Respiratory

Question 1

Hemothorax / Pneumothorax Patho

Answer 1

blood or air accumulated in pleural space

lung collapsed

Question 2

Hemothorax / Pneumothorax S/sx

Answer 2

SOB
increased HR
diminished breath sounds on affected side
chest pain
cough
CXR - shows air or blood
Subcutaneous emphysema (air trapped in tissue)

Question 3

Hemothorax / Pneumothorax Treatment

Answer 3

Thoracentesis

Chest tube

daily CXR

Question 4

Tension Pneumothorax Causes

Answer 4

trauma
to much PEEP
clamping a chest tube
insertion of central venous line
taping an open pneumothorax on all 4 sides without an air valve

Question 5

Tension Pneumothorax Patho

Answer 5

pressure has built up in the chest / pleural space and has collapsed the lung –> pressure pushes everything to the opposite side (mediastinal shift)

Question 6

Tension Pneumothorax S/sx

Answer 6

subcutaneous emphysema
absence of breath sounds on one side
asymmetry of thorax
respiratory distress
cyanosis
distended neck veins (JVD)
can be fatal as pressure compresses vessels --> decreases venous return --> decreases CO

Question 7

Tension Pneumothorax Treatment

Answer 7

large bore needle placed into 2nd intercostal space. to allow air to escape

treat the cause (chest tube)

Question 8

Open pneumothorax patho

Answer 8

sucking chest wound (GSW, stab)

opening through chest that allows air into pleural space

Question 9

Open Pneumothorax Treatment

Answer 9

have client inhale and hold or Valsalva or hum
- increases intra-thoracic pressure so no more outside air can get into body
place piece of petroleum gauze over the area
- tape down 3 sides / 4th side is an air vent or flutter valve
have client sit up to expand lungs
- trauma clients stay flat until evaluated for other injuries

Question 10

Thoracentesis Pre-procedure

Answer 10

stop anticoagulants
obtain baseline VS, O2, and pain
CXR done prior
sit on edge of bed, w feet supported, lean over bedside table
- can’t sit up = lie on unaffected side with HOB at 45 degrees

Question 11

Thoracentesis Procedure

Answer 11

client must be very still; no coughing or deep breaths

fluid / blood / exudate is being removed from pleural space, making lung expand

check VS, O2, and pain

Question 12

Thoracentesis Post-Procedure

Answer 12

another CXR
VS
listen to lungs for absent or reduced breath sounds on affected side
check puncture site and dressing for bleeding
monitor for subcutaneous emphysema, infection, tension pneumothorax
turn, cough, deep breathe

Question 13

Chest Tube Insertion

Answer 13

if tube is in upper anterior chest (2nd intercostal space) its removing air

if its placed latterally in lower chest (8th or 9th intercostal space) then its for fluid

 * they can have both fluid and air at same time

chest tube is sutured to chest wall and an air-tight dressing is applied around chest tube exit site

Question 14

Drainage collection chamber of CDU

Answer 14

tube connects to 6 foot tube

if it fills up, get another CDU

Question 15

Water seal chamber of a CDU

Answer 15

2 cm of water that acts as one-way valve

bubbling when client coughs, sneezes, or exhales is expected

Tidaling –> slight rise and fall of water in water seal tube as pt breathes

Question 16

Suction Control Chamber in CDU

Answer 16

controls amount of pressure

sterile water is placed up to 20 cm line

turn on wall vacuum suction until you have slow, gentle continuous bubbling

Question 17

Assessment of Closed Chest Drainage System

Answer 17

dressing - tight and intact
listen for breath sounds in both lungs
make sure O2 is >90%
check for subcutaneous emphysema
record chest drainage every hour for first 24 hrs and then every 8 hours
deep breathe, cough, use incentive spirometer
watch for fever, increased WBC, and drainage = infection
watch daily CXR for improvement / re-expansion

• Notify HCP if:
  
  • 200 mL of drainage or greater in first hour
  • 100 mL or greater any hour after first hour
  • change in color (yellow to bright red)
• 20 g needle or smaller and tube will reseal itself

Question 18

Maintaining CDU

Answer 18

keep system below level of chest (gravity drainage)

tubing straight / free of kinks (dependent loop)

tape all connections (closed system)

monitor water levels

need to see tidaling with respirations
- if tidaling is not present, it means lung re-expanded, there’s a kink or dependent loop in system.

Bubbling is only a problem if it’s continuous bc it indicates a leak

never clamp a chest tube without a prescription because it can lead to tension pneumothorax

Question 19

Tubing becomes Disconnected?

Answer 19

keep another sterile connector at beside and reconnect ASAP

Question 20

If Chest tube gets ripped out?

Answer 20

sterile occlusive dressing taped on 3 sides (put glove on and cover)

otherwise, everytime they breathe they will pull air into the pleural space

Question 21

What happens if there is no water in the water seal chamber?

Answer 21

air will collapse the lung

so if water seal is empty we put water in to 2 cm (even if its not sterile)

Question 22

Chest tube removal:

Answer 22

client take deep breath and hold their breath or hum and place an occlusive dressing over the site

tape ALL sides down

Question 23

Fractures of ribs and sternum S/sx

Answer 23

pain and tenderness
crepitus
shallow respirations
respiratory acidosis

Question 24

Fractures of ribs and sternum:

treatment & complications

Answer 24

non-narcotic agents (don’t want to slow breathing)

incentive spirometry

nerve block to assist with producive coughing

support injury with hands

do NOT immobilize client with chest binder (leads to shallow breathing = atelectasis and pneumonia)

• • • complications: pneuothorax, hemothorax, flail chest

Question 25

Flail Chest

Answer 25

occurs with multiple rib fractures

Question 26

Flail Chest S/sx

Answer 26

anxious / SOB pain paradoxical chest wall movement (see-saw chest) - chest sucks inwardly on inspiration and puffs out on expiration - to assess, stand at foot of bed and watch dyspnea cyanosis increased pulse

Question 27

Flail Chest Treatment

Answer 27

humidified O2 pain management stabilize area intubate ventilate positive pressure ventilation stabilizes area and promotes lung expansion - invasive posiitive pressure ventilation (PEEP - positive end experatory pressure) - non-invasive positive pressure ventilation (BiPAP and CPAP)

Question 28

PEEP

Answer 28

Positive End Expiratory Pressure - client is on ventilator - at the end of expiration the vent exerts pressure into lungs to keep alveoli open - this improves gas exchange and decreases work of breathing - expands and realigns ribs so they can heal - also used to treat pulm edema and severe hypoxemia - mainly for ARDS (acute respiratory distress syndrome)

Question 29

BiPAP and CPAP

Answer 29

apply pressure to lungs to open alveoli and improve ventilation and oxygenation both used for sleep apnea, ARDs, COPD, and pulm edema clients moved to these devices when they are weaned from ventilator

Question 30

CPAP

Answer 30

Continuous Positive Airway Pressure pressure is delivered continuously during inspiration and expiration *obstructive sleep apnea and infants with underdeveloped lungs

Question 31

BiPAP

Answer 31

Bi-level Positive Airway Pressure pressure applied at 2 different pressure settings. One pressure on inhalation and a lower pressure on exhalation. non-obstructive sleep apnea - better tolerated since they don't have to exhale against a high pressure

Question 32

Anytime you see PEEP, CPAP, or Bi-PAP, your priority nursing assessment is to check bilateral....

Answer 32

lung sounds every 2 hours

Question 33

Pulmonary Embolism Causes

Answer 33

``` dehydration venous stasis from prolonged immobility or surgery obesity birth control pills clotting disorders heart arrhythmias like A-fib ```

Question 34

Pulmonary Embolism S/sx

Answer 34

``` hypoxemia #1 PaO2 decreased SOB / cough / increased RR restlessness / apprehension petechiae over chest cyanosis hemoptysis (coughing up blood) increases pulse chest pain (sharp / stabbing) atelectisis on CXR pulmonary HTN (at risk for right sided HF) ``` *most come from DVTs that break off

Question 35

DVT

Answer 35

thrombosis in deep veins of the legs or the arms

Question 36

PE

Answer 36

thrombosis that has broken off and lodges in lung artery

Question 37

VTE

Answer 37

when you have both a DVT and PE venous thrombus embolism

Question 38

Pulmonary Embolism Diagnosis

Answer 38

increased D-dimer (increased with PE) - will tell if clot is located anywhere in body (not just lungs) computerized tomography angiogram (CTA) - most frequent - dye is used (check renal function) Positive VQ scan (ventilation / perfusion scan that can detect an embollus) - measures airflow and bloodflow to lungs (no dye) * * * PULMONARY ANGIOGRAPHY --> most sensitive and specific test (invasive and expensive)

Question 39

Pulmonary Embolism Prevention

Answer 39

change position every 2 hrs prevent stasis (flexing / extending feet, knees, hips q2-4 hrs) need to walk 4 to 6 times a day TED hose Pneumatic compression devices will not be used if they suspect a DVT bc it can dislodge it Hydrate (force fluids)

Question 40

aPTT

Answer 40

30-40 seconds

Question 41

PT

Answer 41

11-12.5 seconds

Question 42

INR

Answer 42

0.8 - 1.1

Question 43

Pulmonary Embolism Treatment

Answer 43

bed rest / elevate affected leg oxygen according to ABGs decrease pain anticoagulants - vit. K antagonist (warfarin) - thrombin inhibitors (heparin / enoxxaparin / dabigatran) - Factor Xa inhibitors (rivaroxaban / fondaparinux) - prevent clot from getting bigger / limit vit. K while on warfarin - target INR will vary if vit K levels do (same amount of it in food each day) bleeding precautions fibrinolytic agents like tPA or alteplase pulmonary embolectomy may be performed fibrinolytics can't be used inferior vena cava infiltration device may be inserted (prevents clots from getting to lungs)