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Acute Care Exam 1 > Ch 10, 38: Chest and Respiratory Issues > Flashcards

Ch 10, 38: Chest and Respiratory Issues Flashcards

1
Q

Severe allergic reaction with rapid onset

A

anaphylaxis

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2
Q

patho of anaphylaxis

A

Immune system produces IgE antibodies that is normally not toxic and antibodies
Antibodies are stored for future exposure and releases histamine
Histamine  flushing, urticaria, angioedema, hypotension, and bronchoconstriction
Occurs within seconds/minutes of exposure
Dx made by objective findings

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3
Q

common triggers for anaphylaxis

A

seafood
latex
drugs
eggs
insects
nuts

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4
Q

mild clinical manifestations of anaphylaxis

A

Warmth,
tingling,
mouth fullness,
nasal congestion,
periorbital swelling,
sneezing,
eye tearing,
pruritis

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5
Q

moderate clinical manifestations of anaphylaxis

A

Flushing,
warmth,
anxiety,
itching,
dyspnea,
cough,
wheezing

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6
Q

severe clinical manifestations of anaphylaxis

A

Bronchospasm,
laryngeal edema,
severe dyspnea,
cyanosis,
hypotension,
dysphagia,
abdominal cramping,
vomiting,
diarrhea,
seizures

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7
Q

prevention of anaphylaxis

A

Strict avoidance of potential allergen
Carry and administer epi - Teach back method
Always carry an emergency kit
Screen for allergies
Wear medical alert bracelet
Desensitization

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8
Q

medical management of anaphylaxis

A

ABC support
-Ensure airway patency
-Oxygenation
-Epi 1:1000 dilution first line treatment
-Antihistamines and corticosteroids
-IVF
-Pressors
-Aminophylline to improve breathing/airway
Be aware of rebound reaction 4-10 hours after initial reaction

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9
Q

nursing management of anaphylaxis

A

Assess for s/s
Prompt notification to provider or EMS
Prepare for emergency procedures
–ET intubation may be difficult; prepare for cricothyrotomy
Education on prevention
Proper management of chronic conditions (asthma)
Be aware of adverse effects from epi

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10
Q

Obstruction of the pulmonary artery by a thrombus/thrombi that originates in the venous system

A

pulmonary embolism

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11
Q

what in a pulmonary embolism leads to impaired gas exchange

A

The embolus travels through venous systems and into the pulmonary circulation and cuts off the blood supply to the alveoli

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12
Q

what in a pulmonary embolism lead to decreased cardiac output

A

Obstruction of pulmonary causes increases pressure and puts a strain on the right ventricle

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13
Q

causes of PE

A

clot,
air,
fat,
amniotic fluid,
tumor cells,
bacteria (vegetation)
injected particles

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14
Q

What is virchow’s triad (PE)

A

blood venous stasis
changes in coagulation
damage to the vessel

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15
Q

third leading cause of death in a hospital

A

pulmonary embolism

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16
Q

risk factors for PE

A

Acute medical illness (a-fib, etc.)
Major surgery
Trauma
Cancer (including therapies)
Hx of VTE
Obesity
Immobility for more than 2 days
Age >40
Hypercoagulable conditions
Prolonged mechanical ventilation
Neuromuscular paralytic use
Central venous catheters
Severe sepsis
Heparin-induced thrombocytopenia
Oral contraceptive use and estrogen therapy
Pregnancy
Tobacco use
Long bone fractures

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17
Q

clinical manifestations of PE

A

Dyspnea
Pleuritic chest pain - have to rule out MI
Anxiety; feeling of impending doom
Syncope
Cough
Hemoptysis
Palpitations
Tachypnea
Crackles
Tachycardia
Presence of S4
Can be asymptomatic
Death can occur within hours

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18
Q

lab and diagnostics for PE

A
  • chest x-ray
  • ABGs - show hypoxemia and hypocapnia (from tachypnea)
  • D-dimer - occurs from fibrin lysis; normal <0.4 mcg/mL; elevated with thromboembolic events
  • ECG - to assess right ventricle function
  • doppler ultrasonography - displays DVT -cause of PE
  • V/Q scan - comparison of ventilation and perfusion
  • CTPA - standard for detecting PE - visualizes pulmonary angiography with IV contrast
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19
Q

prevention of PE

A

Prevent DVT!!
-Active leg exercises
-Early ambulation
-Elastic compression stockings or electronic compression devices (SCD)
-Prophylactic anticoagulation with expected immobilization
–Low dose heparin
–Low-molecular weight heparin
-Patient education
-Smoking cessation
-Avoid crossing legs
-Avoid long periods of immobility
-Prevent PE with traveling
-Stay hydrated
Early recognition of problems!!!

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20
Q

emergency management of PE

A
  • oxygen
  • IVF
  • Perfusion scans, ABGs, CT, angiogram, ECG, echo
    -Vasopressors or inotropes
    -Dig, IV diuretics, antiarrhythmics if appropriate
    -Labs
    –Coagulation studies (PT, PTT, INR, d-dimer)
    –Serum electrolytes
    –CBC
    -Possible intubation and mechanical ventilation
    -Indwelling catheter
    -IV morphine or sedatives
    -IV thrombolytics
    -Anticoagulants
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21
Q

anticoagulant therapy for PE (heparin)

A

PREVENTS does not DISSOLVE
Continuous heparin infusion
-Goal: Therapeutic PTT to reduce risk and recurrence of PE
-Dosed by weight
-Initial bolus IV dose 80 units/kg then a continuous infusion of 18 units/kg/hr
-Maintain PTT 1.5-2.5 times the control (21-35 sec; for heparin therapy 50-70 sec)
-Titrated based on PTT (drawn Q6 hours)
-Monitor and report s/s of bleeding
-Have antidote available
LMWH
-For hemodynamically stable clients (with stable PE)
-No need to monitor labs

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22
Q

Anticoagulant therapy for PE (Warfarin)

A

Prevent does NOT dissolve
Warfarin
-Can be added to IV therapy (bridge therapy)
-Monitor INR (normal 1, goal with warfarin is 2-3)
-The higher the INR the longer it takes for blood to clot
-Have antidote available
-Monitor amount of vit K in diet
Other orals
-Apixaban (Eliquis), dabigatran (Pradaxa), rivaroxaban (Xarelto)

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23
Q

antidote for heparin

A

protamine sulfate

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24
Q

antidote for warfarin

A

Vit K

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25
Q

thrombolytic therapy for PE

A

DISSOLVES clots
Examples: urokinase, streptokinase, alteplase, reteplase
Indications
–Severe, unstable PE/DVT (hypotensive, right ventricle dysfunction, large/saddle embolism, significant hypoxemia despite supplemental 02)
Not continuous therapy, single time dose
Absolute contraindications
–Hx of hemorrhagic CVA, active intracranial neoplasm, recent brain/spinal surgery (< 2 months), internal bleeding within 6 months
Relative contraindications
–Bleeding tendency, uncontrolled HTN, nonhemorrhagic CVA within 2 months, post surgery <10 days ago, thrombocytopenia
BIG SIDE EFFECT OF BLEEDING/HEMORRHAGE
Invasive procedures are avoided during therapy and 24 hours after

26
Q

emobolectomy: surgery for PE

A

Rarely done; only for massive PE or hemodynamic instability
Removes the clot surgically with cardiopulmonary bypass

27
Q

IVC Filter: surgery for PE

A

Mesh-like devices to trap thrombi from lower extremities and pelvis to prevent them from traveling to lungs
Used for people with recurrent PE and absolute contraindication to anticoags

28
Q

nursing interventions for PE

A

-minimize the risk and evaluate potential for PE
-prevent thrombus formation
-monitor pharmacological therapy
-manage pain and anxiety
- managing oxygen therapy
- post-op care and monitor for complications

29
Q

how to prevent thrombus formation

A

-ambulation
-pumping of leg exercises
-positioning - dont cross legs, stasis, no restrictive clothing
-do not leave IV catheters for prolonged periods

30
Q

how to manage manage pain and anxiety for PE

A
  • semi-fowler
  • turn and reposition
  • opioids
  • therapeutic communication
31
Q

managing oxygen therapy for PE

A

-assess for s/s of hypoxemia
-deep breathing, IS
-nebs and postural drainage

32
Q

what is a flail chest

A

Three or more adjacent ribs are fractured in two or more sites  free floating rib segments

33
Q

what causes flail chest

A

blunt force trauma to the chest (MVC, CPR in elderly, contact sports)

34
Q

process of flail chest

A

Chest wall loses stability  resp impairment  resp distress

35
Q

expiration and inspiration of flail chest

A

Detached part of rib is pulled inward during inspiration
Detached part of rib is pushed outward during expiration

36
Q

complications of flail chest

A

Retained airway secretions
Atelectasis
Hypoxemia
Impaired gas exchange
Respiratory acidosis
Decreased cardiac output

37
Q

clinical manifestations of flail chest

A

Unequal chest expansion
Paradoxical chest wall movement
Tachycardia
Hypotension
Dyspnea
Cyanosis
Anxiety
Chest pain

38
Q

medical and nursing management for flail chest

A

Providing ventilatory support
–Oxygenation
–Intubation and mechanical ventilation for severe injury
–Surgery for severe
Clear secretions from lungs
–Positioning, coughing, deep breathing, IVF, suctioning, pulmonary chest physiotherapy, IS, nebs with bronchodilators and mucolytics
Control pain
–Intercostal nerve blocks, cautious use of opioids, PCA, epidural analgesia
Monitor CXR, ABG, pulse ox, and pulmonary function test

39
Q

what is a pneumothorax

A

Pleura are punctured and pleural space is exposed to positive atmospheric pressure
Presence of air or gas in the pleural space that causes lung collapse

40
Q

what is a simple pneumothorax

A

Air enters pleural cavity through a ruptured bleb (blister)
Can occur in a healthy person
hemodynamically stable**

41
Q

what is a traumatic pneumothorax

A

Air enters pleural space from a trauma or thoracic procedures

42
Q

what is a hemothorax

A

Blood enters pleural cavity from lung lacerations or lacerations of great vessels

43
Q

what is a tension pneumothorax

A

air enters the pleural cavity with inspiration but can’t escape with expiration
from penetrating trauma
causes increased pressure on heart and lung leading to decreased cardiac output, tracheal shift to unaffected side and collapsed lung
hemodynamically unstable**

44
Q

how do we diagnose a pneumothorax

A

chest x-ray and ABG; thoracentesis for hemothorax

45
Q

clinical manifestations of pneumothorax

A

Depend on size and cause
Sudden, pleuritic chest pain
Diminished breath sounds
Hyperresonance in lungs
Decreased chest expansion
Subcutaneous emphysema

46
Q

clinical manifestations of simple or uncomplicated pneumo

A

Slight chest discomfort and tachypnea
Minimal resp. distress

47
Q

clinical manifestations for large pneumo

A

Anxious
Dyspnea
Air hunger
Use of accessory muscles
Severe hypoxemia

48
Q

clinical manifestations of tension pneumo

A

Trachea deviation to unaffected side
Decreased chest expansion
Diminished or absent breath sounds
Hyperresonance
Air hunger
Agitation
Increasing hypoxemia
Central cyanosis
Hypotension
Tachycardia

49
Q

medical management of pneumothorax

A

Goal = evacuate air/blood from pleural space
Chest tube to drain fluid and air
Pain management with opioids

50
Q

medical management of tension pneumo

A

Inserting large-bore 14 gauge needle at second intercostal space - needle decompression
midclavicular line on affected side;
THEN chest tube

51
Q

indications of medical management of emergency thoracotomy

A

If injury is suspected through trauma
Done if more than 1500 mL of blood is aspirated by thoracentesis OR if chest tube output >200 ml/hr

52
Q

nursing management of pneumothorax

A

Administer 02
Astute assessment
Monitor ABGs, Sp02, CBC, and CXR
Positioning for maximum ventilation
Emotional support
Administer meds
Encourage rest periods
Encourage coughing, deep breathing, IS
Collaboration with interdisciplinary team
Chest tube management

53
Q

indications of chest tube

A

Drain fluid,
blood,
lymph,
pus, or air;
Re-establish a negative pressure; Facilitate lung expansion;
Restore normal intrapleural pressure

54
Q

uses of a chest tube

A

Used for
pneumothorax,
hemothorax,
post-op drainage for open heart surgery,
pleural effusion,
pulmonary empyema

55
Q

insertion of chest tube

A

Inserted in ER, bedside, or OR
Can be inserted in right or left pleural spaces or mediastinum

56
Q

three chambers for chest tube

A

Drainage collection
Water seal
Suction control (wet or dry

57
Q

ways of drainage for chest tube

A

drain by suction or gravity

58
Q

continuous bubbling in the water seal chamber of chest tube drainage means:

A

air leak

59
Q

additional interventions for chest tube

A

Position in semi-high fowlers to promote ventilation
Keep two hemostats, sterile water, and occlusive dressing at bedside ALWAYS
Only milk or clamp tubing when prescribed
If leak suspected, determine the location by using clamps, notify MD, and tighten connections or change system
Mark drainage hourly/daily
Frequent reposition
ROM of affected arms/shoulder
CXR daily

60
Q

when is it indicated to remove chest tube

A

No more fluid fluctuations in water seal chamber
Clear CXR
Slowed drainage

61
Q

process of removing chest tube

A

Assist provider
Pain medication 30 min before
Instruct the client to take a deep breathe, exhale, and bear down (Valsalva) OR take a deep breath and hold it
Tube is then clamped and removed quickly by provider
Immediately after, place an airtight petroleum gauze dressing and thoroughly cover with nonporous tape (same with accidental removal and then immediately notify provider)
If chest tube drainage system is compromised  immerse end of chest tube in sterile water for temp water seal
Obtain CXR

Acute Care Exam 1 (3 decks)

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