Exam 2 Flashcards
Arterial Blood Gases
This is from the artery, after they draw hold pressure longer because it is an artery to prevent bleeding.
Respiratory Alkalosis
Increased pH (>7.4) and decreased PCO2, Increased loss of CO2 from lungs
Causes: Hyperventilation Anxiety High altitudes Pregnancy Fever Hypoxia Initial stages of pulmonary emboli
Manifestations: Seizures Deep, rapid breathing Hyperventilation Tachycardia Decreased or normal BP Hypokalemia Numbness and tingling of extremeties Lethargy and confusion Light headedness N/V
Respiratory Acidosis
Decreased pH (<7.4) and increased PCO2, Retention of CO2 by lungs
Causes: Hypoventilation Drug overdose Pulmonary Edema Chest trauma Neuromuscular Disease COPD Airway obstruction Respiratory Depression (Anesthesia, Overdose, Increased ICP) Decreased Alveolar Capillary Diffusion (Pneumonia, COPD, ARDS, PE)
Manifestions Hypoventilation-> hypoxia Rapid, shallow respirations Decreased BP Skin/mucosa pale to cyanotic HA Hyperkalemia Dysrhythmias due to increased potassium Drowsiness, dizziness, disorientation Muscle weakness, hyperreflexia
Metabolic Alkalosis
Increased pH (>7.4) and increased HCO3, Decreased acid or increase in base
Causes: Loss of gastric juices Potassium wasting diuretics Overuse of antacids Severe vomiting Excessive GI suctioning
Manifestations: Restlessness followed by lethargy Dysrhythmias (Tachycardia) Compensatory Hypoventilation Confusion (decreased LOC, dizzy, irritable) N/V/D Tremors, muscle cramps, tingling of fingers and toes Hypokalemia
Metabolic Acidosis
Decreased pH (<7.4) and decreased HCO3, Decreased ability of the kidney to excrete acid or conserve base
Causes: Renal Failure Severe Diarrhea Sepsis Shock Salicylate OD Diabetic Ketoacidosis
Manifestations:
HA, Decreased BP, Hyperkalemia, muscle twitching, warm flushed skin (vasodilation), N/V/D
Changes in LOC
Kussmaul Respirations
Low-Flow Oxygen Delivery Systems
Partial rebreather mask
Non-rebreather mask:
Ensure sufficient oxygen flow so the reservoir doesn’t collapse during inspiration
12-15 liters per minute is recommended
When applying non-rebreather do not forget to set the oxygen to 12-15 or it won’t function correctly
High-flow Oxygen Delivery System
Venturi mask Face tent Aerosol mask Tracheostomy collar T-piece
Thoracic Surgery
Preop: Education, patient on vent, foley, IV, chest tube.
Post-op: Check incision for drainage/bleeding
Pain magement: Monitor
Bleeding precautions/drainage: Monitor
They will have a chest tube, if you have 350 ml of drainage in 1 hour call the provider because that is too much.
Pleural Effusion
Patho: Excess fluid in the pleural space
Manifestations: Caused by underlying disease Determined by the size of effusion Compresses adjacent lung tissue causing: Dyspnea, pain, diminished/absent breath sounds, dull to percussion, limited chest wall movement
Medical Management:
Thoracentesis- Remove fluid from pleural space to obtain sample for analysis, restore lung to full volume, and relieve dyspnea, limit amount removed to 1200-1500 mL to prevent CV collapse
Thoracentesis
Pre-op:
Get consent signed
Assessment and education
Encourage pt to take cough suppressant before, don’t want them to cough or breath deeply.
Post-op:
Assess breathing
Look at insertion site for bleeding and drainage
X-ray to look for complications
Inform provider if they have trouble breathing, cough up blood, fever, chills, pain gets worse
Complications:
Pneumothorax, lung collapse, pain, bleeding, bruising, infiltration, infection
Acute Respiratory Failure
Sudden, life-threatening deterioration of gas exchange
PaO2 <60, PaCO2 > 50, pH < 7.35
Early Signs:
Restlessness, fatigue, HA, Dyspnea, tachypnea, tachycardia, HTN
Hypoxia progression:
Confusion, lethargy, tachypnea, central cyanosis, diaphoresis
Management: Intubation
Nursing Management:
-Intubation:
Hold patient still
HOB elevated 30 degrees to prevent aspiration
Oral care Q2-4 hours
Suction the patient as needed to clear the airway, do not suction on schedule!
Turn Q2 hours
Maintain ventilator
Assess LOC, ABGs, pulse ox, VS
Implement turning schedule, mouth care, skin care, ROM
Care of a patient with an Endotracheal Tube
-Immediate after intubation
-Extubation: Removal of endotracheal tube
Have self-inflating bag and mask ready, suction, remove tape, and deflate cuff
Give 100% oxygen for a few breaths, insert new, sterile suction catheter tube. Have patient inhale at peak inspiration remove the tube and suction the airway while the tube is pulled out
Tracheostomy
Harder to deal with because they aren’t sedated
Do trach care, they have a stoma
Trach care is once per shift, plus as needed
Suction as needed
DVT prophylaxis, HOB elevated, oral care
Assess skin around the trach
Check ABG
Mechanical Ventilation Nursing Management
Frequent assessment Assessment of ventilator equipment Promote effective airway clearance Promote mobility Promote coping Promote communication Prevent complications Participate in weaning: Monitor for respiratory distress to see if they can breath on their own
Acute Respiratory Distress Syndrome (ARDS)
Happens in the small part of the lungs
Manifestations: Pulmonary edema (pink and frothy fluid) Arterial hypoxemia does not respond to oxygen Severe SOB Labored, rapid breathing Confusion, fatigue Tachycardia/arrhythmia Low PaO2
Management: Intubation with PEEP Identify and treat underlying condition Circulatory/fluid support: Trat hypovolemia, hypotension without causing further overload Nutritional support (35-45 kcal/kg/day) Pharm: Inotropic, vasopressor agents Neuromuscular blockers, sedatives
ARDS Nursing Management
Close, ICU monitoring
- VS. pulse ox, ABGs
- Tracheostomy, suctioning, bronchoscopy
- Neuro: LOC
Positioning:
Oxygenation may improve in prone position
Rest is essential (limit oxygenation consumption)
Maintain Ventilator: PEEP: maintain gas exchange "fight" ventilator Sedative: midazolam NMBDs: pancuronium Ensure all alarms are on
Eye and oral care
VTE prophylaxis
Prevent foot drop, PUD, skin breakdown
Ventilator Bundle: HOB: elevated if not prone Daily oral care Turn patient Q2h Assess lips, restraint sites, and back of neck
Pulmonary Hypertension
Seen in patients with left heart disease, lung disease
-Dyspnea with exertion
Medications: Calcium Channel Blockers Prostanoids Endothelin Antagonist Phosphodiesterase-5 inhibitors
Nursing Management:
Identify clients who are at high risk (heart failure)
Admin O2 appropriately (90%), home oxygen teaching
Med Administration: Calcium channel blocker
Psychosocial support
ABGs
pH:
Below 7.35- acidic
Above 7.45- Basic
paCO2:
Above 45- Acidic
Below 35- Basic
HCO3:
Below 22- Acidic
Above 26- Basic
Mechanical Ventilation
Volume-cycled ventilators: Volume of air delivered with each inspiration is preset
Pressure-cycled ventilators: Deliver a flow of air until it reaches a preset pressure
Settings include rate, fraction of inspired air (FIO2), tidal volume, and positive end expiratory pressure (PEEP)
PEEP: when you breath out you get the air out, we want to save a little air in your lungs because that is easier for the air flow back in
Lung Cancer
Risk Factors: Smoking! People who live with smokers Exposure to radon Exposure to ionizing radiation Inhaled irritants (asbestos)
CM: Early Stage: -Remains local -None or vague symptoms -Initial symptoms attributed to chronic -Bronchitis
Late Stages:
- Metastasize: most likely to lymph nodes, bone, brain, and liver
- Symptoms relate to location and spread of tumor
- May present with symptoms related to primary tumor, manifestations of metastatic disease, or with systemic symptoms
Pulmonary:
- Chronic cough or change in cough
- Blood or rust colored sputum (hemoptysis)
- Change in respiration pattern
- Dyspnea, wheezing
- Swelling of neck, face
- Chest, shoulder, or back pain that does not go away and gets worse with deep breathing
- Dull, aching, pleuritic pain
- Recurring episodes of pleural effusion, pneumonia, or bronchitis
Non-Pulmonary: -Fever -Hoarseness -Dysphagia Late signs: Weight loss Anorexia Fatigue Weakness Bone pain Confusion Lethargy Personality change Clubbing of fingers/toes
Diagnoses:
- Chest X-ray: pulmonary density, pulmonary nodule, atelectasis, and infection
- Diagnoses 1st evidence of disease
- Fiberoptic bronchoscopy
- CT scan of chest: Small nodule, Lymphadenopathy
- Thoracoscope: Need biopsy, under CT guidance to obtain cells or tissue
- PET scan to identify metastasis
Grading and Staging of Lunch Cancer
Done to assess size and extent of tumor
TNM Grading
T=Tumor Size
N= Lymph node involvement
M= Metastasis
Staging I-IV
Stage I: small, localized, and usually curable
Stage II and III: Cancers typically are locally advanced and/or have spread to local lymph nodes
Stage IV: usually metastatic and considered inoperable
Treatment of Lung Cancer
Prevention of lung cancer must be the primary goal. Encourage smoking cessation.
Pre-op:
- Note history of smoking, cardiac and respiratory disorders, and other chronic disorders
- Provide emotional, psychological support
- Instruct about post-op procedures: respiratory therapy, breathing exercises, coughing techniques
- Establish a way to communicate if endotracheal tube planned post-op
Post-op: -Hemorrhage, assess drainage from chest tubes and report excess bleeding >70 ml/hr -Respiratory Therapy: Critical for recovery Cough/deep breathing/splinting IS every 1 hr while awake Monitor O2 sats Oxygen delivery/mechanical ventilation Pain management Activity plan
Chemo:
-Fresh flowers and fresh plants not in room, limit raw fish and meat.
-S/E:
Anorexia, loss of taste, aversion to food
Erythema, painful ulcerations in GI tract (mucositis)
N/V/D
-Alopecia
-Bone Marrow Suppression: Neutropenia, anemia, thrombocytopenia
Radiation:
Best used in combo w/ surgery or chemo
Treatment of choice if surgery is not feasible
Treatment Goals: curative, palliative- shrink tumor, pre-surgical treatment to debulk tumor
Nursing Management:
- Manage side effects such as dyspnea, fatigue, N/V, and anorexia
- Relieve breathing problems
- Reduce fatigue
- Provide psychological support: anticipatory grieving
- Pain management
Pneumothorax
Air accumulates in the pleural space, can cause lung collapses
CM:
- Pain, pleuritic chest pain, dyspnea, SOB, tachycardia, tachypnea
- Asymmetrical chest wall movement, diminished or absent breath sounds
- Hypotension, Shock
- Distended neck veins
Treatment: Chest Tube: -Air removed through upper tube -Blood removed through lower tube -Connect to drainage collection device with or without suction
Nursing Interventions:
Monitor Client
-Assess VS and resp. status q 4 hours and pain
-Palpate surrounding area for crepitus or SC-air
-Check and record drainage
-Encourage frequent cough and deep breathing
-Use IS
Monitor drainage system
-Secure to avoid dislodgement
-Never clamp or disconnect
-When full, do not empty. Connect a new system
-When transporting, keep drainage system below client’s chest and disconnect system from suction source
Ischemic Stroke
Blockage of an artery to the brain (blood clot), no O2 to the brain
Clinical Manifestations:
B: Balance; Dizziness, loss of balance, or coordination
E: Eyes; Sudden trouble seeing out of one or both eyes. Vision changes or disturbances
F: Face; Facial weakness, uneven smile
A: Arm; Weakness, unable to raise both arms
S: Speech; Impaired, slurred, difficulty repeating simple phrases
T: Be fast!! Respond Fast
-Sudden severe headache
Assessment: First ask the last time the patient seemed fine or was seen well!!
Medical Management: PREVENTION IS KEY!!
Thombolytic Therapy: Use of IV tPA= dissolves the blood clot.
-Give w/in 60 minutes of pt arriving to ED
-Must be given within 3 hours of onset of symptoms
-Max dose 90 mg
-10% of dose given bolus over 1 min, the rest given IV over 1 hour
-BP should be less than 180/105
-Do not give anticoagulants for 24hrs
Endovascular Therapy: Large IV cath grabs and takes out the blood clot
National Institutes of Health Stroke Scale (NIHSS)
- 0 indicates normal performance
- > 25: Very severe neurological impairment
- 5-14: Mild to adequately severe neurological impairment
- < 5: Mild impairment
Transient Ischemic Attach (TIA)
-Last 1-2 hours
-Manifestations;
Sudden loss of motor, sensory, or visual function
-Warning sign of impending stroke
Ischemic Stroke Nursing Interventions
Improving Mobility and Preventing Joint Deformities
- Put pillow in axilla to prevent shoulder adduction
- Hand in slight supination
- Splint to support wrist and hand
- Botox injections for spasticity
- Change positions Q2H, limit time on affected side, prone for 15-30 min/day
- Passive exercises and ROM to affected extremities 5x/day
- Maintain sitting and standing balance, use parallel bars and cane
Prevent Shoulder Pain:
- Never lift or pull the flaccid shoulder
- Sling when first ambulating
- ROM exercises
- Pharm therapy
Self-Care:
- Encourage independence in person hygiene activities
- Set realistic goals
- Use assistive devices
- Add new task each day
Adjusting to physical changes:
- Keep items and approach patient on unaffected visual side
- Increase lighting in environment
Nutrition:
- Swallow assessment
- Consult speech therapy
- Diet thickened liquid/pureed food
- Aspiration precautions
- Enteral tubes
Attaining bladder/bowel control:
- Intermittent caths
- Voiding schedule
- Provide high-fiber diet and adequate fluid intake for constipation
Improve Thought
Processes:
-Multidisciplinary (neuropsychologist, primary provider, psychiatrist)
-Provide support – give positive feedback, convey an attitude of confidence and hope
Improve communication:
- Consult speech therapy
- Provide atmosphere/environment conducive to communication
- Maintain consistent schedule, routine, and repetition
- Use of a communication board
- Allow time for patient to process and do not complete their thoughts or sentences
Maintain skin integrity
- Frequent skin assessments
- Use of a specialty bed
- Provide regularly turning schedule
- Minimize shear and friction forces when moving
- Keep skin clean and dry
Improve Family Coping:
- Encourage family participation in patient’s care and setting goals
- Provide resources for counseling and support groups
- Remind that the rehab process can be slow and long
- Maintain a supportive and optimistic attitude
Monitor and manage potential complications;
- Increased ICP
- Pneumonia
Hemorrhagic Stroke
Loss of function resulting from bleeding on the brain
Manifestations:
- Severe HA
- N/V
- Sudden Change in LOC
- Visual disturbances
- Tinnitus
- Dizziness
- Seizure
- Hemiparesis
- Same as ischemic stroke
Diagnoses:
- CT scan
- Cerebral angiography
- Transcranial Doppler Ultrasound
Concerns:
- Cerebral Hypoxia
- Vasospasm
- Increased Intracranial Pressure (ICP)
Medical Management:
- Allow brain to recover from initial insult
- Prevent/minimize the risk of rebleeding
- Prevent/treat complications
- Best rest, sedation, prevent agitation/stress
Treatment of ICP:
- CSF drainage
- Mannitol
- Elevate HOB 30 degrees
- Avoid hyper/hypoglycemia
- Sedation
- Hypertonic solutions
- Adequate oxygenation with supplemental O2
- Maintain hemoglobin/hematocrit
- Adequate hydration (IVF)
Treat HTN:
- Lower BP
- Antihypertensive (Nicardipine, Labetalol, Hydralazine)
- Hemodynamic monitoring
Treatment of vasospasm: (subarachnoid hemorrhage)
- Nimodipine- calcium channel blocker
- Triple H Therapy: induced hypertension, hypervolemia, and hemodilution
