respiratory system Flashcards
TB skin test
negative: redness without induration
positive: induration > 15 mm in healthy individuals
induration > 10 mm in immunocompromised pts
induration > 5 mm in high risk pts (e.g. HIV, organ transplant pts, pt had recent contact with TB)
positive for TB
no symptoms –> chest x-ray
symptoms –> sputum culture
types of TB
latent and active
nursing for TB
airborne precautions, wear N95 mask
latent TB
no symptoms, no sputum culture, not transmissible
active TB
symptoms, positive sputum culture, transmissible
flail chest
paradoxical respirations: chest moves in and out when breathing, pain, SOB, high HR, increased RR, decreased lung sounds
nursing for flail chest
elevate HOB 30-45 degrees, O2, DB&C, prep for possible intubation
nursing for influenza
lung sounds, fluids, meds (antipyretics, antivirals)
pneumothorax
lung collapse due to air in pleural space
types of pneumothorax
open, tension
open pneumothorax
opening in chest area
tension pneumothorax
injury to chest
S/S of pneumothorax
no lung sounds on that area, SOB, pain, increased RR
nursing for pneumothorax
chest dressing, O2, elevate HOB 30-45 degrees, prep for chest tube insertion
nursing for asthma
airway patent, meds (corticosteroids to open airway)
types ofCOPD
emphysema and bronchitis
emphysema
damaged alveoli leading to impaired gas exchange
bronchitis
airway filled with mucus
s/s of COPD
wheezing, crackles heard upon auscultation of lung sounds, barrel chest,, respiratory acidosis
nursing for COPD
keep SpO2 88-92%, administer meds (bronchodilators), ABG
causes of pneumonia
bacterial, viral, fungal, aspiration
nursing for pneumonia
C+S, droplet precautions, O2, LOC, DB&C, elevate HOB 30-45, chest physiotherapy to break up secretions, ensure good fluids, meds (antibiotics)
PE
blockage in pulmonary artery
s/s of pulmonary embolism
blood tinged sputum, SOB, high HR, high RR
nursing for pulmonary embolism
elevate HOB, O2, ABG, meds (anticoagulants)
empyema
pus in lungs
nursing for empyema
elevate HOB, O2, DB&C, meds (antibiotics), drainage (e.g. via chest tube)
pleural effusion
fluid in pleural space that stops lungs from being able to fully expand
s/s of pleural effusion
SOB, decreased lung sounds in that area when auscultating,
nursing for pleural effusion
elevate HOB, monitor lung sounds, prep for thoracentesis
ventilator alarms
high pressure –> increased secretions, tube kinked, pt coughing
low pressure –> tube disconnected, pt stopped breathing
types of O2 delivery
nasal prongs: 1-6 L/min, can be used long-term
face mask: 5-8 L/min, short-term O2, emergencies
Venturi mask: 4-10L/min, respiratory failure
partial rebreather mask: 6-15 L/min
non-rebreather mask: 60-100%, deteriorating resp status
chest tube suction type
wet and dry suction
suction control chamber
wet: suction regulated by height of water
dry: set by dial
removal of chest tube
Valsalva maneuver and hold breath
nursing for chest tube
keep system below pt
if chest tube dislodged
cover with sterile dressing on all sides so air cannot get in
drainage
colour, amount
normal chest tube drainage
less than 100 cc/hr
water seal chamber
water should fluctuate with every inspiration and expiration
if no fluctuation in water seal chamber
kink, expanded lung
how air leak shown?
bubbling
if pt has pneumothorax, then intermittent bubbling is okay
lung sounds
fine crackles: crackling, popping coarse crackles: crackling, popping wheeze: high pitched, musical sound ronchi: snoring stridor: life-threatening, obstruction in airway
diseases with crackles
pneumonia, heart failure, pulmonary
edema
diseases with wheezes
asthma
nursing for wheezing
meds (albuterol)
diseases with ronchi
bronchitis
diseases with stridor
aspiration of foreign object, anaphylaxis,
epiglottitis
