Exam 1 Flashcards
risk factors for sepsis
immunocompromised, CLABSI, open wounds, malnutrition, invasive procedures, cancer, older than 80, alcoholism, diabetes mellitus, transplants, hepatitis, HIV/AIDS, GI ischemia, Hepatitis, transplant recipient, CKD, infection with resistant oraganisms, mucous membrane fissures in prolonged contact with bloody/ drainage soaked packing
stages of sepsis
SIRS, Sepsis, Severe Sepsis, Septic Shock, MODS
s/s of infection and sepsis
SIRS and confirmed infection
SIRS=2/4 criteria
body temp >100.5 or <96.8
HR>90
RR>20/PaCO2<32
WBC >12,000 or <4,000 or >10% immature bands
Infection:
fever
tachycardia
pain
swelling
warmth
redness
inc WBC
labs to assess for sepsis
sepsis labs: increased WBC, Decreased PLTs and Clotting factors, increased lactate, increased procalcitonin, BUN/creatinine, ABG, H&H, blood cultures, ALT, AST
labs to assess for infection progress
CRP(C-reactive protein), ESR (erythrocyte sedimentation rate) to track inflammation(is there a downtrend?), blood cultures, and labs listed for sepsis
nursing interventions for sepsis
hour-1 bundle
observe for organ dysfunction/worsening of s/s (decreased output, low BP, cyanosis, jaundice, etc)
qSOFA
SOFA
prioritization of nursing interventions for sepsis
hour-1 bundle
1. measure Lactate level
2. obtain blood cultures before adminstering antibiotics
3. administer broad-spectrum antibiotics
4. begin rapid adminstration of 30mL/kg crystalloid for hypotension or lactate > 4mmol/L
5. apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure >65 mm Hg
tx of sepsis
treat infection/fungal (broad-spectrum first, specific after blood cultures result), treat hypotension with vasopressors, start fluids 30mL/kg
prioritization of tx for sepsis
obtain blood cultures and lactate level, begin broad-spectrum abx, start 30mL/kg crystalloid fluid, adjust abx as blood culture sample gets back, monitor for worsening of s/s, monitor VS, and for rxns to abx and fluids.
adrenal function related to sepsis
decreased kidney function= toxins not released->furthering inflammation and decreasing perfusion r/t edema–> can indicate/lead to MODS
blood glucose levels related to sepsis
high glucose levels released from liver due to stress response; the more severe the response, the higher the glucose level
expected outcomes to sepsis tx
improvement in BP, return of WBC counts, increased O2 sat, decreased lactate level, increased perfusion, lack of edema, decreased procalcitonin
what has the highest risk of death over sepsis alone?
septic shock
DIC
disseminated intravascular coagulation
Disseminated intravascular coagulation; patho
microthrombi formed where not needed widespread; this consumes AVAILABLE PLTs and clotting factors and leads to hypoxia–> metabolic acidosis and organ dysfunction(inc hypoxia= inc metabolites-toxic-which amplifies inflammation and repeats poor gas exchange and perfusion)
discharge teaching for a pt at risk for sepsis
s/s of sepsis:
s/s of infection:
identify pt at risk for CV disease
male, over 40/45,smoker, alcohol, family hx, obese, sedentary lifestyle, african american, high cholesterol diet, uncontrolled HTN, uncontrolled stress
Modifiable risk factors
lifestyle, diet, exercise, smoking, drinking alcohol
non-modifiable risk factors
age, gender, ethinicity, family hx
NSR
normal sinus rhythm
describe normal sinus rhythm
impulse intiated by SA node
reg rhythm
rate 60-100bpm
normal P wave in lead
P wave before each QRS
normal PR, QRS, and QT intervals
sinus bradycardia
impulse initiated in SA node
sinus rhythm w/ rate <60
normal p wave
p wave before each QRS
causes for sinus bradycardia
vagal, drugs, ischemia, disease of nodes, ICP, hypoxemia, athletes(normal)
s/s of sinus bradycardia
can be asymptomatic
OR
confusion, SOB, CP, diaphoresis, syncope, lightheadedness, hypotension
sinus tachycardia
sinus rhythm with rate 100-150
normal P wave
p wave before every QRS
what does P wave represent
atrial depolarization
what does QRS complex represent?
ventricular depolarization
what does QT interval represent?
measures the complete ventricular cucles (depolarization AND repolarization)
what does T wave represent?
ventricular repolarization
normal values for P wave
0.12-0.2
normal values for QRS complex
0.06-0.10 seconds (longer=slower)
normal values for PR interval
0.12-0.20 seconds
normal values for QT interval
<0.44 seconds
how do you determine HR on an ECG strip?
find the tick marks, make sure strip is 6 seconds long. count the QRS complexes and multiply it by 10 (or count QRS in 30 boxes and multiply by 10)
how may seconds is one single box on an ECG strip?
0.04 seconds per small box
how many seconds is 5 boxes on an ECG strip
0.2 seconds for 5 boxes
what does amplitude measure on an ECG?
force of contraction
how is Time measured on an ECG strip?
horizontally
nursing interventions for sinus bradycardia
-monitor VS, monitor for confusion, SOB, CP, diaphoresis, syncope, lightheadedness, hypotension
-give fluids for hypotension
-anticipate orders for atropine or external pacing
nursing interventions for sinus tachycardia
assess for s/s: confusion, hypotension, lightheadedness, delay cap-refill, anxiety
monitor VS
anticipate medications
impact on beta-blockers on the heart
lower HR and BP
Risk factors for DVT/PE
endothelial injury, stasis of blood flow, hypercoagulable state (virchow’s triad)
Virchow’s Triad
endothelial injury, stasis of blood flow, hypercoagulable state
what falls under “endothelial injury”
part of Virchow’s triad for VTE risk factores:
surgery- Hip, knee, prostate
trauma
athersclerosis
smoking
catheter
what falls under the “hypercoagulable state”?
part of Virchow’s triad for VTE risk factors:
-malignancy
-congenital coagulation defect
-thrombophilia
-oral contraceptives
-inflammatory bowel disease
what falls under the “stasis of blood flow”?
part of virchow’s triad for VTE risk factors:
-immobility
-atiral fibrillation
-venous insufficiency
-venous obstruction
-Heart failure
diagnostics for DVT/PE
D-Dimer lab- tells if there is a clot that is breaking and floating
Venous Duplex Ultrasound- preferred method to dx DVT
non-surgical interventions for DVT/PE
early ambulation is the most important!
-SCDs
-ROM exercises
-TEDs
-elevation
-adequate hydration
-IS use
-coughing
-deep breathing
-turning while in bed
pt education about tx and prevention of DVT/PE
-prevent by walking frequently after procedures, perform gas pedal pumps and ROM in bed, wear compression stockings, maintain adequate hydration.coughing and deep breathing
-Rx for clot busters and anticoagulants may be given- enoxaparin/lovenox injection instructions or NOAC (novel oral anticoagulants)
-surgical:thrombectomy-remove clot by catheter aspiration suction
mechanical thrombectomy- blood clot is broken up into small pieces and removed
warfarin pt education
-vitamin K is the antidote- keep diet consistent, do not increase or decrease vitamin K consumption once therapeutic level of warfarin prescribed (leafy greens)
-s/s bleeding and prevention
-takes 3-4 days to be effective
-must have INR monitored as ordered (1.5-2)
-avoid prolonged sitting and crossing legs
-avoid smoking
-report abd pain
-pregnancy category X
-s/s hepatitis: jaundice, abd pain, nausea,etc.
ABG interpretation
pH level: 7.35-7.45 (acidosis or alkalosis)
PaCO2(respiratory):45-35
HCO3(bicarb;metabolic):22-26
pt prep for Chest X-RAY
education, no prep
Pt prep for thoracentesis
explain procedure and informed consent
supplies
pt position upright leaning on table
educate to remain absolutely still
VS
pt prep for bronchoscopy
-consent
-complete labs and diagostics needed
-NPO 4-8 hrs before
-remove dentures and oral prosthetics
-admin meds and topical anesthetics
pt prep for pulmonary function test
explain why tests are given: assess lung capacity and volumes, screen for respiratory complications and compare baseline overtime to others
-no smoking 6-8 hrs before
-no bronchodilator 4-6 hrs before
pt education for chest x-ray
used to monitor chest tubes insertion/placement daily
assess pulmonary issues, tubes,lines, evaluate condition of pneumothorax, pneumonia, abcess
pt prep for thoracentesis
local anesthetic, positioning, education, support, stay still, sterile procedure, collect specimen for tests and biopsies
pt education for bronchoscopy
used to assess lung cancer, gather culture and sensitivity (what is in lungs and how it can be treated), remove foreign bodies
-NPO 4-8 hrs begore
-local anesthetic
-level of monitoring
pt education for pulmonaryfunction test
no smoking 6-8 hours before
NPO 4-8 hours before
used to screen for disease, lung dysfunction, potential complications for surgeries and anesthesia
instructions for performing test
indications for chest x-ray
pulmonary issues, tubes, lines, pneumonia, TB, abcess,pneumothorax
indications for thoracentesis
discomfort due to fluid in pleural space–>needs removal, air built up in pleural space, instill medications into pleural space, obtain biopsy/samples from pleural space
indications for bronchoscopy
view airway structures and obtain tissue samples to DX and manage pulmonary diseases (lung cancer)
remove foreign bodies
culture and sensitivity
indications for pulmonary function tests
need a baseline to compare to other tests to view progress in pulmonary disease; monitor lung function
nursing implications and post-procedure care for chest x-ray
if pt has diminished or absent breath sounds->pneumo?
hx of pulm disease or untreated infection?
-make pt comfortable and advocate
nursing implications and post procedure care for thoracentesis
client complains of SOB, CP, diaphoresis, labored breathing, asymmetrical chest expansion, CXR shows collapsed lung or excess fluid
-dressing apply, pt comfortable, monitor VS and resp status
assess and look for s/s pnemo
-chest XRAY/iamging after
-turn, cough, deep breathing
nursing implications and post procedure care for bronchoscopy
s/s or hx of lung disease, removal of foreign bodies
vital signs q15 min for 2 hrs
monitor VS and sedation level
did gag reflex return?->meds after
pain control
nursing implications and post procedure care for pulmonary function test
screen for surgical complications, assess lung function, compare results to evaluate interventions and manage chronic pulm disease
-answer questions
-monitor resp status
-turn, deep breath, cough
-IS
monitor VS
assessment findings for pneumothorax
-decreased/absent breath sounds on affected side
-asymmetrical chest expansion
-anxiety
-diaphoresis
-tachycardia
-tachypnea
-resp distress
-Resp failure
-distended neck veins
-hemodynamic instability
tension pneumothorax: tracheal deviation towards unaffected side, cyanotic, resp distress, absent breath sounds on affected side
-hypotension
-CP
-hyperresonance on percussion
assessment findings for hemothorax
decreased or absent breath sounds on affected side, hypotension, poor gas exchange, poor perfusion (slow cap refill), chest pain, SOB, possible asymmetrical chest expansion,possible trachea deviation, dullness on percussion
assessment findings for pleural effusion
decreased/absent breath sounds on affected side, dullness on percussion, low SpO2, slow cap refill, SOB, tachypnea, tachycardia
assessment findings of flail chest
chest pain, paradoxical movement, Dyspnea, tachycardia, tachypnea,hypotension, 2 or more adjacent rib fractures in a couple places
assessment findings for pulmonary contusion
Crackles, decreased breath sounds, wheezes over affected area. Bruising over injury, dry cough, tachycardia, tachypnea, dullness to percussion
diagnostics for pneumothorax
chest xray, ABG, resp assessment
diagnostics for hemothorax
chest XRAY, chest CT, CBC, resp assessment
diagnostics for pleural effusion
chest xray, resp assessment
diagnostics for flail chest
chest Xray
resp assessment
diagnostics for pulmonary contusion
chest CT, resp assessment
treatment for pneumothorax
needle aspiration, thoracentesis (emergent for tension)
chest tube
tx for hemothorax
thoracentesis, needle aspiration or chest tube
tx for pleural effusion
chest tubes, needle aspiration
tx for flail chest
pain management, promote lung expansion
tx for pulmonary contusion
pain management, splinting chest with positioning, coughing and deep breathing exercises.
nursing care for pneumothorax
Assess lung sounds, prepare for chest tube insertion, maintenance of water levels for water sealed CDU, keep dressing occlusive, care for dry suction CDU, assess for leaks and kinks, TCDB
nursing care for hemothorax
Assess lung sounds, prepare for chest tube insertion, maintenance of water levels for water sealed CDU, keep dressing occlusive, care for dry suction CDU, assess for leaks and kinks, TCDB, monitor drainage and if more than expected per hour
nursing care for pleural effusion
Blood cultures before abx, education about chest tube insertion and prepare, maintenance of chest tube, VS, education and prep for Thoracentesis
nursing care of flail chest
Assess for dyspnea, paradoxical chest movement, cyanosis, tachycardia,and hypotension. Stabilize by positive pressure ventilation. Maintain airway, oxygen PRN, education/prep for x ray, pain control
nursing care for pulmonary contusion
Teach how to splint, TCDB, how to use IS, ambulate
pt education for pneumothorax
Hygiene and chest tube maintenance, things to report, complications, procedure for if chest tube dislodged/falls out, valsalva maneuver
pt education for hemothorax
Hygiene and chest tube maintenance, things to report, complications, procedure for if chest tube dislodged/falls out, valsalva maneuver
pt education for pleural effusion
pt education for pulmonary contusion
medications for pneumothorax
medications for hemothorax
medications for pleural effusion
medications for flail chest
medications for pulmonary contusion
complications of pneumothorax
complications of hemothorax
complications for pleural effusion
complications for flail chest
complications for pulmonary contusion
prioritization of care for pneumothorax
prioritization of care for hemothorax
prioritization of care for pleural effusion
prioritization of care for flail chest
prioritization of care for pulmonary contusion
safety considerations for penumothorax
safety considerations for tension pneumothorax
safety considerations for hemothorax
safety considerations for pleural effusions
safety considerations for flail chest
safety considerations for pulmonary contusion
assessment findings for tension pneumothorax
diagnostics for tension pneumothorax
tx for tension pneumothorax
nursing care for tension pneumothorax
pt education for a tension pneumothorax
medications for tension pneumothorax
complications for tension pnuemothorax
prioritization of care for tension pneumothorax
safety considerations for tension pneumothorax
prioritization of assessment and care following cheset trauma
atelectasis
collapse of alveoli
prevention of atelectasis
incentive spirometer use, coughing and deep breathing exercises
tx for atelectasis
thoracentesis
purpose for NIPPV
benefit of oxygenation and ventilation improvement without intubating
NIPPV
non-invasive positive pressure airway
purpose for CPAP
continuous pressure to keep airway open and patent- improve oxygenation
purpose for BiPAP
bi-level intermittent inspiratory and expiratory pressures to keep airway open, patent, and improve ventilation
Purpose of PEEP
NIPPV devices are used for pts with….
obstructive sleep apnea
CPAP devices are used for pts with
sleep apnea
HF
BiPAP devices are used for pts with…
COPD
HF
PEEP devices are used for pts with…
prep for chest tube insertion
clean room, OR preop checklist, VS (baseline), pt education, supplies, premedicate as ordered
indications for chest tube insertion
pneumothorax, hemothorax, pleural effusion
assessment of a pt with a chest tube
-insertion site: s/s infection?
-appropriate dressings
-pain level?
-kinks/occulsions of tubing?
-suction control chamber water level appropriate?
-water seal tidaling?
-water seal bubbling gently or aggressively(leak?)(on?)
-collection chamber full?
-CDU need to be changed?
-collection chamber marked hourly?
-dry/wet suction?
-suction levels appropriate?
troubleshooting a chest tube
cannot clamp for long, clamp and unclap briefly to check for leaks
kinks/occlusions in tube effect suction and pressures
suction control at marked line?
tidaling present in water seal chamber?
is there gentle or aggressive bubbling (on vs leak in system)
proper function of chambers of chest drainage system
collection chamber: collects fluid/air from pt pleural space
water seal chamber: prevents air from traveling back into pt pleural space
suction control chamber: controls suction based on level water (wet suction) or dial (dry suction), keep water at ordered level
complications of chest tubes
