Exam 1 Mod 1&2 Flashcards
Compression of the trigeminal nerve (CN V) causing irritation, focal demyelination of the nerve, inflammation.
Pain occurs abruptly & lasts a short amount of time.
Trigeminal Neuralgia
Trigeminal Neuralgia drug therapy includes:
Carbamazepine- first line
Corticosteroids
Diazepam or tricyclic antidepressants
What are some possible triggers for trigeminal
neuralgia?
-Smiling
-Brushing teeth
-Eating
Surgical tx trigeminal neuralgia
gamma knife radiosurgery or microvascular decompression
What is the post-surgical care for trigeminal neuralgia?
-Ice pack
-Soft diet
-Avoid chewing on the affected side
-Perform frequent cranial nerve assessments
What is a seizure?
Abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain.
May result in a change in LOC, motor or sensory ability, and/or behavior.
What type of seizure?
Loss of consciousness
Stiffening of body
Jerking of extremities
May be associated with biting tongue, incontinence
Postictal: muscle soreness, tired
Generalized Tonic-Clonic (Grand-Mal) Seizure
What type of seizure?
Staring spell or brief loss of consciousness
Can be precipitated by hyperventilation or flashing lights
Generalized Absence (Petit Mal) Seizure
What type of seizure?
May remain focal or progress to generalized tonic-clonic
Simple-partial: No loss of consciousness, focal motor
Partial Seizures
Status epilepticus is a medical emergency. It is continuous or rapidly occurring seizures. What does it cause?
brain damage, arrhythmias, hypoxemia, & acidosis
What is considered to be “impending status epilepticus?”
Seizure activity lasting longer than 5 minutes
What do we do for status epilepticus?
Initially, intravenous lorazepam/diazepam is administered to stop motor movements. This is followed by the administration of phenytoin.
May require endotracheal intubation for airway protection
Steps to Seizures
What do we do first?
Seizure Management Pearls
Protect the patient from injury.
Do not force anything into the patient’s mouth.
Turn the patient to the side to prevent aspiration and keep the airway clear.
Remove any objects that might injure the patient.
Suction oral secretions if possible without force.
Loosen any restrictive clothing the patient is wearing.
Do not restrain or try to stop the patient’s movement; guide movements if necessary.
Steps to Seizures
What medications?
IV push lorazepam or diazepam.
What do all anticonvulsants cause?
All anticonvulsants can cause drowsiness, ataxia (lack of coordination) and CNS depression (resp. depression)
Levetiracetam (Keppra): best choice for outpatient,
most popular, monitor CBC.
Phenytoin: causes gingival hyperplasia, bone marrow
suppression, rash, IV vesicant, monitor blood levels
and CBC (q3 months).
Carbamazepine: causes bone marrow suppression,
monitor blood levels and CBC.
Divalproex (Depakote): causes hepatotoxicity, bone
marrow suppression, monitor CBC, blood levels and
LFTs.
Steps to Seizures
What do we do once the seizure has stopped?
Reorient the pt.
Record the time the seizure began and ended.
Check blood glucose levels. Seizures can occur due to hypoglycemia.
Make sure airway is clear.
Ask if they have felt an aura before the seizure or have triggers.
A nurse is assessing a client who has a seizure disorder.
The client tells the nurse, “I am about to have a seizure.”
Which of the following actions should the nurse implement? (select all that apply)
A. Provide Privacy
B. Ease the client to the floor if standing
C. Move furniture away from the client.
D. Loosen the client’s clothing
E. Protect the client’s head with padding
F. Restrain the client
A. Provide Privacy
B. Ease the client to the floor if standing
C. Move furniture away from the client.
D. Loosen the client’s clothing
E. Protect the client’s head with padding
A nurse is caring for a client who just experienced a
generalized seizure. Which of the following actions
should the nurse perform first?
A. Keep the client in a side-lying position
B. Document the duration of the seizure
C. Reorient the client to the environment
D. Provide client hygiene
A. Keep the client in a side-lying position
B. Document the duration of the seizure
The greatest risk to the client is aspiration during the postictal phase. Side-lying position allows secretions to drain from the mouth, keeping the airway patent.
Priority is always safety.
A nurse is providing discharge instructions to a client who
has a prescription for phenytoin. Which of the following
instructions should the nurse include?
A. Consider taking an antacid when on this medication
B. Watch for receding gums when taking the medication
C. Take the medication at the same time every day
D. Provide a urine sample to determine therapeutic levels of
the medication
C. Take the medication at the same time every day
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in the review? (select all that apply)
A. Avoid overwhelming fatigue
B. Remove caffeinated products from the diet
C. Limit looking at flashing lights
D. Perform aerobic exercises
E. Limit episodes of hypoventilation
F. Use of aerosol hairspray is recommended
A. Avoid overwhelming fatigue
B. Remove caffeinated products from the diet
C. Limit looking at flashing lights
How do we differentiate between bacterial
and viral meningitis? Which one is worse?
Meningitis is an acute infection and inflammation of meninges.
Differentiate by CSF analysis w/ lumbar puncture
Bacterial meningitis is an acute, life threatening emergency.
Good prognosis for viral meningitis.
What type of precautions is used for meningitis?
droplet
Clinical Presentation of Meningitis
-Headache like they have never felt before
-Nuchal rigidity, back of the neck is stiff
-Nausea/vomiting
-Photophobia: eye discomfort due to exposure to light
-Brudzinski Sign: flexion of the neck elicits flexion of hips and knees
-Kernig Sign: bilateral hamstring pain prevents straightening of the leg
What is the most important thing to monitor for meningitis?
level of consciousness
What do we do stat with bacterial meningitis?
Requires STAT LP followed by immediate IV antibiotics.
Do not give antibiotics before the LP, can skew the results.
What do we do for viral meningitis?
supportive care- antipyretics, hydration, and rest
A nurse is assessing a client who reports severe headaches
and a stiff neck. The nurse’s assessment reveals positive
Kernig’s and Brudzinski’s signs. Which of the following
actions should the nurse perform first?
A. Administer antibiotics
B. Implement droplet precautions
C. Initiate IV access
D. Decrease bright lights
B. Implement droplet precautions
A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (select all that apply)
A. Implement seizure precautions
B. Perform neurological checks 4 times a day
C. Administer morphine for the report of neck and generalized pain
D. Turn off the lights and television
E. Monitor for impaired extra-ocular movements
F. Encourage the client to cough frequently.
A. Implement seizure precautions
D. Turn off the lights and television
E. Monitor for impaired extra-ocular movements
What is the priority assessment post craniotomy?
-Monitor for and prevent increased ICP is the PRIORITY
Followed by:
-Observe dressing
-Prevent infection (handwashing)
-Monitor neurological status
-Monitor fluid and electrolytes
-Monitor for diabetes insipidus
-Prevent complications of immobility: DVT prophylaxis, skin breakdown
What is the drug of choice for cerebral edema?
Dexamethasone (Decadron)
What is the difference between a primary spinal cord injury and a secondary injury?
Primary Injury: Initial disruption of cord.
Secondary injury: on-going damage from ischemia, inflammation, toxic metabolites, and edema.
What types of shock should you look out for w/ spinal cord injuries?
Neurogenic- damage to the nerves themselves
Hypovolemic- fluid loss
What is our priority with cervical spinal injuries?
Above C4 requires mechanical ventilation
C3, 4, & 5 keep the diaphragm alive.
All cervical injuries cause respiratory insufficiency meaning the pt will have
-Decreased cough
-Decreased vital capacity
-High risk of atelectasis and pneumonia
What do we see in spinal shock?
Due to acute spinal injury
Loss of motor, sensory and reflex activity at the level of injury and below:
-Flaccid paralysis
-Flaccid bladder
-Paralytic ileus- gut is going to slow down or stop
-Loss of sensation
-Decreased or absent reflexes
Can last days to months. Spasticity may emerge after spinal shock resolves.
Who has the highest risk of developing neurogenic shock?
High risk w/ injury above T6
What sets neurogenic shock apart from spinal shock?
hemodynamic phenomenon
What are the three critical features of neurogenic shock?
Hypotension
Bradycardia
Poikilothermia
What is the cause of autonomic hyperreflexia?
distended bladder and fecal impaction
What are the priority symptoms of autonomic hyperreflexia?
Severe, life-threatening hypertensive crisis.
Other sx include: HA, blurred vision, diaphoresis, & flushing
What is the nursing care for autonomic hyperreflexia?
-Elevate HOB
-Monitor BP
-Remove noxious stimuli
-If BP remains elevated administer BP medication
-Close neuro assessment
Immediate Post- Spinal Cord Injury
-Immobilize injury w/ backboard & neck brace
-Prioritize ABCs
-Comprehensive neuro assessment (touch, pain, muscle strength)
-Methylprednisolone (Solu-Medrol) can help w/ inflammation
-Maintain MAP between 80-90 (may require dopamine)
-NG tube for ileus
-Stress ulcer prophylaxis with a PPI
-DVT prophylaxis (SCDs & Lovenox)
What is the formula to calculate MAP?
(SBP + 2DBP) / 3
A nurse is caring for a client who has a spinal cord injury and reports a severe headache and is sweating profusely. Vital signs include blood pressure of 220/110 mmHg and apical heart rate of 54/min. Which of the following actions should the nurse take first?
A. Examine skin for irritation or pressure
B. Sit the client upright in bed
C. Check the urinary catheter for blockage
D. Administer antihypertensive medication
B. Sit the client upright in bed
A nurse is caring for a client who has a C4 spinal cord
injury. The nurse should recognize the client is at greatest
risk for which of the following complications?
A. Neurogenic Shock
B. Paralytic ileus
C. Stress Ulcer
D. Respiratory Compromise
D. Respiratory Compromise
What is a Transient Ischemic Attack (TIA)?
“Mini-stroke”
Reversible cerebral ischemia. Usually precedes thrombotic stroke: “Warning sign”.
TIA is commonly caused by
carotid stenosis
What is the ABCD assessment tool for stroke risk?
Age of at least 60 years
BP of at least 140/90 (either SBP, DBP, or combination)
Clinical TIA features
Duration of symptoms
TIA- Carotid ultrasound ordered to identify arterial stenosis, which may lead to
decreased cerebral blood flow
What is the medication management for TIA?
Antiplatelets drugs such as aspirin or Plavix
What are other management techniques for TIA?
ABCS of stroke management
-Blood pressure management
-Controlling diabetes, if necessary
-Lifestyle changes: smoking cessation, encouraging physical activity, dietary management
What are the two types stroke?
Ischemic (occlusive) and Hemorrhagic (bleeding)
What are the two types of ischemic strokes? What is the main cause of each type?
-Thrombotic –> Atherosclerosis
-Embolic –> A-Fib
What are the 4 types of hemorrhagic strokes? What is the main cause if each type?
-Intracerebral hemorrhage –> severe or sustained HTN
-Subarachnoid hemorrhage –> ruptured aneurysm or AVM rupture
-Aneurysm
-Arteriovenous malformation (AVM) –> congenital abnormality
Interventions for cerebral aneurysms
clipping and coiling
Thunder clap headache
Subarachnoid hemorrhage
What are the hallmark signs/sx of a stroke?
-Sudden weakness
-Difficulty talking
-Difficulty understanding
-Severe headache with no known cause
What is the first priority for stroke patient?
Ensure pt is transported to a stroke center.
Complete focused/rapid assessment. Remember that there is always a risk that LOC will change.
Broca’s aphasia
difficulty talking
What is FAST?
facial dropping, raise arms, slurred speech, time = brain
Wernicke’s aphasia
difficulty understanding
Emergent Care Stroke
-Assess ABCs
-Provide oxygen (this is an ischemic issue)
-2 Large bore IVs
-Take blood samples and blood glucose
-Perform NIH Stroke Scale
-Order a non-contrast CT- must be read within 45 minutes
-Obtain 12-lead to look for A-fib
-Do not delay CT to get ECG
Within 45 minutes of the patient’s arrival, the specialist must decide, based on the CT scan, if a hemorrhage is present.
Take these actions if a hemorrhage is present:
-Note that the patient is not a candidate for fibrinolytics.
-Arrange for a consultation with a neurologist/neurosurgeon.
-Consider transfer, if available.
If it is hemorrhagic you need to get a
neurosurgeon consult immediately
Within 45 minutes of the patient’s arrival, the specialist must decide, based on the CT scan, if a hemorrhage is present.
Take these actions if a hemorrhage is NOT present:
-Decide if the patient is a candidate for fibrinolytic therapy.
-Review criteria for IV fibrinolytic therapy
-Repeat the neurological exam (NIHSS)
If ischemic- assess criteria for tPA
What is the criteria?
Period of time between symptom onset and arrival time to the stroke center.
FDA approves use of tPA within 3 hours of stroke symptom onset.
The American Stroke Association endorses 4.5 hours, if no exclusion criteria are present.
Exclusion criteria for tPA
Age older than 80 years
Anticoagulation therapy
Baseline NIHSS score greater than 25
History of both stroke and diabetes
Evidence of active bleeding
BP greater than 185 systolic or 110 diastolic
History of cerebral bleed
Elevated PT/INR
If they are not a candidate for tPA, what is next?
Endovascular interventions
Mechanical embolectomy- MERCI Retrieval System
Intra-arterial thrombolysis: tPA is delivered directly to the thrombus within 6 hrs of symptom onset
Carotid artery angioplasty with stenting
Carotid Endarterectomy (CEA)
Mechanical embolectomy- MERCI Retrieval System is for patients that do not qualify for tPA or fail tPA therapy. Has to be completed
within 8 hours of stroke onset
If we do a carotid endarterectomy, what do we watch for?
swelling in the airway
Nursing Care for Stroke
-FALL PRECAUTIONS
-Transfer to the strong side
-Place objects in their visual field and approach them from the unaffected side
-NPO until swallow study
-Sit up 90 degrees
-Assess gag reflex
Spatial perceptual deficit
Agnosia
inability to recognize objects
Spatial perceptual deficit
Apraxia
Inability to perform tasks
Nursing Care for Mobility
-Maintain ROM
-Position to prevent contractures
-Prevent foot drop
-Fall precautions
-Transfer to strong side
-Address functional incontinence
Nursing Care for Unilateral Neglect
-Place objects in patient’s visual field
-Approach patient from unaffected side
-Teach patient to turn head to affected side
-Teach patient to stimulate affected side
-Teach patient to use mirror to survey affected side
A nurse is caring for a client who has experienced a right hemispheric stroke. The nurse should expect the client to have difficulty with which of the following?
A. Impulse control
B. Moving the left side
C. Depth perception
D. Speaking
E. Situational Awareness
A. Impulse control
B. Moving the left side
C. Depth perception
E. Situational Awareness
Concussion
What is second impact syndrome?
A second concussion that occurs before the brain can completely recover from the first.
Can result in massive cerebral edema.
What are the clinical manifestations of an epidural hematoma?
Arterial bleeding into the space between the skull and the dura. Faster bleed.
-Immediate post-traumatic unconsciousness, followed by “lucid interval”
-Rapid deterioration in LOC may follow, up to and including death
-Ipsilateral pupil enlargement
-Increasing headache
-Seizures
-Motor weakness
What do we do for an epidural hematoma?
Requires emergent surgical evacuation
Is a subdural hematoma emergent or nonemergent?
nonemergent, but can be fatal.
Sx are less severe and is a slower bleed.
What are the three components of ICP?
-Brain tissue
-Blood
-Cerebrospinal fluid (CSF)
What is the normal ICP?
Normal ICP is 10-15 mm Hg.
How do we calculate Cerebral Perfusion Pressure (CPP) and what does it mean?
MAP-ICP= CPP
Pressure needed to ensure adequate perfusion of brain
CPP ranges
CPP 70-100 normal
CPP 50-60 minimum required for adequate cerebral perfusion
CPP < 50 brain ischemia, neuronal death
CPP <30 incompatible with life
What are the clinical manifestations of increased ICP?
-Change in level of consciousness (LOC)
-Headache and projectile vomiting.
-Compression of CN III Oculomotor (“blown pupil”)
-Cushing’s Triad (systolic hypertension, widened pulse pressure, bradycardia)
-Decorticate & Decerebrate posturing
-Brain stem herniation
-Death
ICP Management
Priority is to manage ICP
*Mechanical ventilation to maintain PO2 > 100
*Maintain SBP between 100-160
*Maintain CPP > 70 (70-100 is normal)
*Osmotic Diuretic (Mannitol)- treats cerebral edema, takes
swelling out of the brain by pulling water out of the
extracellular space decreasing brain edema
*Loop Diuretics
*Anticonvulsants- increased ICP= increased risk for seizures
*Fentanyl may be used to help manage agitation when patients are ventilated
*HOB elevated to 30 degrees and head midline
*Limit suctioning and stimulation
Should gloves be worn when examining the eyes?
Always wear gloves when examining the eyes. Eye infections are highly contagious.
Primary angle-closure glaucoma (aka acute glaucoma) is a medical emergency. Signs/sx include:
-Sudden pain around eyes
-Nausea and vomiting
-Seeing colored halos around lights
-Blurred vision
-Ocular redness
-Corneal edema
-Pupil may be dilated and non-reactive
Main goal of treatment for primary angle-closure glaucoma is
to reduce IOP
Do not dilate!
Who is more at risk for developing retinal detachment?
-diabetics
-people who are nearsighted, their eyes are longer than average from front to back causing the retina to be thinner & more fragile
What are the sx of retinal detachment?
Medical emergency
-Lights flashing, photophobia
-“Wavy,” or “watery” vision
-Veil or curtain obstructing vision
-Shower of floaters that resemble spots, bugs or spider webs
-Sudden decrease of vision
-Painless
What are our post-operative care priorities for retinal detachment?
-Maintain eye patch and/or eye shield
-Assess for drainage
-Report sudden increase in pain, and/or pain associated with nausea to the surgeon immediately
-Avoid activities that increase IOP
-Avoid activities that promote rapid eye movement (reading, writing, etc.)
-Report sudden reduced visual acuity, eye pain, pupil that does not constrict to light response (signs of detachment)
Eye Trauma Priorities
-Assess peripheral vision
-Antibiotics can be given to prevent infection
-NEVER TAKE OUT THE FOREIGN BODY
-MRI is contraindicated because it can pull out the object and the eye
External Otitis is inflammation/infection of the outer ear.
Sx include:
Pain, ear canal swelling, and drainage.
Possible hearing loss from obstruction.
Potential causes of external otitis include
Swimming, trauma, and piercing cartilage of the upper ear and ear lobe piercings are risk factors.
Bacteria and Fungus are the two main causes with bacteria being more common.
Tx for external otitis includes:
-Remove materials from ear canal
-Apply heat 3 times a day
-Topical antibiotics and eardrops
-Avoid water for 7-10 days
Infection of mastoid air cells caused by progressive otitis media (middle ear infection).
Mastoiditis
Signs and sx of Mastoiditis
-Swelling behind ear
-Pain when moving ear or head
-Red, dull, thick, immobile eardrum
Mastoiditis- have pt report any sx of headache or stiff neck. Why?
could indicate meningitis
What are the priorities for Mastoiditis?
Priorities:
-Reduce inflammation, pain, and edema
-Provider to clean the ear first through an otoscope
Nursing priorities:
-Comfort measures
-Heat application 3 x daily for 20 minutes
-Minimize head movements to minimize pain
-Topical antibiotics and steroids
-More severe cases may require either oral or IV antibiotics
-Avoid water activities for 7-10 days (occlude ear canal with petroleum gauze when showering)
-Teach patient to minimize ear canal moisture, trauma or exposure to irritants
How are ear drops administered?
-Wash hands and don gloves
-In the adult patient, pull the pinna (auricle) upward and outward to straighten the ear canal.
-Be careful to avoid touching the tip of the dropper bottle to the ear.
-In the pediatric patient (younger than 3-years-old), pull the pinna back and down.
What is Meniere’s Disease?
Meniere’s disease is characterized by sx of inner ear disease with episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss.
Other sx include pallor, sweating, nausea, and vomiting.
What is the priority for Meniere’s Disease?
Priority safety measure for Meniere Disease is to place the patient on Fall Risk Precaution.
What are some nursing interventions for Meniere’s Disease?
Nursing interventions include eliminating environmental noise, promoting a quiet environment, and restricting caffeine, nicotine, and alcohol.
Prescribing a diet low in caffeine, sodium and monosodium glutamate has been proven helpful in some clients.
A nurse is caring for a client who has suspected Meniere’s
disease. Which of the following is an expected finding?
A. Presence of purulent lesion in the external ear canal
B. Feeling of pressure in the ear
C. Bulging, red bilateral tympanic membranes
D. Unilateral hearing loss
D. Unilateral hearing loss
Name COPD complications
Hypoxemia
Acidosis
Respiratory infections
Right sided HF
Cardiac dysrhythmias
Respiratory failure
What would a chest x-ray look like for a COPD pt?
Often hyperinflation > flattened diaphragm + widely spaced ribs
Oxygen therapy for COPD
- SPO2 levels *
All hypoxic patients, including patients with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and bring SPO2 levels between 88-92%.
Anything above that can decrease respiratory drive.
What type of medications do we use for COPD pts?
Beta-adrenergic agents
Cholinergic antagonists
Methylxanthines
Corticosteroids
NSAIDs
Mucolytics
What type of breathing technique can we teach COPD pts?
pursed lip breathing
What is the diet for a COPD patient?
high protein & high calorie
A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following statements should the nurse include?
A. Take quick breaths upon inhalation
B. Place your hand over your stomach
C. Take a deep breath in through your nose
D. Puff your cheeks upon exhalation
C. Take a deep breath in through your nose
Seasonal influenza is a highly contagious acute viral respiratory infection. Sx include:
Rapid onset of severe headache, muscle ache, fever, chills, fatigue, weakness, anorexia.
What is the time limit for antiviral agents when treating seasonal influenza?
- Drugs end in -ivir *
24-48 hours
Not effective after 48 hours
When is seasonal influenza contagious?
Contagious between 24 hours before symptoms occur – 5 days after symptoms begin.
Isolation is key to prevent spread
What are the complications associated with seasonal influenza?
pneumonia & death
Supportive care for seasonal influenza
-Rest
-Increase fluid intake (take precautions with fluid restrictions)
-Saline gargles to reduce throat pain
-Antihistamines for rhinorrhea
Rapid influenza diagnostic test has high false-negative rates. Do you retest?
No, provide supportive care based on sx.
Pneumonia is caused by excess fluid in lungs resulting from inflammatory process.
What are some symptoms?
purulent sputum, fever, pleuritic chest pain
What should we see on a chest x-ray for pneumonia pt?
consolidation in lobes
What should we always monitor for pneumonia pts?
pulse ox and vital signs
Nursing care for pneumonia
Improve gas exchange
-Oxygen therapy, incentive spirometry
Prevent airway obstruction
-Cough and deep breathing exercises Q2 hours
-Fluid promotion to thin secretions
-Bronchodilators for bronchospasms
-Inhaled or IV steroids for inflammations
-Expectorants (guaifenesin)
Prevent sepsis
-Anti-infectives for bacterial sources
-Prevent aspiration
Prevent/manage empyema
-Antibiotic management
-Chest tube may be needed to promote lung expansion and drainage
What are two ways we can prevent pneumonia?
Smoking cessation and immunization
A nurse is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the nurse expect to be at risk? (select all that apply)
A. Client who has dysphagia
B. Client who has AIDS
C. Client who was vaccinated for pneumococcus and influenza 6 months ago
D. Client who is postoperative and has received local anesthesia
E. Client who has a closed head injury and is receiving mechanical ventilation
F. Client who has myasthenia gravis
A. Client who has dysphagia (risk for aspiration)
B. Client who has AIDS (immunocompromised)
E. Client who has a closed head injury and is receiving mechanical ventilation (risk for VAP)
F. Client who has myasthenia gravis (difficulty clearing secretions due to generalized weakness)
A nurse is caring for a client who, upon awakening, is
disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?
A. Obtain baseline vital signs and oxygen saturation.
B. Obtain a sputum culture.
C. Obtain a complete history from the client.
D. Provide pneumococcal vaccine.
A. Obtain baseline vital signs and oxygen saturation.
A nurse is caring for a client who has pneumonia. Assessment
findings include temperature 37.8 degrees Celsius (100 degrees F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and oxygen saturation 91% on room air. Prioritize the following nursing interventions.
A. Administer antibiotics
B. Administer oxygen therapy
C. Perform a sputum culture
D. Instruct the client to obtain a yearly influenza vaccine
B. Administer oxygen therapy
What is the most common substance to cause Pulmonary Embolus (PE)?
blood clots
Sx of PE
sense of impending doom, dyspnea, coughing up blood (hemoptysis), syncope
What will you see on diagnostic assessment for PE?
-obtain ABGS
-pulse ox
-D-dimer increased
-abnormal heart sounds/ECG
-systemic HTN
PE Lifestyle changes
No smoking, weight reduction, increased physical activity, DO NOT massage leg muscles
Name PE Priorities
-Hypoxemia (dead space unit)
-Hypotension (no circulation)
-Potential for bleeding with fibrinolytic therapy
-Anxiety (feeling of impending doom)
PE Treatment includes
-Oxygen, elevate HOB, comfort patient
-Anticoags/fibrinolytic
-IV fluids for hypotension –> vasopressors used if it persists
-Surgical management may be necessary
A nurse is reviewing prescriptions for a client who has acute
dyspnea and diaphoresis. The client states “ I am anxious an unable to get enough air.” Vital signs are HR 117/min, respirations 38/min, temperature 101.2 degrees F, and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority?
A. Notify the provider
B. Administer heparin via IV infusion
C. Administer oxygen therapy
D. Obtain a CT scan
C. Administer oxygen therapy
Acute Respiratory Failure
What is the problem with ventilatory (hypercapnic) failure?
-Physical problem of lungs or chest wall
-Defect in respiratory control center in brain
-Poor function of respiratory muscles, especially diaphragm
Acute Respiratory Failure
What causes ventilatory (hypercapnic) failure?
CNS depression, neuromuscular disorders
Acute Respiratory Failure
What is the problem with oxygenation (gas exchange) failure?
-Insufficient oxygenation of pulmonary blood at alveolar level
-Ventilation normal, lung perfusion decreased
-Right to left shunting of blood
-Ventilation/perfusion (V/Q)mismatch
-Low partial pressure of O2
-Abnormal hemoglobin
Acute Respiratory Failure
What causes oxygenation (gas exchange) failure?
Pneumonia, ARDS, pulmonary edema
Can you have combined? If so, what causes it?
yes, often occurs in patients with lung disease: Chronic bronchitis, Emphysema, asthma
Diseased bronchioles and alveoli cause oxygenation failure; work of breathing increases; respiratory muscles unable to function effectively.
Acute Respiratory Failure symptoms include:
*restlessness, irritability, and agitation
*Dyspnea
*Decreased responsiveness
*Confusion
*Increased dyspnea or decreased effort (especially in hypercapnic failure in patients with COPD)
End Tidal CO2 monitoring can help with what?
-In the OR for monitoring sedation
-Identifying rescuer fatigue in CPR
-Identify sepsis
What is refractory hypoxemia?
hypoxemia that persists even when 100% oxygen is given
What do we see on a chest X-ray in ARDS pt?
Dense pulmonary infiltrates on chest x-ray
What is the main site of injury in ARDS?
Alveolar-capillary membrane is main site on injury
-Increased permeability to larger molecules (debris, protein and fluid). Lungs are going to get stiff.
-Thick exudate inhibits gas exchange
What will vital signs shows in ARDS pt?
HTN, tachycardia, & dysrhythmias
ARDS pts require intubation and PEEP. What is PEEP?
Positive end-expiratory pressure, is a pressure applied by the ventilator at the end of each breath to ensure that the alveoli are not prone to collapse.
What are the three phases of ARDS?
Exudative phase
Fibrosing alveolitis phase
Resolution phase
What do we see during the Exudative phase?
Pulmonary shunting and atelectasis (alveoli becoming fluid filled). Appears as lung infiltrates on CXR. Pulmonary edema in the absence of heart failure. Inactivation of surfactant.
Presentation:
Acute onset
Dyspnea
Restlessness and confusion
Tachycardia
Diffuse crackles
Dry cough
What do we see during the Fibrosing alveolitis phase?
What complication are they at risk for?
Increased lung injury > pulmonary HTN and fibrosis. Decreased gas exchange and oxygenation.
MODS
What is happening during the Resolution phase?
Usually occurs after 14 days
Resolution of injury may occur or damage has resulted in chronic lung disease
Mortality rate very high if patient reached this phase
What do we need to do when an ET tube is placed?
Chest x-ray to verify placement
Assess for breath sounds bilaterally, symmetrical chest movement, & air emerging from ET tube.
What is assist control ventilation?
full support, tidal volume &respiratory rate are preset and mandatory breaths
Can cause hyperventilation
What is synchronized intermittent mandatory ventilation (SIMV)?
What is SIMV best used for?
Tidal volume and respiratory rate are preset, allows for spontaneous breaths at patient’s own rate.
Used when weaning off ventilator *
What is pressure support ventilation?
used for spontaneous breathing, no preset tidal volume
What are some noninvasive pressure support ventilation systems?
CPAP & BiPAP
What happens if the pt is bucking the vent?
sedate pt
What is the VAP Bundle?
-Elevation of the HOB between 30 and 45 degrees
-Oral care per facility policy (including antimicrobial rinse)
-Preventing aspiration
-Peptic ulcer disease prophylaxis
-Pulmonary hygiene (chest physiotherapy, postural drainage, turning and repositioning)
What are early signs of respiratory fatigue? What are late signs?
Early:
Mild dyspnea, Coughing, Inability to expectorate
Late:
Stridor > Requires immediate attention and treatment> Racemic epinephrine& monitor for possible need for reintubation. Obtain emergency reintubation materials at the bedside prior to extubating as a precautionary measure.
Extubation steps
Hyperoxygenate, suction the ET tube, deflate the cuff, remove, tell the patient to cough, administer O2 initially, remove sedation
Pulmonary Contusion occurs after chest trauma & inhibits gas exchange. Sx include:
Bloody sputum, decreased breath sounds, crackles, wheezes
How do we treat a pulmonary contusion?
Maintenance of ventilation and oxygenation
Rib fractures are often caused by direct blunt trauma to the chest. Chest usually not splinted by tape or other materials.
Uncomplicated rib fractures reunite spontaneously.
Focus is on pain management, why?
Decrease pain so that adequate ventilation is maintained
Encourage incentive spirometer
Flail Chest is r/t two or more rib fractures causing the chest wall to destabilize.
What will you see on assessment with flail chest?
Paradoxical chest movement—“Sucking inward” of loose chest area during inspiration, “puffing out” of same area during expiration.
What will you see on the assessment of tension pneumothorax?
-Asymmetry of thorax
-Tracheal movement away from midline toward unaffected side
-Respiratory distress
-Absence of breath sounds on one side
-Distended neck veins (r/t increase in central venous pressure)
-Cyanosis
-Hypertympanic sound on percussion
How do we treat tension pneumothorax?
chest tube to decompress the area and help lung expand
A nurse is assessing a client following a gunshot wound to
the chest. For which of the following findings should the
nurse monitor to detect a pneumothorax?
A. tachypnea
B. deviation of the trachea
C. Bradycardia
D. Decreased use of accessory muscles
E. Pleuritic pain
B. deviation of the trachea
Ventilation/Perfusion Mismatch- Normal unit, dead space unit, shunt unit, or silent unit?
Oxygenated blood is coming into lungs, there is ventilated alveoli
normal unit
Ventilation/Perfusion Mismatch- normal unit, dead space unit, shunt unit, or silent unit?
Physiologic – alveoli are ventilated but not perfused
Ex: PE, cardiogenic shock
dead space unit
Ventilation/Perfusion Mismatch- normal unit, dead space unit, shunt unit, or silent unit?
Pathologic – alveoli are perfused but not ventilated
Ex: pulmonary edema, pneumonia
shunt unit
Ventilation/Perfusion Mismatch- normal unit, dead space unit, shunt unit, or silent unit?
Absence of ventilation and perfusion; increased oxygen cannot correct this
Ex: pneumothorax, ARDS
silent unit
Oxyhemoglobin Dissociation Curve- percentage of oxygen at different pressures – based on tissues’ need for O2
Shift to the left means?
Tissues need less O2. Metabolism is slower than normal.
HoLds the O2
Oxyhemoglobin Dissociation Curve- percentage of oxygen at different pressures – based on tissues’ need for O2
Shift to the right means?
Need for O2 is higher in the tissues. Hemoglobin dissociates faster.
Releases more Readily
Pandemic influenza is prevalent among animals and birds. Virus can mutate and become infectious to humans.
Examples include H1N1 (swine flu), H5N1 (bird flu), MERS, SARS, COVID-19.
What type of precautions should be taken?
Strict isolation precautions- contact and airborne until specific type of pandemic influenza is identified w/ routes of transmission known.
What type of treatment is provided for pandemic influenzas
Treatment is often supportive:
-recover at home and avoid exposures
-encourage rest and fluids
-acetaminophen for myalgias
When should antiviral drugs be started for pandemic influenzas?
Antiviral drugs can be started within the first 48 hrs of symptom onset
*Oseltamivir (Tamiflu), zanamivir (Relenza)
