Case Study

Question 1

WT is an18-year-old male who is brought into the urgent care center complaining of respiratory distress
He states he was playing soccer when he developed shortness of breath and frequent nonproductive cough
Assessment:
RR 42; HR 110; T 98.8; SpO2 95% on room air
Alert and oriented, but also very anxious
Using accessory muscles to breathe and you note retractions at his sternal notch (between clavicles and is sucking in); also can suck at in intercostal spaces (between ribs) - classic asthma things if in resp distress - in severe distress and see retractions
Lung sounds: bilateral expiratory wheezes
Which of the following is the most likely diagnosis at this time?
a.Asthma
b.Pneumonia
c.Foreign body aspiration
d.Pleural effusion

Answer 1

Answer: A
What assessments give you cues?
RR 42 - very elevated; HR 110 - elevated and goes with resp distress
History and was just doing some exertion; a lot pats with asthma have certain triggers; hopefully with asthma if treated appropriately know triggers but varies pat to pat
Anxiety - anyone SOB
Using accessory muscles to breathe - diaphragm and intercostal muscles not enough to inhale and exhale and using extra muscles
Retractions at his sternal notch
Bilateral expiratory wheezes
Respiratory distress

Question 2

Dyspnea - SOB
Chest tightness - classic sign and feel this
Coughing - can be productive and nonproductive - not infectious but obstruction: airways clamping down; patho: bronchiole muscles constricting and inflammation within airway - why have wheezing - air past really narrow airway and have wheezing sound
Hypoxemia/Cyanosis - can become hypoxic and if are this or hypoxemia give O2
Tachypnea
Use of accessory muscles
Retractions (suprasternal notch and intercostal spaces)
Lungs wheezing throughout
Long breathing cycle (prolonged exhalation)
Barrel chest (with long standing, severe asthma) - not seen unless poorly controlled asthma - in frequently and bad exacerbations; seen more in COPD: emphysema pats

Answer 2

Asthma Assessment/symp

Question 3

Which of the following would be the best treatment at this time?
a. Oxygen 2 Liters per nasal cannula
b. Oxygen 5 liters per face mask
c. Oral antibiotics
d. Aerosolized bronchodilators

Answer 3

Answer: D
Number 1 way is give Aerosolized but can give bronchodilators PO but not acute exacerbation and want give directly into airway; want to relax smooth muscles on outside airway to open airway as much as can – want do with acute exacerbation

Question 4

WT is placed on a continuous nebulized treatment of bronchodilators (albuterol). Considering the side effects of bronchodilators, what type of monitoring does this patient need? - beta agonist bronchodilator
A. SpO2 monitoring
B. Telemetry monitoring
C. Internal temperature monitoring
D. Every 15 minute blood pressure monitoring

Answer 4

Answer: B
Common side effect of beta agonists is tachycardia; esp continuous nebulizer very high risk for severe tachycardia need monitor tele; monitoring regardless even if get every now and then
Tele monitoring - heart monitor - rhythm stips where print and remote monitoring in heart: electrical activity of heart

Question 5

control and prevent episodes, improve airflow, relieve symptoms
Open up airways when having acute exacerbations
Prevent episodes - identify triggers, premedicate if know going to exposed

Answer 5

Goal - asthma

Question 6

Can be inhaled (bronchodilators/steroids) or systemic
Preventive therapy (controller drugs)
Rescue drugs
Educate importance of timing of preventative and rescue medications
Bronchodilators
Anti-inflammatory agents

Answer 6

Medications

Question 7

Change airway responsiveness to prevent asthma attacks - happening because airways hyperresponding to offense: allergic rxn, pet, cold, exercise; cause all that inflammation inside airway and clamping down on muscles outside airway
Used every day, regardless of symptoms

Answer 7

Preventive therapy (controller drugs)

Question 8

Stop attack once it has started

Answer 8

Rescue drugs

Question 9

Short- and long-acting beta2 agonists; shortacting - rescue meds - when having acute exacerbation, immediate relaxation of bronchioles; inhaled steroids and longacting bronchodilators - controller meds - meds take all time or know have something going on and for couple weeks but not relieve in acute exacerbation - make sure pat knows this
Cholinergic antagonists
See combovent inhalers that have multiple drugs in one inhaler
Methylxanthines
Short acting are “rescue drugs”

Answer 9

Bronchodilators

Question 10

Fix inside inflammation as well - do with steroids - be on preventative inhaled or come in with exacerbation after give bronchodilator give these IV potentially; decrease inflammation within airway
Corticosteroids - controller meds
NSAIDs
Leukotriene antagonists
Immunomodulators
Inhaled corticosteroids are “preventative drugs”

Answer 10

Anti-inflammatory agents

Question 11

Goal
Medications
Avoidance of Triggers
Inhalers/Nebulizers
Oxygen therapy

Answer 11

treatments/nursing care

Question 12

Education to avoid triggers, pre medicate prior to or medicate after exposure
Review asthma action plan and peak flow - typ peds pop; make plans pats identify triggers; children use where something going on to use as a guide

Answer 12

Avoidance of Triggers

Question 13

Green, yellow and red zones

Answer 13

Review asthma action plan and peak flow - typ peds pop; make plans pats identify triggers; children use where something going on to use as a guide

Question 14

Teach proper use/technique
Use of spacer for meter dose inhalers - spacers do is puts med in tube and have time breathe it in; squirt it while in mouth puts into throat and not much time inhale into lungs; not spacer leave inhaler outside mouth and time breathing which why spacers nice; get most med with spacer

Answer 14

Inhalers/Nebulizers

Question 15

If hypoxia is present
If needed
For acute asthma attack

Answer 15

Oxygen therapy

Question 16

AC is a 65-year-old male presents to the emergency department complaining of severe dyspnea
He has a history of shortness of breath and a 100 pack year history
When attempting to obtain his history he is unable to complete a sentence - very common symp in severe distress because so dyspneic
Assessment
RR 38; HR 128; T 99.1; SpO2 80% on room air
Occasional cough productive of small amounts of thick, pale yellow sputum
Skin color is gray
Clubbing of fingers
Barrel chest
Lung sounds: decreased lung sounds with bilateral rhonchi in bases (coarse lung sounds)
Stat portable chest film shows basically clear lung fields with flattened diaphragms
Arterial blood gas results are called
pH 7.29
PaCO2 74 mmHg
HCO3 34 mEq
PaO2 59 mmHg
SaO2 82%
Partially compensated respiratory acidosis with hypoxia since hypoxic - body trying to compensate but has not yet because pH still out of range
Which of the following is the most likely diagnosis for this patient?
a.Bacterial pneumonia
b.Viral pneumonia
c.Asthma
d.Exacerbation of COPD

Answer 16

Answer: D
(Specifically emphysema - breakdown of alveoli)
Chronic bronchitis - just bronchioles inflamed and lot secretions
2 disease processes under COPD
What assessments give you cues?
RR 38; HR 128; SpO2 80% on room air
Occasional cough productive of small amounts of thick, pale yellow sputum - some sputum production
Skin color is gray
Clubbing of fingers
Decreased lung sounds with bilateral rhonchi in bases - coarse lung sounds
Flattened diaphragm - if have chronic lung disease and lot RV every time exhale eventually flattens diaphragm and no longer concave - secondary to having RV build up and typ with chronic lung - trapping air and not able to get it out
100 pack year smoker - number one cause of emphysema; sometimes genetic predisposition and get emphysema causes where breaks down alveoli sim to where smoked
Barrel chest
Sputum production with some emphysema

Question 17

Dyspnea
Orthopnea - SOB when laying flat; like to be in recliner/want HOB up; very winded when lay head flat
Cough with sputum production
Use of accessory muscles - esp when in distress
Hypoxemia
Could have Chronic acidosis - 50/50 club; have PO2 running in 50s and CO2 in 50s and compensate for it and bad ABG - everything out of it but pH norm - chronic prob
Weight loss - very common in emphysema - working hard to breathe and nutrition big issue and energy conservation
Fatigue - very common in emphysema - working hard to breathe and nutrition big issue and energy conservation
Barrel chest (caused by hyperinflation of lungs/flat diaphragm)
Cyanosis - may see this with chronic cyanosis
Clubbing of fingers
ANXIETY - anxiety ridden to not be able to breathe; chronic lung disease notice breathing constantly - lot anxiety; cannot give antianxiety because suppresses resp sys; be careful and work with pat outside meds to reduce it; so SOB

Answer 17

COPD Assessment/symp

Question 18

What would be the best treatment to apply at this time?
A. Increase oxygen to 6 liters per nasal cannula
B. BIPAP (bilevel positive airway pressure)
C. Intubation and full mechanical ventilation
D. Repeat aerosolized bronchodilator

Answer 18

Answer: B
Reduce CO2 - was 74 so need facilitate airway in and out to get rid of it
Careful with O2 in COPD pats
Can get to stabilize with BIPAP better for pat - not invasive
Late for bronchodilator more aggressive because severely acidodic
Why not oxygen at 6 LNC?
Hypoxic vasoconstriction - not lot O2 in blood stream and want O2 going to healthy part of lung so naturally vasoconstrict blood vessels go to damaged part of lung; if increase O2 point 96-99% O2 sat lose protective mechanism - plenty O2 let blood flow everywhere to all parts lung; facilitate shunting blood to healthy part lung; want 88-90%; still oxygenate but goal not as high
Careful with O2
Why not mechanical ventilation?
Maybe, but let’s try BIPAP first

Question 19

(continuous positive airway pressure)
One set pressure or volume is delivered with each cycle of inhalation/exhalation
One pressure; keeping airway open; very common for chronic obstructive sleep apnea; can be on home and keep airway open; for upper obstructive pats and give + pressure so not collapse when sleep; plug O2 into there; not a rescue

Answer 19

CPAP

Question 20

(Bi-level positive airway pressure)
Different pressure is set for inhalation and exhalation
Sometimes for obstructive sleep apnea (in upper airway that collapses while sleep and while overweight) need this if fail on CPAP; can use this as a rescue in hospital before intubation/between ventilator; 2 levels pressure for inhalation and exhalation; plug O2 into there
Still bleed in O2 so get O2 - keep airway open and increase gas exchanges

Answer 20

BiPAP

Question 21

CPAP
BiPAP
APAP = noninvasive and adjust based on pat and after BiPAP; can give volume
Nice that not have intubate pats if catch early in resp situation
Nursing considerations:

Answer 21

NIPPV

Question 22

Ensure mask has an adequate seal - if not and alarm and air come out
Monitor for skin breakdown - variety of face masks to find best one for pat; work with RT for best mask for pat; bring in own mask if possible
Monitor for vomiting/aspiration - vomit with mask vomit not go anywhere aspirate easier with mask on

Answer 22

Nursing considerations:

Question 23

Answer: D
Is working - pat is improving; he is resting, resp less labored; O2 sat within norm range; he is doing fine and is comfy

Answer 23

AC is placed on a BIPAP. He is sleeping and respirations are less labored
His SpO2 is 89% with a 4 liter bleed in of oxygen (hooking O2 into machine so getting it in addition to what get from machine) through the BIPAP
The nursing assistant is concerned when obtaining vitals and informs you of SpO2
What is the most appropriate action?
a. Check the seal of the mask
b. Remove from the BIPAP
c. Notify the health care provider
d. Continue current treatment
e. Awaken the client
f. Increase oxygen flow rate

Question 24

After 1 hour on the BIPAP AC starts to wake up and is getting agitated and is pulling off his BIPAP mask.
Another ABG result is obtained with a slight improvement but he is still in respiratory acidosis. - pH still below 7.35
He keeps yelling out about needing to call court because he is going to miss a court date tomorrow
You replace his mask and educate him about the importance of wearing the BIPAP at this time. - good
What is the next step the nurse should take?
A. Try another type of Bipap mask
B. Call the health care provider
C. Remove the Bipap
D. Place the client in restraints
E. Administer lorazepam (Ativan)
F. Call Ladonna at Municipal court

Answer 24

Answer: F
Another mask - not terrible option
HCP - have to have reason for calling HCP; tell: pulling off mask and agitated; ask what figured out and tell call RT; do not need HCP for assistance; not need order to try fix prob
Not remove BiPAP - could give trial without BiPAP since improving but still acidotic so not want take off - then call provider and explain agitated and pulling off BiPAP and pH within norm limits; then say try; still acidotic so not take out
Restraints - last thing do; also is on BIPAP; if vomits has bad aspiration pneumonia and possibly code and die; never restrain if have BiPAP unless one on one in room - have to observe continually to put restraints if on BiPAP because huge safety huge issue
Lorazepam - try without med is great - is a sedative; slow down resp rate which trying to stop and want him to breathe; least invasive things first
Calling court - that is prob and find solution to help that prob; least invasive way to address prob and thinking about comps
Don’t want to sedate him
No restraints with patient on BIPAP
Still in respiratory acidosis, not ready

Question 25

Goal with emphysema/COPD:
Oxygen therapy
Positioning
Smoking cessation -
Energy conservation -
Breathing exercises
Nutritional counseling: nutrition is big
Chest physiotherapy (CPT)
Lung volume reduction surgery
Medications
Control anxiety
Use fans/cool rooms - if have circulating air when SOB perception of SOB decreases; should have fan in every single room; SOB is subj symp so if perceive air flowing less SOB

Answer 25

treatments/nursing care

Question 26

Attain or maintain gas exchange within the patient’s baseline and control symptoms - facilitate exchange O2 and CO2

Answer 26

Goal with emphysema/COPD:

Question 27

Keep O2 saturation 88-90%
Hypoxic vasoconstriction with emphysema

Answer 27

Oxygen therapy

Question 28

Elevate head of bed - excellent for pats - least invasive and relieve distress; tripod positioning - opens up airway

Answer 28

Positioning

Question 29

prevent further damage but not reverse what already happened to alveoli

Answer 29

Smoking cessation -

Question 30

have set routine because know minimal activity can do and what can tolerate

Answer 30

Energy conservation -

Question 31

Diaphragmatic breathing - push abdomen out that pushes diaphragm and helps exhale CO2; pursed lip breathing - helps forced exhalation and get rid CO2
Sometimes sitting with them and slowing down breathing with them and decreasing anxiety helps them

Answer 31

Breathing exercises

Question 32

chronic bronchitis and tons secretions machines where bang on backs and break up secretions, do with hands and vests that shake them; if on tele while getting shake: let tele know while in it because shakes leads

Answer 32

Chest physiotherapy (CPT)

Question 33

New methods are placement of endobronchial valves to divert airflow away from damaged lung tissue
Not done much anymore

Answer 33

Lung volume reduction surgery

Question 34

Bronchodilators
Anti-inflammatory agents
Mucolytic agents

Answer 34

Medications

Question 35

Short- and long-acting beta2 agonists
Cholinergic antagonists
Methylxanthines
Relax smooth muscle to open up airways

Answer 35

Bronchodilators

Question 36

Decrease inflammation
Corticosteroids
NSAIDs

Answer 36

Anti-inflammatory agents

Question 37

Manage secretions if have a lot
Expectorants - help thin and manage secretions if have a lot

Answer 37

Mucolytic agents

Question 38

KR is a 57-year-old female who presents to the emergency department complaining of shortness of breath of recent onset
She has a history of and is currently being treated for non-small cell lung cancer.
Assessment
RR 32; HR 92; T 98.7; SpO2 93% on room air
Alert and oriented and visibly short of breath
No cough noted
Lung sounds: diminished in right base with crackles on left side
CXR shows a white mass over the right base that obliterates the diaphragm
Which of the following diagnosis is most likely for this patient?
A. Left pneumothorax
B. Right bacterial pneumonia
C. Right pleural effusion
D. Asthma exacerbation

Answer 38

Answer: C
White on xray - no air so either fluid/secretions; white is bad; want be dark
Pleural effusion - fluid in pleural cavity
What assessments give you cues?
History of lung cancer - pleural effusions commonly happens when have lung cancer - often how diagnose lung cancer
RR 32 - high; SpO2 93% on room air
Dyspnea
No cough noted
Lung sounds diminished in right base
CXR shows a white over the right lung

Question 39

Dyspnea
Persistent cough or change in cough - key for change in cough; pat already has emphysema because smoking major causes of lung cancer
Hemoptysis/Rust colored sputum - blood in sputum
Hoarseness
Pain (chest, back, shoulder, pleuritic) - if metastasis: lung cancer speficially go to bone and brain; usually bone first
Decreased lung sounds where mass is located and dullness when percussed; wheezing if there is obstruction
Recurrent pleural effusions
Late signs:

Answer 39

Lung cancer assessment

Question 40

Collection of fluid in the pleural space

Answer 40

Recurrent pleural effusions

Question 41

Weight loss; fatigue; dysphagia; anorexia - seen if have metatstatic cancer

Answer 41

Late signs:

Question 42

A thoracentesis is planned.
The client is at highest risk for developing pneumothorax AEB absent lung sounds. - took needle into thoracentesis and punctured lung - air now leaking from lung into pleural space and now allowing lung to inflate and air trapped there; not hear lung sounds because no air moving in and out and air trapped in pleural cavity
A thoracentesis to drain the pleural fluid is performed on the patient
After the procedure the patient has an acute onset of shortness of air and SpO2 is now 81% on room air.
What is the first priority?
A. Call health care provider for a CXR
B. Place patient on oxygen
C. Call patient’s family
D. Lay patient flat

Answer 42

Answer: B
Need to address hypoxia and help pat first then call for a CXR
Do need CXR but need do something to help pat rn; then call HCP and then fam; do not lay flat because not best for pat

Question 43

A chest tube is placed and set to 20 cm of continuous suction using a wet suction chest drainage unit. Upon initial assessment the nurse notes continuous bubbling in the suction chamber. - pneumothorax and this scenario would put in a tube; chest tubes put into pleural cavity and put to suction; suck air/fluid/blood out to keep lung inflated; when lungs start healing, see chest tube not to suction to see if lung can stay inflated without suction and if so then chest tube out but initially all to suction - is wet suction chamber
What intervention should the nurse implement?
A. Decrease the suction
B. Clamp the chest tube
C. Continue to monitor the drainage system
D. Notify the health care provider

Answer 43

Answer: C
It is expected to have bubbling in the suction chamber of a wet chest drainage unit
Completely norm finding if have wet suction drainage - expected to have bubbling suction chamber
Dry suction chamber - no water in suction chamber

Question 44

The nurse also observes that there is fluid in the water seal chamber is fluctuating. What action should the nurse perform?
A. Have the client hold their breath
B. Observe the client’s respirations
C. Ask the client to change positions
D. Loosen the dressing

Answer 44

Answer: B
Chest tube have 3 sections: water seal prevents air going chest drainage unit because not want air from outside into pleural space; suction manages suction; other for drainage that comes out of body
Tidaling or fluctuation in the chest tube and the water seal chamber is expected - what want; if tube in pleural cavity and fluid in tubing or water seal chamber, when take breaths fluid will fluctuate or move check to make sure in right place; see no tidaling/fluctuation in either water seal or fluid in tubing would be concerning because may mean plugged or not in right spot anymore

Question 45

What further interventions should be included when caring for this client? (select all that apply)
A. Check water level in water seal and suction chamber
B. Assess lung sounds
C. Periodically clamp tube to assess client’s muscular effort
D. Record drainage according to policy
E. Keep drainage system above the level of the heart

Answer 45

Answer: A, B, D
Water seal - Kept at 20 sonometers - kept at chamber needs be at
Do not clamp tubes - just increasing pressuring - want be flowing; clamp if changing canister but very quick: not want air come in while putting new one on
Below heart - if drainage and lift up go right back and once out body gets contaminated

Question 46

Consider when taking care
Ensure that the dressing on the chest around the tube is tight and intact
Assess for shortness of air listen to lung sounds
Check alignment of trachea - tension pneumothorax - completely trapped air in pleural cavity shifts trachea because pressure so great so need to monitor for it
Palpate area for puffiness or crackling that may indicate subcutaneous emphysema - find this around insertion site; if out too far then increasing and if starts to increase doc and keep track if increasing or get better
Observe for signs of infection at insertion site or excessive bleeding
Check to see if tube “eyelets” are visible - holes in chest tube and if see migrating out is concerning
Assist patient to deep breathe, cough, perform maximal sustained inhalations
Do not “strip” the chest tube - clamp on there and pull down and strip it increases intrathoracic pressure
Keep drainage system lower than the level of the patient’s chest
Keep the chest tube as straight as possible, avoiding kinks and dependent loops
Ensure all connections are securely taped
Assess bubbling in the water seal chamber (gentle bubbling on expiration - only in wet): pneumothorax see bubbling in water seal chamber initially because air there; as heals bubbling should stop; doc what see; see if always had and if new check XR and if something changed in pat
Assess for “tidaling”
Check water level in the water seal chamber
Check water level in the suction control chamber, and keep at the level prescribed by the surgeon
Clamp the chest tube only for brief periods to change the drainage system or when checking for air leaks
Check and document amount, color, and characteristics of fluid

Answer 46

Chest tube care

Question 47

Parts: goes to pat and drains into portion, suction, water seal
Water seal - fluctuation in blue water when breathe and that is ok because tells us in right spot; always want jeep levels where are because suction keeps maintain suctioning - attached to wall suctioning but within unit what determines at

Answer 47

Wet drainage

Question 48

Parts: goes to pat and drains into portion, suction, water seal
Suction - controlled by dial at 20 sonometers
No bubbling because no water

Answer 48

Dry drainage

Question 49

MH is a 61-year-old man who presents to the emergency department with extreme respiratory distress of recent onset.
Assessment
RR 38; HR 130; T 98.9; SpO2 78% on room air
Pt is using accessory muscles to breathe
Jugular vein distention noted
Cough productive of thin foamy secretions
Lungs: bilateral coarse crackles
The patient is placed on a 100% non-rebreather mask
A stat portable chest film reveals an enlarged right ventricle
Blood is drawn and his BNP is 1100
Which of the following is the most likely diagnosis?
A. Bacterial pneumonia
B. Asthma
C. Exacerbation of COPD
D. Exacerbation of right sided heart failure

Answer 49

Answer: D (Cor Pulmonale)
Right sided HF - cor pulmonale - specifically caused by chronic lung disease - increased pressure in lungs and backs up into heart
What assessments gave you cues?
RR 38; HR 130; SpO2 78% on room air - terrible
Using accessory muscles to breathe
Jugular vein distention - KEY: right sided HF; backing up into periphery
Cough productive of thin foamy secretions - indicates fluid; little bit of left with foamy secretions
Lungs with bilateral coarse crackles
BNP 1100 - lab value look at for rt sided HF; 1100 is very high; happens when ventricles stretch and releases this peptide and when ventricles full fluid they stretch and this lab goes up
Enlarged right ventricle - pressure on right side heart from lung disease

Question 50

Hypoxemia
Dyspnea
Cyanosis
Vein distention - right side not pump out backs up to periphery: KEY
Systemic edema - fluid overload; right side not pump out backs up to periphery: KEY
Acidosis
Fatigue
Enlarged liver - right side not pump out backs up to periphery: KEY
Chest pain

Answer 50

Cor pulmonale assessment

Question 51

Which of the following is the best respiratory treatment to provide at this time?
A.CPAP
B. Intubation and full mechanical ventilation
C. Bronchodilators via nebulizer
D. Maintain as is

Answer 51

Answer: B
Why?
Extreme respiratory distress
SpO2 78% - really bad
Need be intubated and put on ventilator
What medications does the nurse expect to administer?
IV diuretics

Question 52

After initial evaluation and treatment, what diagnostic test would be used to measure the pressure in the right atrium?
A. Echocardiogram
B. Right heart catheterization
C. Electrocardiogram
D. Chest X-ray

Answer 52

Answer: B
All things might do for pat with HF; but Right heart catheterization to measure pressure in RA
Echocardiogram - func and structure of heart; EF
ECG - electrical activity, effected if in HF
CXR - show if heart is enlarged

Question 53

Arterial blood gas (ABG)
Brain natriuretic peptide (BNP)
Echocardiogram
Right heart catheterization
Ventilation Perfusion scan(V/Q scan)

Answer 53

Cor pulmonale Diagnostics

Question 54

Assess for hypoxia

Answer 54

Arterial blood gas (ABG)

Question 55

Assess the function of the heart
Increased levels with increased work of the heart
Increased levels indicate fluid overload

Answer 55

Brain natriuretic peptide (BNP)

Question 56

Assess for heart function

Answer 56

Echocardiogram

Question 57

Assess for pulmonary artery pressures

Answer 57

Right heart catheterization