Lower Resp, Tb & Trauma Flashcards
What is TB caused by?
And what does it mainly infect?
Mycobacterium Tuberculosis
Lungs
If you heart and lungs are not working, what happens?
Nothing is working
Remember lungs -> effect cardiac
cardiac not working -> lungs effect
What is the ultimate goal worldwide from TB?
The eradication of it
Most of the time we like to selective screening programs to help detect TB, but why do we do this?
Because there are some high risk groups and social determinants
What are some risk factors for TB?
Give some example
Homeless
Foreign born persons
IV injecting drug users
The best measure of peripheral perfusion??
Test question
Urine output
The reason is because the first thing to stop when your heart is pumping well, urine/renal decreased
Test question
What is the best method to show that peripheral perfusion has improved ?
Increased Urine output!!
Test question
If your patient is on a proton pump inhibitor, what is the best measure that it’s being effective?
( remember this is used for ulcers )
Lack of blood in stool !!
( occult blood )
Why do we do ADPIE?
Because it’s effect and can help us understand the patient better than like a lab
Edema
Where is it when laying in bed?
If they are standing ?
Sacral
Feet
Aorta arch and ascending aorta
Where is the lack of perfusion going to be at?
Lower abdominal aneurysm?
Concerned for the perfusion of upper extremities
Lower extremities lack of perfusion
What does the pulse ox measure?
Measures the % of hemoglobin that has oxygen attached to it
If you have blood loss, half of your hemoglobin what happens to you perfusion ?
But your lungs work fine, what’s your pulse ox?
Normal 100 hemoglobin = 100 pulse ox
100 hemoglobin but not all picking up oxygen = 80 pulse ox
Bleeding but lungs are fine = 100 pulse ox
It decreases it because it loses the hemoglobin
It’s gonna be 100%
What is the first thing you will see when someone is not perfusing well?
They are gonna be agitated ( yelling at you, get out of bed )
If you see this, think of perfusion
See a change into agigated think of oxygenation
If your patient has respiratory issues, what position are we gonna do?
Sit them up
Assess their respiratory status
( vital signs, listen to lungs )
If your patient is gonna die, ignore assess and take care of their distress
Who do you talk to when a patient is at risk for aspiration?
Speech therapist
Nursing assessment and interventions by body system
Following flashcards
Before anything we want to collect a history about a patient,
Give example to what things we want to ask about patients?
Signs and symptoms
A baseline
Prior health history
Medications
Past surgeries
Family history
Recent exposure
Cardiac / peripheral perfusion nursing assessment
What are some things we will do to help assess cardiac on a patient?
Capillary refill
Level of consciousness
Skin color ( remember pink !! )
Urine output is your best friend !!!!
Labs
Auscultations breathe sounds
Drains
JVD assessment
Heart rate
Blood pressure
Pulses = bilaterally assessment
( expect neck )
What is the main lab we want to be looking at when it comes to the heart?
Potassium!!
H&H as well as
What are the pulses associated with the ascending aorta and aortic arch? (3)
Carotid
Radial
Temporal
What are the pulses associated with the descending aorta? (4)
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Vasospams and hypothermia can cause what?
Absense of lower extremity pulses
When edema is a concerned we want to assess the 6Ps which are?
Pain
Pulseleness
Paresthesia
Paralysis
Pallor
Poikilothermia ( cold )
Nursing assessment of respiratory
What should we be doing?
Are they using accessory muscles? Flaring? Retractions?
Positions
Color
Clubbing in fingers
Symmetry
Pulse ox
Lungs
Agitation
Fluid status
What is some nursing assessment of GI?
Abdominal shape
Bowel sounds
Stool character
Aspiration risk
Knowing diet
Early feeds
Stress ulcers
What are some nursing assessment of neurologic status?
LOC
PERRLA - pupils equal round reactive light accommodation
EOM - eyes of motion
orientation
Quality of speech
Facial symmetry
Infection
The biggest thing to know with infection if that some patients, mainly those who are elderly and immunosuppressive they will?
Not present with a fever :(!!
Before you give an antibiotic, you want your make sure the patient doesn’t have a blood culture order first as to why?
It can effect the results
Back to the original presentation of respiratory
How is TB spread?
Airborne ( droplets )
If someone has TB, is it a reportable thing?
Yes, it’s a very serious health condition
We do a skin test, how do we identify as positive for TB?
Normal
immunocompromised
Remember it’s by the size not the color
10mm more + =for normal people
Less than 10mm = negative
5mm + HIV = positive
When doing a skin test, what is the time frame we can read the thing?
Too early or too late doesn’t count and you have to redo the thing
48-72 hours
What’s the vaccine for TB?
What if someone has this vaccine and get a skin test what can happen?
BCG vaccine
TB test usually come out positive on the skin test ; questionable
If a patient comes out positive for a skin test, what’s the next step?
Chest x-ray and symptom screening
If a patient is positive with a skin test for TB but negative on chest x-ray, what does that mean?
Latent TB
If you have latent TB, remember no symptoms, it can become ACTIVE!!
How so
Simply change in symptoms
What is latent vs active TB differences?
Latent
- no symptoms
- not contagious
Active
- symptoms
- contagious
What’s the problem of treating TB?
The resistance is insane
People get tired of taking medication and just simply don’t like the meds
The problem of people not taking their TB meds resulted in what?
DOT
Directed observed therapy
These people come in and watch them take their medications every single day
Can TB he spread by touching, sharing food utensils, kissing or other physical contact?
No
What’s the typical symptoms of active TB?
Fever
Weight loss
Night sweats
Tired
Cough
What’s an acutely ill symptoms of TB?
High fever
Productive cough
Crackles
Adventitious breath sounds
Remember if you are immunosuppressive, what if you get TB?
You are less likely to have a fever and die quicker
What is miliary TB?
Bloodstream to distant organs
Other complications
NOTES
can get bacterial meningitis
Peritonitis
All from having TB
What is the TB test called?
Tuberculin skin test (TST)
What is the blood work for TB?
Interferon release assays - screening tool
Can not be effected by BCG vaccine
What is the gold standard of TB?
How many samples?
To be considered negative they what?
How long does it take to get results?
Do we treat them still?
The sputum culture
3x at 8 to 24 hours intervals
No TB in the cultural
6 weeks
Yes, treat them as they have active TB
What is the 4 medications to remember of Tb we use to treat?
RIPE
rifampin
Isoniazid
Pyrazinamide
Ethambutol
What is the INH side effects? (4)
Do you take with foods or no food?
How do we treat one of their symptoms?
Photosensitivity
Tinnitus
Peripheral neuropathy
Hepatotoxicty
No food, empty stomach
Treat peripheral neuropathy with vitamin B6 ( pyridoxine )
All the 4 TB meds can effect your what?
So what do we do?
What do we tell them to avoid (2)?
Liver
Get them base line of liver
Tyneol & alcohol
What do we tell patients with ethambutol?
What do we do before hand?
Teach them to do what? (2)
Damage to eye causing blurred or changed vision
Eye exams
Sunglasses and call doctor of vision changes
What do we tell patients about rifampin?
What about female patients ?
Every fluid in your body will be orange !!
Oral contraceptives will become ineffective, another form of birth control is needed
Do we tell patients with TB to take meds everyday or stop when they feel better?
YES!!
KEEP GOING!!
Oral preparations may be given with meals to reduce GI upset stomach however we recommend patients to taken them what?
1 hour Before or 2 hours after
Two phases of active TB
first phase ( how long and how many drugs )
Second phase
( how long and how many meds )
8 weeks to 3 months
4 meds
18 weeks
2 meds ( INH & rifampin )
Sensitivity test determines drugs
For active TB
initial 4-5 meds for at least 6 months
What are they ^ (4)
Continuation ?
How many and how long
Notes
Two new drugs used in combination therapy?
2 first line meds - fluoroquinolone & injectable antibiotic & 1 more second line
4 drugs for 18-24 months
Bedaquiline (sirturo)
Delamanid (deltyba)
Treatment for LATENT TB?
How long?
They also are on what?
HIV patients ?
INH
6-9 months
Vitamin b6
Usually they are on it longer
When a patient is active TB, what do we do in the hospital?
Nurse mask what do we wear?
Transport patient with TB, what mask?
Single room with 6-12 airflow exchanges/hour
N95
Surgical mask
Chest trauma and thoracic injuries !!
Flashcards !!
What are the 2 types of chest trauma ?
Blunt
Penetrating
What is blunt chest trauma?
Appear minor externally
There is no hole or bruising at first
But severe internally injury
What is penetrating chest trauma?
Examples?
Open wound through the pleural space
Knife, gunshot wound, shape objects
What is the main thing you do for emergency management?
ABC
Airway
Breathing
Circulation
After you establish their airway, we want to do what after a major management ?
Two large bore IV sites
Because of cardiovascular collapse is a big concern
Airway, breathing, stop the bleeding
Two large bore IV sites !!
Big stuff first then other injuries
What is the most common ribs to break?
5-9
What happens or one of the concerns to why people with brokes ribs end up getting?
Atelectasis -> pneumonia
Because they don’t wanna take deep breaths because it hurts!
What are the clinical manifestations besides fractured ribs? (4)
Pain with inspiration
Coughing
Splinting
Shallow respirations
What is the treatment for fractured ribs?
NSAIDS
Opioids
Splinting - holding their chest
Deep breathing
Incentive spirometry
If you break more than 1 rib, what can you develop?
Flail chest
What is flail chest?
Unstable chest wall and paradoxical movement with breathing
What is the like patho behind flail Chest
Like what is happening
Inspiration
Expiration ?
What happens to our gas exchange?
Inspiration - the ribs suck into their body
Expiration - the ribs are pushed out
It’s disturbed
What can you find on a flail chest on physical exam? (3)
Shallow respiration
Crepitus ( pop sound )
Asymmetric
What is the treatment of flail chest?
Ensure adequate ventilation
Intubation if really bad
Pain mangament - nerve blocks
What is pneumothorax ?
Collapse lung
What is the cause of pneumothorax?
Air entering pleural cavity
What is the patho behind a pneumothorax?
Negative pressure is usually present in chest cavity - air entering space causes positive pressure in cavity caused lung to collapse
Remember you don’t need an open chest or close chest to have a pneumothorax !!
Noyes ^!
What are some types of pneumothorax?
Spontaneous
Latrogenic
Traumatic penetrating
Traumatic blunt
What is a spontaneous pneumothoax?
Mainly caused by?
Risk factors?
Rupture of blebs ( air filled blister on lungs )
COPD, asthma, pneumonia
Smoking, thin, make
What is latrogenic pneumothorax?
Caused by medical procedures
What is traumatic penetrating pneumothorax ?
Caused by sucking Chest wound
Air sucked into chest cavity during inspiration ^
How do we apply dressing to help with traumatic penetrating pneumothorax?
Occlusive dressing secured on 3 sides!!!
Covers wound during inspiration, allows air to escape during expiration
The reason why not 4, is because we hope the air that doesn’t belong, goes out the small one
What is traumatic blunt closed pneumothoax caused by?
Lung laceration secondary to rib fracture
Alveolar rupture
What is hemothorax?
Treatment ^
What is hemo-pneumothorax?
What is chylothorax?
Treatment?
Blood in plural space
Treat with chest tube
Blood and air in pleural space
Lymphatic fluid in pleural space
Surgery, meds
What is the manifestations of small pneumothoax? (2)
Large?
Diagnostic study?
Mild Tachy and dyspnea ?
respiratory distress
Absent breath sounds
Chest x-ray
Do you ever pull something out of a patient?
No!!!
What is the treatment of pneumothorax? (2)
Chest tubes with water- seal drainage
Partial pleurectomy, stapling,
pleurodesis
^ surgically put this powder in the space, that causes inflammation reaction and the lung scares itself to the chest wall to hold in it place
( this is used for small things )
What is tension pneumothorax?
WORST ONE!!!!
Accumulation of air in pleasure space that does not escape
Causes medisatinal shift towards unaffected side, causing compression of good lung
What is the emergency treatment for a tension pneumothorax?
Emergent needle decompression
To help relieve that pressure that bad lung is doing to the good lung
Can tension pneumothorax occur with open or closed pneumothorax?
Yes
What is the purpose of chest tubes and pleural drainage?
To remove air or fluid from pleural and or mediastinal space
If you are having a patient with multiple chest tubes
Lets say one up top
One down low
Which one does what, or helping with what?
Up top - air
Down low - blood and fluid
All draining out
What is the nurse job with chest tubes? (3)
Consent forms
Assessment before start and then after
( vital signs )
Drainage system !!
What are the 2 types of pleural drainage systems?
Water and dry
Where should the chest tube be at?
Where should the drainages be at?
Should water suction be at the side?
If it’s water suction you put water in the water seal, no water in the dry
Below the heart
On the floor
NEVER!!
What are the 3 compartments of the pleural drainage?
1- collection chamber
Fluid stays ; air goes to 2nd
2 - water seal chamber
Contains 2cm of water, air goes in and bubbles out but not in the patient
3rd - suction control
Uses Column of water to control suction from regulator
What is the term of water fluctuation when putting in a drainage?
Tidaling
What is normal tidaling in water seal chamber ?
Fluctuation of water with pressure changes during respiration
Deep breath
Water level rises and fall with respirations
NORMALL!!
If we can not see tidaling in water seal chamber
Like stops suddenly
What do we check?
Occlusion in chest tube or machine
Bubbling is normal in a water seal chamber is put in at first, however when are the only 2 other times which is normal then it’s is not normal?
What if they are not coughing or sneezing, what does not mean if it’s still bubbling?
Coughing and sneezing
Leaking
If there is a leak, and bubbling still going what do we do?
We search with any of the tapes or anything
What is a flutter or Heimlich valve?
It’s like a small chest tube
Without a really big drainage system, just a small one
When would we put in a flutter or heimlich valve?
Small to moderate sized pneumothorax
What are the two nozzles function in flutter or heimlich calve?
Inlet- allows air to pass in the valve through chest drainage tube
Outlet - air passes to environment or collect device during expiration
Can patients go home with a flutter or heimlich valve?
Can they move?
Yes
Yes
When using the drainage bag of a flutter or heimlich valve, what must be done?
Vent the atmosphere to prevent tension pneumothoax
Cut small slit in top of bag
Nursing management
Consent and aware of procedures
Gather and set up equipment as per order
Drainage system
Keep tubing loosely coiled
Keep connections tight ; taped
Observe ; tidaling, bubbling, air leak fluid levels
Assess
Vital signs
Lung sounds
Pain
Drainage amount
Infection
Subcutaneous emphysema
Encouraged
Deep breathing
ROM exercises
Keep below chest
Avoid overturning unit
No milking or stripping chest tubes
What type of dressing do you want on chest tubes ?
Petroleum gauze ( Vaseline gauze )
Why is it important to manage their pain when putting a chest tube or chest related trauma ?
Because it hurts to breathe !
We want them to be able to breathe fine
If it hurts to take a deep breathe
What’s the order of the complications?
Atelectasis ->
Pneumonia
Patients may have subcutaneous emphysema
Describe what that is^
What if don’t have it and then 4 days later they do?
Air around the chest tube, kinda crunchy, but it should go away!!
Leaking air
You always are looking for signs of infection
What are some examples or things to look for?
Drainage looks cloudy, pus-y
Redness
Inflammation
Anytime someone has trouble taking a deep breath we want them ro do what?
Deep breathing
Deep coughing
Range of motion
Movement
Turn
Incentive spriometer
Increase fluid intake
IV Bolus if they can’t take PO
Or tube feeding -> dilute it
Make and measure drainage
Reports greater than ____ in first hour
And ___ there after
200
100
If a patient chest tube comes out
What are we gonna do?
What if the chest tube stays in
But the end of the tube leaves the container, what do we do?
Occlusive dressing that’s tape on 3 side
Place end of the chest tube in 2cm water in sterile container
Why do we stick in water?
To keep the water seal
Reason why is because air from outside will come inside the chest tube
If you can’t stick the tube in water, what do we do?
Clamp it
But last resort
you have decreased respiratory function, you’ll have decreased cardiac function
What are some complications?
Changing in heart rate
Changing in blood pressure
Adventurous breathe sounds
Remember subcutaneous emphysema
What do we need to know?
Normal at the start and should go away
Not normal if it just came if it wasn’t there, problem -> meaning leakage
How do we remove the chest tube?
Doctor does it
Premediate it
Chest x ray
- breathe out and pull
After chest tube out, doesn’t need to be vent dressing, it can be normal gauze
What does thoractomy mean?
Surgical incision into the chest
Before you do a chest surgery, what do we want to assess?
Cardiopulmonary status
Smoking cessation
Chest x ray
Electrolytes
CBC
Pain management
Anesthesia consult
The best time to teach patient about post surgery, is when?
Before the surgery
Before the day off !!
Pre op visit
If a patient had to cough, sneeze with surgery, what do we recommend?
Splitting
Put pressure on the site
Other than ateletisis and pneumonia why do we want them up?
To avoid DVT and PE
What are some pain management post op we can give patients with chest surgery?
PCA
epidural
Nerve blocks
What are some respiratory status of post op care?
RR
Breath sounds
Sputum volume
Color
Chest tube
What is thoracentesis?
How much fluid normally?
Putting a needle into the chest to drain the fluid
1000-1200ml
What is the biggest thing of thoracentesis?
Poking your lung and pneumothorax
Larger volumes of fluids being removed from thoracentesis can result in what?
Hypotension
Hypoxemia
Re-expansion pulmonary edema
Anytime you have decreased function of chest wall you have decreased ability what?
Gas exchange
What is restrictive repository disorders?
Disorders that impair movement of the chest walls and diaphragm
What’s the hallmark characteristic of restrictive respiratory disorders?
Reduced forced expiratory volume (FEV1) on PFTS
What is atlectasis mean?
What do we hear?
Caused by?
Who is at risk?
Prevention and treatment?
Collapsed, airless alveoli
Dullness on percussion
Secretions obstructing small airways
Bedridden and post op abdominal chest surgery patient
Deep breathing exercises, incentitice spirometer and early movement
What does pleurisy mean?
Inflammation of the pleura
The linking inside the chest cavity, take a deep breathe and your lungs press the chest wall and it hurts
- people tend not to take deep breathes
How do people get pleurisy?
Infection
Cancer
Autoimmune disorders
Chest trauma
Gi disease
How do we treat pleurisy?
Underlying cause and pain management
What is pleural effusion?
Abnormal amount of fluid in pleural space ; sign of disease
What is pleural effusion caused by?
Increased pulmonary capillary pressures
Decreased oncotic pressure
Increased pleural membrane permeability
Lymph flow obstruction
What do you hear in pleural effusion? (2)
Crackles
Adventitious breath sounds
What are some manifestation of pleural effusion?
Cough
Sharp chest pain
What’s treatment of pleural effusion?
Treat underlying cause
Chemical pleurodesis
