.
• The use of magnets precludes the ability to scan a client who has an artificial device (pacemakers, surgical clips, intravenous access port). If these are present, shielding may be done to prevent injury.

Question 42

Acute Pain

Answer 42

• Acute pain is protective, temporary, usually self-limiting, and resolves with tissue healing.
• Physiological responses (sympathetic nervous system) are fight-or-flight responses (tachycardia, hypertension, anxiety, diaphoresis, muscle tension).
• Behavioral responses include grimacing, moaning, flinching, and guarding.

Question 43

Chronic Pain

Answer 43

• Chronic pain is not protective. It is ongoing or recurs frequently, lasting longer than 6 months and persisting beyond tissue healing.
• Physiological responses do not usually alter vital signs, but clients may have depression, fatigue, and a decreased level of functioning.
• Psychosocial implications may lead to disability.
• Chronic pain may not have a known cause, and it may not respond to interventions.
• Management aims at symptomatic relief.
• Chronic pain can be malignant or nonmalignant.

Question 44

Nociceptive Pain

Answer 44

• Arises from damage to or inflammation of tissue other than that of the peripheral and central nervous systems.
• It is usually throbbing, aching, and localized.
• This pain typically responds to opioids and nonopioid medications.
• Types of nociceptive pain include:
  
  • Somatic – in bones, joints, muscles, skin, or connective tissues.
  • Visceral – in internal organs such as the stomach or intestines. It can cause referred pain in other body locations separate from the stimulus.
  • Cutaneous – in the skin or subcutaneous tissue.

Question 45

Neuropathic Pain

Answer 45

• Arises from abnormal or damaged pain nerves.
• Includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy.
• Neuropathic pain is usually intense, shooting, burning, or described as “pins and needles.”
• This pain typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants).
• Adjuvant medications include:
  • Anticonvulsants: carbamazepine (Tegretol)
  • Antianxiety agents: diazepam (Valium)
  • Tricyclic antidepressants: amitriptyline (Elavil)
  • Antihistamine: hydroxyzine (Vistaril)
  • Glucocorticoids: dexamethasone (Decadron)
  • Antiemetics: ondansetron (Zofran)

Question 46

Meningitis

Answer 46

• Meningitis is an inflammation of the meninges, which are the membranes that protect the brain and spinal cord.
• Viral, or aseptic, meningitis is the most common form of meningitis and commonly resolves without treatment.
• Fungal meningitis is common in clients who have AIDS.
• Bacterial, or septic, meningitis is a contagious infection with a high mortality rate.
• Vaccinations available: Hib (babies), MCV4 (adolescents and military in communal living, PPSV (immunocompromised and older adults in communal living)

Question 47

Meningitis: S/S

Answer 47

Subjective Data

• Excruciating, constant headache
• Nuchal rigidity (stiff neck)
• Photophobia (sensitivity to light)

Objective Data

• Fever and chills
• Nausea and vomiting
• Altered level of consciousness (confusion, disorientation, lethargy, difficulty arousing, coma)
• Positive Kernig’s sign (resistance and pain with extension of the client’s leg from a flexed position)
• Positive Brudzinski’s sign (flexion of extremities occurring with deliberate flexion of the client’s neck)
• Hyperactive deep tendon reflexes
  • 0 = absent,
  • 1 = slight, but definitely present (may or may not be normal)
  • 2 = present, normal,
  • 3 = very brisk (may or may not be normal)
  • 4 = a tap elicits a repeated reflex (clonus); always abnormal
• Tachycardia
• Seizures
• Red macular rash (meningococcal meningitis)
• Restlessness, irritability

Question 48

Meningitis: Patient Care

Answer 48

Interventions

• Droplet precautions for bacterial (at least until 24 hrs of antibiotic and reduction of secretions)
• Minimize light and stimulation
• Bed rest, HOB 30
• Avoid coughing/sneezing which can increase ICP
• Maintain fluid balance
• Anti-fever interventions

Medications

• Ceftriaxone (Rocephin) or cefotaxime (Claforan) in combination with vancocin (Vancomycin)
  
  • Antibiotics given until culture and sensitivity results are available. Effective for bacterial infections.
• Phenytoin (Dilantin)
  
  • Anticonvulsants given if ICP increases or client experiences a seizure.
• Decadron (dexamethasone)
  
  • Corticosteroid, may improve outcome in adults if given before first dose of antibiotic
• ​Analgesics for headache and/or fever – nonopioid to avoid masking changes in the level of consciousness.

Question 49

Seizures & Epilepsy

Answer 49

• Seizures are abrupt, abnormal, excessive and uncontrolled electrical discharge of neurons within the brain that may cause alterations in the level of consciousness and/or changes in motor and sensory ability and/or behavior.
• Epilepsy is the term used to define a syndrome characterized by chronic recurring abnormal brain electrical activity.
• The International Classification of Epileptic Seizures uses three broad categories to describe seizures:
  
  • Generalized (tonic-clonic)
  • Partial or focal/local
  • Unclassified or idiopathic

Question 50

Generalized Seizure

(Tonic-Clonic Seizure)

Answer 50

• May begin with an aura (alteration in vision, smell, hearing, or emotional feeling).
• Tonic episode - a few seconds of stiffening of muscles) and loss of consciousness.
  
  • Breathing may stop
• Clonic episode - 1 to 2mins of rhythmic jerking of the extremities
  
  • ​​Breathing may be irregular
• ​​Incontinence can also accompany a seizure.
• A period of confusion and sleepiness may follow the seizure (the postictal phase)

Question 51

Partial or focal/local seizure

Answer 51

■■ Complex partial seizure

• Complex partial seizures have associated automatisms (behaviors that the client is unaware of, such as lip smacking or picking at clothes).
• The seizure can cause a loss of consciousness for several minutes.
• Amnesia may occur immediately prior to and after the seizure.

■■ Simple partial seizures

• Consciousness is maintained throughout simple partial seizures.
• Seizure activity may consist of unusual sensations, a sense of déjà vu, autonomic abnormalities, such as changes in heart rate and abnormal flushing, unilateral abnormal extremity movements, pain or offensive smell.

Question 52

Unclassified or Idiopathic Seizures

Answer 52

Account for half of all seizure activities and occur for no known reason.

Question 54

Seizures: Nursing Care

Answer 54

■■ During a seizure - safety first!

• Position client to provide a patent airway.
• Be prepared to suction oral secretions.
• Turn the client to the side to decrease the risk of aspiration.
• Loosen restrictive clothing.
• Do not attempt to restrain the client.
• Do not attempt to open jaw or insert airway during seizure activity

■■ Post seizure (postictal phase):

• Side-lying position to prevent aspiration and to facilitate drainage of oral secretions.
• Check vital signs, assess for injuries, perform neurological checks.
• Allow the client to rest if necessary.
• Reorient and calm the client (may be agitated or confused).
• Institute seizure precautions including placing the bed in the lowest position and padding the side rails to prevent future injury.
• Antiepileptic drugs (AED)
  
  • phenytoin (Dilantin)
    
    • ​Avoid oral contraceptives and warfarin
• Document onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence).

Question 55

Status Epilepticus

Answer 55

• Prolonged seizure activity occurring over a 30-min time frame.
• Maintain an airway, provide oxygen, establish IV access, perform ECG monitoring, and monitor pulse oximetry and ABG results.
• Administer a loading dose of diazepam (Valium) or lorazepam (Ativan) followed by a continuous infusion of phenytoin (Dilantin).

Question 56

Parkinson’s Disease (PD)

Answer 56

A progressively debilitating disease affecting motor function

• Characterized by four primary symptoms:
  
  • tremor,
  • muscle rigidity,
  • bradykinesia (slow movement),
  • postural instability.
  • These symptoms occur due to overstimulation of the basal ganglia by acetylcholine.
• Treatment of PD focuses on increasing the amount of dopamine or decreasing the amount of acetylcholine in a client’s brain.
  
  • Dopamine has an inhibitory effect on muscles
    
    • Acetylcholine has anexcitatory effect on muscles

Stages

• Stage 1 – Unilateral shaking or tremor of one limb.
• Stage 2 – Bilateral limb involvement occurs, making walking and balance difficult.
• Stage 3 – Physical movements slow down significantly, affecting walking more.
• Stage 4 – Tremors may decrease but akinesia and rigidity make day-to-day tasks difficult.
• Stage 5 – Client unable to stand or walk, is dependent for all care, and may exhibit dementia.

Question 57

Parkinson’s: Medications

Answer 57

Dopaminergics:

• Levodopa
• Often given with carbidopa (to limit side effects)
• Adverse effects are often dose-related and can be minimized with dose adjustments
• Instruct pts to take with food but not with protein – protein inhibits absorption

Anticholinergics:

• Benztropine (Cogentin) to help control tremors and rigidity
• Monitor for anticholinergic effects (dry mouth, constipation, urinary retention, acute confusion).

Question 58

Parkinson’s: Nursing Considerations

Answer 58

Aspiration pneumonia – as PD advances in severity, alterations in chewing and swallowing will worsen, increasing the risk for aspiration.

Altered cognition (dementia, memory deficits) – advanced stages of PD may exhibit altered cognition in the form of dementia and memory loss.

Question 59

Parkinson’s:

Nursing Considerations & Client Outcomes

Answer 59

Nursing Care

• Add thickener to liquids to prevent aspiration.
• Consult with a dietician about appropriate diet.
• Encourage periods of rest between activities.
• Allow adequate time to rise slowly from a sitting to standing position.
• Encourage slower speech when expressing thoughts.
• Observe for signs of depression and dementia.

Client Outcomes

• The client will maintain weight by adequate fluid and nutrition intake.
• The client will have a safe environment by ambulating with assistive devices.
• The client will have an established routine medication schedule to prevent “wearing-off” effects of the medication.
• The client will have a support system to assist in coping with fears related to the disease process.

Question 60

Alzheimer’s: Nursing Care

Answer 60

Cognitive stimulation

• Offer varied environmental stimulations such as walks, music, and craft activities.
• Keep a structured environment. Introduce change slowly.
• Use a calendar to assist with orientation.
• Use short directions when explaining care to be provided, such as a bath.
• Be consistent and repetitive.
• Use therapeutic touch.

Memory training

• Reminisce about the past.
• Help the client make lists and rehearse.
• Repeat the client’s last statement to stimulate memory.

Question 61

Brain Tumors

Answer 61

Brain tumors apply pressure to surrounding brain tissue, resulting in

• decreased outflow of cerebrospinal fluid,
• increased intracranial pressure,
• cerebral edema, and
• neurological deficits.
• Tumors that involve the pituitary gland may cause endocrine dysfunction
  
  • SIADH
  • Diabetes Insipidus

Question 62

Brain Tumors: Medications

Answer 62

• Nonopioid analgesics are used to treat headaches - opioids can decrease LOC
• Corticosteroids are used to reduce cerebral edema.
• Anticonvulsant medications are used to control or prevent seizure activity.
• H₂-antagonists are used to decrease the acid content of the stomach, reducing the risk of stress ulcers (this is primarily preventative)
• Antiemetics are used if nausea with or without vomiting is present.
  
  • Nausea and vomiting may be present as a result of the increased intracranial pressure, the site of the tumor, or the treatment required.

Question 63

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Answer 63

• Fluid is retained as a result of an overproduction of vasopressin or antidiuretic hormone (ADH) from the posterior pituitary gland.
• Occurs when the hypothalamus has been damaged and can no longer regulate the release of ADH – may be due to brain tumor or surgery.
• Tx of SIADH consists of fluid restriction, administration of oral demeclocycline, and treatment of hyponatremia (?).
• S/S: oliguria (hypouresis); client may be disorientated, report a headache, and/or vomit.
• If severe or untreated, this condition may cause seizures and/or a coma.

Question 64

Diabetes Insipidus (DI)

Answer 64

• Large amounts of urine are excreted as a result of a deficiency of ADH from the posterior pituitary gland.
• The condition occurs when the hypothalamus has been damaged and can no longer regulate the release of ADH - may be due to brain tumors or injury
• Treatment of DI consists of massive fluid replacement, careful attention to laboratory values, and replacement of essential nutrients as indicated.

Question 65

Multiple Sclerosis

Answer 65

• An autoimmune disorder characterized by development of plaque in the white matter of the central nervous system (CNS)
  
  • This plaque damages the myelin sheath and interferes with impulse transmission between the CNS and the body.
  • B/c autimmune, many things such as stress and extreme changes in temp can trigger a relapse
• MS is a chronic disease with no known cure that progresses in severity over time
  
  • The disease is marked by relapses and remissions
  • Overtime, the client may eventually progress to the point of quadriplegia.

Question 66

Amyotrophic Lateral Sclerosis (ALS)

Lou Gehrig’s disease

Answer 66

A disease of the upper and lower motor neurons characterized by muscle weakness progressing to muscle atrophy and eventually paralysis and death.

ALS does not involve autonomic changes, sensory alterations, or cognitive changes.

Death usually occurs due to respiratory failure within 3 to 5 years of the initial manifestations. The cause of ALS is unknown, and there is no cure.

Nursing Care

• Maintain a patent airway, and suction and/or intubate as needed.
• Monitor ABGs, and administer oxygen, intermittent positive pressure ventilation, bilevel positive airway pressure, or mechanical ventilation as needed.
• Keep the head of the bed at 45°; turn, cough, and deep breathe every 2 hr; and conduct incentive spirometry/chest physiotherapy.
  
  • Monitor for pneumonia

Question 67

Myasthenia Gravis

Answer 67

♦ A progressive autoimmune disease that produces severe muscular weakness.

• Characterized by periods of exacerbation and remission.
• Muscle weakness improves with rest and worsens with increased activity.
  
  • Decreased muscle strength, especially of the face, eyes, and proximal portion of major muscle groups
• Caused by antibodies that interfere with the transmission of acetylcholine at the neuromuscular junction.

Question 68

Multiple Sclerosis: Medications

Answer 68

■ Azathioprine (Imuran) and cyclosporine (Sandimmune)

• Immunosuppressive agents are used to reduce the frequency of relapses.
• Be alert for manifestations of infection.
• Assess for hypertension & kidney dysfunction.

■ Prednisone

• Corticosteroids are used to reduce inflammation in acute exacerbations.
• Monitor for increased risk of infection, hypervolemia, hypernatremia, hypokalemia, hyperglycemia, gastrointestinal bleeding, and personality changes.

■ Dantrolene (Dantrium), tizanidine (Zanaflex), baclofen (Lioresal), and diazepam (Valium)

• Antispasmodics are used to treat muscle spasticity.
• Intrathecal baclofen can be used for severe cases of MS.

Question 69

Amyotrophic Lateral Sclerosis

(ALS; Lou Gehrig’s disease) : Medications

Answer 69

■ Riluzole (Rilutek) is a glutamate antagonist that can slow the deterioration of motor neurons by decreasing the release of glutamic acid.

• It must be taken early in disease process, and will add approximately 2 to 3 months of life to the client’s overall lifespan.
• Monitor liver function tests – hepatotoxic risk.
• Assess for dizziness, vertigo, and somnolence.

■ Baclofen (Lioresal), dantrolene sodium (Dantrium), diazepam (Valium)

• Antispasmodics are used to decrease spasticity.

Question 70

Myasthenia Gravis: Diagnostic Test

Answer 70

Tensilon testing

♦ Baseline assessment of the cranial muscle strength is done.

♦ Edrophonium (Tensilon) is administered.

• Medication inhibits the breakdown of acetylcholine, making it available for use at the neuromuscular junction.

♦ A positive test results in marked improvement in muscle strength that lasts approximately 5 min.

• ♦ Helps to differentiate btwn myasthenic crisis and cholinergic crisis*
• ♦ Atropine is the antidote*

Question 71

Myasthenia Gravis: Medications

Answer 71

■ Anticholinesterase agents are the first line in therapy: pyridostigmine (Mestinon), neostigmine (Prostigmin)

• inhibits the breakdown of acetylcholine and prolongs its effects thus increasing muscle strength
• Administer timely, usually four times a day.
• Administer with food to address gastrointestinal side effects.
• Eat within 45 min of taking the medication to strengthen chewing and reduce the risk for aspiration.

​■ Immunosuppressants such as prednisone and azathioprine (Imuran)

• Given during exacerbations when pyridostigmine is not adequately effective.
• Decrease the production of antibodies.

Question 72

Migraines

Answer 72

With aura

• Prodromal stage: symptoms hours to days before onset (irritability, depression, food cravings, diarrhea/constipation, and frequent urination)
• Aura stage: develops over minutes to an hour to include neurologic findings (numbness and tingling of mouth, lips, face, or hands; visual disturbances - light flashes, bright spots).
• Second stage: severe, incapacitating, throbbing headache that intensifies over several hours and is accompanied by nausea, vomiting, drowsiness, and vertigo.
• Third stage (4 to 72 hr): headache is dull. Older adults may continue with aura, and pain subsides (visual migraine).
• Recovery with pain and aura subsiding. Muscle aches and contraction of head and neck musclesare common. Physical activity worsens pain, and client may sleep.

Without aura

• Unilateral, pulsating pain.
  
  • ​Pain is aggravated by physical activity.
• One or more of these manifestations present: photophobia, phonophobia, nausea, and/or vomiting.
• Persists for 4 to 72 hr; often occurs in early morning, during periods of stress, or with premenstrual tension or fluid retention.

Question 73

Migraines: Medications

Answer 73

Abortive therapy aims to alleviate pain during aura or soon after start of headache.

Mild migraines

• NSAIDs (ibuprofen, naproxen), acetaminophen, and over-the-counter anti‑inflammatory medications in formulations for migraines (Advil Migraine Capsules).
• Antiemetics (metoclopramide [Reglan]) to relieve nausea and vomiting.

Severe migraines

• Triptan preparations (zolmitriptan [Zomig], sumatriptan [Imitrex], eletriptan [Relpax]) to produce a vasoconstrictive effect.
• Ergotamine preparations with caffeine (Cafergot, dihydroergotamine [Migranal]) to narrow blood vessels and reduce inflammation.
• Isometheptene in combination formulations (Midrin) when other medications do not work.
• Expected Pharmacological Action – vasoconstriction of cranial carotid arteries.

Preventive therapy for frequent headaches or when other therapies are ineffective.

• NSAIDs with beta-blocker (propranolol [Inderal]), calcium channel blocker, beta-adrenergic blocker or antiepileptic medications (divalproex [Depakote], topiramate [Topamax]).
• Client is instructed to check pulse when taking beta-adrenergic blockers and calcium channel blockers.

Question 74

Macular Degeneration

Answer 74

The central loss of vision that affects the macula of the eye.

• Dry macular degeneration is the most common and is caused by a gradual blockage in retinal capillary arteries, which results in the macula becoming ischemic and necrotic due to the lack of retinal cells.
• No cure for macular degeneration.
• No. 1 cause of vision loss in people over the age of 60.

Question 75

Cataracts

Answer 75

A cataract is an opacity in the lens of an eye that impairs vision.

Encourage clients to protect their eyes (i.e. wear sunglasses outside)

Question 76

Glaucoma

Answer 76

Increased ocular pressure (IOP) due to decreased fluid drainage or increased fluid secretion increases intraocular pressure and can result in atrophic changes of the optic nerve and visual defects. The “angle” refers to the angle between the iris and sclera.

An expected reference range for IOP is between 10 and 21 mm/Hg.

Open-angle glaucoma

• Most common form of glaucoma.
• The aqueous humor outflow is decreased due to blockages in the eye’s drainage system, causing a rise in IOP.
• Headache, mild eye pain, loss of peripheral vision, decreased accommodation
• Elevated IOP (greater than 21 mm Hg)

Angle-closure glaucoma

• Sudden increase in IOP
• Decreased or blurred vision
• Seeing halos around lights
• Pupils are nonreactive to light
• Severe pain and nausea
• Photophobia
• ●● Glaucoma is a leading cause of blindness. Early diagnosis and treatment is essential in preventing vision loss from glaucoma.*

Question 77

Glaucoma: Medications

Answer 77

Once eyedrop is instilled, apply pressure using the punctal occlusion technique (placing pressure on the inner corner of the eye).

Pilocarpine (Isopto Carpine – ophthalmic solution)

■ Pilocarpine is a miotic, which constricts the pupil and allows for better circulation of the aqueous humor. Miotics can cause blurred vision.

Timolol (Timoptic – ophthalmic solution)

■ Beta-blockers (timolol) and carbonic anhydrase inhibitors (acetazolamide) decrease IOP by reducing aqueous humor production.

IV mannitol (Osmitrol)

■ IV mannitol is an osmotic diuretic used in the emergency treatment for angle-closure glaucoma

to quickly decrease IOP.

Prednisolone acetate (Pred Forte – ophthalmic solution)

■ Prednisolone acetate is an ocular steroid used to decrease inflammation.

Acetazolamide (Diamox – oral medication)

■ Acetazolamide is administered preoperatively to reduce IOP, to dilate pupils, and to create eye paralysis to prevent lens movement.

☐ Always ask clients whether they are allergic to sulfa. Acetazolamide is a sulfa-based medication.

Question 78

Ménière’s disease

Answer 78

A vestibular (inner ear) disease characterized by a triad of manifestations: tinnitus, unilateral sensorineural hearing loss, and vertigo.

Medications

Some antihistamines, anticholinergics, antiemetics, and diazepam may help with vertigo and/or the N/V associated with veritgo.

Question 79

Labyrinthitis

Answer 79

Labyrinthitis is an infection of the labyrinth (inner ear), usually secondary to otitis media.

Question 80

Ototoxic Medications

Answer 80

Ototoxic medications include:

■■ Multiple antibiotics – gentamicin, amikacin, or metronidazole (Flagyl)

■■ Diuretics – furosemide (Lasix)

■■ NSAIDs – aspirin or ibuprofen (Advil)

■■ Chemotherapeutic agents – cisplatin

Question 81

Intracranial Pressure

Answer 81

Manifestations

• Severe headache.
• Deteriorating LOC, restlessness, irritability.
• Dilated, pinpoint, or asymmetric pupils, slow to react or nonreactive.
• Alteration in breathing pattern
• Deterioration in motor function, abnormal posturing (decerebrate, decorticate, or flaccidity).
• Cushing reflex, which is a late finding characterized by severe hypertension with a widening pulse pressure (systolic – diastolic) and bradycardia.
• Cerebrospinal fluid leakage from the nose and ears (“halo” sign – yellow stain surrounded by blood on a paper towel; fluid tests positive for glucose).
• Seizures

Reference Range

• 10 to 15 mm Hg

Measures to Decrease ICP

• Elevate head at least 30°
• Avoid extreme flexion, extension, or rotation of the head, and maintain the body in a midline neutral position.
• Maintain a patent airway and administer oxygen as indicated to maintain an oxygen saturation level of greater than 92%.
• Hyperventilate clients on mechanical ventilation to keep the PaCO2 between 35 to 38 mm Hg. This reduces cerebral blood flow.
• Provide a calm, restful environment (limit visitors, minimize noise).
• Provide adequate fluids to maintain cerebral perfusion and to minimize cerebral edema.
• When a large amount of IV fluids are prescribed, monitor for excess fluid volume which could increase ICP

​Medications

■ Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema.

Question 82

Head Injuries: Nursing Care & Considerations

Answer 82

■ There is a 1 hr “golden window” for treatment of head injuries. Emergency treatment provided during this time frame decreases the morbidity and mortality rates associated with these conditions, especially for epidural hematomas.

■ Respiratory status is the priority assessment

• The brain is dependent upon oxygen to maintain function and has little reserve available if oxygen is deprived.
• Brain function begins to diminish after 3 min of oxygen deprivation.

■ Even if the level of consciousness is decreased, explain to the client the actions being taken and why.

• Hearing is the last sense affected by a head injury

Medications

■ Phenytoin (Dilantin) is used prophylactically to prevent or treat seizures.

■ Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema.

Question 83

Brain Herniation

Answer 83

◯ A brain herniation is the downward shift of brain tissue due to cerebral edema.

◯ The brain consists of brain matter, cerebrospinal fluid, and intravascular blood. The Monro-Kellie doctrine states that any alteration in the volume of one of these results in a compromise in the other components.

◯ When trauma creates a shift in these components, and the other components are unable to accommodate, the brain shifts from the cranial vault, or herniates – moving downward, through the foramen magnum.

◯ Clinical findings include fixed dilated pupils, deteriorating level of consciousness, Cheyne-Stokes respirations, hemodynamic instability, and abnormal posturing.

Question 84

Hemorrhagic Stroke

Answer 84

Disruption in the cerebral blood flow secondary to a ruptured artery or aneurysm.

• Ischemia
• Increased ICP

If caught early and evacuation of the clot can be done with cessation of the active bleed, the prognosis of a hemorrhagic stroke improves significantly.

Question 85

Thrombotic Stroke

Answer 85

Disruption in the cerebral blood flow secondary to the development of a blood clot on an atherosclerotic plaque in a cerebral artery that gradually shuts off the artery and causes ischemia distal to the occlusion.

• Symptoms of a thrombotic stroke evolve over a period of several hours to days.

Question 86

Embolic Stroke

Answer 86

These occur secondary to an embolus traveling from another part of the body to a cerebral artery.

Blood to the brain distal to the occlusion is immediately shut off causing neurologic deficits or a loss of consciousness to instantly occur.

An embolic stroke may be reversed with a thrombolytic enzyme, such as recombinant tissue plasminogen activator (rtPA [Retavase]), if given within 4.5 hours of the initial symptoms.

Question 87

Stroke: General

Cerebrovascular Accident

Answer 87

Symptoms will vary based on the area of the brain that is deprived of oxygenated blood.

Left-hemispheric stroke
The left cerebral hemisphere is responsible for language, mathematics skills, and analytic thinking.

• Expressive and receptive aphasia (inability to speak and understand language respectively)
• Agnosia (unable to recognize familiar objects)
• Alexia (reading difficulty)
• Agraphia (writing difficulty)
• Right extremity hemiplegia (paralysis) or hemiparesis (weakness)
• Slow, cautious behavior
• Depression, anger, and quick to become frustrated
• Visual changes, such as hemianopsia (loss of visual field in one or both eyes)

Right-hemispheric stroke
The right cerebral hemisphere is responsible for visual and spatial awareness and proprioception.

• Altered perception of deficits (overestimation of abilities)
• One-sided neglect syndrome (ignore left side of the body – cannot see, feel, or move affected side, so client unaware of its existence). Can occur with left-hemispheric strokes, but is more common with right-hemispheric strokes.
• Loss of depth perception
• Poor impulse control and judgment
• Left hemiplegia or hemiparesis
• Visual changes, such as hemianopsia

Question 88

Stroke / CVA: Nursing Care & Considerations

Answer 88

◯ Monitor the client’s vital signs every l to 2 hr. Notify the provider immediately if the client’s blood pressure exceeds a systolic greater than 180 mm Hg or a diastolic greater than 110 mm Hg. This can indicate the client is experiencing an ischemic stroke.

◯ Monitor the client’s temperature. A fever can cause an increase in intracranial pressure.

◯ Provide oxygen therapy to maintain the client’s oxygen saturation level greater than 92%, or if the client’s level of consciousness is decreased.

◯ Place the client on a cardiac monitor to detect arrhythmias.

◯ Conduct a cardiac assessment, and auscultate the client’s apical heart rate to detect murmurs or irregularity.

◯ Monitor for changes in the client’s level of consciousness (increased ICP sign).

◯ Elevate the client’s head of the bed approximately 30° to reduce ICP and to promote venous drainage. Avoid extreme flexion or extension of the neck, and maintain the client’s head in the midline neutral position.

◯ Institute seizure precautions.

◯ Assess swallowing and gag reflexes before feeding

• The client should be taught to flex her neck, tucking the chin down and under, to close the epiglottis during swallowing.

◯ Encourage passive range of motion every 2 hr to the affected extremities and active range of motion every 2 hr to the unaffected extremities

Medications

■ Use of anticoagulants is controversial and not recommended due to the high risk of intracerebral bleeding.

■ Low-dose aspirin is given within 24 to 48 hr following a stroke to prevent further clot formation.

• Other antiplatelets, such as clopidogrel (Plavix), are not recommended.

■ Thrombolytic medications reteplase recombinant (rtPA [Retavase]) - give within 4.5 hours of the initial symptoms.

Question 89

Spinal Cord Injuries: General

Answer 89

Spinal cord injuries (SCIs) involve the loss of motor function, sensory function, reflexes, and control of elimination.

Injuries in the cervical region result in quadriplegia – paralysis/paresis of all four extremities and trunk.

• An injury at C4 or above poses a great risk for impaired spontaneous ventilation because of the involvement of the phrenic nerve.

Injuries below T1 result in paraplegia – paralysis/paresis of the lower extremities.

● Hyperflexion injuries are caused by acceleration injuries that cause sharp forward flexion of the spine (head-on collision, fall, or diving).

● Hyperextension injuries are caused by a backward snap of the spine (rear-end collision or a downward fall onto the chin).

Question 90

Spinal Cord Injuries: Manifestations

Answer 90

■ Inability to feel light touch when touched by a cotton ball, inability to discriminate between sharp and dull when touched with a safety pin or other sharp objects, and an inability to discriminate between hot and cold when touched with containers of hot and cold water.

■ Absent deep tendon reflexes.

■ Flaccidity of muscles.

■ Hypotension that is more severe when the client is in sitting in an upright position.

■ Shallow respirations.

■ Dependent edema.

■ Neurogenic shock, which accompanies spinal trauma, causes a total loss of all reflexive and autonomic function below the level of the injury for a period of several days to weeks.

■ Loss of temperature regulation: hyperthermia or hypothermia.

Question 91

Spinal Cord Injuries: Nursing Care & Considerations

Answer 91

■ Monitoring the client’s respiratory status is the first priority.

• Involuntary respirations can be affected due to a lesion at or above the phrenic nerve or swelling from a lesion immediately below C4.
• Lesions in the cervical or upper thoracic area will also impair voluntary movement of muscles used in respiration (increase in depth or rate).

■ Tissue perfusion – Neurogenic shock occurs after a SCI and can cause total loss of voluntary and autonomic function for several days to weeks.

• Hypotension, dependent edema, and loss of temperature regulation are common symptoms.

■ I/O, neuro status

■ Muscle strength & tone

• Clients who have upper motor neuron injuries (above L1 and L2) will convert to a spastic muscle tone after neurogenic shock.
• Paraplegics who have lower motor neuron injuries (below L1 and L2) will convert to a flaccid type of paralysis.
• Encourage active range-of-motion (ROM) exercises when possible and assist with passive ROM

■ Mobility, Sensation, & Skin Integrity – decreases in mobility and sensation result in increased risk for skin breakdown​

■ GI function – monitor bowel sounds to assess for paralytic ileus

Question 92

Spinal Cord Injuries: Medications

Answer 92

■ Glucocorticoids – methylprednisolone (Solu-Medrol) aid in decreasing edema of the spinal cord, which can cause spinal cord compression and areas of ischemia.

■Vasopressors – norepinephrine and dopamine are given to treat hypotension, particularly during neurogenic shock.

■ Antimuscarinic – atropine sulfate may be used to treat bradycardia.

■ Plasma expanders – dextran, a volume expander, is used to treat hypotension secondary to spinal shock

■ Muscle relaxants – baclofen (Lioresal) and dantrolene sodium (Dantrium) – Given to clients who have severe muscle spasticity.

■ Cholinergics – bethanechol (Urecholine) decreases spasticity of the bladder, allowing for easier bladder training and fewer accidents.

■ Analgesics – opioids, nonopioids, and NSAIDs are given for pain.

• Clients may or may not be able to feel pain from spinal cord injury.
• Clients who do have muscle spasticity may report feeling discomfort from the muscle spasms.

■ Anticoagulants – heparin or enoxaparin are used for deep-vein thrombosis prophylaxis.

■ Stool softeners and bulk-forming laxatives

■ Vasodilators – hydralazine(Apresoline) andnitroglycerin (Nitrostat) used PRN to treat episodes of hypertension during automatic dysreflexia.

Question 93

Neurogenic Shock

Answer 93

◯ Neurogenic shock is a common response of the spinal cord following an injury.

◯ Symptoms (due to the loss of autonomic function)

• bradycardia,
• hypotension,
• flaccid paralysis,
• loss of reflex activity below level of injury, and
• paralytic ileus

​◯ Nursing Actions

• Monitor vital signs for hypotension and bradycardia.
• Treat symptoms with appropriate medications (vasopressors or atropine).

Question 94

Autonomic dysreflexia

Answer 94

◯ Occurs secondary to the stimulation of the sympathetic nervous system and inadequate compensatory response by the parasympathetic nervous system.

◯ Stimulation of the sympathetic nervous system causes:

• extreme hypertension
• sudden severe headache
• pallor below the level of the spinal cord’s lesion dermatome
• blurred vision
• diaphoresis
• restlessness
• nausea
• piloerection (goose bumps).

◯ Stimulation of the parasympathetic nervous system causes bradycardia, flushing above the corresponding dermatome to the spinal cord lesion (flushed face and neck), and nasal stuffiness.

◯ Common causes

• Distended bladder – most common cause (kinked or blocked urinary catheter, urinary retention, or urinary calculi)
• Fecal impaction
• Cold stress or drafts on lower part of the body
• Tight clothing
• Undiagnosed injury or illness (kidney infection or stone, lower extremity fracture)

◯ Sit the client up (to decrease blood pressure secondary to postural hypotension).

◯ Clients who have lesions below T6 do not experience dysreflexia because the parasympathetic nervous system is able to neutralize the sympathetic response.

Question 95

Arterial Blood Gas

ABGs

Answer 95

◯ An ABG sample reports the status of oxygenation and acid-base balance of the blood.

◯ ABGs can be obtained by an arterial puncture or through an arterial line.

• Immediately after an arterial puncture, hold direct pressure over the site for at least 5 min.
• Pressure must be maintained for at least 20 min if the client is receiving anticoagulant therapy.

Components

■ pH: 7.35-7.45; the amount of free hydrogen ions in the arterial blood (H+)

■ PaO₂: 80-100mmHg; the partial pressure of oxygen.

■ PaCO₂: 35-45mmHg; the partial pressure of carbon dioxide.

■ HCO₃: 21-28mEq/L; the concentration of bicarbonate in arterial blood.

■ SaO₂: 95-100%; percentage of oxygen bound to Hgb as compared with the total amount that can be possibly carried.

Question 96

Hematoma

Answer 96

■ A hematoma occurs when blood accumulates under the skin.

• Observe the client for changes in temperature, swelling, color, loss of pulse, or pain.
• Notify the provider immediately if symptoms persist.
• Apply pressure to the hematoma site.

Question 97

Arterial Air (Gas) Embolism

Answer 97

■ Air enters the arterial system during catheter insertion; may directly stop blood flow to an area fed by the artery

• Place the client on his left side in the Trendelenburg position.
• Monitor the client for a sudden onset of shortness of breath, decrease in SaO2 levels, chest pain, anxiety, and air hunger.
• Notify the provider immediately if symptoms occur, administer oxygen therapy, and obtain ABGs.
• Continue to assess the client’s respiratory status for any deterioration.

■ Venous air embolism are less critical because the lungs can usually diffuse the gas bubble (unless the gas bubble is large enough to block flow in the heart to the lungs)

Question 98

Pleural Effusion & Thoracentesis

Answer 98

■ Large amounts of fluid in the pleural space (effusion) compress lung tissue and can cause pain, SOB, cough, and other symptoms of pleural pressure.

■ Assessment of the effusion area may reveal decreased breath sounds, dull percussion sounds, and decreased chest wall expansion; pain may occur due to inflammatory process.

■ Thoracentesis is the surgical perforation of the chest wall and pleural space with a large-bore needle for the purpose of

• Obtaining specimens for diagnostic evaluation
• Instilling medication into the pleural space
• Removing fluid (effusion) or air from the pleural space for therapeutic relief of pleural pressure

■ The amount of fluid removed is limited to 1 L at a time to prevent cardiovascular collapse

■ Position the client sitting upright with his arms and shoulders raised and supported on pillows and/or on an overbed table and with his feet and legs well-supported.

Question 99

Pneumothorax

Answer 99

■ Pneumothorax is a collapsed lung.

■ Monitor the client for:

• diminished breath sounds
• deviated trachea
• pain on the affected side that worsens upon exhalation,
• affected side does not move in and out upon inhalation and exhalation
• increased heart rate
• rapid shallow respirations
• “nagging” cough
• feeling of air hunger

Question 100

Chest Tubes

Answer 100

● Chest tubes are inserted into the pleural space to:

• drain fluid, blood, or air;
• reestablish a negative pressure;
• facilitate lung expansion; and
• restore normal intrapleural pressure

● A disposable three-chamber drainage system is most often used.

• First chamber: drainage collection
• Second chamber: water seal
• Third chamber: suction control

● Water seal allows air to exit from the pleural space on exhalation and stops air from entering with inhalation.

• Chamber must be kept upright and below the chest tube insertion site at all times.
• Monitor the water level due to the possibility of evaporation – add fluid as needed to maintain the 2 cm water seal level.

● The height of the sterile fluid in the suction control chamber determines the amount of suction – a suction pressure of -20 cm H₂O is common.

• Application of suction results in continuous bubbling in the suction chamber.
• Monitor the fluid level and add fluid as needed to maintain the prescribed level of suctioning.

● Tidaling (movement of the fluid level with respiration) is expected in the water seal chamber

• Cessation of tidaling in the water seal chamber signals lung reexpansion or an obstruction within the system.

● Document the amount and color of drainage hourly for the first 24 hr and then at least every 8 hr.

• Mark the date, hour, and drainage level on the container at the end of each shift.
• Report excessive drainage (greater than 70 mL/hr) or drainage that is cloudy or red

● Monitor for expected findings:

• Tidaling in the water seal chamber
• Continuous bubbling only in the suction chamber.
  
  • Continuous bubbling in the water seal chamber indicates an air leak

● Do not strip or milk tubing

● If the chest tube drainage system is compromised, immerse the end of the tube in sterile water to restore the water seal.

● If a chest tube is accidentally removed, an occlusive dressing taped on only three sides should be immediately placed over the insertion site. This allows air to escape and reduces risk for development of a tension pneumothorax.

Question 101

Nasal Cannula

Answer 101

■ Low-flow administration of oxygen

■ FiO2 – 24% to 44% at flow rates of 1 to 6 L/min

• Provide humidification for flow rates of 4 L/min and above

■ Advantages

• Safe, easy to apply, comfortable, and well tolerated.
• The client is able to eat, talk, and ambulate.

■ Disadvantages

• The FiO2 varies with the flow rate and the client’s rate and depth of breathing.
• Extended use can lead to skin breakdown and drying of the mucous membranes.
• Tubing is easily dislodged.

■ FiO2 = fraction of inspired air; atmospheric air is 20.9% oxygen (FiO2 .21); oxygen-enriched air has a higher FiO2, up to 1.00, which means 100% oxygen

Question 102

Simple face mask

Answer 102

■ Low-flow administration of oxygen; covers the client’s nose and mouth

■ FiO2 – 40% to 60% at flow rates of 5 to 6 L/min (the min flow rate is 5 L/min to ensure flushing of CO2 from the mask).

■ Advantages

• A face mask is easy to apply and may be more comfortable than a nasal cannula.

■ Disadvantages

• Flow rates of 5 L/min or lower can result in rebreathing of CO2.
• Device is poorly tolerated by clients who have anxiety or claustrophobia.
• Eating, drinking, and talking are impaired.

■ FiO2 = fraction of inspired air; atmospheric air is 20.9% oxygen (FiO2 .21); oxygen-enriched air has a higher FiO2, up to 1.00, which means 100% oxygen

Question 103

Partial Rebreather Mask

Answer 103

■ Low-flow administration of oxygen; covers the client’s nose and mouth

■ FiO2 – 60% to 75% at flow rates of 6 to 11 L/min

■ Advantages

• The mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to one third of exhaled air together with room air.

■ Disadvantages

• Complete deflation of the reservoir bag during inspiration causes CO2 buildup.
• The FiO2 varies with the client’s breathing pattern.
• Mask is poorly tolerated by clients who have anxiety or claustrophobia.
• Eating, drinking, and talking are impaired.

■ Keep the reservoir bag from deflating by adjusting the oxygen flow rate to keep it inflated.

■ FiO₂ = fraction of inspired air; atmospheric air is 20.9% oxygen (FiO₂ .21); oxygen-enriched air has a higher FiO₂, up to 1.00, which means 100% oxygen

Question 104

Nonrebreather Mask

Answer 104

■ Low-flow administration of oxygen; covers the client’s nose and mouth

■ FiO₂ – 80% to 95% at flow rates of 10 to 15 L/min to keep the reservoir bag two-thirds full during inspiration and expiration.

■ Advantages

• Delivers the highest O₂ concentration possible (except for intubation).
• A one-way valve situated between the mask and reservoir allows the client to inhale maximum O₂ from the reservoir bag. The two exhalation ports have flaps covering them that prevent room air from entering the mask.

■ Disadvantages

• The valve and flap on the mask must be intact and functional during each breath.
• Poorly tolerated by clients who have anxiety or claustrophobia.
• Eating, drinking, and talking are impaired.

■ Perform hourly assessments of the valve and flap.

■ FiO2 = fraction of inspired air; atmospheric air is 20.9% oxygen (FiO2 .21); oxygen-enriched air has a higher FiO2, up to 1.00, which means 100% oxygen

Question 105

Venturi Mask

Answer 105

■ High-flow oxygen delivery system delivers precise amounts of oxygen when properly fitted.

■ FiO2 – 24% to 55% at flow rates of 2 to 10 L/min via different sizes of adaptors

• FiO2 = fraction of inspired air
• Atmospheric air is 20.9% oxygen (FiO2 .21)
• Oxygen-enriched air has a higher FiO2, up to 1.00, which means 100% oxygen

■ Advantages

• Delivers the most precise oxygen concentration.
• Humidification is not required.
• Best suited for clients who have chronic lung disease.

■ Disadvantages

• Expensive.

■ Nursing Actions

• Assess frequently to ensure an accurate flow rate.
• Make sure the tubing is free of kinks

Question 106

Aerosol Mask, Face Tent, and Tracheostomy Collar

Answer 106

■ High-flow oxygen delivery system delivers precise amounts of oxygen when properly fitted.

■ FiO₂ – 24% to 100% at flow rates of at least 10 L/min (provide high humidification with oxygen delivery)

• FiO₂ = fraction of inspired air
• Atmospheric air is 20.9% oxygen (FiO₂ .21)
• Oxygen-enriched air has a higher FiO₂, up to 1.00, which means 100% oxygen

■ Advantages

• Good for clients who do not tolerate masks well.
• Useful for clients who have facial trauma, burns, and/or thick secretions.

■ Disadvantages

• High humidification requires frequent monitoring.

■ Nursing Actions

• Empty condensation from the tubing often.
• Ensure that there is adequate water in the humidification canister.
• Ensure that the aerosol mist leaves from the vents during inspiration and expiration.
• Make sure the tubing does not pull on the tracheostomy.

Question 107

Hypoxia & Hypoxemia

Answer 107

■ Hypoxia refers to a state of inadequate oxygen supply

■ Hypoxemia is an inadequate level of oxygen in the blood.

Early Signs

• Tachypnea
• Tachycardia
• Restlessness
• Pale skin and mucous membranes
• Elevated blood pressure
• Symptoms of respiratory distress (use ofaccessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds)

Late Signs

• Confusion and stupor
• Cyanotic skin and mucous membranes
• Bradypnea
• Bradycardia
• Hypotension
• Cardiac dysrhythmias

■ Place the client in semi-Fowler’s or Fowler’s position to facilitate breathing and promote chest expansion

■ Provide oxygen therapy at the lowest flow that will correct hypoxemia.

Question 108

Hypercarbia

Answer 108

Elevated levels of CO₂

S/S: restlessness, hypertension, and headache

Question 109

Oxygen Toxicity

Answer 109

■ Oxygen toxicity can result from

• High concentrations of oxygen (typically above 50%)
• Long durations of oxygen therapy (typically more than 24 to 48 hr)
• The client’s degree of lung disease.

■ S/S:

• include a nonproductive cough
• substernal pain
• nasal stuffiness
• nausea, vomiting
• fatigue, headache
• sore throat
• hypoventilation

■ Nursing Actions

• Use the lowest level of oxygen necessary to maintain an adequate SaO2.
• Monitor the ABGs, and notify the provider if SaO2 levels are outside of the expected reference range.
• Use an oxygen mask with continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or positive end expiratory pressure (PEEP) as prescribed while the client is on a mechanical ventilator to help decrease the amount of needed oxygen.

Question 110

Oxygen-induced hypoventilation

Answer 110

■ Clients who have COPD rely on low levels of arterial oxygen as their primary drive for breathing.

■ Providing supplemental oxygen at high levels can decrease or eliminate their respiratory drive.

■ Nursing Actions

• Monitor the client’s respiratory rate and pattern, level of consciousness, and SaO2.
• Provide oxygen therapy at the lowest flow that corrects hypoxemia.
• If the client tolerates it, use a Venturi mask to deliver precise oxygen levels.
• Notify the provider of impending respiratory depression, such as a decreased respiratory rate and a decreased level of consciousness.

Question 111

Mechanical Ventilation

Answer 111

■ Provides breathing support delivering warm (body temp 37°C), 100% humidified oxygen at FiO₂ levels between 21% to 100%.

■ Positive-pressure ventilators deliver air to the lungs under pressure throughout inspiration and/or expiration to keep the alveoli open during inspiration and to prevent alveolar collapse during expiration.

■ The benefits include the following:

• Forced/enhanced lung expansion
• Improved gas exchange (oxygenation)
• Decreased work of breathing

■ Mechanical ventilators can be cycled based on pressure, volume, time, and/or flow.

■ Ventilator alarms:

• Volume (low pressure) alarms indicate a low exhaled volume due to a disconnection, cuff leak, and/or tube displacement.
• Pressure (high pressure) alarms indicate excess secretions, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, and/or pneumothorax.
• Apnea alarms indicate that the ventilator does not detect spontaneous respiration in a preset time period.

Question 112

Endotracheal Tube

Answer 112

☐ A tube is inserted through the client’s nose or mouth into the trachea allowing for emergency airway management of the client.

☐ The cuff on the tracheal end of an ET tube is inflated to ensure proper placement and the formation of a seal between the cuff and the tracheal wall.

• The seal ensures that an adequate amount of tidal volume is delivered
• Maintain the cuff pressure below 20 mmHg to reduce the risk of tracheal necrosis.
• Assess the cuff pressure at least every 8 hr.
  
  • Assess for an air leak around the cuff (client speaking, air hissing, or decreasing SaO2).
  • Inadequate cuff pressure can result in inadequate oxygenation and/or accidental extubation.

Question 113

Mechanical Ventilation: Medications

Answer 113

■ Analgesics – morphine and fentanyl (Sublimaze)

■ Sedatives – propofol (Diprivan), diazepam (Valium), lorazepam (Ativan), midazolam (Versed), and haloperidol (Haldol)

• Clients receiving mechanical ventilation may require sedation or paralytic agents to prevent competition between extrinsic and intrinsic breathing and the resulting effects of hyperventilation.

■ Neuromuscular blocking agents – pancuronium bromide (Pavulon), atracurium (Tracrium), and vecuronium (Norcuron)

• Neuromuscular blocking agents paralyze muscles, but do not sedate or relieve pain.
• The use of a sedative or analgesic agent in conjunction with a neuromuscular blocking agent is typically prescribed by the provider.

■ Ulcer-preventing agents – famotidine (Pepcid) or lansoprazole (Prevacid)

■ Antibiotics for established infections

Question 114

Mechanical Ventilation: Weaning Intolerance

Answer 114

■ Respiratory rate >30/min or <8/min

■ Blood pressure or heart rate changes more than 20% of baseline

■ SaO2 less than 90%

■ Dysrhythmias, elevated ST segment

■ Significant decrease in tidal volume

■ Labored respirations, increased use of accessory muscles, and diaphoresis

■ Restlessness, anxiety, and decreased level of consciousness

Question 115

Acute Respiratory Disorders

Answer 115

● Acute respiratory disorders include

• Rhinitis
• Sinusitis
• Influenza
• Pneumonia

● A nursing priority for clients who have acute respiratory disorders is to maintain a patent airway to promote oxygenation.

Question 116

Pneumonia

Answer 116

● Pneumonia is an inflammatory process in the lungs that produces excess fluid.

• It is triggered by infectious organisms or by the aspiration of an irritant, such as fluid or a foreign object.
• The inflammatory process in the lung parenchyma results in edema and exudate that fills the alveoli.

● Pneumonia can be a primary disease or a complication of another disease or condition.

● Community-acquired pneumonia (CAP) is the most common type and often occurs as a complication of influenza.

● Health care-associated pneumonia (HAP) has a higher mortality rate and is more likely to be resistant to antibiotics.

• Immobility is a contributing factor in the development of pneumonia.

Question 117

Rhinitis

Answer 117

● Rhinitis is an inflammation of the nasal and sinus mucosa that can be caused by infection (viral or bacterial) or allergens.

● The presence of an allergen causes histamine release and other mediators from WBCs in the nasal mucosa. The mediators bind to blood vessel receptors causing capillary leakage, which leads to local edema and swelling.

● The common cold (coryza) is caused by viruses spread from person to person in droplets from sneezing and coughing, or by direct contact.

Question 118

Sinusitis

Answer 118

● Sinusitis is an inflammation of the mucous membranes of one or more of the sinuses, usually themaxillary or frontal sinus. Swelling of the mucosa can block the drainage of secretions, which may cause a sinus infection.

● Sinusitis often occurs after rhinitis and may be associated with a deviated nasal septum, nasal polyps, inhaled air pollutants or cocaine, facial trauma, dental infections, or loss of immune function.

● The infection is commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, diplococcus and bacteroides.

● Meningitis and encephalitis can occur if pathogens enter the bloodstream from the sinus cavity.

Question 119

Influenza

Answer 119

● Seasonal influenza or “flu” occurs as an epidemic, usually in the fall and winter months.

● Adults are contagious from 24 hr before manifestations develop and up to 5 days after they begin.

• Airborne precautions!!

● Pandemic influenza refers to a viral infection among animals or birds that has mutated and is becoming highly infectious to humans. The resulting viral infection has the potential to spread globally, such as H1N1 (“swine flu”) and H5N1 (“avian flu”).

Influenza vaccines

■ Trivalent vaccines are prepared yearly depending upon the suspected strain of influenza expected to appear. They include an IM injection of Fluvirin or Fluzone and a live attenuated influenza vaccine (LAIV) by intranasal spray (FluMist).

■ Vaccination is encouraged for everyone over 6 months of age.

• Clients who have a history of pneumonia, chronic medical conditions, and those over age 65, pregnant women, and health care providers are at higher risk and require vaccination.

■ A chest x-ray will show consolidation (solidification, density) of lung tissue.

Question 120

COPD: General

Answer 120

♦ Encompasses two diseases: emphysema and chronicbronchitis.

• Most clients who have emphysema also have chronic bronchitis.

♦ COPD is irreversible.

♦ Emphysema is characterized by the loss of lung elasticity and hyperinflation of lung tissue.

• Emphysema causes destruction of the alveoli, leading to a decreased surface area for gas exchange, carbon dioxide retention, and respiratory acidosis.

♦ Chronic bronchitis is an inflammation of the bronchi and bronchioles due to chronic exposure to irritants.

Question 122

COPD: S/S

Answer 122

■ Dyspnea upon exertion

■ Productive cough that is most severe upon rising in the morning

■ Hypoxemia

■ Crackles and wheezes

■ Rapid and shallow respirations w/ use of accessory muscles

■ Barrel chest or increased chest diameter (with emphysema)

■ Hyperresonance on percussion due to “trapped air” (with emphysema)

■ Thin extremities and enlarged neck muscles

■ Dependent edema secondary to right-sided heart failure

■ Clubbing of fingers and toes

■ Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)

■ Decreased oxygen saturation levels (expected reference range is 95% to 100%)

■ An increased hematocrit level due to low oxygenation levels.

■ Hypoxemia (PaO2 less than 80 mm Hg)

■ Hypercarbia (PaCO2 greater than 45 mm Hg)

■ Respiratory acidosis w/ metabolic alkalosis compensation

■ X-ray shows hyperinflation of alveoli and flattened diaphragm in the late stages of emphysema.

Question 123

COPD: Nursing Care & Considerations

Answer 123

■ Promote adequate nutrition – increased work of breathing increases caloric demands

■ Encourage diaphragmatic (abdominal) breathing OR pursed lip breathing (in through nose, out through pursed-lipped mouth, do not puff cheeks)

■ Incentive spirometry

■ Remember: in COPD, low arterial levels of oxygen serve as the primary drive for breathing – use the lowest amount of O2 possible (no more than 4L/min)

■ Encourage exercise conditioning (ex: 20min walk 2-3x/wk)

■ Encourage the client to drink 2 to 3 L/day to liquify mucus

Question 124

COPD: Medications

Answer 124

Bronchodilators (inhalers)

■ Short-acting beta2 agonists, such as albuterol (Proventil, Ventolin) provide rapid relief.

■ Anticholinergic medications such as ipratropium (Atrovent), block the parasympathetic nervous system - long-acting to prevent bronchospasms.

■ Methylxanthines, such as theophylline (Theo-24), relax smooth muscles of the bronchi - require close monitoring of serum levels and should only be used when other methods are ineffective

Anti-Inflammatories

■ Corticosteroids, such as fluticasone (Flovent) and prednisone (Deltasone)

■ Leukotriene antagonists, such as montelukast (Singulair)

Mucolytic Agents

■ These agents help thin secretions making it easier for the client to expel.

■ Nebulizer treatments – acetylcysteine (Mucomyst), or dornase alfa (Pulmozyme).

■ Oral agent – guaifenesin (Mucinex, Robitussin).

Question 125

Tuberculosis: General

Answer 125

● Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis.

● Airborne precations - N-95mask

● Only a small percentage of people infected with TB actually develop an active form of the infection – the TB bacillus may lie dormant for many years before producing the disease.

• Can become active as the individual becomes older or immunocompromised.
• Individuals who have latent TB may have a positive Mantoux test and may receive treatment to prevent development of an active form of the disease.

● The risk of transmission decreases after 2 to 3 weeks of antituberculin therapy.

● A client will have a positive intradermal TB test within 2 to 10 weeks of exposure to the infection.

● TB diagnosis should be considered for any client who has the following S/S:

• has a persistent cough lasting longer than 3 weeks,
• chest pain, weakness,
• weight loss, anorexia,
• hemoptysis, dyspnea,
• fever, night sweats, or chills.

„● Possible complication – Pericarditis

• Dyspnea, swollen neck veins, pleuritic pain, and hypotension due to an accumulation of fluid in the pericardial sac that inhibits the heart’s ability to pump effectively

Question 126

Tuberculosis: Medications: General

Answer 126

♦ Combination therapy of up to four medications at a time is recommended due to the development of resistant strains

• Medication noncompliance is a significant contributing factor in the development of resistant strains of TB.

♦ The current four-medication regimen includes:

• isoniazid (Nydrazid)
• rifampin (Rifadin)
• pyrazinamide
• ethambutol hydrochloride (Myambutol)

Question 127

Tuberculosis: Medications: Isoniazid

Answer 127

Isoniazid (Nydrazid)

■ Commonly referred to as INH

■ Bactericidal and inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall.

■ This medication should be taken on an empty stomach.

■ Monitor for hepatotoxicity and neurotoxicity, such as tingling of the hands and feet.

• Vitamin B6 (pyridoxine) is used to prevent neurotoxicity

■ Avoid alcohol due to increased risk of hepatotoxicity.

Question 128

Tuberculosis: Medications: Rifampin

Answer 128

Rifampin (Rifadin)

■ Commonly referred to as RIF

■ Bacteriostatic and bactericidal antibiotic that inhibits DNA-dependent RNA polymerase activity in susceptible cells.

■ Monitor for hepatotoxicity.

■ Urine and other secretions may appear orange.

■ Advise the client to report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise immediately.

■ May interfere with the efficacy of oral contraceptives.

Question 129

Tuberculosis: Medications: Pyrazinamide

Answer 129

Pyrazinamide

■ Commonly referred to as PZA

■ Bacteriostatic and bactericidal – exact mechanism of action is unknown.

■ Observe for hepatotoxicity.

■ Drink a glass of water with each dose and increase fluids during the day.

■ Report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise immediately.

■ Avoid drinking alcohol

Question 130

Tuberculosis: Medications: Ethambutol

Answer 130

Ethambutol (Myambutol)

■ Commonly referred to as EMB

■ Bacteriostatic and works by suppressing RNA synthesis, subsequently inhibiting protein synthesis.

■ Obtain baseline visual acuity tests and determine color discrimination ability.

• Instruct the client to report changes in vision immediately.

■ This medication should not be given to children younger than 13 years of age.

Question 131

Tuberculosis: Client Education

Answer 131

■ Exposed family members should be tested for TB.

■ Continue medication therapy for its full duration of 6 to 12 months.

• Emphasize that failure to take the medications may lead to a resistant strain of TB.
• Instruct the client to continue with follow-up care for 1 full year.

■ Inform the client that sputum samples are needed every 2 to 4 weeks to monitor therapy effectiveness.

• Clients are no longer considered infectious after 3 negative sputum cultures.

■ Encourage proper hand hygiene.

■ Instruct the client to cover mouth and nose when coughing or sneezing.

• Inform the client that contaminated tissues should be disposed of in plastic bags.

■ Advise clients who have active TB to wear an N95 or HEPA respirator when in public places.

Question 132

Pulmonary Embolism

Answer 132

● A pulmonary embolism (PE) occurs when a substance (solid, gaseous, or liquid) enters venous circulation and forms a blockage in the pulmonary vasculature.

● Emboli originating from deep-vein thrombosis (DVT) are the most common cause.

● A PE is a medical emergency.

• Prevention, rapid recognition, and treatment of a PE are essential for a positive outcome.

Question 133

Pulmonary Embolism: Assessment Findings

Answer 133

Subjective Data

■ Anxiety, Feelings of impending doom, Pressure in chest, Pain upon inspiration and chest wall tenderness, Dyspnea and air hunger

Objective Data

■ Pleurisy and pleural friction rub

• Pleurisy is inflammation of the lining of the lungs and chest (the pleura) that leads to chest pain (usually sharp) when you take a breath or cough

■ Tachycardia, tachypnea

■ Hypotension

■ Adventitious breath sounds (crackles) and cough

■ Heart murmur in S3 and S4

■ Diaphoresis

■ Low-grade fever

■ Decreased oxygen saturation levels, cyanosis

■ Petechiae over chest and axillae

■ Pleural effusion (fluid in the lungs)

Laboratory Tests

■ Early – respiratory alkalosis (low PaCO2) due to initial hyperventilation

■ Late – respiratory acidosis due to hypoxemia

■ D-dimer – Elevated above expected reference range in response to clot formation and release of fibrin degradation products (the expected reference range is 0.43 to 2.33 mcg/mL).

Question 134

Pulmonary Embolism: Medications

Answer 134

Anticoagulants

■ Enoxaparin (Lovenox), heparin, warfarin (Coumadin)

• Used to prevent clots from getting larger or additional clots from forming.
• Assess for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma).
• Monitor bleeding times – (PT, INR, aPTT)
• Monitor for side effects of anticoagulants (e.g., thrombocytopenia, anemia, hemorrhage).

Thrombolytic therapy

■ Alteplase (Activase) and streptokinase (Streptase)

• Used to dissolve blood clots and restore pulmonary blood flow.
• Administer slowly to prevent hypotension
• Monitor blood pressure, heart rate, respirations, and oxygen saturation per facility protocol before, during, and after administration.

Question 135

Pneumothorax & Hemothorax

Answer 135

● A pneumothorax is the presence of air or gas in the pleural space that causes lung collapse.

• Hyperresonance on percussion due to trapped air
• Subcutaneous emphysema (air accumulating in subcutaneous tissue)
• Respiratory failure due to inadequate gas exchange
• Large-bore needle may be used for decompression
• Recovery may be lengthy; report the following:

upper respiratory infection, fever, cough, difficulty breathing, sharp chest pain

● A tension pneumothorax occurs when air enters the pleural space during inspiration through a one‑way valve and is not able to exit upon expiration.

• Trapped air causes pressure on the heart and the lung.
• Air and pressure continue to rise in the pleural cavity, which causes a mediastinal shift
  
  • Tracheal deviation to the unaffected side
• The pressure compresses blood vessels and limits venous return, leading to a decrease in cardiac output (hypotension develops)
• Distended neck veins (an indication the condition is worsening) are due to impaired gas exchange, which compresses the blood vessels and limits blood return
• Death can result if not treated immediately.

● A spontaneous pneumothorax can occur when there has been no trauma – A small bleb on the lung ruptures and air enters the pleural space.

● A hemothorax is an accumulation of blood in the pleural space.

• Dull percussion
• Chest tube

● A flail chest occurs when several ribs, usually on one side of the chest, sustain multiple fractures.

• Ribs and the fractured segments have minimal attachments, and there is instability of the chest wall.
• ​This results in significant limitation in chest wall expansion.

Question 136

Acute Respiratory Failure (ARF): General

Answer 136

♦ Failure to adequately ventilate and/or oxygenate.

• Ventilatory failure is due to a mechanical abnormality of the lungs or chest wall, impaired muscle function (the diaphragm), or a malfunction in the respiratory control center of the brain.
• Oxygenation failure can result from a lack of perfusion to the pulmonary capillary bed (pulmonary embolism) or a condition that alters the gas exchange medium (pulmonary edema, pneumonia).

♦ Diseased lungs (e.g. asthma, emphysema) can cause oxygenation failure and increased work of breathing, eventually resulting in respiratory muscle fatigue and ventilatory failure.

♦ Criteria for acute respiratory failure are based on ABG values.

• Room air, PaO2 <60 mmHg, and SaO2 <90
• PaCO2 >50 mmHg in conjunction with a pH <7.30

Question 137

Acute Respiratory Distress Syndrome (ARDS)

Answer 137

■ A state of acute respiratory failure with a mortality rate of 25% to 40%.

• May result from localized lung damage or from the effects of other systemic problems

■ A systemic inflammatory response injures the alveolar-capillary membrane, which permeable to large molecules, and the lung space is filled with fluid.

■ A reduction in surfactant weakens the alveoli, which causes collapse or filling of fluid, leading to worsening edema.

■ S/S

• Dyspnea
• Bilateral noncardiogenic pulmonary edema
• Reduced lung compliance
• Diffuse patchy bilateral pulmonary infiltrates
• Severe hypoxemia despite administration of 100% oxygen

■ Pulmonary capillary wedge pressure is usually low or within the expected reference range (4 to 12 mm Hg).

• Continuous hemodynamic monitoring is important for fluid management.

■ Positive-end expiratory pressure (PEEP) often is used to prevent alveolar collapse during expiration BUT a high PEEP can cause a pneumothorax

Question 138

Severe Acute Respiratory Syndrome (SARS)

Answer 138

♦ SARS is the result of a viral infection from a mutated strain of the coronaviruses (a group of viruses that also cause the common cold)

♦ The virus invades the lungs, which leads to an inflammatory response of the pulmonary tissue

♦ The virus is spread easily through airborne droplets from sneezing, coughing, or talking.

Question 139

Acute Respiratory Failure: Medications

Answer 139

Benzodiazepines: Lorazepam (Ativan), Midazolam

• Reduces anxiety and resistance to ventilation and decreases oxygen consumption
• Monitor respirations on clients who are not ventilated.
• Monitor blood pressure and SaO2.
• Use cautiously in conjunction with opioid narcotics.

General Anesthesia: Propofol (Diprivan)

• Sedates clients who are to be placed on mechanical ventilation
• Contraindicated for clients with hyperlipidemia and egg allergies.
• Administer only to clients who are intubated and ventilated.
• Monitor ECG, blood pressure, and sedation levels.
• Monitor for hypotension.

Corticosteroids: Methylprednisolone (Solu-Medrol), Dexamethasone

• Reduces WBC migration, decreases inflammation, and helps stabilize the alveolar‑capillary membrane during ARDS
• Administer with an antiulcer medication to prevent peptic ulcer formation.
• Monitor weight, blood pressure, glucose, electrolytes

Neuromuscular-Blocking Agents: Vecuronium

• Adjunct to general anesthesia-induce muscle relaxation for endotracheal intubation, mechanical ventilation
  
  • Facilitates ventilation and decreases oxygen consumption
  • They do not sedate or relieve pain. (Clients may be awake and frightened.)
  • Give pain medication and sedatives with neuromuscular blocking agents.
• Often used with painful ventilatory modes (inverse ratio ventilation and PEEP)
• Monitor ECG, blood pressure, and muscle strength.
• Antidote: neostigmine methylsulfate and atropine sulfate reverse the effects

Opioid Analgesics: Morphine, Fentanyl (Sublimaze)

Antibiotics: Vancomycin

Question 140

Cardiac Enzymes: Creatine kinase MB (CK-MB)

Answer 140

CK level that is more sensitive to myocardium

Reference Range
0% of total CK (30 to 170 units/L)

Detectable after injury
4 to 6 hr

Duration of elevated level
3 days

Question 141

Cardiac Enzymes: Troponin T

Answer 141

Reference Range
< 0.2 ng/L

Detectable after injury
3 to 5 hr

Duration of elevated level
14 to 21 days

Question 142

Cardiac Enzymes: Troponin I

Answer 142

Reference Range
<0.03 ng/L

Detectable after injury
3 hr

Duration of elevated level
7 to 10 days

Question 143

Cardiac Enzymes: Myoglobin

Answer 143

Reference Range
Less than 90 mcg/L

Detectable after injury
2 hr

Duration of elevated level
24 hr

Question 144

Lipid Panel

Answer 144

Cholesterol (total)
Less than 200 mg/dL

HDL
Females – 35 to 80 mg/dL
Males – 35 to 65 mg/dL

LDL ›› Less than 130 mg/dL ›› “Bad” cholesterol can be up

to 70% of total cholesterol

Triglycerides ››Males – 40 to 160 mg/dL

›› Females – 35 to 135 mg/dL

›› Older adults (over age 65) – 55 to 220 mg/dL

›› Evaluating for atherosclerosis

Question 145

Cardiac Stress Test

Answer 145

♦ The cardiac muscle is exercised by the client walking on a treadmill.

• This provides information regarding the workload of the heart.
• Once the client’s heart rate reaches a certain rate, the test is discontinued.

♦ Instruct the client to fast 2 to 4 hr before the procedure and to avoid tobacco, alcohol, and caffeine before the test.

♦ If a pharmacological stress test is prescribed, a medication such as adenosine (Adenocard) or dobutamine (Dobutrex) is given to stress the heart instead of walking on the treadmill.

Question 146

Hemodynamic Testing: Nursing Considerations

Answer 146

♦ Place the client in supine position prior to recording hemodynamic values. HOB can be elevated 15° to 30°.

♦ Level the transducer at the phlebostatic axis before readings and with all position changes.

♦ Zero system to atmospheric pressure.

♦ Compare hemodynamic findings to physical assessment.

♦ Monitor trends in values obtained over time.

Question 147

Coronary Angiogram
Cardiac Catheterization

Answer 147

► An invasive diagnostic procedure used to evaluate the presence and degree of coronary artery blockage.

► Involves the insertion of a catheter into a femoral (sometimes a brachial) vessel and threading it into the right or left side of the heart.

► Coronary artery narrowings and/or occlusions are identified by the injection of contrast media under fluoroscopy.

► Indications include unstable angina and ECG changes (T wave inversion, ST segment elevation, depression)

Question 148

Cardiac Catheterization:
Nursing Care & Considerations

Answer 148

■ Maintain the client on NPO status for at least 8 hr (due to the risk for aspiration when lying flat for the procedure).

■ Ensure that the consent form is signed.

■ Assess for iodine/shellfish allergy (contrast media) and renal function prior to introduction of contrast dye.

■ Administer premedications as prescribed (methylprednisone [Solu-Medrol], diphenhydramine [Benadryl]).

Question 149

Cardiac Tamponade

Answer 149

■ Results from fluid accumulation in the pericardial sac.

​■ Manifestations include

• hypotension,
• jugular venous distention,
• muffled heart sounds, and
• paradoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration).

​■ Hemodynamic monitoring reveals intracardiac and pulmonary artery pressures are similar and elevated (plateau pressures).

■ Notify the provider immediately.

​■ Administer IV fluids to combat hypotension as prescribed.

​■ Obtain a chest x-ray or echocardiogram to confirm diagnosis.

​■ Prepare the client for pericardiocentesis (informed consent, gather materials, administer medications as appropriate).

• Monitor hemodynamic pressures as they normalize.
• Monitor heart rhythm; changes indicate improper positioning of the needle.
• Monitor for reoccurrence of signs after the procedure.

Question 150

Pituitary Gland

Answer 150

Master gland; located at base of hypothalamus

Directly affects the function of the other endocrine glands

Promotes growth of bo