MED/SURG EXAM #3 Flashcards
Go over gag reflex, acid-base
Difference between upper respiratory problems vs. lower respiratory problems
UPPER respiratory tract problems occur in the structures in the larynx or above. (Anaphylaxis)
LOWER respiratory tract problems involve the airways below the larynx (e.g. COPD)
Active TB + wher to place patient
Room with exhaust directly to outside environment
– (+) pressure room
NOTE: question stating that there aren’t anymore (-) pressure rooms
How to check for cyanosis on the body
oral mucosa
Interventions for COPD patients
— Position in high-Fowler’s to maximize ventilation
— Increase fluid intake and drink 2-3L/day to liquefy mucus
— Take walks 20 minutes daily 2-3x/wk
— O2 2-4L/min (nasal cannula) OR up to 40% Venturi mask
— Chronically increased PaO2 levels will usually need 1-2L/min O2 via nasal cannula
— O2 maintained b/w 88-92%
Determinants of when to eat and how medication will make you feel
— Medication may make you feel jittery after taking (e.g. Albuterol) b/c steroid within, so give food before administration
NOTE: S/Sx after administration: nervousness, HR palpitations, dysrhythmias, tremors, insomnia, increased BP
Diagnostic studies for lower RR problems
— Hx + physical examination
— Chest XRAY
— Thoracentesis/bronchoscopy
— Pulse oximetry
— Arterial blood gases (ABGs)
— Sputum gram stain, culture, and sensitivity (ideally before antibiotics have been started)
— Blood cultures
— CBC w/ differentials
Position placement of patient during thoracentesis + Why?
Sitting while leaning forward over the side table
WHY?
— When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client’s ribs and allows for aspiration of accumulated fluid and air.
NOTE: Increased HR = complications; serosanguinous fluids = normal
How to use inhaler w/ spacer (IN ORDER)
1st press down on inhaler then within 5 seconds SLOWLY breathe in
Hold breath for 10 seconds
Wait ~1min b/w puffs
Client COPD + difficulty breathing + what to do?
Assess (RN intervention r/t process)
Gag reflex
What are Cheyenne-Stokes?
Periods of apnea and ventilation —> about to DIE
alternating periods of
Pneumothorax intervention
Chest tube is BELOW the chest
Pneumothorax w/ chest tube in place + trachea has moved to the other side + what to do?
problem of tension pneumonia —> notify MD
What to do if chest tube comes OUT of body?
Place in sterile water
ABGs + Respiratory drugs, what to look out for
— ABGs (sedating and opioid drugs, respiratory drugs; respiratory acidosis)
What does constant bubbling indicate for a chest tube? Continuous bubbling in water-seal chamber?
—Continuous bubbling in H2O seal chamber = BAD = air leak (bloody fluid level fluctuation and cannot tell b/c chest tube has been dislodged somewhere)
Hyperventilation: when would you do this?
When providing suction care to clear mucus from airway
–hyperventilate for 2-3 minutes prior to suctioning
Chest tube: how to know if lung has re-expanded
No fluctuation noticed
MEDICATIONS: Check for allergic rxns
Patient has IV + client states they are itchy and cannot breathe + what to do?
STOP INFUSION
— S/Sx = N/V, wheezing
Atelectasis + how do we get it?
Loss of lung volume (atelectasis)
Will hear decreased lung sounds
PNA will hear crackles
When to use rescue inhaler vs. maintenance
Albuterol = rescue = given first
Maintenance = Trelegy (COPD)
Rescue/reliever –> corticosteroid
Central cyanosis + what to look for?
Look at the fingers and toes for pale/blue color
Viral pharyngitis + elevated WBC?
No b/c its bacterial, will not see, so do a throat culture to determine
Drug therapy
— Rifampin, Ethambutol (TB)
— Ecyclivir (herpes)
— Montalukast (Singulair for asthma, COPD)
Treatment for active TB disease
2 phases of Tx
— Initial: 8wks to 3 mos = 4 drugs
— Continuation: 18wks = 2 drugs (Isoniazid, Rifampin)
4-Drug regimen:
— Isoniazid
— Rifampin
— Pyrazinamide
— Ethambutol
What to monitor with Active TB drug therapy
— Isoniazid: hepatitis
— Rifampin: hepatitis; orange body fluids
— Pyrazinamide: hepatitis
— Ethambutol: ocular toxicity
NOTE: Monitor LFTs = sclera of eyes/skin, tenderness in RUQ (enlargement), clay-colored stool
ARDS complications of pneumonia
— Manifestations = on O2 or vent? VENT b/c cannot tolerate O2 (it is not helping)
Watch out for Veceronium and Panceronium
Vecuronium — nondepolarizing agent that achieves skeletal muscle paralysis; it works by blocking the signals between your nerves and your muscles.
Panceronium — used to suppress/paralyze respiratory effort
– Facilitate mechanical ventilation
Therapeutic effect for a medication Sleepiness medication
ALBUTEROL inhalation process
— Hold for 10 seconds
Diuretics to get off ; ARDS needs supplemental foods, but is BETTER in prone position (when on vent, otherwise in HIGH Fowler’s)
Fatty embolism syndrome can cause what?
A pulmonary embolism
Indications of a fatty embolism
Ca2+ serum level decreased
Drop down dyad of ABGs + what to do 1st, 2nd, etc
Bow tie bronchodilators, asthma, PFT
Diphenhydramine given when
anaphylactic allergic reaction
Pneumonia (PNA) etiology
— Acute infection of lung parenchyma
— Associated with significant morbidity and mortality
Normal defense mechanisms: air filtration, epiglottis closure over trachea, cough reflex, mucociliary escalator, and reflex bronchoconstriction; IgA, IgG, alveolar macrophages
— Defense mechanisms become incompetent or overwhelmed: aspiration, tracheal intubation, air pollution, smoking, viral URI, aging, chronic diseases
Pneumonia (PNA) etiology
— Acute infection of lung parenchyma
— Associated with significant morbidity and mortality
— Normal defense mechanisms: air filtration, epiglottis closure over trachea, cough reflex, mucociliary escalator, and reflex bronchoconstriction; IgA, IgG, alveolar macrophages
— Defense mechanisms become incompetent or overwhelmed: aspiration, tracheal intubation, air pollution, smoking, viral URI, aging, chronic diseases
3 ways organisms reach lungs in patients with pneumonia
- Aspiration of normal flora from nasopharyngeal or oropharynx
- Inhalation of microbes present in air
- Hematogenous spread from primary infection elsewhere in the body
Incentive spirometry purpose + steps
Purpose: monitor optimal lung expansion to reduce risk of PNA
STEPS
1. Keep tight mouth seal around mouthpiece
2. Inhale and hold for 3-5sec
3. During inhalation, the needle of the spirometry machine will rise.
Respiratory Failure medication options
NOTE: driven by the cause/reason
— Rescue drug inhalers/nebulizers
— Maintenance inhalers
— Beta agonists (e.g. AlbuTEROL, LevalbuTEROL, FomoTEROL)
— Anticholinergics (e.g. IpaTROPIUM, TriaTORPIUM)
— Diuretics
— Antibiotics
— Methyxanthines (e.g. AminoPHYLINE)
— Steroids (e.g. FluticaSONE, BudeSONide, PredniSONE)
Cause of metabolic acidosis + examples
Cause = An overproduction of hydrogen ions
— XS oxidation of fatty acids
— Starvation
— Diabetic ketoacidosis
— Hypermetabolism: heavy exercise, seizure activity, fever, hypoxia, ischemia
— XS ingestion of acids: ethanol/methanol intoxication,
Cause of metabolic acidosis + examples
Cause = An overproduction of hydrogen ions
— XS oxidation of fatty acids
— Starvation
— Diabetic ketoacidosis
— Hypermetabolism: heavy exercise, seizure activity, fever, hypoxia, ischemia
— XS ingestion of acids: ethanol/methanol/salicylate intoxication
— Overproduction of bicarbonate: kidney/liver failure, pancreatitis, dehydration
— Overelimination of bicarbonate: diarrhea
Respiratory acidosis examples
Under elimination of H+ ions:
— RR depression: anesthetics, opioids, electrolyte imbalance
— Inadequate chest expansion: muscle weakness, airway obstruction, alveolar-capillary block
METABOLIC ACIDOSIS EXAMPLES
Increase of base components:
— Oral ingestion of bases: antacids
— Parenteral base administration: blood transfusions, NaHCO3, total parenteral nutrition (TPN)
— Decrease of acid components: prolonged vomiting, nasogastric suctioning, HYPERcortisolism, HYPERaldosteronism, thiazide diuretics
RESPIRATORY ALKALOSIS EXAMPLES
NOT producing enough CO2, so not producing NaHCO3, therefore not enough H+ but excessive HCO3 in body —> increasing pH
XS loss of CO2:
— Hyperventilation
— Fear/anxiety
— Mechanical ventilation
— Salicylate toxicity
— High altitudes
— Shock
— Early-stage acute pulmonary problems
OPEN vs. CLOSED pneumothorax
OPEN: brought on by an external source, causing internal trauma; penetrates integrity of body
— e.g. knife/gun wound, arrow/spear
CLOSED: may originate externally or internally
— e.g. pneumothorax (chest tube now needed d/t unequal chest expansion after insertion); complication from central line
What is the purpose of a chest tube? Where?
To reestablish ventilation and oxygenation in the pleural cavity/space which allows an avenue for air/fluid to exit = reexpansion of lungs results in increased O2’ation by ventilation capabilities improvement
pleural space is b/w parietal + visceral
Anatomy of lung
Lung —> Visceral pleura —> Pleural cavity —> Parietal pleura —> Endothoracic fascia —> Innermost intercostal muscle
Chest tube insertion location: AIR vs. FLUID
AIR = b/w 3rd-4th intercostal space
— “air rises,” so want removal of air (e.g. pneumothorax)
FLUID = 5th intercostal space or further below
— “fluid settles below in a cavity” (e.g. emphysema, hemothorax)
Egophony
Spoken “E” similar to “A” on auscultation because of altered transmission of voice sounds
— Increased resonance of voice sounds heard when auscultating the lungs.
WHY? PNA, pleural effusion
Fine crackles
Short, discontinuous, high-pitched sounds heard just before the end of inspiration.
— Result of rapid equalization of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open.
— Similar sound to that made by rolling hair between fingers
WHY? Interstitial edema (early pulmonary edema), alveolar filling (PNA), loss of lung volume (atelectasis), early phase of heart failure, idiopathic pulmonary fibrosis
Course crackles
Louder, discontinuous, low-pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall
— May be heard on inspiration/expiration/both
— Similar to sounds of blowing through straw underwater
WHY? XS fluid w/in lungs, heart failure, pulmonary edema, PNA w/ severe congestion, COPD
Stridor
Continuous musical/crowning sound of constant pitch resulting of partial obstruction of larynx/trachea
— e.g. Croup, epiglottitis, vocal cord edema after exhumation, foreign body object stuck
Wheezing
Continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls. First evident on expiration but possibly evident on inspiration as obstruction of airway increases. May be audible without stethoscope
— e.g. Bronchospams (caused by asthma), airway obstruction (caused by FBO), COPD
What is a pleural friction rub?
Creaking or grating sound from roughened, inflamed pleural surfaces rubbing together. Evident during inspiration, expiration, or both. No change with coughing. Often uncomfortable, especially on deep inspiration
WHY? Pleurisy, PNA, pulmonary infarct
Bronchophony
Spoken or whispered syllable more distinct than normal on auscultation
WHY? Pneumonia
Whispered pectoriloquy
Spoken or whispered syllable more distinct than normal on auscultation
ICS/LABA
— BudeSONide/Formoterol (Symbicort) — MDI
— FluticaSONE/Salmeterol (Advair Diskus or HFA) — DPI, MDI
— FluticaSONE/Vilanterol (Breo Ellipta) — MDI
— Mometasone furoate/formoterol fumarate (Dulera) — MDI (not for relief of acute bronchospasm)
LAMA/LABA
Umeclidinium/vilanterol (Anoro Ellipta) — DPI (for COPD, but not for relief of acute bronchospasms)
SAMA/SABA
Ipratropium/albuterol (Combivent Respimat, DuoNeb) — Nebulizer, inhalation spray
Methylxanthines
IV agent: Aminophylline (2nd line therapy)
PO: Theophylline
MOA:
NOTE: 1/2 life is reduced by smoking and increased by heart failure + liver disease
RF for impaired gas exchange
— Age
— Smoking: modifiable
— Immunosuppresion
— Reduced state of cognition: CF and CE
— Brain injury: increased risk of aspiration
— Prolonged immobility: fluid builds up, pts. not taking deep breaths
— Chronic conditions: COPD, CF
Populations with the greatest for impaired gas exchange
— Infants have anemia for first 2-3 months
— Young children = less alveolar surface area + narrow branching of airways (easily obstructed)
— Older adults = stiffer chest wall, less effective cough, weakened chest muscles, loss of elasticity
TB is a highly communicable disease caused by what organism
Microbacterium tuberculosis, rod-shaped bacteria; slow-growing
RF for TB disease
— Environmental exposure: homeless, crowded places, poor ventilation, contact w/ untreated people
— Travel: Asia, Africa, Russia
— SES: lower income (b/c medically underserved)
S/Sx of TB
— hemoptisis + cough lasting 3+ weeks
— night sweats/chills
— fatigue/malaise
NOTE: TB = droplet precautions.
Patient education on reduction of TB transmission in home environment
— Medication compliance
— Cover mouth + nose w/ cough/sneeze
— HH
— Sleep alone
— No visitors until non-infectious
— Open windows to allow ventilation
— Avoid public places (wear surgical mask if you do go out)
— Family should get tested
Criteria for TB patients to be considered non-infectious?
ALL 3 must be met:
1) Drug tx >/2 weeks
2) Symptoms improved
3) 3 consecutive negative sputum cultures/smears (must be 8 hrs apart, one must be in the AM)
What vaccine is used to treat tuberculosis?
Medical term for “raccoon eyes?” Why?
Periorbital ecchymosis
WHY? To evaluate for basilar skull fractures
RN Interventions for INH-Isoniazid
— Take on empty stomach to increase absorption
— Avoid antacids
— Take daily multivitamin b/c depletes Vitamin B
— Report yellow appearance (jaundice), easily bruising, bleeding
— Take at night b/c can cause severe nausea
RN interventions for Rifampin
— Reddish- orange tinge (urine, secretions- NORMAL)
— Oral contraceptives- decreases effectiveness, 2nd BC method while on and a month after
— Avoid alcohol: S/S liver failure
— Take a bedtime
— Ask if they have had gout
8 oz of water, increase fluid intake (uric acid increase)
Wear protective stuff in the sun (sunburn)
Avoid alcohol
Report yellow appearance to skin or whites of eyes, darkening urine, bruising or bleeding
— S/S liver failure
— Take at bedtime b/c of severe nausea
RN Interventions for PZA (Pyrazinamide)
P = photosensitivity
— Ask if they have had gout
— 8 oz of water, increase fluid intake (uric acid increase)
— Wear protective stuff in the sun (sunburn)
— Avoid alcohol
— Report yellow appearance to skin or whites of eyes, darkening urine, bruising or bleeding
— S/S liver failure
— Take at bedtime b/c of severe nausea
RN Interventions for EMB (Ethambutol)
E = eyes
— Ask about gout
— Take with 8oz of water
— REPORT VISION CHANGES (can cause blindness) optic neuritis
— Avoid alcohol
— Take at bedtime
Differences in symptoms of allergic rhinitis
— Episodic—sporadic exposure
— Intermittent—less than 4 days/week or less than 4 weeks/year
— Persistent—greater than 4 days/week or greater than 4 weeks/year
Chest tube insertion
3 Basic compartments of pleural drainage
Purpose: collect fluid, air, or blood in chest cavity
1st — collection chamber | fluid stays IN; air vents to 2nd compartment
2nd — H20 -seal chamber | contains 2cm of H2O; acts as one-way valve; air goes IN, bubbles OUT, but can’t go back to patient
3rd — suction control chamber | Uses column of H2O to control suction from regulator
Bubbling in H2O-seal chamber in pleural drainage
— Brisk at first, eventually disappears as lung expands
— Intermittent with exhalation, coughing, or sneezing
Tidaling in H2O-seal chamber in pleural drainage
— Fluctuation of water with pressure changes during respiration
— Disappears as lung re-expands
— If stops suddenly, check for occlusion
Management for chest drainage
Keep below chest
— Mark and measure drainage
— Report greater than 200 mL/hr in first hour and 100 mL/hr thereafter; replace unit when full
— Avoid overturning unit
— Breakage of unit: place distal end of chest tube in 2 cm water in sterile container; replace unit
— No milking or stripping chest tube
Management for wet suction chest drainage
Monitor:
Water levels
Suction at—20 cm H2O
Gentle bubbling
Management for DRY suction chest drainage
— Turn dial to ordered amount
— If decrease suction; depress high-negativity vent and check water level in water-seal chamber
Chest tube dressings management
Change according to agency policy and procedure
Petroleum gauze
Aseptic technique
Monitor for infection
Document
Which test measures volume of the air the lungs can hold after maximum inhalation?
Pulmonary function tests
— used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.
Expected finding for chest tube placement postprocedure
– H2O seal chamber: tidaling
– Suction chamber: continuous bubbling only
