Nursing Respiratory Test Flashcards
pathophysiology of epistaxis
aka a nosebleed. Anterior region is most common and originate from vessels called Kiesselbach plexus. Blood vessels of the posterior nose are larger and bleeding can be severe and difficult to control
etiology of epistaxis
nosebleed. most common cause is dry cracked mucous membranes. trauma, blowing nose, nose picking, increased pressure on fragile capillaries from hypertension. hemophilia, leukemia, regular aspirin use, anticoagulant therapy, chemotherapy, cocaine use
therapeutic measure for epistaxis
nosebleed. sit in chair and lean forward (avoid aspirating or swallowing blood.) place pressure on nares for 5-10 min. ice pack (constricts vessels.) decongestants (vasoconstrictors) cauterize. gauze to pack it. IV fluid replacement for a lot of blood loss.
nursing care for pt with epistaxis
monitor bleeding, note amount and color. monitor vital signs and hemoglobin levels. swallowing repeatedly sign of bleeding. If bleeding does not stop in 10-15 minutes notify RN or MD immediately. monitor for airway blockage if packing is used. teach pt to avoid bending over
pathophysiology and etiology of nasal polyps
grape like clusters of mucosa in nasal passage. usually benign, can obstruct nasal passages. related to chronic inflammation and people with allergies.
what is the aspirin triad asthma
three components
asthma, allergic to aspirin, nasal polyps
therapeutic measures for nasal polyps
control of allergy symptoms. oral antihistamines or nasal corticosteroid sprays to control inflammation. can be removed. avoid aspirin products.
pathophysiology and etiology of deviated septum
septum dividing nasal passages is slightly deviated. result from trauma. can block sinus drainage, interfere with breathing
signs and symptoms of deviated septum
chronically stuffy nose. discomfort from blocked sinus drainage. headaches and nosebleeds
therapeutic interventions for deviated septum
decongestants, antihistamines, intranasal cortisone spray to reduce inflammation. nasoseptoplasty
nursing care for pt after nasoseptoplasty
monitor vitals and bleeding. swallowing sign of bleeding, check for blood running down back of throat. will have mustache dressing. maintain semi-Fowler’s position. avoid sneezing, coughing, straining to move bowels. stool softeners and cough suppressants can be ordered. aspirin is avoided. antibiotics can be given. ice to reduce swelling.
pt education for pt after nasal surgery
- your nose will feel stuffy and may drain
- change mustache dressing as often as needed
- do not blow your nose
- if you must sneeze, do it with mouth open
- drink plenty of fluids
- use cool mist vaporizer to humidify hair(prevent nasal drying)
- keep head elevated or sleep in recliner
- ice pack to reduce swelling
- pain med as prescribed
- call physician if temp is higher than 101
- return to see physician as directed
pathophysiology and etiology of sinusitis
inflammation of the mucosa of one or ore sinuses. can be acute or chronic (symptoms for more than 2 months and unresponsive to treatment)
Most common are maxillary and ethmoid sinus. often result of bacterial infection and may follow a viral upper respiratory illness. most common organism are Streptococcus pneumonia and Haempophilus influenza. also caused b allergies, nasal polyps, fungal infection, intubation
signs and symptoms of sinusitis
pain over region of affected sinus.
if maxillary-pain over cheek and upper teeth.
ethmoid-between and behind the eyes
frontal-forehead
fever may be present, fatigue, foul breath
complications of sinusitis
can spread to surrounding areas causing osteomyelitis, cellulitis of orbit, abscess, meningitis, trigger asthma symptoms
diagnostic tests for sinusitis
based on symptoms alone. x-ray, nasal endoscopy, CT, MRI, culture nasal discharge
therapeutic measures for sinusitis
aimed at relieving pain and promoting sinus drainage. nasal irrigation with normal saline solution. corticosteroids, adrenergic nasal sprays (up to 3 days). hot moist packs. expectorants, fluids, room humidifier. antihistamines, antibiotics
why should adrenergic nasal sprays be used cautiously in pt with heart disease/hypertension
vasoconstriction increases blood pressure
nasal sprays for more than 3 days causes what
rebound congestion
nursing care for the patient with sinusitis
uncomplicated sinusitis are cared for at home. increase water intake. maintain semi-Fowler’s position. hot moist packs, analgesics, prescribed meds. finish antibiotic.
pathophysiology and etiology of rhinitis/common cold
rhinitis (aka coryza) is inflammation of the nasal mucous membranes. release of histamine and other substances causes vasodilation and edema. may occur as reaction to allergens like pollen, dust, mold, some foods, viral or bacterial infection
s/s of rhinitis
nasal congestion, localized itching, sneezing, sore throat, nasal discharge. viral/bacterial rhinitis can be accompanied by fever and malaise
diagnostic tests for rhinitis
if allergic rhinitis is suspected-skin testing
a blood test for IgE antibodies
therapeutic measures for rhinitis
antihistamines inhibit histamine response. allergy shots. antibiotics not effective for viral rhinitis. tylenol. decongestants.
why should cough syrup and cold medicine be used with caution for pt with rhinitis/common cold
do not treat underlying cause of the cold, and contain different medications which are often not needed.
pathophysiology and etiology of pharyngitis
inflammation of the pharynx. usually related to bacterial r viral infection. may occur as result of trauma to the tissues. most common bacterial is beta-hemolytic streptococci (strep throat)
if strep throat is not treated with antibiotics it can lead to what
rheumatic fever, glomerulonephritis, or other serious complications
s/s of pharyngitis
most common symptom-sore throat
dysphagia, throat red and swollen, exudate (drainage or pus) may be present. fever, chills, headache, malaise
differentiating respiratory tract infection
onset= cold:slow–influenza: sudden
fever= cold:non/low grade–flu:common
headache= cold:rare– flue:common
muscle ache= cold:less common–flu: common, severe
cough= cold:present– flu: present, usually dry
chest pain= absent– flu: common
fatigue=cold: slight– flu: common, prolonged, severe
runny nose= cold: common– flu:less common
sore throat= cold:common– flu:less common
complications= cold:rare– flu:pneumonia
treatment= cold: rest/fluids– flu:rest, fluids, antiviral
nursing diagnosis for pt with an upper respiratory infection
impaired comfort
hyperthermia
risk for infection
diagnostic tests for pharyngitis
throat culture and sensitivity test
therapeutic measures for pharyngitis
if bacterial-antibiotics tylenol or throat lozenges saltwater garles honey and lemon mice with warm water encourage fluids and rest
pathophysiology and etiology of laryngitis
inflammation of the mucous membrane lining of the larynx (voice box.) caused by irritaion from smoking, alcohol, chemical exposure, GERD, viral, fungal, bacterial infection. often follows an upper respiratory infection.
s/s of laryngitis
most common symptom is hoarseness.
cough
dysphagia
fever
diagnostic tests for laryngitis
tiny mirror to view larynx. laryngoscopy and biopsy to rule out cancer
therapeutic measures of laryngitis
rest, fluids, humidified air, aspirin or tylenol. antibiotics if bacterial. med to control GERD. avoid speaking. whispering strains the voice even more.
pathophysiology and etiology of tonsillitis/adenoiditis
filtering function becomes overwhelmed with a virus or bacteria and infection results. more common in children.
function of the tonsils
filter microorganisms to protect the lungs from infection
s/s of tonsillitis/adenoiditis
usually begins suddenly with sore throat, fever, chills, pain on swallowing. headache, malaise, myalgia. tonsils appear red and swollen, may have yellow or white exudate on them. may mention snoring, nasal obstruction, nasal tone to voice
diagnostic tests for tonsillitis/adenoiditis
throat culture
WBC and differential
chest x-ray
therapeutic measures for tonsillitis/adenoiditis
antibiotics for bacterial infection. tylenol, lozenges, saline gargles.
After tonsillectomy: semi-Fowler’s (reduce selling and promote drainage.) monitor for bleeding, airway latency, provide comfort measures. fluids for hydration. room humidifier. suction available for emergencies
pathophysiology and etiology of influenza
flu. viral infection of respiratory tract. new strains each year. elderly at particular risk. transmitted via droplets. incubation period is 1-3 days
s/s of flu
abrupt onset of fever, chills, myalgia, sore throat, cough, malaise, headache
complications of flu
most common: pneumonia
diagnostic tests for flu
viral cultures, nasal swabbing.
therapeutic measures for flu
primarily symptomatic. tylenol for fever, headache, myalgia aspirin is avoided-Reye's syndrome rest and fluids essential antiviral meds
nursing care for pt with influenza
closely monitored for complications assess lung sounds and vitals q4h monitor for dehydration encourage rest and fluids no aspirin in under 18
summarize bird flu
aka avian influenza
infects wild and domestic birds
contract it form contact with infected bird or excrement
symptoms are similar to flue
summarize SARS
severe acute reparatory syndrome
high fever, body aches, often progress to pneumonia
transmission from close contact with person or object
H1N1 flu
aka swine flu
usually affects pigs
west nile virus
transmitted from birds to humans by mosquitos.
use mosquito repellent
eliminate standing water where mosquitoes lay eggs
pathophysiology of cancer of the larynx
usually develops in the squamous cells of the mucosal epithelium. evaluated based on TNM staging system. most often a primary cancer and can spread to lungs, liver, lymph nodes. prognosis is often poor.
etiology of cancer of larynx
risk factors: Hx of alcohol, tobacco use, exposure to industrial chemicals, hardwood dust, chronic overuse of voice, diet low in fruits and vegetables. men more likely to be affected
prevention of cancer of larynx
educate on relationship between cancer and alcohol/tobacco use. seek treatment when symptoms first occur. any hoarseness that lasts longer than 2 weeks should be investigated
s/s of cancer of larynx
most common symptom is hoarseness because vocal cords are located in larynx
throat or ear pain, SOB, chronic cough, difficulty swallowing
stridor
weight loss and halitosis (foul breath)
diagnostic tests for cancer of larynx
examined with mirror. laryngoscope examination. CT scan, MRI
therapeutic measures for cancer of larynx
may be treatable with radiation therapy; will preserve patient’s voice. chemo as well. surgery (larynx will be partially or completely removed) parietal laryngectomy. radical neck dissection with total laryngectomy (loss of voice)
nursing diagnoses for cancer of larynx
risk for ineffective airway clearance acute pain impaired verbal communication risk for imbalanced nutrition impaired swallowing grieving related to loss of voice disturbed body image
laryngal cancer: risk for ineffective airway clearance related to excessive secretions and new trach/laryngecotmy. What to do
monitor and record amount, color, consistency of secretions vitals, lung sounds, signs of respiratory distress provide trach care sterile technique semi-Foweler's position deep breathe and cough qh avoid use of powders, sprays, airborne materials
laryngal cancer: acute pain related to surgical procedure. what to do
assess pain level q4h and pen
assess sedation and reap status often
opioids given carefully
admin analgesics as prescribed
which is the best explanation by the nurse for why a physician did not prescribe antibiotics for influenza?
influenza is caused by viruses. viruses are not treated with antibiotics
acute bronchitis
inflammation of the bronchial tree. mucous membranes (that line the bronchial tree) become irritated and inflamed, excessive mucous is produced. result is congested airways. usually an isolated episode
pathophysiology of bronchiectasis
dilation of the bronchial airways. dilated areas become flabby and scarred. secretions pool in areas and difficult to cough up. creates and environment when bacteria flourish. infection is common.
etiology of bronchiectasis
usually occurs secondary to another chronic reps disorder (CF asthma, TB, bronchitis, exposure to toxin)infection and inflammation of airways weakens the bronchial walls and reduces ciliary function. airway obstruction from excessive secretions that predisposes the pt to development of bronchiectasis
s/s of bronchiectasis
recurrent lower reap infection sputum is copious an purulent foul smelling sputum sputum can be bloody can experience dyspnea even with minimal exertion wheezes and crackles fever present if active infection cor pulmonale (right sided HF) clubbing of fingers
diagnostic test for bronchiectasis
chest x-ray
CT
bronchoscopy
sputum cultures
therapeutic measures for bronchiectasis
aimed at keeping airways clear of secretions, controlling infection, correcting underlying problem. antibiotics vaccinations for prevention bronchodialators mucolytic agents and expectorants chest physiotherapy oral fluids encouraged
pathophysiology of pneumonia
acute inflammation and/or infection of lungs. transmitted by the cough. when microorganisms multiply, they release toxins and induce inflammation in lung tissue, causing damage to mucous and alveolar membranes. leads to edema and exudate. this reduces surface area available for exchange of carbon dioxide and oxygen. also causes necrosis of lung tissue. can be confined to one lobe or scattered.
etiology of pneumonia; bacterial pneumonia
most common cause of community acquired bacterial pneumonia is streptococcus pneumonia.
etiology of pneumonia; viral pneumonia
influenza viruses most common cause. generally less ill with viral pneumonia than bacterial pneumonia, but usually sick longer
etiology of pneumonia; fungal pneumonia
candida and aspergillus are two types. typically causes pneumonia in pts with AIDS
etiology of pneumonia; aspiration pneumonia
aspiration of foreign substances. most often occurs in pt with decreased LOC or impaired cough or gag reflex. increases risk for subsequent bacterial pneumonia
gas exchange occurs in which structures
alveoli
while providing care a nurse notes the pts shoulders are rising with each breath. this is documented as:
the se of accessory muscles to aid breathing
the nurse is auscultating a pt lungs but is unable to hear much air movement. what is the next step
have pt deep breath through the mouth
the nurse notes a pt with periods of fast, deep respirations alternating with periods of apnea. this pattern is:
Cheyene-Stokes
which term describes a loud crowing sound that results from obstruction of the airways by a tumor or foreign body
stridor
a pt arterial blood gas analyzes shows a pH of 7.28 with high PaCO2. what does pt have
respiratory acidosis
nurse is examining a chest drainage system on a pt with a pneumothorax and notes the water level in the water seal chapter fluctuating with each pt respirations. the nurse should
no action is necessary, this finding is expected
a pt returns to SDS from surgery for a deviated septa. which of the following would most concern the nurse.
the pt swallows frequently
what is most common complication of influenza
pneumonia
which assessment finding does the nurse anticipate noting in a pt being evaluated for cancer of larynx
a hoarse voice
antidote for narcotic overdose
(Narcan)
naloxone
corticosteroids such as methylprednisolone (Solumedrol) are used in the pt with COPD for which purpose
reduce airway inflammation will increase BS will suppress immune system aggressive behaviors moon face (round puffy) can't abruptly stop med
s/s of pneumonia
fever, shaking, chills, cheats pain, dyspnea, fatigue, productive cough, sputum is purulent (rust colored or blood tinged) crackle and wheezes. can also experience fatigue, sore throat, dry cough, n/v.
elder can become confused or lethargic
complications of pneumonia
pleurisy and pleural effusion, atelectasis, septicemia, meningitis, septic arthritis, pericarditis, endocarditis
which med can help reduce acute dyspnea in pt with end stage COPD
IV morphine
small enough to ease respirations
diagnostic test for pneumonia
chest x-ray. sputum and blood culture.
therapeutic measures for pt with pneumonia
broad spectrum antibiotics (oral or IV) rest and fluids antiviral medications expectorants bronchodialators analgesics nebulized mist treatment O2
term used to describe blood tinged sputum
hemoptysis
TB pathophysiology and etiology
infectious disease. primarily affects the lungs, but can also affect kidneys, liver, brain, bone. acid fast bacillus.
spread by inhalation. once bacilli enter lungs, they multiply and begin to disseminate to the lymph nodes.
priority nursing diagnoses for pt with pneumonia
impaired gas exchange
ineffective airway clearance
activity intolerance
