exam 2 Flashcards
Respiratory complications=life threatening complications
Priority
What are common nursing diagnoses?
ineffective airway clearance
impaired gas exchange
eneffective breathing pattern
resp complications
Cessation of breathing while sleeping due to upper airway obstruction
Interferes with ability to get adequate sleep
What else will this affect?
judgement, mood, weight, mental clarity (confusion, difficultly concentrating)
obstructive sleep apnea - upper airway
At least 5 obstructive events / one hour of sleep –> hypoxia & hypercapnia –> sympathetic nervous system response
What can cause obstruction?
-Reduced diameter of upper airway or continuous changes in airway
Leads to HTN, MI, CVA, death, arrhythmias, vascular disease
More prevalent in patients with CAD, CHF, metabolic syndrome, DM
-Men
-Older
-Overweight
-Structural changes (inflamed tonsils or airway)
osa patho
tachycardia, restlessness, anxious, tachypnea, sweating, cold and clammy
sympathetic nervous system response
Snoring Breathing cessation for 10 sec or longer, 5 episodes or more/hour, abrupt awakening, blood oxygen levels drop Need a sleep study + clinical symptoms to diagnose Treatments weight loss oral appliances CPAP BIPAP (more inspiration than expiration)
s/s and treatment of osa
CPAP
Positive pressure that keeps the alveoli open
Keeps the upper airway and trachea open during sleep
Patient must be able to breathe on own
BIPAP
Provides pressure support ventilation
2 different levels of positive airway pressure
Inspiratory
Expiratory
Used for severe COPD, severe sleep apnea
Hard to tolerate
CPAP and BIPAP
Monitor skin - break down & pressure ulcers
Monitor for dryness of nasal passages, nasal congestion
Education
On OSA
On cpap/bipap, oxygen
On weight loss
Avoid alcohol, sedatives
nursing management for cpap
Abnormal accumulation of fluid in the lung tissue and/or alveolar space
Due to fluid in alveoli, gas is not exchanged hypoxemia
Manifestations
Respiratory distress
Anxiety
Frothy sputum - when air mixes with fluid leaked from aveoli, froth forms
Confusion
What will lungs sound like?
CXR-interstitial fluid
Tachycardia - sympathetic ns/ fight/flight increases heartrate
Decreased oxygen saturations
pulmonary edema
lower resp tract
Fix the underlying problem!
Oxygen-what form of oxygen may be needed?
Morphine-vasodilator, reduces preload - preload: volume in ventricles at end of diastole (diastole = resting of heart)
Vasodilators - dilate and reflex
Inotropic medications-increase contractility and this increases cardiac output
Diuretics
pulmonary edema treatment
Inflammation of the pleurae Caused from Pneumonia, URI, TB, chest trauma, PE, cancer Severe, sharp pain worse on inspiration Patients will often hold their breath or breath shallow to decrease the pain Treat underlying cause Analgesics Anti-inflammatory medication Steroids
Pleurisy
Pleural effusion-collection of fluid in the pleural space
Complication of
Heart failure - due to poor pump –> backflow
TB
Pneumonia
Viral infections
PE
Tumors
Empyema-collection of pus like fluid within the pleural space (this is a type of pleural effusion)
pleural effusion and empyema
Can be clear fluid, bloody fluid, purulent fluid
The size of the effusion will determine the severity of symptoms
Dyspnea
Fever, chills, pain, cough
Patient will have decreased or absent breath sounds over the effusion
Tracheal deviation
Hypoxemia
Hypotension
Tachycardia
pleural effusion
Must find underlying cause of effusion Relieve dyspnea Thoracentesis - needle in chest -Removes fluid -Ultrasound -Blind -- need to assess BP due to fast removal of fluid Chest tube Surgery What is the nurse’s role? Baseline assessments, immobilize, keep still, sit up, document fluid appearance/amount, set up equipment
pleural effusion management
Sudden life-threatening deterioration of gas exchange
PaO2 <50 mmHg on RA
PaCO2 >50 mmHg, pH <7.35
Ventilation/perfusion mismatch: area in lung that receives blood flow or no oxygen or oxygen with no blood flow
*respiratory failure increases CO2, ven/perfus mismatch
acute respiratory failure
Manifestations Restlessness Fatigue Dyspnea Headache Tachycardia Tachypnea Cyanosis Management Intubation - for vent/perfus mismatch - give high concentration of oxygen Mechanical ventilation Assess patient: what focused assessment is PRIORITY? - respiratory: work of breathing Monitor O2 sats continuously Assess vital signs Assess underlying event
acute respiratory failure
Obstruction of the pulmonary artery or one of it’s branches by a thrombus
Starts somewhere in the venous system or the right side of the heart
3rd leading cause of death in hospitalized patients. WHY? due to being immobile. Puts you at risk for DVT and PE so use SCD’s
What leads to PE?
Trauma
Arrhythmia (atrial fibrillation): irregular heart rate: ventricles pump, atria quivers, doesn’t pump like they should and blood pools - admin anticoagulant
Surgery
Pregnancy
Heart failure - inadequate pump pumping good blood flow –> risk for clots
Prolonged immobility
pulmonary embolism (PE)
Thrombus obstructs pulmonary artery or branch –> decreases alveolar dead space –> impaired gas exchange
Clot causes vasoconstriction in surrounding bronchioles and blood vessels –> surfactant decreases –> atelectasis and hypoxemia
Increased pulmonary artery pressures increase workload on heart –> right ventricle fails –> decreased cardiac output –> hemodynamic instability
pulmonary embolism (PE) pathophys
Manifestations Acute dyspnea Chest pain Cough Hemoptysis - coughing up blood/sputum Palpitations Tachypnea Crackles Tachycardia Often associated with DVT….so what other physical assessment will you be looking for? - came from somewhere so check legs for swelling, redness, warmth in calf *severity S/S depends on size/location of embolism
pulmonary embolism
Chest X-ray ABGs Doppler studies Spiral or contrast angiogram CT scan (contrast: 1. pt with kidney failure can't do this b/c it goes through kidneys 2. allergy to contrast dye/shell fish) What patients cannot have CT scan? D Dimer to detect clotting
pulmonary embolism (PE) diagnostic tests
Must prevent DVT! Leg exercises Ambulation TEDS/SCDs Look at pg. 304 table 10-3 Meds Heparin SQ Enoxaparin Arixtra
prevention of PE
This is an emergency! So give Oxygen and Treat hypotension (due to decreased cardiac output)
-IVF, vasopressors, inotropic medications (give fluids)
Monitor EKG
Heparin-IV: look at PTT to ensure PTT is therapeutic. If it is then they’re blood is where we want it to be
Thrombolytics-if hemodynamically compromised
-Alteplase (TPA: clot buster; give if pt is hemodynamically compromised: low BP, increased heart rate)
Inferior vena cava (IVC) filters
management of PE
Assess Control pain Manage oxygen Relieve anxiety Monitor vitals Monitor for complications
PE: potential complication is right side heart failure - look and prepare for this
nursing management of PE
ADPIE and ABCs
Either parietal or visceral pleura punctured positive pressure enters pleural space lung collapses
Three types
Simple
Traumatic
Tension
Pneumothorax
Also called spontaneous
Can happen in ‘healthy’ people
Also happens with emphysema or pulmonary fibrosis
simple pneumothorax
Air escapes from a laceration in the lung and enters pleural space or when air enters the pleural space through a wound in the chest wall
Blunt trauma
Penetrating trauma
Diaphragm tear
Lung biopsy
Insertion of subclavian line - they could have nicked it
Barotrauma from mechanical ventilation pressure on chest
Often will result in hemothorax (blood fills pleural space)
traumatic pneumothorax and reasons for it
Tension pneumothorax-air into pleural space that cannot escape. This will create a build up of positive pressure and will decrease the venous return to the heart
This is life threatening! Both respiratory and circulatory issues will occur.
Patient will experience immediate shortness of breath
Cardiac output will decrease and cardiac arrest can occur
- PEA: pulseless electrical activity: on heart monitor it looks good, but when you assess them they’re dead (no pump or squeeze)
Trachea will shift toward unaffected side-late sign
What is this called?
Tension pneumothorax
Pain Shortness of breath Respiratory distress Anxiety Increased use of accessory muscles Tracheal shift (tension pneumo) Decreased breath sounds/absent breath sounds on affected side Cyanosis
pneumothorax manifestations
Chest tube
Needle decompression - emergency needle decompression: blind stick between ribs into pleural space to drain and allow pressure back in
Nursing management
Respiratory assessment
Oxygen assessment
Assess tracheal alignment
pneumothorax management
Chest trauma
-MVA
Often leads to respiratory issues
Often results in tension pneumothorax
chest trauma
Used to drain fluid or air
Restores negative pressure needed to re-expand the lung
Suction-will generally see dry suction used at CHI
Gravity
Tidaling: increase with inspiration and decrease with expiration
-No tidaling means 1. lung rexpanded/fixed so take chest xray to verify 2. chest tube stuck on wall so xray to verify
chest tubes
Subcutaneous emphysema-air enters the tissues under the skin
Crackling “rice krispies” - can feel/see if it’s bad enough - edema is affected airway or xray
Will spontaneously resolve when air leak stopped
chest tube - subcutaneous emphysema
crepetis and subcutaneous air all mean it too
Monitor pain level
Assess respiratory status
Assess oxygen levels
Assess chest tube! look for crepitus, air leak, drainage
Monitor dressing for bleeding and s/s of infection
Monitor for crepitus
Assess insertion site of chest tube
Document! What should you document? All that and is it to gravity/suction, tidaling, location, drainage
What if it accidentally comes out? Cover with occlusive dressing*
Maintain tube patency
Keep below chest level
Do not kink or clamp without MD order
Why? never clamp/kink it due to positive pressure and backflow
chest tube nursing management
Fluid and electrolytes for intracellular space
2/3rd body fluid
increase concentration of potassium, magnesium and phosphorus
inside the cells
