Exam 4 Flashcards
Bronchoscopy
Direct visualization of bronchi with a fiber optic bronchoscope, Need: informed consent NPO status vital signs Assess labs Remove dentures Prepare suction equipment Begin IV/administer sedative Emergency equipment available
Lung biopsy
purpose to obtain tissue, cells, or secretions for evaluation Transbronchial approach Percutaneous or Transthoracic needle Video-assisted thoracic surgery (VATS) Open lung biopsy (surgery)
Transbronchial Approach or Transbronchial Needle Aspiration
Obtain consent, NPO, Sensation of pressure may be felt during needle insertion and aspiration
Monitor VS
Apply dressing and monitor for drainage or bleeding
Monitor for signs of respiratory distress/notify MD
Monitor for signs of pneumothorax/notify MD
Thoracentesis
Used to obtain pleural fluid for diagnosis, remove pleural fluid, or instill medication
Epistaxis
Nose bleed pinch nose and lean slightly forward
Causes:
Trauma Foreign bodies topical corticosteroid use Nasal spray abuse Street drug use Anatomic malformations Allergic rhinitis tumors
Any condition that prolongs bleeding time or alters platelet counts
If it does not stop pack it or get nasal sling
Acute Pharyngitis
Acute inflammation of pharyngeal walls which may include the tonsils, palate, and uvula.
Can be caused by Bacteria Virus Fungus
Acute Bronchitis
Most common symptom- cough (10-20 days) Clear mucus Headache Malaise shortness of breath on exertion sometimes low-grade fever Chest discomfort
Diagnosis: chest xray or history
Acute bronchitis treatment
Usually self-limiting
Treatment supportive: fluids Rest Anti-inflammatory agents
Cough suppressants & bronchodilators for nocturnal cough or wheezing Humidifier or steam in bathroom
Antibiotics only if prolonged infection associated with systemic symptoms
Antiviral drugs (oseltamivir-Tamiflu) if started within 48 hours of onset of infection
Pneumonia
Acute Inflammation of one or both lungs caused by microorganisms
Pneumonia results when the defense mechanism become incompetent or overwhelmed by the virulence or quantity of infectious agents
Can reach lungs by aspiration inhalation of microbes from air or hematogenous spread from other place in the body
Clinical manifestations of pneumonia
Fever, chills, or sweats Respiratory rate greater than 20 Heart rate greater than 100 Crackles heard on auscultation; dullness with percussion Chest discomfort Dyspnea Rusty colored sputum Cough Fatigue, muscle aches, headache, nausea
Atypical pneumonia
Pneumonia that manifests with a more gradual onset, a dry cough, and extrapulmonary manifestations (fever, headache, sore throat, nausea, vomiting, and diarrhea
Labs and diagnosis of pneumonia
Chest x-ray Sputum gram stain and culture CBC ABG Blood cultures
More H+ =
decrease PH- acid
Less H+ =
Increased PH - base
normal arterial blood PH
7.35-7.45
PH lower than 6.8 and higher than 7.8 are
fatal
pCO2 normal level
35-45, controlled by the lungs
pCO2 higher than normal is ____ lower is _____
acidosis, alkalosis
HCO3 normal level
22-26, controlled by the kidney
HCO3 higher than normal _____ lower is _____
alkalosis, acidosis
buffer system
acts immediately, acts chemically to change strong acids into weaker acids or to bind acids to neutralize their effect, first line of defense at the cellular level to buffer excess acid or base
decrease PH Increased acid= ____ K
increase
increase PH increase alkaline = ____ K
decrease
hold pressure for ___ minutes after ABG
5
ROME
respiratory opposite metabolic equal
If uncompensated or partially compensated
the pH remains outside the normal range
If fully compensated
the pH has returned to within the normal range (the other values may still be abnormal)
Complications of hypertension
Blindness stroke mi heart failure kidney failure
Cultural diffderences for hypertension
Hypertension is increased in African Americans
Hypertension affects African American females more than African American males
Hypertension in Whites and Hispanics is more prevalent in males than in females
African Americans acquire hypertension at a younger age and are more at risk for hypertensive kidney disease.
The highest rate of hypertension in the United States occurs among African Americans living in the southeastern states
How to prevent and control hypertension
Healthy weight Reduce sodium intake Increase physical exercise Limit alcohol Monitor B/P and know what is normal Take medication as directed
For bp to rise
CO or SVR must increase
Primary hypertension
90-95% of all cases, unknown cause
Risk factors for primary hypertension
Age alcohol cigarette use diabetes excess sodium or fat diet elevated lipids gender family history obesity ethnicity sedentary lifestyle socioeconomic status stress
Secondary hypertension
Elevated BP with a cause that can be identified and corrected, people over 50 that suddenly have high BP
Causes of secondary hypertension
Cirrosis , congenital narrowing of the aorta , endocrine disorders medications, pregnancy induced, renal disease, sleep apnea
Clinical manifestations of hypertension
Often called silent killer (asymptomatic)
Patient with severe hypertension may experience symptoms secondary to: effects on blood vessels in various organs, increased workload of heart
Symptoms may include: Fatigue, reduced activity tolerance, Dizziness, Palpitations, Angina, Dyspnea, Headache
Complications of hypertension
Heart Disease (Coronary Artery Disease Heart failure)
Cerebrovascular Disease
Peripheral Vascular Disease
Retinal damage
Diagnostic studies of hypertension
Because most HTN is primary, testing for secondary causes is not routinely done
Basic lab studies are performed to: identify or rule out causes of secondary HTN, evaluate target organ disease, determine overall cardiovascular risk, establish baseline levels before initiating therapy
U/A, BUN, creatinine, serum electrolytes
Lipid profiles
DASH diet
Dietary approaches to stop hypertension,Rich in grains, fruits, vegetables and low fat dairy products
Limits fat, saturated fat, cholesterol, and salt
Dietary sodium reduction
A low sodium food should contain less than 140 mg/serving or less than 5% of daily allowance of sodium
Foods with more than 400 mg of sodium/serving should be avoided
Read labels for sodium content
It takes 2-3 months for the taste buds to adapt to changes in salt intake
Drug therapy for hypertension
Diuretics, Beta-blockers, ACE inhibitors, ARBs, Calcium channel blockers
Two main actions:
decrease volume of circulating blood
Decreases systemic vascular resistance
Orthostatic hypotension
Orthostatic hypotension (if any of the following occur from supine to standing position)
A decrease of 20 mmHg or more in SBP
A decrease of 10 mmHg or more in DBP
Increase in heart rate of greater than or equal to 20 beats/min
Causes
Intravascular volume loss
Inadequate vasoconstrictor mechanisms related to disease or medications
Hypertensive crisis
Severe and abrupt elevation in systolic and/or diastolic B/P.
Occurs most commonly in patients: with a history of HTN who have failed to comply with their meds, those who have been under medicated
Also cocaine or crack amphetamines phencyclidine (PCP), and lysergic acid diethylamide (LSD)
Less damaging (hypertensive urgency) no evidence of organ damage developed over days to weeks
Hypertensive emergency
More damaging, Classified by the degree of organ damage and the rapidity with which the B/P must be lowered, develops over hours to days, is a situation in which a patient’s B/P is severely elevated (systolic greater than 180 & diastolic greater than 120) with evidence of: acute target organ damage, Stroke, Change in level of consciousness, Heart attack, Eye or kidney damage, Angina, Pulmonary embolism
Serious manifestations of CAD
Unstable angina (UA) ,myocardial infarction (MI), and SCD (sudden cardiac death) are more serious manifestations of CAD termed acute coronary syndrome (ACS)
Coronary artery disease
A type of blood vessel disorder that is included in the general category of atherosclerosis
Begins as soft deposits of fat that harden with age
Referred to as “hardening of arteries”
Modifiable risk factors of CAD
Hyperlipidemia, Hypertension, Tobacco use, Physical inactivity, Obesity
Contributing factors: Metabolic syndrome, Psychological state, Homocysteine level, Diabetes Mellitus, Periodontal disease, Sleep apnea
Risk factors in women for CAD
Premature menopause birth control pills hormone replacement therapy
Therapy for CAD
Cholesterol-lowering drug therapy, Antiplatelet therapy, Low dose aspirin (81 mg.)
Garlic, Niacin, Psyllium, Omega 3 Fatty acids, Plant sterols, Red yeast rice, Soy, Stress management
Chronic stable angina
Angina pectoris (chest pain) is the clinical manifestation of reversible myocardial ischemia, Primary reason for insufficient blood flow is narrowing of coronary arteries, For ischemia to occur the artery is usually obstructed 75% or more
Therapy for chronic stable angina
Drug therapy (NRS 255): Antiplatelet therapy, Cholesterol lowering drugs, Nitrates (NTG), Beta blockers, Calcium channel blockers, Reduction of risk factors
Precipitating factors of angina
Physical exertion, Temperature extremes, Strong emotions, Consumption of a heavy meal, Tobacco use, Sexual activity, Stimulants, Circadian rhythm patterns
Acute intervention for anginal shock
Administration of supplemental oxygen & upright position unless contraindicated, Assess vital signs, 12-lead ECG, Prompt pain relief first with a nitrate followed by an opioid analgesic if needed, Auscultation of heart sounds
Diagnostic studies of stable angina
Health history/physical examination, Laboratory studies, CK-MB, Cardiac troponin, Myoglobin, Lipid panel, CBC, Chest x-ray, Exercise stress test, holter monitoring (recordes electrical activity), echocardiogram (ultrasound waves), coronary angiography, PTCA
PTCA percutaneous transluminal coronary angioplasty
Can be done with a balloon or stent, opens area occluded by plaque
Heart failure
An abnormal condition involving impaired cardiac pumping and/or filling, Heart is unable to produce an adequate cardiac output (CO) to meet metabolic needs
Heart failure risk factors
Primary risk factors: Coronary artery disease (CAD), Advancing age
Contributing risk factors: Hypertension, Diabetes, Tobacco use, Obesity, High serum cholesterol, African American descent
Systolic heart failure
characterized as a weakened heart muscle
Diastolic heart failure
stiff heart muscle making ventricular filling difficult
The heart attempts to compensate for its inability to pump efficiently by
Increasing the rate of contractions
Increasing the size and strength of the ventricular muscle (hypertrophy)
Increasing the capacity of the ventricle (dilation)
Left-sided HF
(most common) from left ventricular dysfunction
Backup of blood into the left atrium and pulmonary veins Pulmonary congestion Pulmonary edema
Right-sided HF
Backup of blood into the right atrium and venous systemic circulation Jugular venous distention Hepatomegaly, splenomegaly Vascular congestion of the GI tract Peripheral edema
Treating CHF: UNLOAD FAST
Up right, Nitrates, Lasix, Oxygen, Ace inhibitors, Digoxin, Fluid decrease, After load decrease, Sodium restriction, Test like Dig ABG potassium
HF diagnostic studies
Primary goal is to determine underlying cause: History and physical examination, Chest x-ray, 12 lead ECG, Lab studies (e.g., cardiac enzymes, BNP- B-type natriuretic peptide; liver function studies), ABG, liver enzymes Endomyocardial biopsy (EMB), Hemodynamic assessment, Echocardiogram, Nuclear stress testing, Cardiac catheterization, Ejection fraction (EF)
Drug therapy for HF
Diuretics (hydrochlorothiazide; HydroDIURIL), ACE inhibitors, ARBs, Vasodilators, Beta adrenergic blockers, Positive Inotropes (digoxin), Digitalis toxicity-anorexia, nausea, vomiting, visual disturbances (yellow vision)
Digoxin immune Fab (Digibind)
Acute Decompensated Heart FailureClinical Manifestations
Pulmonary edema (lung alveoli become filled with fluid) often life-threatening
Early: Increase in the respiratory rate Decrease in PaO2
Later: Tachypnea, Worsening blood gas values
Acute Decompensated Heart FailureClinical Manifestations of Pulmonary Edema
Anxious, pale, possibly cyanotic Cool, clammy skin
Orthopnea, Dyspnea, tachypnea, Use of accessory muscles; distended jugular veins, Cough with frothy, blood-tinged sputum, Breath sounds: Crackles, wheezes, rhonchi, Tachycardia, Hypotension or hypertension
MAD DOG pulmonary edema treatment
Morphine, Aminophylline, Digitalis, Diuretics, Oxygen, blood Gases
Ultrafiltration (UF)
removes extracellular and intravascular fluid volume
Chronic HF FACES
Heart Failure Society of America (HFSA) F—fatigue A—limitation of activities C—chest congestion/cough E—edema S—shortness of breath
