Exam 2 Flashcards
Common causes of impaired gas exchange (6)
Age
Smoking
Chronic and acute medical conditions
Brain injury
Prolonged immobility
Inhalation irritants
Diagnostics for Gas exchange problem (8)
- Chest X-ray (detect TB)
- CT Scan
- Pulmonary Function Studies (usually reduced in COPD and restrictive diseases, old age)
- Invasive (Bronchoscopy, laryngoscopy (larynx), mediastinoscopy (above sternum for tumors)
- CBC
- ABG
- sputum (negative after 3 months of TB treatment)
- BNP (rule out CHF)
Nursing Care and Patient education for Pulmonary Function tests (5)
- Explain purpose and procedure to reduce anxiety-induced dyspnea
- May need to withhold bronchodilators 4-6 hrs before the test
- Patient should not smoke 6-8 hrs before test
- Patient breathes through mouth (Nose clip to prevent air escaping through nose)
- Assess patient for dyspnea or bronchospasm after procedure
4 Types of Pulmonary Function Studies
Forced vital capacity (FVC)- max amount of air that can be exhaled as quickly as possible after maximum inspiration. (decreased)
Forced expiratory volume (FEV)- max amount of air exhaled (decreased)
Peak expiratory flow rate (PEFR)- usually decreased
FRC (functional residual capacity) - the amount of air remaining in the lungs after normal expiration. (increased w/ air trapping i.e. emphysema)
Purpose of Bronchoscopy (5)
- Diagnose and manage pulmonary disease
- Help place or change endotracheal tube
- Collect specimens
- Removal of secretions not cleared by normal suctions
- Stent placement (open up strictures in trachea and bronchus)
5 Potential complications after Bronchoscopy (and nursing care for each)
- hypoxemia (maintain airway; give O2; monitor vitals q15 monitor for first two hrs)
- aspiration (check for gag reflex (pt NPO till return), suction prn)
- bleeding (hemoptysis)
- infection
- bronchospasm (indicated by stridor
Preparation for Bronchoscopy (4)
- Explain procedure and verify consent given
- Document patient allergies
- Patient is NPO 4-8 hrs prior to procedure (and 2 hrs after until gag reflex returns) to prevent aspiration
- Benzos or opioids given for sedation
Bronchoscopy: Benzocaine
Use
Complication
s/s of complication (3)
Treatment of complication (2)
Use: topical anesthetic used cautiously to numb oropharynx
Complication: methemoglobinemia (conversion of hemoglobin to methemoglobin which does not carry oxygen so leads to tissue hypoxia)—less likely with lidocaine
S/s: cyanosis after topical anesthetic, no response to supplemental oxygen, blood is chocolate-brown color
Treatment: oxygen and IV of 1% methylene blue
Acute findings of Impaired Gas exchange (8)
Tachypnea
Tachycardia
Accessory Muscle Use
Paradoxical chest movement (in on inspiration, out on expiration)
Pursed lip breathing
Pale skin
Adventitious Breath Sounds
Mucus/secretions
Chronic problems of impaired gas exchange (4)
Cyanosis
Clubbing of nails
Barrel chest (emphysema)
Orthopneic
Normal ABG values
pH
CO2
pO2
HCO3
O2 sat
pH: 7.35-7.45
CO2: 35-45 mm Hg
pO2: 80-100 mm Hg
HCO3: 21-28 mEq/L
O2 sat: 95-100%
ABGs: What do the following present as?
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis: pH < 7.35; CO2 > 45
Respiratory Alkalosis: pH > 7.45; CO2 < 35
Metabolic Acidosis: pH < 7.35; HCO3 < 21
Metabolic Alkalosis: pH > 7.45; HCO3 > 28
COPD: Basic Pathophysiology - 2
Chronic Bronchitis: airway problem due to inflammation of airway after exposure to irritants
Pulmonary emphysema: alveolar problem where lung elastic tissue loses ability to recoil after stretching
Risk factors for COPD (3)
- cigarette smoking (esp 20 pack year)
- Alpha1-antitrypsin deficiency ( ATT is normally in lungs and inhibits excess protease activity so protease only breaks down pollutants and not lungs but w/o ATT, protease breaks down lungs)
- asthma
S/s of chronic bronchitis (5)
- bronchospasm
- copious sputum (leads to narrowed airways
- thin/wasted
- hypoxemia (low PaO2) and cyanosis
- clubbing
Complications of COPD (6)
- Hypoxemia (leads to polycythemia)
- Acidosis (r/t CO2 retention and hyperinflation)
- Respiratory infection (due to increased mucus; pneumonia and influenza vaccines important)
- Cor pulmonale (right sided heart failure due to pulmonary disease leads to right ventricular hypertrophy and backup of blood into venous system; S/s: dependent edema)
- Dysrhythmias (due to hypoxemia, drug effects, acidosis)
- Respiratory Failure
S/s of emphysema (7)
- hyperinflation of lungs (flattened diaphragm)
- tachypnea and dyspnea
- barrel chest
- orthopneic or tripod position (forward-bending posture w/ arms held forward)
- hypercapnia (due to uncoordinated breathing; respiratory acidosis)
- chronic hypoxia (leads to polycythemia i.e. increased RBC)
- breath sounds: wheezes or reduced if airflow obstruction
Anti-inflammatory drugs for COPD
Corticosteroids (Beclomethasone, Prednisone)
5 patient education points
- use daily b-c max effectiveness w/ 48-72 hrs of continued use
- Side effects: increase risk for infections (Candida albicans in mouth; URI if around people w/ one)
- avoid Risky activities (fragile BVs increase risk for bruising and petechiae)
- do not stop abruptly stop drug b-c it suppresses adrenal production of essential corticosteroids
- take with food to reduce risk for GI ulceration
Bronchodilators for COPD
SABA (albuterol) -1
LABA (arformoteral) -1
Anticholinergic (ipratropium) -3
SABA
- for acute relief
LABA
- for long term relief
Anticholinergic
- prevent COPD bronchospasm
- carry at all times
- S/s of overdose: blurred vision, eye pain, headache, nausea, palpitations, tremors, inability to sleep, dry mouth (increase fluids)
Other drugs for COPD
Mucolytics (Acetylcysteine, dornase alpha, guaifenesin) - 2
Oxygen - 2
Mucolytics (Acetylcysteine, dornase alpha, guaifenesin)
- thins secretions so easier to expectorate and cough up
- guaifenesin can raise cough threshold
Oxygen
- Usually oxygen flow of 2-4 L/min via nasal cannula or 40% via venturi mask
- ALL hypoxic patients should get oxygen therapy so SpO2 b/w 88-92%
COPD: nonpharmacological management of impaired gas exchange (5)
- Positioning (HOB elevated, orthopneic )
- Effective and controlled coughing ( scheduled coughing in morning, prior to bed, and at meals)
- Exercise conditioning (2-3 times a week of walking; resistive breathing, isocapnic hyperventilation machine)
- Suctioning (only if weak cough, pulmonary muscles or inability to expectorate)
- Hydration ( 2L of fluid a day)
COPD: Weight loss prevention (8)
- Collab w/ RDN for easy to chew and non-gas forming foods
- High calorie, high protein
- Plan biggest meal of day when pt most hunger and well rested
- 4-6 small, frequent meals preferred to 3 large meals
- Use breathing techniques and bronchodilators 30 minutes prior to meal to reduce bronchospasm
- Avoid dry foods that stimulate coughing
- Avoid caffeine that can increase urine output and lead to dehydration
- Avoid drinking fluids before or during meals if early satiety
COPD: Improving Endurance
Patient Education (5)
- Avoid rushing in morning b-c can increase dyspnea
- Use energy conservation (plan and pace activities for best tolerance and minimum discomfort i.e. divide activities into smaller parts)
- Avoid working w/ arms raised (raised arms reduce exercise tolerance b-c accessory muscles work to keep arms up instead of helping w/ breathing)
- Do not talk during activities requiring energy (walking)
- Avoid breath holding while performing any activity
COPD: Breathing Exercises
- Diaphragmatic/ abdominal breathing
- Pursed-lip breathing (2)
Diaphragmatic/ abdominal breathing
- Patient consciously increases movement of diaphragm while lying on back to relax abdomen
Pursed-lip breathing
- Mild resistance created by breathing through pursed lips to prolong exhalation and increase airway pressure
- Delays airway compression and reduces air trapping
Purpose of Pleural chest tube (3)
- Lung Re-Expansion
- Drains Air/Blood from Pleural Space
- Creates Negative Pressure
7 Nursing Care for patient w/ chest tube
- Inspect insertion site( eyelets of tube should not be visible; s/s of infection (redness, purulent drainage, excess bleeding))
- Palpate Insertion Site (may have subQ emphysema if puffiness or crackling
- Ensure Intact Dressing at Site
- Assess/reassess Respiratory Status (breathing, pulse ox, breath sounds)
- Observe Trachea (tension pneumothorax if shifted)
- Assess/reassess Pain (give meds and reposition)
- Encourage Cough, Deep Breathing, Incentive Spirometry
9 Nursing Care for chest tube system
- Avoid kinks, Occlusions, or Loose Connections (should be straight)
- Do NOT Strip/Milk Tubing
- Keep Drainage System Below Level of Chest
- Assess for “Tidaling” (water level rises inhalation and fall exhalation)
- bubbling seen on exhalation, forceful cough, position changes (EXCESS BUBBLING = air leak)
- Always have at least 2 cm of water to prevent air from returning to patient in water seal chamber
- Limit clamping of a chest tube b-c will increase pressure in pleural space and may cause tension pneumothorax
- No need to disconnect chest tube for transport
- never let drainage come in contact w/ tubes (can cause tension pneumothorax)
9 Emergency Situations w/ Chest tube
- Tracheal Deviation
- Sudden onset of increased dyspnea
- O2 sat <90%
- Drainage >70ml/hr (D)
- Visible eyelets on chest tube
- Chest tube falls out of the patient’s chest (first, cover the area with dry, sterile gauze)
- Chest tube disconnects from the drainage system (first, put end of tube in a container of sterile water and keep below the level of the patient’s chest)
- Drainage in tube stops (in the first 24 hours)
- Drainage bloody after a couple days (drainage is always bloody in first few hrs)
Mantoux skin test
Purpose
Procedure
Results
Purpose: screen for TB; diagnosis made w/ sputum culture
Procedure: intradermal injection read after 48- 72 hrs
Results: positive = induration (area of hardness) > 10 mm or > 5mm in immunocompromised
TB drugs: Isoniazid
Nursing Care (4)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use
- Avoid antacids
- take drug on an empty stomach (1 hour before or 2 hours after meals) to prevent slowing of GI absorption
- Teach patients to take a daily multiple vitamin w/ B-complex vitamins b-c drug can deplete the body of this vitamin.
TB drugs: Rifampin
Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use
- Warn patients to expect an orange-reddish staining of the skin and urine and all other secretions to have a reddish-orange tinge; also, soft contact lenses will become permanently stained
- Women w/ oral contraceptives need additional method of contraception while taking this drug and for 1 month after stopping it because this drug reduces the effectiveness of OCs
TB drugs: Pyrazinamide
Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use
- Drink at least 8 ounces of water when taking this tablet and Increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse.
- Photosensitivity (Teach patients to wear protective clothing, a hat, and sunscreen when going outdoors in the sunlight because the drug causes photosensitivity and greatly increases the risk for sunburn)
TB drugs: Ethambutol
Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use
- Optic neuritis at high doses ( Instruct patients to report any changes in vision (reduced color vision, blurred vision, or reduced visual fields) immediately to HCP)– Minor eye problems are usually reversed when the drug is stopped.
- Instruct patients to drink at least 8 ounces of water when taking this drug and to increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse.
risk factors for Diabetes (6)
- 1st relative w/ diabetes mellitus
- Age 45 years or older
- sedentary lifestyle
- Hx of vascular disease, PCOS, gestational diabetes, pancreatitis, Cushing Syndrome, or given birth to an infant > 9 lb
- Metabolic Syndrome (Central Obesity, Hyperlipidemia, Hypertension (uncontrolled), Hyperglycemia)
- Lifetime of high-carb, high-sugar diet causes insulin to tire out
S/s of hyperglycemia (10)
- Polyuria (due to glycosuria)
- Polydipsia (due to dehydration–s/s of dehydration: dry skin, rapid thready pulse, hypotension)
- Polyphagia (due to starvation– may have some weight loss)
- Fatigue
- kussmaul respirations (compensate for metabolic acidosis)
- fruity breath
- LOC changes (headache, seizures)
- ketonuria
- hot dry skin
- blurry vision
Expected Glucose levels (what indicates problem?)
Normal range
Fasting glucose
Oral glucose test
Rapid glucose check
Glycosated hemoglobin (HbA1C)
Normal Range (70-110)
Fasting plasma glucose (FPG) - greater than 126mg/dL (8 hrs. after fasting, can have water while fasting)
Oral glucose tolerance test (OGTT)- greater than 200mg/dL (2hrs after oral glucose test; pt fasts 10-12 hrs prior to test
Rapid glucose check - Greater than 200md/dL (Finger prick; no fasting required)
Glycosated hemoglobin (HbA1c) - Greater than 6.5 % (measures Average of blood glucose over 3 months, the lifespan of RBC b-c glucose binds to Hgb A)– target <7% for diabetic
Oral antidiabetes: Biguanides (Metformin)
Action (3)
Side effects (2)
Action:
- reduce glucose production by liver
- increase sensitivity to insulin
- delay carb absorption in intestines
Side effect
- GI effects (flatulence, anorexia, NV)
- lactic acidosis (caution in AKI– s/s myalgia, sluggishness, somnolence, hyperventilation)
Oral antidiabetes: Biguanides (Metformin)
Nursing Care (4)
Nursing care
- Take w/ food
- Take vitamin B12 and folic acid supplements
- Stop med 24-48 hrs before any radiographic test w/ iodine dye (restart 48 hrs after b-c can cause lactic acidosis from acute kidney injury
- Avoid alcohol which can increase risk for lactic acidosis
Oral antidiabetes: Sulfonylureas (Glipizide)
Action (2)
Side effects (2)
Nursing Care (2)
Action
- stimulates insulin release from pancreas to decrease blood glucose
- increase tissue sensitivity to insulin
Side effects
- hypoglycemia
- disulfiram effect (do not use alcohol)
Nursing care
- avoid with sulfa allergy
- give 30 minutes before mealsd
Non-insulin injectable: Amylin Analog (Pramlintide)
Action
Side effect
Nursing Care (3)
Action: suppress glucagon secretion to control postprandial rise in glucose
Side effect: hypoglycemia
Nursing care
- Give subQ right before any major meal
- Do not give if client hypoglycemia unawareness, noncompliance, or poor adherence to treatment regimen or SMBG
- Give 5 cm/ 2 in away from any insulin injection given at same time
SubQ Insulin: Rapid Acting (aspart, lispro)
Onset
Peak
Nursing Care (2)
Onset: 15 min
Peak: 30 min - 1.5 hr
Nursing Care
- used w/ longer-acting
- meal must be eaten at time of injection
SubQ Insulin: Short Acting (regular)
Onset
Peak
Nursing Care (2)
Onset: 30 min
Peak: 2-5 hr
Nursing Care
- covers insulin needs for meal within 30-60 minutes
- only insulin that can be given via IV (usually for DKA in ICU)
SubQ Insulin: Intermediate Acting (NPH, Novolin 70/30)
Onset
Peak
Nursing Care (3)
Onset: 1.5 hr
Peak: 4-12 hr
Nursing Care
- covers insulin needs b/w meals or overnight
- can be combined w/ rapid or short acting insulin (ALWAYS PULL UP SHORTER ACTING ONE FIRST TO AVOID CONTAMINATION)
- appears white and cloudy
SubQ Insulin: Long Acting (glargine, detemir)
Onset
Peak
Nursing Care (3)
Onset: 1-4 hr
Peak: none
Nursing Care
- give once daily at same time each day
- never mix with another insulin
- never give IV (always give subQ)
Insulin storage (3)
- Always have insulin on hand (esp if traveling)
- Can store at room temp for 30 days
- Can store longer in refrigerator
5 things to know before giving insulin
- Type of insulin plus onset, peak
- Blood glucose level
- Food that will be given
- s/s of hypoglycemia
- Always document site of injection
3 Complications of Insulin therapy (and prevention)
What are they?
How can it be prevented?
Hypoglycemia
- prevent w/ sliding scale checks
Lipoatrophy (uneven tissue) and Lipohypertrophy (lumps of fatty tissue)
- prevent by rotating sites within same area of body to also prevent change in absorption rates
Dawn phenomenon
- 5-6am rise in glucose due to cortisol release
- Prevention: Check blood glucose at bedtime and adjust insulin accordingly
Patient Education for Insulin pump (2)
- take off for baths and swimming
- change needle q2-3 days to prevent infection
Diabetic Neuropathy: Autonomic Symptoms (4)
Affects nerve conduction of
▪ Heart (exercise intolerance, painless MI, altered left ventricular function, syncope)
▪ GI (gastroparesis, reflux, early satiety) – promote motility w/ metoclopramide
▪ GU (urinary retention, decreased bladder sensation)
▪ Masks hypoglycemia and traditional indicators of heart attack (chest, back, or jaw pain)
Diabetic Nephropathy: Interventions (4)
- Report output < 30 mL/ hr
- Urinalysis, BUN, microalbumin, blood creatinine levels taken yearly
- Avoid soda, alcohol, and toxic levels of NSAIDs and acetaminophen
- Consume 2-3 L/day of fluid from food, beverages w/ artificial sweetener, and drink adequate water
Chronic Complications of Diabetes: Microvascular (6)
- Retinopathy (blurry vision -> blindness)- leading cause of blindness
- Nephropathy (kidney dysfunction and increased permeability)
- Neuropathy (nerve dysfunction)- Fingers, toes, feet; autonomic; Tingling, numbness, prickly
- Sexual dysfunction (Male- ED or retrograde ejaculation; Female- decreased libido, dyspareunia)
- periodontal disease
- integumentary disorders (infections, poor wound healing, patchy color changes, sclerosing)