Exam 2 Pulmonary part 3 Flashcards
Pneumonia interventions/nursing care
- Elevate bed to 45 degrees
- Incentive spirometer: 10x every hour
- Hydration
- Coughing and deep breathing
- Repositioning patient
- Nutrition: small frequent meals
- Auscultate lung sounds
Tuberculosis diagnosis criteria
- Induration of 10 mm or greater diameter = positive for exposure
- Induration of 5 mm = positive in those with decreased immunity
Tuberculosis drug therapy
Combination drug therapy with strict adherence:
- Isoniazid
- Rifampin
- Pyrazinamide
- Ethambutol
Tuberculosis management
- Airborne precautions in the hospital
negative pressure room
N95 masks
Remains in isolation until there are 2 consecutive negative sputum cultures - Home care
Not in isolation since exposure has already occurred
family needs testing
Acute Respiratory Failure: Ventilatory failure etiology
- Musculoskeletal or anatomical lung dysfunction or suppression
- Airway pressure does not change enough to allow air movement in and out of lungs
Acute Respiratory Failure: Oxygenation Failure etiology
- Breakdown of O2 transport from the alveolus to the arterial flow
Acute Respiratory Failure: Ventilatory failure diagnosis criteria
- V/Q mismatch:
air movement inadequate/perfusion ok
ABGs:
PaCO2 > 45 AND pH < 7.35
SaO2 < 90%
Respiratory acidosis
Acute Respiratory Failure: Oxygenation Failure diagnosis criteria
- V/Q mismatch:
air movement adequate/perfusion is decreased
ABGs:PaO2 < 60 mm Hg
SaO2 < 90%
PaCO2 34-45 Normal
Acute Respiratory Failure: Combined ventilatory and oxygenation failure etiology
- Both ventilation and perfusion are inadequate
- abnormal lungs
Acute Respiratory Failure: Oxygenation management
- Supplemental oxygen
Invasive/non-invasive - Minimize oxygen consumption
Sedation
Neuromuscular paralysis
Acute Respiratory Failure: ventilation management
Mechanical ventilation
Acute Respiratory Failure: pharmacologic management
- Bronchodilators
Beta2 agonists
Anticholinergics - Steroids
- Sedation
- Analgesics
- Paralytics
Acute Respiratory Failure: Complications
- Hypoxia complications
Anoxic encephalopathy
Cardiac dysrhythmias - Ventilator complications
DVT (SCDs, heparin)
GI bleeding (PPI)
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) Pathophysiology
- Injury to the pulmonary vasculature or the airways which results in noncardiac pulmonary edema and disruption of the alveolar-capillary membrane.
- Activation of neutrophils and macrophages, and release endotoxins
- Release mediators Tumor necrosis factor, Interleukin 1, proteases
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) etiology: direct injury
- Pulmonary contusion
- Gastric aspiration
- Near drowning
- Inhalation injuries
- Some infections
- Radiation
- Oxygen toxicity
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) etiology: indirect injury
- Septicemia
- Shock, prolonged hypotension
- Nonthoracic trauma
- CABG
- Drug overdose
- Head injury
- Pancreatitis
- Diabetic coma
- Multiple blood transfusion
- Fat embolus
- Amniotic fluid embolus
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) Diagnostic criteria: Mild
PaO2/FIO2 of 201-300 mm Hg with PEEP or continuous positive airway pressure (CPAP) of 5 cm H2O or greater.
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) Diagnostic criteria: moderate
PaO2/FIO2 of 101-200 mm Hg with PEEP of 5 cm H2O or greater
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) Diagnostic criteria: Severe
PaO2/FIO2 of 100 mm Hg or less with PEEP of 5 cm H2O or greater.
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS): Phase 1
- Exudative phase
First 72 hours after injury
Mediators are causing injury to pulmonary capillaries
Increased capillary membrane permeability
Development of microemboli
Increased pulmonary pressures, but PAOP can remain low or normal
Results in interstitial edema, alveolar edema
Type I and Type II cells are damaged, leading to alveolar collapse
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS): Phase 2
- Fibroproliferative phase
Disordered healing begins
Cellular granulation, collagen deposition
Fibrotic alveoli, pulmonary capillaries scarred
Increased stiffening and increased pulmonary HTN
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS): Phase 3
- Resolution phase
Structural and vascular remodeling
Restoration of the alveolus
Macrophages remove debri
Type II cells multiply & some convert to Type I
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS): Phase 4
- Late or Chronic ARDS
- Permanent lung damage common
- Problems may include cough, limited exercise tolerance and fatigue.
- Anxiety, depression and flashback memories of their critical illness
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) mechanical ventilation treatment
O2 at the lowest level needed
FIO2: Goal SaO2 90 with FIO2 <65%
Mode: Assist Control Allows vent to do most the work
Pressure Control for worsening ARDS
Tidal volume
Smaller tidal volumes with higher respiratory rates
6-10 ml/kg
PEEP: Recruits collapsed alveoli, decreases pulmonary shunting and improves gas exchange
Decreases venous return, Barotrauma
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) Treatment
- Inverse ratio
- Permissive hypercapnea
- Pressure control ventilation
- Inhaled nitric oxide
- Partial liquid ventilation
- ECMO
Acute Respiratory Distress Syndrome (primarily oxygenation problem) (ARDS) complications
- Severe dyspnea, using accessory muscles
- Dry cough
- Altered LOC, restlessness, anxiety, confusion
- Lung expansion reduced
- Vocal fremitus increased
- Increased density from diffuse pulmonary edema
- Bronchiovesicular BS over most lung fields
- Adventitious sounds-diffuse crackles over all lung fields
Pulmonary embolism risk factors/etiology
Virchow’s triad:
- Hypercoagualbility
- Injury to vascular endothelium
- Venous stasis
Pulmonary embolism treatment/management
- O2
- Positive Inotropic drugs, fluids
- Systemic Thrombolytic Therapy
- Anticoagulation therapy
Heparin IV drip - Pulmonary Embolectomy
- Prophylaxis:
Anticoagulation:
Greenfield Filter: Umbrella shaped filter placed in inferior vena cava to catch traveling blood clots from lower extremities.
Chest trauma: Tension pneumothorax
- Air admitted in pleural space through rupture in lung or hole in chest wall.
- Flap of tissue in lung or hole acts as flutter valve allowing air in and not out.
- Pressure in pleural space increases
Chest trauma: Hemothorax
- Collapse of lung due to blood in pleural space
- Chest trauma, complication anticoagulant therapy, lung malignancy
Flail Chest
- Caused by fractured ribs
- Leads to chest wall instability
- Results in opposite chest movement with respirations
- Prevents adequate ventilation of injured area
Chest tube nursing care
- No stripping, gentle milking “only” if needed
- Monitor for air leak
- Observe for excessive bloody drainage
- Monitor q 15 min for first 1-2 hours
