Module 2 Exam 1- Flashcards
Acute Respiratory Distress Syndrome (ARDS)
severe form of respiratory failure with rapidly progressing hypoxemia; causes alveolar injury and damage to endothelial lining; reduction of lung compliance, volume, and gas exchange; d/t pneumonia, sepsis, or multiorgan failure; most fatal in 24-48 hours
common causes of ARDS
aspiration of gastric contents, shock, sepsis
signs and symptoms of ARDS
hypoxia that doesn’t improve with O2 is major sign; tachypnea, increased dyspnea, tachycardia, HTN, restlessness, xray shows visible bilateral infiltrates and pulmonary edema (BNP distinguished from pulmonary edema)
prone positioning for ARDS
improves oxygenation, increases end-expiratory lung volume, improves bronchial drainage, improves functional residual capacity, improves gas exchange; use of rotoprone
high pressure alarm on ventilator
coughing, mucus plug, kinked tubing, decreased lung compliance (bucking the vent), atelectasis or bronchospasm
low pressure alarm ventilator
increase in lung compliance; leak in ventilator tube; leak in ET cuff
suctioning when pt intubated
not a routine thing; suctioned if - visible secretions in ET tube, onset of respiratory distress, suspected aspiration, increased airway pressure, adventitious breath sounds over trachea or bronchi, increased RR, sustained coughing, sudden decrease in O2 levels, or for sputum culture
sedation vacation
once a shift to observe neuro status
if cause of ventilator alarm cannot be determined…
ventilate manually until problem corrected
nursing management of epistaxis
pinch and lean forward for 5-10 minutes
obstructive sleep apnea
obstruction of upper airway causing decreased ventilation and gas exchange; intermittent breathing
clinical manifestations of obstructive sleep apnea
as described by parter- loud snoring/snorting, apneic events, gasping, recurrent waking, sleep disruption, choking; as reported by pt- excessive daytime sleepiness, workplace or car accidents, decreased cognitive functioning, retention and performance compromise
risk factors for obstructive sleep apnea
obesity, DMII, heart failure, pulmonary HTN, large neck circumference
diagnosis of obstructive sleep apnea
health history and sleep study
treating obstructive sleep apnea
lifestyle modifications, CPAP (constant positive airway pressure), surgery
polysomnography
overnight sleep study to monitor number, duration, and frequency of apneic episodes
nursing management of epistaxis
pinch soft portion of nose and lean forward 5-10 min; maintain adequate ABCs; vital signs (cardiac and pulse ox); teach pt to avoid nasal trauma, increase humidity if dry air, and seek health care attention if continues after 15 min
laryngectomy
removal oof whole or partial larynx/voice box
laryngectomy nursing intervention
preop teaching, reduce anxiety, maintain airway, control secretions, decide alternative communications d/t loss of communication following surgery, promote adequate nutrition and hydration, positive body image
complications with laryngectomy
respiratory distress, hemorrhage (leads to aspiration of blood), wound breakdown, aspiration, hoarse voice, edema
pulmonary embolism
clot in pulmonary artery or branch that occludes blood flow; can be fat, air, thrombus, amniotic, or septic; severity based on size; increased vascular resistance and pulmonary arterial pressureris
risk factors for developing ppulmonary embolism
virchows triad, DVT in legs arms or pelvis
virchows triad
venous stasis, hypercoagulative state (pregnant or COPD), endothelial damage (diabetes or HTN)
saddle PE
clots forms at biforkation of lungs blocking bloodflow to both lungs
clot busting drug for PE
altiplase
clot preventing drug for PE
warfarin
pulmonary embolism clinical manifestations
sudden dyspnea, pleuritic chest pain, anxiety/impending doom, tachycardia, cough, diaphoresis (profuse), hemoptysis, syncope, petechiae
diagnostic test for pulmonary embolism
elevated d-dimer, ekg, chest xray, ABG, spiral CT, VQ scan (ventilation/perfusion), pulmonary arteriogram (golden standard)
preventing PE in hospital
active leg exercises, mobility with PT, early ambulation, anticoag (heparin and warfarin), sequential compression device or “pressing gas”
if develop HIT…
switch to argatroban
treatment of PE
improve resp. and vascular status via O2, IV access, EKG monitoring; anticoag therapy with heparin or warfarin; thrombolytic therapy w/ streptokinase and alteplase (monitor for bleeding with labs, assess., vitals); surgical embolectomy, IVC filter in inferior vena cava, EKOS ultrasonic waves
nursing management of PE
assessment to identify high risk pt; prevent thrombus formation with early ambulation and passive leg exercise, manage O2 therapy with pulse ox and deep breathing etc.; monitor for complications (shock, bleeding, hypoxia); monitor thrombolytic therapy via VS and PTT (q4)
pneumothorax
partial or complete collapse of lung due to positive pressure in pleural space; can be hemothorax or tension pneumo
tension pneumothorax
emergency situation when pneumothorax increases pressure in pleural space and displaces heart and lungs; can be opened or closed; open is one way air in but not out (ex. GSW or stabbing)
manifestations of tension pneumothorax
TD, resp distress, JVD
treatment of pneumothorax
chest tube/dart in 2nd intercostal space prior to intubating
diagnosing pneumothorax
presentation and assessment; related history; x-ray; ABG shows respiratory acidosis (decrease PaO2 and increased PaCO2)
if open pneumothorax…
3 sided occlusive dressing to allow blood and air out but no air in
pneumectomy post op care
assess breath sounds, O2 sat, vitals, cardiac rhythm; elevate HOB 30-45; change pt position from back to side often; incentive spirometry, cough, deep breath; assess and monitor drainage; arm and shoulder exercise to alleviate shoulder pain; pain relief modality; balancing rest and activity; smoke cessation, avoid bronchial irritants; keep airway patent and suction when needed
nursing care of chest tube
narcotics and local anesthetic for tube placement; NSAIDs for tube duration; anxiety meds PRN; keep tubing connections patent and kink free; drainage below chest level; monitor levels of fluid and suction control; vitals, pulmonary assessment, site eval; daily xray
bubbling in chest tube…
not good means there is an air leak; tidaling is ok
chest tube removal
suction is discontinued for 6-24 hurs prior; chest xray prior; ensure lungs re-expanded and no more pleural drainage; pre medicate; cut sutures holding tube; remove tube on exhale; occlusive dressing over wound; wound self heals; NSAIDs PRN
if chest tube becomes disconnected…
place other end in sterile water for seal
monitoring fluid from chest tube
measure; quality of drainage
normal pH value
7.35-7.45 (7.4 is middle)
normal PaCO2
35-45; regulated to the lungs
normal HCO3
22-26; regulated by kidneys
whern looking at ABGs
check pH to see if acidic or alkalotic; then evaluate PaCO2; then evaluate HCO3; (then for entire clinical picture look at PaO2 and O2 for hypoxemia and impaired oxygenation)
acidotic values
CO2 > 45 ; HCO3 < 22
alkalotic values
CO2 < 35 ; HCO3 > 26
Rome method
Respiratory opposite (pH and CO2 are opposite); Metabolic equal (pH and HCO3 are equal)
uncompensated values…
when pH is out of rand and one of CO2 or HCO3 is in range
partially compensated values…
CO2, pH, and HCO3 all out of range
fully compensated values
pH is in range
respiratory compensation
body can partially compensate for metabolic imbalances by adjusting ventilation
metabolic compensation
respiratory imbalances can be compensated through changes in bicarbonate levels
causes for respiratory acidosis
lungs retain too much CO2; kidneys excrete excess hydrogen and retain HCO3
DEPRESS breathing
cause for retaining CO2; drugs, edema, pneumonia, respiratory center of brain damaged, emboli, spasms of bronchial, sac elasticity damaged
interventions for respiratory acidosis
admin O2, semi-fowlers, turn cough deep breath, increase of fluid and antibx in pneumonia, if CO2 > 50 intubate, monitor potassium
causes for respiratory alkalosis
lungs lose too much CO2, kidneys excrete too much bicarb and retain hydrogen; increased temp, aspirin toxicity, hyperventilation all cause
interventions for respiratory alkalosis
emotional support, fix breathing problem, encourage good breathing pattern, rebreathing into paper bag to retain CO2, anti-anxiety meds or sedatives, monitor K and Ca levels
metabolic acidosis causes
kidney hold too much hydrogen and release too much bicarb, lungs blow off CO2’; caused by DKA, AKI/CKD, malnutrition, severe diarrhea
interventions for metabolic acidosis
monitor I/O, admin IV solution of sodium bicarb, initiate seizure precautions, monitor K; if diabetic issue give insulin
causes of metabolic alkalosis
kidneys release too much HCO3 and remove too much H+; lungs compensate by retaining CO2; too many antacids, diuretics, excess vomiting or GI suctioning, hyperaldosteronism
interventions for metabolic alkalosis
monitor k and Ca, admin IV fluids to help kidneys get rid of bicarb, replace K, give antiemetics for vomiting, watch for signs of respiratory distress
metabolic alkalosis values
pH > 7.45 and HCO3 > 26
metabolic acidosis values
pH < 7.35 and HCO3 < 22
respiratory acidosis values
pH < 7.35 and CO2 > 45
respiratory alkalosis values
pH > 7.45 and CO2 < 35
SaO2 normal levels
95-100%; if lower than 90 then supplement
