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
fluid and electrolyte extracellular space
- intravascular: fluid within blood vessels
- increased: increase BP and heart rate
- decreased: decreased BP and heart rate - Interstitial: surrounds cells
- increased: edema, crackles
- decreased: dehydration
concentration of solutes
Increase: blood increases, body released adh and urine gets concentrated
decrease: blood decreases, suppresses adh and urine is more dilute
osmolality
movement of water caused by a concentration gradient
lower solute concentration to area of increased solute
equalize solutes of concentration
osmosis
natural tendency of a substance to move from an area of higher concentration to one of lower concentration
ex: exchange between CO2 and O2
diffusion
the separation of a liquid from the undissolved particles floating in it
Kidneys
filtration
located in the cell membrane and actively moves sodium from the cell into the ECF
sodium potassium pump
movement of molecules across a cell membrane from a region of lower concentration to higher concentration in the direction against a concentration gradient
active transport movement
measures kidneys ability to excrete/conserve water
- 010-1.025
- larger volume of urine - lower specific gravity
urine specific gravity
end product of metabolism of protein
10-20
increase due to dehydration, fever, sepsis, diet
BUN
end product of muscle metabolism
0.7-1.4
best indicator of kidney function
creatinine
measure volume percentage of RBC in blood males: 42-52% females: 35-47% increase when dehydrated fluid overload --> decrease
hematocrit
assess volume status
200 meq/24 hrs
changes with no intake and change in fluid volume
used to diagnose hyponatremia and acute renal failure
urine sodium
Fluid and electrolyte balance
Functions:
Regulation of volume & osmolality
-decrease in kidney function, volume in body goes up and osmolality goes down
Regulation of electrolyte levels in the ECF
Regulation of pH of the ECF
Excretion of metabolic wastes and toxic substances
kidneys
Remove approximately 400ml of water daily via exhalation
Acid-base balance
What conditions increase the loss of water from lungs? coughing, rapid respirations
What conditions decrease the loss of water from lungs? Humidity - will decrease water loss
lungs
posterior pituitary gland body conserves water regulates volume and osmolality by conservation of H20 Increased=volume increase Decreased=volume decrease
pituitary: adh
Increased secretion: sodium retention & water retention
Decreased secretion: sodium & water loss; K+ retention
regulates Na and K values and regulates BP and fluid balance
adrenal: aldosterone
Renin-enzyme that converts angiotensinogen to angiotensin I
Angiotensin-converting enzyme (ACE) converts angiotensin I to II.
Angiotensin II-vasoconstrictor (increases arterial perfusion)
Aldosterone released when SNS activated because of increased renin in body
Aldosterone-regulates volume and will increase reabsorption of sodium & water-increasing plasma volume
renin angiotensin aldosterone system
Expand the ECF volume Expand intravascular space Use cautiously in patients with Hypertension Heart failure Types D5W-limited ability to expand intravascular volume - treat hypernatremia 0.9% Normal saline-remains in ECF Lactated Ringers-contains K+, Ca++ - fluid replacement: does have electrolytes so use for GI distress
isotonic
Provide Na, Cl, and free water
Treat hypernatremia
Types
0.45% NS
Use cautiously-can lead to intravascular fluid depletion due to a fluid shift
hypotonic
Increase ECF volume
Critical situations-hyponatremia
Administer slowly-can cause volume overload and pulmonary edema
Assess respiratory and BP
Types
3% NS
5% NS
Both are only administered in intensive care
hypertonic s
Loss of ECF volume exceeds the intake of fluid Water and electrolytes are both lost at the same proportion Causes Inadequate intake Vomiting Diarrhea GI suctioning Sweating Diabetes Insipidus Hemorrhage Third-space shifts
hypovolemia or fluid volume deficit (FVD)
Rapid weight loss Decreased skin turgor Oliguria (low urine output) Concentrated urine Postural hypotension (low bp when stand) Tachycardia Cool, clammy skin, dry mucous membranes Altered LOC BUN increased not in proportion to creatinine Hematocrit increased (rbc get suspended and hemoconcentrated) Electrolytes: Sodium and Potassium Urine specific gravity increased Urine osmolality increased
manifestations of hypovolemia
Oral fluids
IV fluids
Isotonic (0.9% NS or lactated ringers)
Rate & volume based on volume loss & hemodynamics
Assessment
I&O
What will the output be? decreased <30 ml/hour
What will the urine look like? very concentrated
Weights
Vital signs
Skin turgor
Mental status
Prevention
nursing management of hypovolemia
Expansion of the ECF
abnormal retention of sodium and water
Causes fluid overload heart failure renal failure cirrhosis: liver issue, decrease albumin and unable to excrete urine excessive salt intake
hypervolmia
Edema JVD Crackles in lungs Tachycardia, bounding pulse, S3 heart sounds Hypertension Increased weight Increased urine output Shortness of breath* very important BUN decreased Hematocrit decreased Urine sodium-increased Chest X-ray-pulmonary congestion
manifestations of hypervolemia
Diuretics
Hemodialysis
Sodium restriction and/or Fluid restriction
Assessment I & O Weight Lung sounds Edema
Prevention
Teaching: fluid/na restriction
nursing management of hypervolemia
keeps water in extracellular space
135-145
sodium
Salt loss that is greater than water loss Causes Diarrhea Diuretics NG tube suctioning manifestations -poor skin turgor -dry mucousa -headache -orthostatic hypotension -nausea
cause of hyponatremia
true salt loss / fluid volume deficit
Excess of water relative to total body sodium Causes CHF Cirrhosis Excessive H2O intake manifestations -edema -crackles -ascites -JVD
cause of hyponatremia
too much water / fluid volume excess
Neurological (especially when NA <115) Altered mental status Headache Lethargy Seizures * Coma
Due to water shifting from the ECF into the cell increased ICF volume cerebral edema
manifestations of hyponatremia
why are they?
-true sodium loss = give sodium in diet
-fluid overload = fluid restriction
neurologic symptoms? critically low; give 3%/5% NaCl slowly to prevent volume OD and monitor lung sounds
edema? sodium and fluids are restricted
early detection? I/O, daily weight, assessments, especially confusion with elder, monitor labs
nursing management of hyponatremia
More sodium than water
Causes Dehydration Enteral feeding with no water flushes Diarrhea Burns manifestations water shifts from ICS to ESC and leaves cell dehydrated, give hypotonic to make cell swell and decrease NA levels neurologic S/S: restless, weak, hallucinations in severe increased deep tendon reflexes thirst = first sign
hypernatremia
excreted via kidneys 3.5-5 98% is in cells 80% excreted via kidney, 20% excreted in stool poor renal function = trouble excreting
potassium
cause:
diuretics: especially Thiazide
diarrhea
vomiting
GI suction
NPO: poor nutrition (alcoholics/elderly) = low potassium
insulin: pushes potassium in ICF cell, not to the blood
hypokalemia
S/S: Fatigue Anorexia Nausea Vomiting Muscle weakness Leg cramps Arrhythmias* Decreased tendon reflexes
Replacement
- Oral
- IV….be careful b/c burns/hurts at site
- worse pain in PIH, less in Central
- Diet: bananas, leafy greens, milk, meats, pickle juice
Watch kidney function*
Assessment!
Cardiac-monitor for arrhythmias
Musculoskeletal-monitor for weakness
management of hypokalemia
Kidney function
Cardiac arrest
Causes
K+ sparing diuretics: Spironalactone (K paring)
Renal failure: dialysis to help excrete
Acidosis: move K out of cell into ECF and cause increase serum
-S/S: cardiac disturbances so watch EKG
hyperkalemia
S/S:
-cardiac disturbances
Restricting diet and K+ meds
Meds
Kayexalate: binds K in bowel and pts excrete it in the stool
Calcium Gluconate: regulates cardiac muscles –> lowers effects of hyperkalemia
Sodium Bicarbonate: give to acidosis pt: makes blood alkaline and pushes K back into cell
Regular Insulin: push K intracellular to lower K levels
Diuretics
Dialysis
Assessment
Cardiac
Muscle weakness
Labs
management of hyperkalemia
Transmits nerve impulses
Regulates muscle contraction and relaxation
Absorbed from foods, excreted in feces & urine
Inverse relationship with Phosphorous (so if Ph is up, Ca is down)
8.5-10.5
calcium
causes: Inadequate calcium intake Acute pancreatitis Medications Decrease in Vitamin D High phosphorous levels
S/S:
Tetany: muscle spasm, tingle on mouth, finger tips and feet. monitor through these tests
-Trousseau’s sign: pump BP all the way, fingers invert
-Chvostek’s sign: tap on facial nerve, twitch
-Chvostek’s Sign and Trousseau’s Sign due to Postoperative Acquired Hypoparathyroidism - YouTube
Seizures: b/c irritability of CNS and peripheral nerves
EKG changes
management of hypocalcemia
IV Calcium-slow (calcium gluconate to increase absorption of ca) Vitamin D Diet Seizure precautions Cardiac monitoring Calcium supplements Teaching Encourage exercise to strengthen bones
manage hypocalcemia
causes:
malignancy: 20% of pts with cancer have increases Ca –> tumor cells secrete PTH and that increases Ca
hyperparathyroidism
immbolization
hypercalcemia
S/S
Muscle weakness: lower tone in smooth muscle
Incoordination
Constipation, anorexia, nausea, vomiting *
Hypertension
Neurologic effects when Ca >16 (slurred speech, impaired memory, confusion, lethargy)
Treat underlying cause (tumor --> chemo) IVF to dilute calcium Furosemide: excrete ca Calcitonin: lower Ca level by increase urinary excetion and helps bones reabsorb Dialysis Increase mobility Encourage fluids Encourage fiber: help constipation Monitor for EKG changes
s/s management of hypercalcemia
1.3-2.3mEq/L, excreted by kidneys
Neuromuscular function
Cardiovascular system
-vasodilation: increase in mag and decrease in BP, causes alcohol withdrawal in hypo magnesium
magnesium
cause: alcohol withdrawal: NG suction, diarrhea Tube feed DKA: acidosis push mag back into cell and mag levels decrease s/s Muscle weakness Tremors Seizures Apathy Depression Agitation EKG changes- torsades de pointes, pvc’ NM diet, oral pills, IV slow assess swallow r/t muscle weakness, DTR (be hyperactive DTR) and teach
hypomagnesaemia
cause: renal failure b/c it's excreted in the kidneys and DKA s/s Hypotension Nausea, vomiting, weakness Lethargy dysarthria Loss of deep tendon reflexes Paralysis Respiratory depression, cardiac arrest when severely elevated nm: Discontinue all magnesium administrations Loop diuretics if renal function allows Dialysis
Assess vitals: BP
Assess cardiac & respiratory status: EKG continuous telemetry
Assess deep tendon reflexes: watch for loss
Assess neuro status
hypermagnesemia
2.5-4.5 mg/dL
Maintenance of acid-base balance
Structural support to bones/teeth
phosphorus
Causes Anorexia Alcoholism Heat stroke DKA Chronic diarrhea s/s Neurologic: irritability, fatigue, weakness muscle weakness: including respiratory NM: Phosphorous infusions -*Sodium phosphorus or potassium phosphorus
Assessment identify patient early Prevent infection: hypo can alter grandular sites Monitor labs Diet
hypophosphatemia
Causes Renal failure * Chemotherapy s/s: like decreased calcium seizures, lethargy(2 tests) nm: Phosphate binders Loop diuretics Dialysis Low phosphorus diet Recognize s/s of hypocalcemia Monitor urine output
hyperphosphatemia
97-107, produced in stomach, inverse relationship with bicarbonate
Found in interstitial fluid, gastric juice, sweat, bile, saliva
Maintains acid-base balance
chloride
Causes GI drainage Severe vomiting, diarrhea Any cause of volume depletion s/s: like hyponatremia, hypokalemia (they're lost with chloride) hypokalemia can cause hypochloremia (watch for cardiac arrhythmias) nm Normal saline Discontinue loop diuretic Diet
Monitor I&O: excess water Monitor ABGs: r/t acid base balance Monitor labs Vital signs Diet teaching
hypochloremia
Causes Related to hypernatremia, bicarb loss, metabolic acidosis Increased intake of chloride Hyperparathyroidism, renal failure s/s Tachypnea Weakness Lethargy Hypertension Usually also has a high sodium level and fluid retention nm Hypotonic IV solutions IV sodium bicarbonate Diuretics Restrict sodium, chloride and fluids
Monitor vitals- respiratory r/t fluid, hypertension, neurological r/t sodium
abgs, I&O
Assess respiratory, neuro and cardiac
hyperchloremia
