Final Weeks 1-7.5 Flashcards
Drugs used in caution with renal disorders
diuretics
antibiotics
NSAIDs
Kayexalate
Used for hyperkalemia to remove potassium by GI tract. Poops it out.
Monitor K levels
Don’t give to: patients with an ileus
Assess: BP, CHF, dig toxicity if taking digoxin, arrythmias, assess bowel function
Reglan
Phosphate binder, removes phoshorous.
Give with food so it can bind with food
Monitor phosphate and calcium levels
Addison’s Disease
Low hormone.
Weight loss
Na: Low
K: High
Hypovolemia
A/N/V/D
Hypotension
Anemia
Fatigue
TNIs: Assess VS, esp. BP, assess for fluid deficit
BP should be: LOW
Addison’s Crisis
Hypotension and shock
Cushing’s Syndrome
Too much hormone.
Truncal obesity
Thin skin
Moon face
Hirsuitism
Acne
GI upset/ulcers
Mood swings
Poor wound healing
Osteoporosis
Na: high
Water retention
K: low
Can’t fight infections
TNIs: assess VS, especially BLOOD PRESSURE, assess for fluid volume excess
BP should be: HIGH
Prednisone
GI symptoms/ulcers
Poor wound healing
Monitor: daily weights, I/O, s/sx of infection, temperature
Give with milk or food to decrease GI symptoms
Titrated to lowest effective dose
Teach not to d/c abruptly, must be tapered
If long term use: every other day dosing to decrease adverse effects
Solumedrol
GI symptoms/ulcers
Poor wound healing
Can be given: PO, IV, IM, PR, intra-articular (avoid SC)
Monitor: weights daily, I/O, s/sx of infection, temperature
Give with milk or food to decrease GI symptoms
One dose given in AM to prevent adrenal suppresion
Titrated to lowest effective dose
Teach not to d/c abruptly, must be tapered
Increase intake of potassium, calcium, vitamin D, protein
If long term use: every other day dosing to decrease adverse effects
Asterixis
Flapping tremors of hands/arms associated with hepatic encephalopathy (ammonia levels too high due to liver disease)
Fetor Hepaticus
musty, sweet odor on breath due to accumulation of digestive by-products associated with hepatic encephalopathy
TNIs Portal Hypertension
- Monitor for bleeding from varices
- Teach to avoid spicy/rough foods and activites that increase portal pressure (valsalva, sneezing, coughing, retching/vomiting) d/t risk of hemorrhage
- Teach to avoid aspirin, hepatotoxic OTC drugs, alcohol to avoid continued liver complications
TNIs Portal encephalopathy
- Monitor for behavioral/orientation changes, speech changes, blood pH, ammonia levels
- Limit physical activity (ammonia is a by-product of protein, exercise)
- Lactulose: po or pr ammonia detoxicant. Take on empty stomach, assess stool, monitor lytes
Spironolactone
Potassium SPARING diuretic.
Hyperkalemia is a side effect.
Asses: lytes
Give in AM with food if nausea occurs
Monitor: weights, I/O
Used with ascites
Liver Biopsy
Needle between ICS on right side with CT guidance
TNIS:
check coagulation status pre-procedure
Ensure blood is typed/cross matched
VS before, during, after
Ensure consent signed
Explain breath holding on expiration when needle is inserted (lungs deflated, liver in normal place)
Patient lies on R side for 2 hours to splint puncture site; then lie flat 10-14 hours.
Complications: hemorrhage, pneumothorax, shock, peritonitis
Paracentesis
Used for those with ascites with impaired respirations or pain
TNIs: teaching, informed consent, empty bladder, measure abdominal girth/weight. High fowler’s during procedure, sterile procedure, measure volume removed (750-1000mL), monitor site, bandaid to site, measure abdominal girth, weight, VS, monitor lytes, s/sx of infection.
Complications: intraperitoneal hemorrhage, perforation of organs, hepatic coma, peritonitis, hypotension/shock from rapid removal of fluid
Diet for Cirrhosis
High calorie (3000/day)
High carbs
Low to moderate fat
Sodium/fluid restriction if ascites/edema are present
Protein from animal sources, might be limited flare up of symptoms
Neonate RR
30-60
Infant RR
20-40
Retration location
Start at intercostals.
If increased effort is needed supra/infra clavicular seen
Children RR
15-25
Adult RR
12-20
What indicates hypoxia?
Agitation/restlessness
What indicates hypercapnia?
Lethargy/somnolence
FEV1
amount of air exhaled in the first second of a quick and forceful expiration that is done at the hospital
PEFR
maximal airflow during expiration. red, yellow, green zones. helpful in moinitoring bronchoconstriction in asthmatics
Ventilation/Perfusion Scan
used to check for presence of PE (not definitive, probable.)
TNIs: undress to waist, no metal, informed consent, check for allergies, void, explain procedure. Inhaled (ventilation) and injected (perfusion) isotopes – diminished radioactivity suggests lack of perfusion of airflow
Thoracentesis
used in pleural effusion r/t heart failure (fluid fills the pleural space, can cause infection) to diagnose, remove fluid or instill meds; sterile technique. Chest xray always performed after procedure to check for pneumothorax.
TNIs: signed consent, explain procedure, pain meds, baseline VS, position upright with elbows on overbed table, feet supported. Instruct not to cough or talk. Monitor vs and o2 sat. observe for hypoxia and pneumothorax afterwards. Verify breath sounds in all lung fields. Encourage deep breathing. Chest tube may be used for persistent pleural effusions instead of doing repeated pleural taps
The three problems with asthma
- bronchoconstriction
- increased mucus produciton
- inflammation
Asthma Triggers
allergens, resp infections, homrones, exercise, ASA, NSAIDs, beta blockers, food additives, air pollution, GI reflux, emotional stress
Status Asthmaticus
meds: controllers, rescuers, IV corticosteroids.
Focus on correcting hypoxemia and improving ventilation.
TNIs: frequent LOC assessments, O2 therapy, monitor VS, ABGs, IV fluids, possible SC epi, HOB up, prepare for intubation
Acute asthma attack TNIs
HOB 45 degrees, encourage incentive spirometer, monitor RR, ABGs, O2 levels, give O2, meds as ordered.
Teach to perform daily PEFR measurements, when to call the doctor.
Rescuers
Albuterol (MDI/NEB): bronchodilator. SE: increased HR, tremors, anxiety, restlessness, insomnia.
Atrovent (MDI, NEB): COPD, bronchodilator, anticholinergic. Dries up secretions. Not as rapid as albuterol. SE: anxiety, dizziness, HA, cough, N/A, bronchospasm
Controllers
Flovent (MDI) – asthma, corticosteroid. SE: thrush, URI, angioedema, bronchospasm. Rinse mouth after use.
Singulair (leukotriene blocker): asthma, bronchodilator. SE: dizziness, fatigue, HA, give in PM unless for exercise induced asthma.
Advair (DPI, beta 2 adrenergic), bronchodilator/corticosteroid): SE: tremors, anxiety, increased HR, thrush, bronchospasm
MDIs
shake well, slow inspiration, spacer can be used, often 2 inhalations per dose
DPIs
don’t shake, rapid inspiration, no spacer, often 1 inhalation per dose (ADVAIR)
Complications of COPD
cor pulmonale (right sided back up of fluid), secondary polycythemia, resp. failure, depression, anxiety, GERD/peptic ulcers (COPD patients may develop GERD because they tend to trap air in their chest cavities, which may then increase pressure on the abdomen, which leads to gastric reflux), acute exacerbations r/t respiratory infections
Hypercapnia (carbon dioxide necrosis)
increased PaCO2 levels with increased HCO3 levels and pH WNL.
This is a compensated state when chronic – may be asymptomatic unless other problems occur with the primary disease.
Assess VS, mental status, ABG before/during O2 treatment.
How often COPD patients perform pursed lip breathing?
8-10 reps, 3-4 X/day
COPD TNIs
- monitor RR, depth, effort, O2 sat,
- ABGs,
- ascultate breath sounds
- monitor client’s LOC
- lean forward if acutely dyspneic
- HOB up
- adequate hydration to liquefy secretions
- huff cough
- controlled deep breathing
- pursed lip breathing
- bronchodilator/oral care before meals
- high calorie/protein diet with supplements
- O2 NC during meals
Respiratory Acidosis
build up of CO2 causes carbonic acid to build up in the blood due to HYPOVENTILATION
S/Sx: HA, dyspnea, HTN, tachycardia, fine tremors, warm flushed skin
Associated with: COPD, ARDS, severe pneumonia, anesthesia, atelectasis, pneumothorax
ABG normals
pH: 7.35-7.45
pCO2: 35-45
HCO3: 24-30
pO2: 80-100
O2: 92-100%
Acid-base Regulation
- Buffer system: immediate change based on hydrogen ions in the body
- Respiratory system: in acidosis, INCREASE in respiratory rate and depth in an attempt to exhale acids
- Kidneys: takes hours to days but controls HCO3 by either reabsorbing or excreting hydrogen ions in urine
Uncompensated
pH is low
High PaCO2
Normal HCO3
Partial Compensated
pH is low
High PaCO2
High HCO3
Compensated
pH is normal
high paCO2
High HCO3
ARDS
acute respiratory failure where alveolar capillary membrane becomes damaged and more permeable to intravascular fluid
Respiratory Acidosis TNIs
correct underlying cause first, intubation, CPAP, BiPAP, O2,
med: bronchodilator, corticosteroid, Lasix (remove pulmonary congestion), antibiotics if infection
decrease in carbs in diet in patient who retains CO2, prevent infection
**assess LOC
maintain HCT/HBG (maximize O2 carrying capacity of blood)
pulmonary toileting to expectorate secretions
monitor CV status, resp status, ABGs, EKG, lytes
Epiglottitis
drooling, agitation, tripod position.
Do NOT use tongue depressor to examine throat – can cause bronchospasm.
Airway protection, corticosteroids, antibiotics.
Most dangerous for peds.
LTB (croup)
stridor, retractions, barking cough. Maintain airway, cool mist humidifier, nebulized epi, corticosteroids. Rest, fluids, monitor respiratory status.
Bronchiolitis
URI symptoms, mild fever, copious secretions (TNI: suction with bulb syringe), caused by RSV.
High humidity, rest, fluids, O2 if hospitalized, aerosolized ribavirin if severe.
Separate room, good hand washing, contact and droplet precautions if RSV (mask within 3 feet of patient)
If in mist tent, watch for hypothermia and change linens frequently (keep them dry); must be a dense fog, patient sitting up
Pneumonia
Common with COPD
fever, unproductive cough, rhonchi/crackles, exudates form in lung lobules. Antibiotics, O2, cool mist, fluids, rest, chest physiotherapy, antipyretics. Monitor VS, rsp status, avoid aspiration from frequent coughing, may require suctioning.
TB
early identification/treatment for suspected TB cases. Airborne isolation. Negative pressure isolation with protective respirators.
TB infection – latent disease.
TB disease: clinically active TB.
Miliary TB: standard precautions, in bloodstream but not in pulmonary system (no airborne precautions needed)
Isoniazid – antitubercular. Taken for six months, issue is compliance. Hepatic studies weekly: avoid triamines/antacids within 1 hour of med, no alchohol, no aluminum based antacids, no tyramine (chocolate, cheese) with meals, antiemetic, vision changes).
TB is no longer contagious after 3 negative AFBs, 2 weeks of meds, reduction of symptoms. Encourage adequate rest and nutrition, set up follow up care.
Anergy
lack of or diminished reaction to an antigen.
Common in older adults.
Booster Phenomenon
two tests done so second test may have a greater reaction, whereas a first test may have given a false negative.
Chest Physiotherapy
postural draining and percussion/cupping to move secretions into central airways for expectoration.
Done 1 hour before or 1-3 hours after meal
Give bronchodilator 15 minutes before
Watch for color changes, hypoxemia, mucous plug, Percuss over ribs only
Evaluate sputum, auscultate lung sounds.
Oxygen Tent
open tent as little as possible. Monitor temp inside tent to reduce hypothermia/cold stress. Keep child warm and dry, assess for air leaks in tent
Oxygen Hood
to deliver a high concentration of O2 to an infant. O2 can’t blow directly on child’s face, hood shouldn’t rub on neck, head, or shoulders
Mist Tent
to moisten airways, minimize fluid loss from lungs, liquefy secretions, allow for small to moderate O2 administration.
Monitor respiratory status, semi-fowlers, frequent temps, empty moisture chamber when full.
At least 10 mL/minute of air or O2 must be supplied at all times to prevent excessive CO2 accumulation
ETT
upper airway obstruction, apnea, high risk of aspiration, ineffective clearance of secretions, respiratory distress
Placement confirmed with CO2 detector (if no CO2, tube is in the esophagus)
Assess for bilateral breath sounds, symmetrical chest movement, monitor for tube placement every 2-4 hours
Secured with hydrocolloid membrane over cheeks to protect skin. Tube secured with tape to skin.
TNIs: HOB in semi fowelers unless medically contraindicated, avoid emesis (risk for aspiration), sedation, analgesic, anti-anxiety meds, provide frequent oral care to prevent VAP, provide alternative ways of communicating (picture boards, note pad, computer) inadvertent extubation: assess LOC, call for help and stay with patient, manually vent with 100% O2
Trach
to bypass upper airway obstructor, remove secretions, long term mechanical ventilation, permit oral intake and speech in the patient that requires long-term mechanical ventilation
TNIS: humidify inspired air because normal airway humidification through nose/mouth isn’t present.
Cuffed trach: for patient at risk for aspiration or on mechanical vent. Keep cuff inflated to maintain seal.
Uncuffed: no risk for aspiration, no mechanical vent, can speak with uncuffed trach
Inner/outer cannulas: to secure tube to faceplate, keep clean.
Speaking valve (passy-muir): cuff must be deflated, allows patient to speak. Removed for sleep.
Suctioning: preoxygenate with 100% O2 for 3-4 breaths, sterile technique, keep to less than 10 seconds, 2-3 times/session, suction 4-6 inches.
Trach Care
to prevent infection and occlusion of trach.
Leave obturator at bedside at all times in case of accidental decannulation.
Patient in semi fowelers: auscultate to see if suction needed
Clean inner cannula with hydrogen peroxide, then rinse with 4X4 soaked in sterile saline.
Don’t cut 4X4s.
maintain position of trach retention sutures.
Apply new ties before removing old ties to prevent accidental deccanulation of the trach. With tie changes, leave one fingerbreadth underneath
Hypoxemic Respiratory Failure
PaO2 less than 60 on 60% oxygen. ARDS, pneumonia, smoke inhalation, PE (others)
Causes of hypercapnic respiratory failure
Asthma
COPD
CF
V/Q mismatch in PE
in normal lung, ventilation/perfusion is 1:1. With PE, the embolus limits blood flow, but has no effect on airflow to the effect on airflow to the alveoli, causing V/Q mismatch
PE
sudden onset chest pain, dyspnea, hemoptysis, anxiety, tachypnea, tachycardia, LOC changes.
TNIs: prevent DVTs: hydration, SCDs/TEDs, early ambulation, prophylactic anticoagulants. HOB up, IV access, continuous SaO2 monitor, telemetry, LOC monitoring, O2 therapy, ABGs, mechanical ventilation, anticoagulation therapy, medication therapy.
Respiratory Failure TNIs
Treat underlying cause, HOB O2 therapy, continuous monitoring, possible bronchodilators, chest PT if applicable, fluids, med therapy (corticosteroid therapy), mechanical ventilation (later stages), fluids, monitor pulmonary/cardiac functioning, nutritional support with protein balance
BiPap
bilevel positive airway pressure (higher for inspiration, lower for expiration)
CPAP
continuous positive airway pressure
Tidal Volume
volume of air inspired/expired with each normal respiration
PEEP
positive end-expiratory pressure, positive pressure applied at the end of expiration to keep alveoli open in between respirations
FiO2
oxygen concentration.
from 21% (room air) to 100%
Mechanical vent TNIs
DO NOT TURN OFF VENT ALARMS!
Position patient for comfort and maximum alveolar ventilation, possible soft restraints to avoid accidental extubation, monitor respiratory status for any changes in respiratory effort, ABGs, continuous O2, maintain vent setting as ordered, nutritional/fluid support as ordered, provide frequent oral care, q 2-4 hours to prevent VAP (sedation vacation, high fowlers, peptic ulcer, DVT prophylaxis), suction only as needed with sterile technique, keep ambu bag connected to O2 source at all times, respond to vent alarms immediately – check the client first and then check the vent
