CHAPTER 2 Flashcards
Recurrent episodes of airway obstruction leading to reduction in ventilation when ASLEEP
Cessation of breath or apnea
Obstructive Sleep Apnea (OSA)
RISK FACTORS OF OSA
O, M, P, A, U
- Obesity- parapharyngeal circumference fat; large neck
- Male
- Post-Menopausal stains
- Advance age
- Unstable respiratory nerves
PATHOPHYSIOLOGY OF OSA
- Decreased upper airway muscle tone (asleep)
- pharynx is compressed by surrounding tissues
- upper airway collapse
- obstruction
Clinical signs of OSA
SN, SL, SO, T
- Snoring/ gasping/ choking
- Sleepiness (hypersomnolence during daytime)
- Significant other report of sleep apneic episodes
- Thick neck circumference
DIAGNOSTIC TEST (OSA)
- Polysomnogram test (sleep study)
- RPSGT (Registered polysomnographic technologist)
- Overnight study - Electroencephalogram
- Electro oculogram
- ECG
- Respiratory
Medical management (OSA)
W, A, P, C, O
- Weight loss
- Avoidance of alcohol and sedatives
- Positional therapy lateral
- CPAP or BiPAP (standard treatment)
- Oxygen inhalation
CPAP airflow (OSA)
- Continuous positive airway pressure
- Single set pressure throughout the sleep
- Generally, more affordable
- Not as great accommodating changes in breathing
- Constant pressure during inhale
- Pressure relief during exhale
BiPAP airflow (OSA)
- Stands for Bilevel positive airway pressure
- Two distich pressure setting for inhale and exhale
- Comple sleep and breathing
- Constant set pressure during inhale
- Constant set pressure during exhale
OSA- Surgical Management
- tonsillectomy
- uvulopalatopharyngoplasty
- maxillomandibular advance surgery
- nasal septoplasty
- tracheostomy
Pt. w/ larger tonsils but low BMI
Tonsillectomy
resection of pharyngeal soft tissue, removal of 15mm free edge of the soft palate and uvula
Uvulopalatopharyngoplasty
Repositioning of upper jaw
Maxillomandibular advance surgery
Nasal septum deformities
Nasal Septoplasty
Last option (develops speech diff. and infections’
Tracheostomy
Pharmacologic management (not generally recommended in OSA)
- Modafinil (Provigil) Stimulants
- Medroxy progesterone acetate (Provera) Progestins
- Protorptylize (triptil) Trycyclic anti-depressants
- Acetazolamide (Diamox)
Decrease time of sleepiness (drug- OSA)
Modafinil (Provigil) Stimulants
Hyper alveolar hypoventilation (drug in OSA)
Medroxy progesterone acetate (Provera) Progestins
Given @ bedtime to increase respi. Drive and improve muscle tone (drug in OSA)
Protorptylize (triptil) Trycyclic anti-depressants
Carbonic anhydrase inhibitor; HypeR alveolar hypoventilation
Acetazolamide (Diamox)
NURSING CONSIDERATIONS (OSA)
Educate patient on Disorder (daytime sleepiness) and Safe use of equipment
Hemorrhage from the nose, caused by tiny ruptures; distended vessels in the mucous membrane
EPISTAXIS
More common on ANTERIOR SEPTUM;
- Anterior ethmoidal artery (Kiesselbach plexus)
- Sphenopalatine artery
- Internal maxillary branches
RISK FACTORS OF EPISTAXIS
- Local Infections
- Systemic infections (scarlet fever, malaria)
- Drying of nasal mucous membranes
- Nasal inhalation of illicit drugs (cocaine)
- Trauma (digitalis trauma, picking of nose, blunt trauma, forceful sneezing)
- Arteriosclerosis
- Hypertension
- Tumor
- Thrombocytopenia- less than the normal (Normal:150,000-450,000 platelets / mcl)
of blood - Use of ASA (aspirin)- Any anti-coagulants
- Liver Disease- Synthesize molecules for clotting
- Rendu-Osler weber syndrome- Vascular dysplasia
Pathophysiology of Epistaxis
- Eroded nasal mucosa
- Exposed vessels
- Rupture of blood vessels
- Bleeding
Medical Management of Epistaxis:
Applying direct pressure:
- Relax
- sit
- Head tilted forward * To prevent aspiration
- Apply direct pressure *Soft portion of the nose: 10- 15 minutes
- May insert small gauze pad into the bleeding nostril then apply digital pressure if bleeding continues
- Seek medical assistance if bleeding continues
Pharmacological management (Epistaxis)
- Determine the site of bleeding
- Penlight, nasal speculum, and suctioning
a. Anteroinferior,
b. Anterosuperior,
c. posterosuperior,
d. posteroinferior
- Nasal Decongestant (Phenylephrine)- vasoconstrictor
- Topical cocaine 4%- anesthetic and vasoconstrictor
• For combination of oxymetazoline (T.Decongestant)
and Tetracaine (T.Anesthetic) - Cauterization (Silver nitrate) * burning sensation
- Use of nasal tampons/pledgets
- Nasal gauze packing *up to 6 days
- Antibiotics- risk for Ca, iatrogenic (infection d/t medical procedure), sinusitis, or toxic shock syndrome - Balloon inflated catheter
Nursing considerations (Epistaxis)
- Monitor VS
- Provide emesis basins
- Help reduce anxiety
- Assess airway and breathing
- Self-care education
Blunt and penetrating trauma
Chest trauma
Sudden compression or positive pressure inflicted to the chest wall
Blunt trauma
- Foreign objects penetrate the chest wall
- Open injuries- lacerations, stab wound, or amputation
Penetrating trauma
Common causes of blunt trauma
- Motor vehicle crashes/accidents
A. Acceleration
B. Deceleration
C. Shearing
D. Compression
moving object hitting the chest or thrown
in an object
Acceleration
Sudden decrease in motor speed
Deceleration
stretching forces to areas of the chest causing tear or rupture
Shearing
direct blow to the chest
Compression
T/F
7 true ribs
3 false ribs
2 floating ribs
True
STERNAL/RIB
Common: Motor vehicular crashes via steering wheel
Sternal
Clinical manifestations of Sternal
A, E, S, S, P
- Anterior chest pain
- Ecchymosis - bruises (superficial)
- Subq crepitus
- Swelling
- Possible chest wall malformation
STERNAL/RIB
- Common: Chest trauma
- 5th to 9th ribs are the most common site of fracture
- Fracture of first, 3 ribs may cause laceration of the subclavian artery
- Lower ribs may be associated with spleen or liver injuries or lacerations
Rib
Clinical manifestations (RIBS)
S, P, M, B
- Severe pain
- Pant tenderness
- Muscle spasms that aggravate by coughing, deep breathing, and movement
- Bruise on affected area
PRIMARY ASSESSMENT (BLUNT TRAUMA STERNAL/RIB)
A, B, C, D
- Airway
- Breathing
- Circulation
- Disability
(Neurologic status)
SECONDARY ASSESSMENT (BLUNT TRAUMA STERNAL/RIB)
- Exposing the patient (remove all clothing to check for injuries)
- Environment is a reminder to prevent the patient from losing too much heat (DECREASED temp = DECREASED metabolism)
- Full set of VS should be obtained
- Family should be present during the treatment
- Giving comfort
- History and head-to-toe assessment
- Inspection of the posterior surfaces of the patient’s body for injury
Assessment (Blunt trauma sternal/rib)
- Auscultation - grating/crackling sound in the thorax (subcutaneous crepitus)
- Identify underlying cardiac injuries
Diagnostics (Blunt trauma sternal/rib)
- Chest x-ray/rib films
- ECG
- Continuous pulse oximetry
- ABG analysis
Medical management (Blunt trauma sternal/rib)
Relief of pain
- Sedation - epidural anesthesia/non-opioid analgesics
- Intercostal nerve block
- Ice compression
- Use of chest binder - it should be snugly enough so as to not impede respiratory excursion
• Pain subsides 5-7 days
• Rib fractures heal in 3-6 weeks - Avoid excessive activity
- Treat associated injuries
Nursing considerations (Blunt trauma sternal/rib)
- Educate patient on use of chest binder
- Ice over the fracture site
- Complication from steering wheel injury/VA/fall
- Occur when 2 or more adjacent rib, sternum, or costal cartilages are fractured at 2 or more sites resulting in free-floating rib segments.
Blunt trauma: Flail chest
Pathophysiology of Flail chest
- Inspiration
- Chest expansion
- Flail rib segment is pulled inward (Pendelluft movement)
- Decreased amount of air Expiration
- Flail rib segment bulges outward
- Expiratory impairment
Clinical manifestations of flail chest
DOB, P, P, R, HYPO, RA, HYPO
- DOB
- Pain in chest wall
- Paradoxical chest wall movement
- Retained airway secretions and atelectasis
- Hypoxemia (low O2 in the arterial blood)
- Respiratory acidosis
- Hypotension, inadequate tissue perfusion and metabolic acidosis
Medical management (Flail chest)
• Ventilatory support
• Clear airway
• Intubation
• Control pain
- Bruises of Lung Parenchyma
- Effected lung tissue can be small, large, entire lobe or whole lung
- More common on blunt type of trauma
Blunt trauma: Pulmonary contusion
Pathophysiology of pulmonary contusion
- Injury to Lung Parenchyma & Tissues
- Leakage of Serum Protein (Neg. Feedback)
- Non-Cardiogenic Pulmonary Edema
- Gas Exchange Interference
- Intra pulmonary shunting
- Hypoxemia
Clinical manifestations of Pulmonary contusion
(Mild symptoms)
T, D, C, H, BL
- Tachycardia, Tachypnea
- Decreased Breath Sounds
- Chest pain
- Hypoxemia
- Blood-tinged secretions
Clinical manifestations of Pulmonary contusion
(Moderate symptoms)
L, C, F
- Large amount of secretions
- Frank Blood in Tracheo blood therapy
- Constant Coughing
Clinical manifestations of Pulmonary contusion
(Severe symptoms in Major Organs)
C, A, P
- Central cyanosis- delivery is affected
- Agitation
- Productive cough w/ frothy-bloody secretions
DIAGNOSTIC TESTS (PULMONARY CONTUSION)
- ABG
- CXR
Medical management (Pulmonary contusion)
- Priority: Maintaining Airway oxygen and controlling pain
- Mild: Hydration, Pain management, anti-microbial therapy, supplemental oxygen (Nasal, Face mask, for
24-36 hours) - Moderate: Intubation, NGT insertion, bronchoscopy
- Severe: Intubation, Diuretics, anti-biotic meds, fluid restriction
- Pain & Antibiotic: According to tolerance of the patient
- Stab wounds are the most common (low-velocity projectile)
- Gun shot wounds (GSW), consider the distance, caliber, shape, size of the bullet
Penetrating trauma
Diagnostic tests (penetrating trauma)
• Chest X-ray
• Blood Chemistry
• ABG
• ECG
• Pulse Oximeter
• CT Scan
• Blood typing
• Cross matching
Management (penetrating trauma)
Objective: Restore & Maintain Cardio-Pulmonary
Function
