Med Surg 2- Respiratory Exam Flashcards
Alveoli
This is where gas exchange occurs.
Healthy adult lungs have 290 million alveoli
Surfacant
coats alveoli, without surfactant can lead to atelectasis
Apex of lungs
the top and extends above the clavicle
Base of the lungs
at the bottom and lies just above the diaphragm
Pleura
smooth membrane that totally encloses the lungs.
Respiratory Changes Associated with Aging
Chart Page 479
Elastic Recoil decreases
Ability to cough decreases= pneumonia
Airways close early
Residual volume decreases (expand/fill lungs)
Vital Capacity decreases
Muscles atrophy
Nursing Implications with older Adults
Encourage vigorous pulmonary hygiene (TC &DB)
Use incentive spirometer
Encourage upright position
Encourage patient activity along with frequent rest periods
Encourage frequent oral hygiene
Assess LOC and cognition
Discuss normal changes with aging
Health Promotion And Maintenance- Health History
Exposure to inhalation irritants
Assess smoking habits (pack-years = number of packs per day x number of years smoked)
Secondhand Smoke
Social Smokers
Electronic Nicotine Delivery Systems
Smoking Cessation Chart- Page 481
Nicotine Transdermal Patches
Don’t smoke with patch on (increases heart attack and stroke)
Bupropion
Smoking cessation aid
can cause manic behaviors/hallucinations
See QSEN alert page 481
Varenicline
Smoking cessation aid
can cause manic behaviors/hallucinations
See QSEN alert page 481
Crepitus
air under bones; can be caused by chest tube (air leak)
Fremitus
decreased vibration in chest on palpation
Other Indicators of Respiratory Adequacy
Cyanosis (a later s/s)
Clubbing of fingers
Weight Loss- hard to eat and breathe at same time
Pallor of skin and mucous membranes
How is patient breathing when moving?
Breath Sounds
Wheezes- asthma, COPD
Stridor- blockage in airway
Rhonchi-bronchitis, COPD, pneumonia
Crackles- fluid
Pleural Rub- worsening pneumonia
Friction
Pulmonary Function Tests (page 491-Table 24-6)
FVC- forced vital capacity
Fev1-Forced expiratory volume in 1 second
TLC- Total Lung Capacity
RV-Residual Volume
BRONCHOSCOPY
Explain the procedure to the patient
Obtain a surgical permit
NPO for 4-8 hrs. prior to procedure
Benzocaine-special assessments QSEN pg. 492 *methemoglobinemia
Post-procedure make sure gag reflex is present
Vitals q 15 min for 2 hrs.
Thoracentesis
Procedure- Needle aspiration of pleural fluid or air from the pleural space.
Educate the patient before the procedure
Thoracentesis care
Rule out possible pneumothorax and mediastinal shift
Check the puncture site and dressing
Assess for reaccumulating fluid, subcutaneous emphysema, infection and tension pneumothorax
Pneumothorax
can happen in 24 hours!
Collapsed lung will have increased RR- bring up HOB, RR/O2 checks, apply O2, call doctor/rapid response, would need a chest tube
Lung Biopsy
Samples collected to make a definitive diagnosis of inflammation, cancer, infection, or lung disease.
There are several types of lung biopsies. (needle biopsy, open biopsy, or transbronchial done during bronchoscopy).
Educate patient pre-operatively, obtain permit, check laboratory studies(PTT), and explore the patient’s feelings.
Post-procedure- Vital Signs, assess for pneumothorax, check breath sounds, and observe for any bleeding (little is normal after procedure)
Oxygen therapy
It is administered for hypoxemia (low levels of oxygen in the blood) and hypoxia (decreased tissue oxygenation).
Oxygen need can be determined, and the therapy monitored by pulse oximetry, capnography and arterial blood gas.
Hazards of Oxygen Therapy
want 4-6 L humidified
Combustion
Oxygen toxicity
Absorptive atelectasis
Drying of the mucous membranes
Infection
Oxygen Delivery Systems
Low flow oxygen delivery includes nasal cannula, simple facemask, partial rebreather and nonrebreather masks.
High flow oxygen includes Venturi mask, aerosol mask, face tent, high flow nasal cannula (HFNC), tracheostomy collar, and T-piece.
NPPV includes CPAP and Bi PAP
Tracheostomy Basics
Complications after surgical tracheostomy include tube obstruction, dislodgement or accidental decannulation, pneumothorax, subcutaneous emphysema, bleeding and infection.
Table 25.3 page 506 for complications of Tracheostomy
Cuffed trach- air goes only down, uncuffed trach-air can move up or down
You need stitches and trach ties on a new trach!
Suctioning
For a responsive patient you may hear crackles or wheezes and they may request it.
For a ventilated patient increased pulse rates, respiratory rates and increase in peak airway pressure on the vent settings indicate the need for suctioning.
best practice suctioning box on page 509
Suction 10-15 secs, 3 times with breaks
Tracheostomy Care
Trach Care must be provided to maintain a new wound and later to remove secretions and prevent infection and skin breakdown.
Great care must be taken to prevent decannulation of the trach.
trach care box and the focused assessment trach boxes, both on page 510.
Obstructive Sleep Apnea (OSA)
Breathing disruption during sleep lasting longer than 10 seconds and occurs minimum of 5x in an hour.
The apnea decreases gas exchange, increases blood CO2, and decreases pH.
What are some causes of OSA?
Weight, deviated septum, smoking, increased BP, short neck, tonsils blocking, pulmonary HTN
OSA Physical Assessment/Signs & Symptoms
Persistent daytime sleepiness, snoring, GERD
Height, weight
Jaw, neck, chin, oral cavity
Cardiovascular system
Psychosocial Assessment
Irritability, personality changes
Depression
OSA DX
STOP-Bang questionnaire and others
Sleep study at home
Polysomnography- Direct observation while wearing monitoring equipment
Monitoring devices- EKG, O2 probe
Improving duration of restorative sleep Pg. 518
Nonsurgical management
Reducing obstruction- tonsils
Changes in sleeping position or weight loss
Position-fixing devices
CPAP, BPAP in hospital
Drug therapy
Surgical management- Considered when patient cannot tolerate CPAP or when it doesn’t improve OSA
Epistaxis
Nosebleed is a common problem
Results from trauma, hypertension, blood dyscrasia, etc.
Often occurs after sneezing or blowing nose
Epistaxis care
Cauterization of affected capillaries may be needed; nose is packed
Posterior nasal bleeding is an emergency! (you can’t reach the bleed)
Assess for respiratory distress, tolerance of packing or tubes
Humidification, oxygen, bedrest, antibiotics(not really), pain medications
QSEN chart- pg 522 table
Direct pressure 10 minutes and Ice
Inflatable balloons- lean head forward!
Nasal packing- don’t blow nose, no aspirin/NSAIDs, no strenuous activity
Assess for respiratory distress and for tolerance of packing or tubes
Administer humidification(saline), oxygen, bedrest, antibiotics, pain medications. (prevent bleeding)
Head & Neck Cancer
Risk Factors:
Tobacco and alcohol use
Voice abuse
Chronic laryngitis
Exposure to chemicals or dust
Poor oral hygiene
Long-term GERD
Oral infection with HPV
Ask about tobacco and alcohol use, and other risk factors
Swallowing difficulty
Lumps in neck
Risk factors
Physical Assessment/Signs & Symptoms, Hoarseness or change in voice quality, Mouth sores, lumps
Imaging assessment- X-rays, CT, MRI, SPECT, PET-CT
Table 26.1 pg. 526
Radiation therapy, Chemotherapy, Biotherapy
Surgical intervention- Laryngectomy, Tracheotomy
Table 26.2
Partial Laryngectomy
removal of a portion of larynx, one vocal cord and the tumor
Tracheostomy needed but temporary
Total laryngectomy
removal of entire larynx, vocal cords and epiglottis
Permanent laryngectomy stoma in the neck is created
Laryngectomy Postoperative Care
Airway patency, gas exchange
Wound, flap, reconstructive tissue care
Hemorrhage
Wound breakdown
Pain management
Nutrition
Speech and language rehabilitation
Head and Neck CA: Nutrition
NG Tube, gastrostomy(feeding tube), or jejunostomy tube is placed during surgery for nutrition support while healing occurs
When would we consider starting tube feeding? Bowel sounds, passing gas
Tube removal/eating- start slow, get x-ray for placement
Before removal: assess pt.’s ability to swallow
Can aspiration occur after total laryngectomy?
Assess pt during the first few swallow attempts
Aspiration Head and Neck CA
speech therapy!
Smaller meals
Keep suction at bedside
Avoid water
What position? Sitting up
Cuff inflated or deflated?
Dry swallow after each bite
Trach Home Care – Patient Teaching pg. 529
Want humidification in home, clean stoma with soap/water
Stoma care
Stoma shield
Suction procedure
Medic alert
Swimming
Showering- no air in airway, be careful shaving
Avoid aerosols
Increase liquids- thin out secretions
Prevent and recognize infections
Smoke detector in home
COPD
a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.
COPD Risk Factors
Cigarette smoking
Passive smoking
Recurrent respiratory infections
Occupational exposure
Air pollution
Genetic - abnormalities
Chronic Bronchitis
Chronic inflammation of airways
Increased mucous production
Decreased respiratory drive and bronchospasm; hypoventilation
Increased risk of infection because mucus is just sitting there
Big/blue, Long-term chronic cough, Unusual lung sounds (crackles/wheezes), Edema(r-side HF)
o2 not being used right leads to cyanosis; can’t fully exhale air because of mucus buildup
Can lead to emphysema!
Emphysema
body is compensating because there isn’t good gas exchange in alveoli
Damage to elastic tissue in airways
Barrel chest from chronic hyper-expansion (air trapping)
Damage to bronchioles, alveoli and capillary beds (no gas exchange =hypoxia)
Decreased mucociliary action
Can’t move air because of damaged alveoli
Pink skin/Pursed lip breathing, Increased size/Barrel chest, No chronic cough, Keep Tripoding
Complications of COPD
Hypoxemia/tissue anoxia
Acidosis
Respiratory infections
Cardiac failure, especially cor pulmonale R-sided HF b/c R side brings blood from body
Cardiac dysrhythmias
Dyspnea Assessment Tool
Laboratory and Diagnostics- COPD
ABGs- Acidosis, increased co2 (hypercarbia)–> advanced emphysema
Sputum Cultures- chronic bronchitis
H&H and electrolytes- increased, compensating to make more o2
Chest X-ray (rule out other lung diseases)
PFT changes (Table 30-2) decreased means more severe
COPD determined by flow rate, forced expiratory volume
COPD Nonsurgical Management
avoid irritants
Breathing techniques
Positioning Tripoding
Effective coughing Turn/cough/DB, spit/cough up early in morning
Oxygen therapy Airway maintenance
Drug therapy pg. 538
Exercise conditioning take breaks, pacing
Suctioning if can’t get out
Hydration break down mucus
Alteration in Respiratory Function COPD
pg. 546 Table 27.2
Avoid irritants
Drug therapy – bronchodilators, corticosteroids, annual flu vaccine, pneumococcal vaccine (see medication handout)
Hydration – 3L/day
Breathing retraining
Pulmonary hygiene
Chest physiotherapy
Home O2 therapy
Alteration in Nutrition COPD
Monitor weight
Supplements or small meals
Assess for S/S PUD, GERD
high protein/calorie foods, less chewing
Activity Intolerance COPD
Provide rest periods
Progressive exercise routine
Avoid fatigue
Potential for Infection COPD
Avoid respiratory infections
Teach S/S of respiratory infection fever, tachycardia, increase sputum/color change
Aggressive early treatment of respiratory infection
Imbalanced Nutrition COPD
Prevent protein-calorie malnutrition through dietary consultation
Monitor weight, skin condition, and serum prealbumin levels
Dyspnea management
Food selection to prevent weight loss
COPD: Community-Based Care
Home care management: Long-term use of oxygen, Pulmonary rehabilitation program
Health teaching: Drug therapy, Manifestations of infection, Breathing techniques, Relaxation therapy
Occupational Pulmonary Disease
Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens
Worsened by cigarette smoke
Prevention through special respirators and adequate ventilation
Construction, coal mining, firefighter, hairdresser
Lung Cancer Risk Factors/Stimuli
Cigarette smoking
Secondhand smoke
Inhaled pollutants
Family predisposition
Lung Cancer Clinical Manifestations
Cough
Pain, dyspnea, wheezing
Respiratory infections
General symptoms
Table 27.5
Lung Cancer DX
biopsy, sputum, x-ray/CT
Lung Cancer Late symptoms
Hemoptysis, clubbing, fatigue, dysphagia
Lung Cancer management
Medical Management
Surgical resection
Radiation
Chemotherapy
Nursing Management
Relieve breathing problems
Reduce fatigue
Psychological support
Pneumonectomy
removal of the entire lung
Lobectomy
removal of a lung lobe
Segmentectomy
removal of one or more segments of a lobe
Wedge Resection
removal of the peripheral portion of small, localized areas of disease.
Lung Cancer Post-Op Nursing Care- Goal: To maintain respiratory function
Assess VS, SpO2, breath sounds, ABG’s
Pulmonary hygiene and physiotherapy
HOB 30 - 40°
Chest tube assessment
Patient positioning and turning- operative side to drain and promote other lung expansions
Post Pneumonectomy care – no chest tube (WHY?), assess for mediastinal shift, tension pneumothorax
Chest Tube
Pleural space has - pressure
Remove air and fluid from the pleural space
Re-expand a collapsed lung
Restore negative pressure to the pleural space
Best Practice p. 561
Chest Tube Care
Check hourly to ensure patency
Keep an occlusive dressing at insertion site
Keep sterile gauze at the bedside if tube becomes dislodged
Position to always prevent kinks and large loops
This can block drainage and keep the lung from re-expanding
If chest tube falls out
tape tube back on with dry gauze
Seasonal Influenza
Highly contagious acute viral respiratory infection
Preventable (or severity is reduced) with vaccination, eldery highest risk
Handwashing is critical
Antiviral agents may be effective if started within 24 to 48 hours of symptoms
Watch for egg allergy
Seasonal Influenza s/s
Rapid onset of severe headache, muscle ache, fever, chills, fatigue, weakness, anorexia
Influenza Prevention
Annual flu vaccine
Assess for allergies to eggs
Annual Vaccination is important for adults who:
Are older than 50
Reside in institutions
Chronic diseases or immunocompromised
Health care workers
Family of at-risk patients
Pandemic Influenza
Potential to spread globally
Avian flu, MERS, SARS
Early recognition and quarantine
Contact and Airborne Precautions (until specific type of pandemic influenza is identified with routes of transmission known)
COVID 19
Spread via droplet transmission and during medical procedures that generate aerosols
Key Features pg. 568
Typically, symptoms appear 2-14 days after exposed
Most common symptoms:
Fever or Chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
New loss of taste or smell
Sore throat
Nausea/Vomiting
Diarrhea
Abdominal Pain
COVID 19 Health Promotion
Vaccines are available
Wear a mask
Frequent Hand washing
Practice Social Distancing
Collaborative Care
Viral(has it) and antibody(had it) tests available
Who is tested?
Exhibiting symptoms
Within 6 feet of infected person for >15 minutes.
Referred by HCP
N95 mask, gown, shoe covers, gloves and goggles
Management:
Quarantine for 14 days
Severe: potential ventilation and intubation
Pneumonia
Excess of fluid in the lungs resulting from an inflammatory process
Inflammation triggered by infectious organisms and inhalation of irritants
Reduction of gas exchange due to:
Infection
Inflammation
Types of Pneumonia: Table 28.2
Pneumonia s/s
Coughing, chest pain, fever, crackles/wheezes
Pneumonia Health Promotion and Maintenance
Vaccination
Avoid crowded places during flu season
Cough, turn, move, deep breathe
Clean respiratory equipment
Avoid pollutants
Stop smoking
Get rest and sleep
Eat healthy diet
Drink 3L of water daily (unless fluids are restricted)
Pneumonia Recognize Cues
History
Risk factors (Table 28.1)
Use of respiratory equipment
Vaccination status
Physical assessment/Signs & Symptoms
Chest pain/discomfort
Headache, fever, chills
Flushed cheeks and anxious
Cough, dyspnea, tachypnea
Crackles: IF fluid is present
Wheezing: IF inflammation and exudates
Table 28.3 p. 572
Pneumonia DX
Laboratory assessment
Gram stain, culture and sensitivity of sputum
CBC
Blood cultures
ABGs
Serum electrolytes, BUN, creatinine- dehydration
Lactate level- sepsis
Imaging assessment
Chest x-ray
Other diagnostic assessment
Pulse oximetry
Thoracentesis
Pneumonia Generate Solutions & Take Action
Improving gas exchange- turn/cough/DB, IS, give o2
Preventing airway obstruction- suction, fluids, expectorant/ bronchodilators
Preventing sepsis- labs, antiinfectives
Managing empyema- chest tube to take out drainage
Pulmonary TB
Acid-fast aerobic rod
Mycobacterium tuberculosis
Airborne transmission N-95, - air room
Can infect other organs
Decrease incidence in US
Pulmonary TB Health Promotion
Recognize risk factors
Avoidance of people who are ill
Good handwashing
Screening (for those who work with people at high risk)
Pulmonary TB Assessment Recognize Cues
History
Past TB exposure
BCG vaccine
Physical assessment
Progressive fatigue
Lethargy
Nausea, anorexia, and weight loss
Irregular menses
*Low-grade fever
*Cough with mucopurulent sputum, blood streaks
Dull aching chest pain
*Night Sweats
Tuberculosis First Line Drugs- pg. 579
Pulmonary TB DX
Chest x-ray definitive
Sputum culture
NAAT
TST (Tuberculin skin test)
IGRA (e.g., QuantiFERON-TB Gold In-Tube test)
Pulmonary Embolus (PE)
Particulate matters (solid, liquid, or air) enter venous system lodges in pulmonary vessels
Obstruct pulmonary blood flow leading to:
Reduced gas exchange
Reduced oxygenation
Pulmonary tissue hypoxia
Decreased perfusion
Potential death
Blood clot is most common cause
Pulmonary Embolus (PE) Risk Factors
Venous Injury- IV, Fracturs, etc.
Venous Stasis- immobility
Increased blood coagulability
What other pts. are @ high risk? Preg, BC, stroke, surgery, cancer
Clinical manifestations?
How will we dx.? D-Dimer (clot), CT
Prevention: p. 587 IV Heparin
Pulmonary Embolus (PE) Recognizing Cues- Key Features p. 588
Sudden onset dyspnea
Sharp pleuritic pain
Respiratory distress
Crackles or friction rub
Anxiety
Cough - hemoptysis
DX – VQ scan and pulmonary angiography
IMPLEMENTATION: HYPOXEMIA
Nursing Management of PE
Oxygen therapy and possible ventilator
Hydration and vasodilation
Heparin and coumadin
Increase cardiac contractility
Lyse clot – thrombolytics
Pulmonary embolectomy – surgical procedure
Prevention for high-risk patients
Pain management
Maintain oxygen therapy, anxiety and monitor for complications
Anticoagulation Therapy
Heparin
What lab test? PTT
Normal range 20-30 sec
Weight based therapy
Antidote? Prodamin sulfate
Warfarin
Lab test? INR
Normal range? 0.8-1.1, 2-3 therapeutic
Antidote? Vit K
Acute Respiratory Distress Syndrome (ARDS)
Results from shock, shock-like state, or direct lung injury
Damage to alveolar capillary membrane drowning lungs
Severe ventilation-perfusion mismatch and gas exchange impairment
Destruction of surfactant producing cells and decreased lung compliance
Complex clinical syndrome
Acute hypoxic injury
Caused by direct or indirect pulmonary injury Table 29.4
ARDS Direct Injury
aspiration, pulmonary infection, near drowning, thoracic trauma or toxic inhalation
ARDS Indirect Injury
shock, sepsis, hypothermia, DIC, multiple transfusion eclampsia, pancreatitis, burns
ARDS Symptoms/Behaviors
Rapid onset dyspnea
Respiratory distress
Decreased CO
CXR – white-out
Low PaO2 even with O2Phases of ARDS
ARDS Endotracheal Tube
Oxygen administration
CPAP – continuous positive airway pressure OR
PEEP- positive end expiratory pressure keep alveoli open
Avoid fluid volume overload
Pulmonary hygiene
Turning and positioning (bed and prone) pneumonia
Corticosteroids
Antibiotics
Bronchodilators
NSAIDS
Nitric Oxide = pulmonary vasodilation
ARDS Nursing Care
PEEP – Positive end expiratory pressure
Anti-anxiety meds
Neuromuscular blockers PRN
Complete sedation (Propofol (diprivan)
What nursing care should be included? Priority is neuro status?
Modes of ventilation
Assist-control (AC) ventilation
Synchronized intermittent mandatory ventilation (SIMV)
Pressure support ventilation
Continuous positive airway pressure (CPAP)
Bi-level positive airway pressure (BiPAP)
REVIEW HANDOUT IN LESSON PLAN
ATI Book: Pg 120
Ventilator Settings
FiO2
Respiratory rate
Tidal volume how much air given in each breath
Peak flow (peak airway pressure- PIP)
Pressure limit
PEEP
Sensitivity
VENTILATOR-ASSOCIATED PNEUMONIA (VAP )
THE ET TUBE OR TRACH BYPASSES THE BODY’S FILTERING PROCESS AND PROVIDES DIRECT ACCESS FOR BACTERIA TO ENTER THE LOWER RESPIRATORY SYSTEM
KEEP HOB ELEVATED AT LEAST 30 DEGREES
ORAL CARE EVERY 12 HRS
ULCER PROPHYLAXIS
PREVENT ASPIRATION
PULMONARY HYGIENE
TURNING FREQUENTLY
IMPAIRED COMMUNICATION
Nursing Management of Patients on Mechanical Ventilation pg. 600, 603
Assess patient first then equipment
Respiratory assessment and VS
Cardiovascular status and fluid balance
Additional nursing interventions?
Weaning Patients from the Ventilator
Criteria – varies
ABG’s, respiratory effort, FiO2 needed to maintain O2 sat
Preparation- Mental, physical, psychological
Collaboration- RN, RT, MD
ABG’s drawn 15 – 30 minutes after each vent change
Chest Trauma
Chest trauma is a contributing factor in about 50% of deaths of patients who experience unintentional traumatic injuries
Pulmonary contusion
Rib fracture
Flail chest
Pneumothorax
Hemothorax
Tension pneumothorax
Sternal and Rib Fractures
Fx of first 3 ribs can lacerate subclavian artery or vein
Fx of ribs 5 – 9 can lacerate liver and/or spleen
Nursing management – pain control, breathing exercises, splint chest
Flail chest
multiple rib fractures 2 or more places
Paradoxical respirations
Nursing management chest trauma
assess for dyspnea, tachycardia, cyanosis Suction, pulmonary hygiene, intubation/ventilation
Pulmonary Contusion
Bruise to the lung caused by chest trauma
Hemothorax
blood in pleural space
Pneumothorax
air in pleural space
Traumatic/Open Pneumothorax
opening between atmosphere and pleural space
Tension Pneumothorax
affected lung collapse;compresses the heart, great vessels, and opposite lung
Tension pneumothorax is life threatening!
Pneumothorax/Hemothorax:Recognizing Cues
Clinical Manifestations:
Tracheal deviation
Reduced or absent breath sounds
Hyperresonance on percussion
Nursing Management
Open pneumo – cover or fill chest wound
Oxygen
Chest tube
Assess respiratory status
Document changes
Pain control
Pulmonary hygiene
COPD Physical Assessment
COPD should be suspected in everyone with dyspnea, chronic cough or sputum production, recurrent lower resp. infection, and genetics or particulate exposure
Physical assessment- monitor for weight loss, respiratory characteristics (changes in chest size).
Lung Cancer Etiology and genetic risks
chronic exposure to asbestos, beryllium, chromium, coal distillates, cobalt, iron oxide, mustard gas, petroleum distillates, radiation, tar, nickel, and uranium.
- Second and third hand smoke
-genetic differences
-familial predispositions
-advancing age
Empyema
blood in pleural space
Hypoxemia nursing interventions
O2, high fowler, cardiac monitor, check respiratory status, skin color, check position of trachea, assess for any cyanosis/edema/abnormal lung sounds.
Complications of Mechanical Ventilation
Aspiration, atelectasis(infection), O2 toxicity, tissue trauma, and decreased cardiac output, oral hygiene is very important Q 4 hours
When should cultures of infectious areas be obtained in relation to antimicrobial therapy? Why?
Before antibiotics are started so that the growth of the infectious organism won’t be affected by the presence of the drug.
When a person receives a specific antimicrobial agent (esp. penicillin), what precautions should the nurse take? Why? What problems should you anticipate? How should you be prepared for those problems?
Observe all patients who receive injectable penicillins for at least 30 minutes after the injection. Always be prepared for an allergic reaction, especially anaphylactic shock.
Why should you teach a patient to complete the prescribed course of antimicrobial therapy?
1 – It may take a full-course of antibiotics to completely eradicate the infectious organisms.
#2 – If infections are only partially treated, resistant organisms may grow and then be spread to infect others.
Describe a common superinfection that may occur in a patient taking an antibiotic. Why do superinfections occur?
Fungal infections, especially candida, are the most common organisms that cause superinfection.
Why is probenecid sometimes administered with penicillins?
Used in few clinical circumstances when high blood levels of penicillin are required. Probenecid blocks renal tubular secretion of penicillin.
What is the purpose of penicillinase-resistant penicillins, like methicillin? Why has methicillin resistance occurred? What precautions should be taken with a patient whose infection is methicillin resistant?
To treat strains of staph infections that, over the years, have become resistant to routinely used penicillins. These antibiotics include: cloxacillin, dicloxacillin, methicillin, nafcillin, and oxacillin. Vancomycin is an antibiotic which is effective against methicillin-resistant staph. Vancomycin has a narrow therapeutic range so blood levels must be monitored. Also, it can cause nephrotoxicity and ototoxicity. If a patient has methicillin-resistant staph they should be strictly isolated to prevent the spread of this difficult to treat organism.
What is an example of a narrow spectrum penicillin and Why? What is an example of a broad spectrum penicillin and Why? What is and example of an expended spectrum penicillin and Why?
Narrow Spectrum – penicillin is an example – it is primarily effective against gram positive bacteria.
Broad Spectrum – tetracycline and cephalosporins – effective against gram negative and gram positive
Extended spectrum – antipseudomonal penicillins – have been specially developed for treating difficult organisms.
Oral administration antibiotics
most cause GI upset and diarrhea. Patients are more likely to miss doses or be non-compliant. May stop taking when they feel better and not fully eradicate the infection.
IM infections antibiotics
use when IV access is difficulty or when a specific antibiotic must be given by that route. Less convenient and more unpleasant than oral route. Not as reliable concentration and not as penetrable to certain areas as IV route. Can be mixed with local anesthetic, lidocaine, to minimize pain. Make sure preparation is indicated for IM use. Give deep into large muscle mass, like gluteal or deltoid. Many are irritating to muscle (especially vancomycin – never give IM!)
IV antibiotics
when high concentrations must reach the site of infection. Important to give on time. Correct dosage critical. Dilute properly. Many antibiotics are incompatible, therefore flush IV tubing between different antibiotics. Many are very irritating to veins and cause phlebitis, therefore monitor IV site for S/S of infiltration, phlebitis, etc.. Rotate sites.
What are the 3 groups of cephalosporins and how are they different?
1st generation – most effective against gram positive
2nd generation – broad spectrum
3rd generation – most effective against gram negative
All cross the blood brain barrier and are available in oral form.
Explain what is meant by cross-sensitivity between cephalosporins and penicillins?
About 10% of people who are allergic to penicillin will also be allergic to cephalosporins because both groups have similar molecular structure.
How is ceftriaxone (Rocephin) different from most other third generation cephalosporins?
Is longer acting and therefore doesn’t have to be given as often.
What are the most common side effects / adverse reactions to cephalosporins?
GI upset, increased bleeding times in large doses. Relatively safe – only about 5% of people have allergy.
What are the main drawbacks of vancomycin? What is an important use of vancomycin today?
Commonly used to treat MRSA infections.
Ototoxicity and nephrotoxicity. Monitor serum vancomycin levels. Obtain peak and trough.
Who should not take tetracyclines and why?
- During first trimester of pregnancy because it can be teratogenic.
- Women in their last trimester of pregnancy and children younger than age 8 should bnot take because it irreversibly discolors permanent teeth.
What instructions would you give to patients taking tetracyclines and Why?
Take one hour before or 2 hours after meals – food and milk can impair absorption.
Calcium and iron impair absorption – avoid taking with antacids and vitamins.
Avoid prolonged sun exposure – photosensitivity.
Watch for signs of candida infection.
Throw out expired tetracycline – med breaks down into a toxic by-product.
What are signs of ototoxicity and nephrotoxicity that the nurse should watch for the patient taking aminoglycosides?
Ototoxicity – hearing loss, tinnitus, roaring sounds, dizziness, ataxia, nystagmus (reversible if drug d/c’d)
Nephrotoxicity – fluid retention, oliguria, increased serum creatinine and BUN, proteinuria. Usually reversible if drug d/c’d
What organisms are often treated with erythromycin (for example, in newborn infants)?
Gram positive organisms (except staph) and some gram negative.
Often prescribed as a penicillin substitute when patient has allergy.
Drug of choice for mycoplasma pneumonia and Legionnaire’s
When taking a sulfonamide antimicrobial agent, why is it important for the patient to drink a lot of water?
To prevent crystalluria – crystals in the urine.
How should nystatin be administered to most effectively treat oral candidacies?
“Swish and Swallow” or swab in mouth with cotton applicator to increase contact with infected areas.
What are the side effects/ adverse reactions / nursing implications for Amphotericin B?
Administer initial test dose
Gradually increase dosage till maximum daily dose of 1mg/kg is reached.
Infuse slowly over 4 – 6 hours.
Don’t use in-line filter or solutions with preservatives; mix with D5W only; protect from light.
SIDE EFFECTS: headache, chills, fever, malaise, muscle and joint pain, anorexia, weight loss, N&V are experienced by almost all patients (usually decreases with time)
Patients may be premedicated with acetaminophen, diphenhydramine, aspirin, and/or corticosteroids.
Phlebitis is common – desirable to deliver through a central line.
Levofloxacin
Fluoroquinolone class antibiotic, used in complicated UTI, PNA, can cause ligament rupture
Rifampin
TB drug, causes hemorrhage in neonates and late pregnancy, turns bodily fluid orange-red
Albuterol
Adrenergic bronchodilator used in rescue situations, monitor for HTN and tachycardia
Acetylcysteine
Mucolytic drug assisting with respiratory secretions
Codeine
effective for cough suppression
Methylprednisolone (solu-Medrol)
IV corticosteroid, raises BG levels
Beclomethasone
Oral inhaled corticosteroid, may cause thrush
Isoniazid
TB drug, causes jaundice, hepatitis, and peripheral neuropathy
Oseltamivir (Tamaflu)
Antiviral for both Flu type A and B
Amphotericin
Antifungal used to treat histoplasmosis, nephrotoxicity
Prednisone
Oral corticosteroid, immunosuppresive
Amantadine
Antiviral, flu type A, also used to treat Parkinson’s diease
