Upper AND Lower Respiratory Problems Flashcards

Question

Tracheostomy nursing management: postprocedure care

Answer 1

Obturator removed (keep at bedside) Cuff (balloon) is inflated Confirm placement: - Auscultate for air entry; end tidal CO2 capnography; passage of suction catheter - Chest x-ray Tracheostomy sutured in place and secured Monitor VS, SpO2, and mechanical ventilator settings

Answer 2

Monitor for complications - *Bleeding, airway obstruction, infection Assess site and patency at least every shift Monitor cuff inflation pressure: 20 to 25 cm H2O - Minimal occlusion volume Suction PRN Humidified air—thins secretions; reduces mucous plugs Tracheostomy care per agency policy

Answer 3

Watch when turning and repositioning Keep replacement tube of equal and/or smaller size at bedside Do not change tracheostomy tapes (ties) for at least 24 hours after placement HCP performs first tube change but not sooner than 7 days after placement

Answer 4

Call for help; know institution policies and procedures and your scope of practice Assess for respiratory distress, if present: - Insert hemostat in opening and spread; insert obturator in spare tracheostomy tube, lubricate and insert; remove obturator; OR - Insert suction catheter; thread tracheostomy tube over catheter, then remove suction catheter - If can’t insert new trach tube; cover stoma with sterile gauze and ventilate with BVM

Answer 5

- Observe tracheostomy site for signs and symptoms of infection - Perform tracheostomy care -- Clean inner cannula -- Suction -- Change tracheostomy tapes - Tube should be changed monthly after 1st tube change then every 1 to 3 months. -- Clean technique is used at home

Answer 6

- Tracheostomy with inflated cuff interferes with normal function of muscles used to swallow - Speech therapist—clinical assessment for swallowing and aspiration risk -- Fluoroscopy or endoscopy evaluation - If no risk for aspiration, leave cuff deflated or replace with a uncuffed tube - Thickened liquids or soft foods may be allowed

Answer 7

Provide patient with writing tools if speaking devices are not used. - Paper and pencil - White board - Cell phone (text) - Magic slate - Picture board - Visual alphabet - Text to speech applications

Answer 8

- Spontaneously breathing patient -- Remove inner cannula, may deflate cuff, and place a cap on tube; allows exhaled air to flow over vocal cords - Fenestrated tracheostomy tubes - Speaking valves -- Passy-Muir mostly seen with people who have had trachs put in for accident or cancer, accident and recovered - it can be reversed

Answer 9

- Air passes from lungs through opening in tracheostomy into upper airway - Must not be at risk for aspiration - Remove inner cannula, deflate cuff, and place cap on tube - Assess patient for any respiratory distress so they can speak; more with chronic patients A&O

Answer 10

Two pigtail tubings - One connects to cuff for inflation - Other connects to opening just above cuff - When second tube is connected to low-flow air source, this permits speech Can be used on patients at risk for aspiration

Answer 11

Removal of tracheostomy tube from trachea - Epithelial tissue forms in 24 to 48 hours; opening closes in 4 to 5 days Criteria for patient: - Hemodynamically stable - Stable intact respiratory drive - Adequately exchanges air - Independently expectorates

Answer 12

- Explain procedure - Monitor VS - Suction tracheostomy and mouth - Remove tapes/ties - Remove sutures - Deflate cuff - Remove in smooth motion

Answer 13

- Apply sterile occlusive dressing - Monitor for bleeding - Monitor respiratory status - Apply alternate O2 device - Patient education: splint stoma with coughing, swallowing, or speaking

Answer 14

Etiology: smoking (85%) Age: most over age 50 Risk factors: - HPV, - excess alcohol, - exposure to: sun, asbestos, industrial carcinogens, marijuana, radiation to head and neck, and poor oral hygiene

Answer 15

Structures includes: nasal cavity, paranasal sinuses, nasopharynx, oropharynx, larynx, oral cavity, and/or salivary glands - Squamous cells in mucosal surfaces

Answer 16

(vary with location) - lump in throat or sore throat (pharyngeal) - white or red patches - change in voice - hoarseness greater than 2 weeks (laryngeal) Other manifestations: - ear pain - ringing in ears - swelling or lump in neck - constant cough - cough up blood - swelling in jaw

Answer 17

- unintentional weight loss - diffculty chewing, swallowing, moving tongue or jaw or breathing - airway obstruction (partial or full)

Answer 18

T - tumor M - metastasis N - nodes

Answer 19

- Radiation therapy: External beam or internal implants - Chemotherapy and targeted therapy -- Used in combination with radiation for stages III or IV - Nutritional therapy: -- Concerns with swallowing after surgery, side effects of chemotherapy and/or radiation, oral mucositis; gastrostomy tube and enteral feedings; assess tolerance, weight, and risk of aspiration - Physical therapy -- Strengthen, support, and move upper extremities, head, and neck to avoid limited ROM; continue after discharge - Speech therapy -- Preoperative: effect of therapy on voice and potential adaptations or restoration; support groups -- Postoperative restoration: electrolarynx, *transesophageal puncture (Blom-Singer prosthesis) esophageal speech

Answer 20

- impaired airway clearance - risk for aspiration - difficulty coping - impaired communication Planning - goals: - Patent airway, no spread of cancer, no complications from therapy; adequate nutritional intake, minimal to no pain, able to communicate, acceptable body image

Answer 21

Radiation therapy - Dry Mouth (xerostomia) - Oral mucositis - Skin care - Fatigue Stoma care Psychosocial needs - Depression, body image, sexuality Preoperatively: physical and psychosocial needs; assess knowledge and understanding; how to communicate post-operatively Postoperatively: airway management, VS, bleeding, wound/drain care, skin flaps, NGT, nutrition, communication, psychosocial issues, pain control, trach care and suction, fluids, and hydration Ambulatory care: Patient and caregiver education - Tracheostomy care and suctioning, stoma and skin care, NGT, enteral feedings - Medic Alert—neck breather - Safety—smoke and CO detectors (loss of smell) - Resume exercise, recreation, sexual activity, employment when able

Answer 22

- self-limiting inflammation of bronchi; most caused by viruses - other triggers: pollution, chemical inhalation, smoking, chronic sinusitis, asthma

Answer 23

- cough - clear/purulent sputum - headache - fever - malaise - dyspnea - chest pain

Answer 24

Diagnosis: based on assessment - breath sounds: crackles or wheezes Treatment goal: symptom relief and prevent pneumonia, supportive - Cough suppressants, oral fluids, humidifier - Beta2-agonist inhaler—wheezing or underlying pulmonary condition - Avoid irritants - Influenza—antivirals within 48 hours - See HCP: fever, dyspnea, or duration greater than 4 weeks

Answer 25

Bordetella pertussis - Gram-negative bacteria attach to cilia, release toxins results in inflammation Highly contagious; increased incidence in United States - Immunity from DPT decreases over time - CDC recommends a one-time vaccine for adolescents (greater than 11+ years) and adults who did not have Tdap

Answer 26

- Stage 1 (1 to 2 weeks): low-grade fever, runny nose, watery eyes, general malaise, and mild, nonproductive cough - Stage 2 (2 to 10 weeks): paroxysms of cough - Stage 3 (2 to 3 weeks): less severe cough, weak Hallmark characteristic: uncontrollable, violent, cough with “whooping’ sound

Answer 27

- acute infection of lung parenchyma - associated with significant morbidity and mortality rates - three ways organisms reach lungs: -- Aspiration of normal flora from nasopharynx or oropharynx -- Inhalation of microbes present in air -- Hematogenous spread from primary infection elsewhere in body

Answer 28

May be classified according to causative organism, characteristics of disease, or radiographic appearance Can be community-acquired (CAP) or hospital-acquired (HAP)

Answer 29

- Acute infection in patients who have not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms - Can be treated at home or hospitalized dependent on patient’s age, VS, mental status, comorbidities, and condition

Answer 30

viral: most common (can be mild or life-threatening) bacterial: may require hospitalization mycoplasma: atypical aspiration necrotizing opportunistic

Answer 31

Most common - cough: productive or nonproductive - *green, yellow, or rust-colored sputum* - fever, chills - dyspnea, tachypnea - pleuritic chest pain - older or debilitated patients: confusion, stupor, hypothermia Physical examination - fine or coarse crackles - with consolidation: -- bronchial breath sounds -- egophony -- increased fremitus - with pleural effusion: -- dullness to percussion

Answer 32

Multidrug-resistant (MDR) pathogens—major problem in treatment Atelectasis Pleurisy Pleural effusion Bacteremia Pneumothorax Acute respiratory failure Sepsis/septic shock Lung abscess Empyema Risk factors: - advanced age - immunosuppression - history of antibiotic use - prolonged mechanical ventilation

Answer 33

- history and physical exam - chest x-ray - thoracentesis and/or bronchoscopy - pulse oximetry - ABGs - sputum gram stain, culture, sensitivity -- ideally before antibiotics - blood cultures - CBC with differential

Answer 34

Preventative: - Pneumococcal vaccines (Table 27-5) - Prevent Streptococcus pneumoniae - Examples: Prevnar 13 and Pneumovax 23 Supportive care: - Oxygen for hypoxemia - Analgesics for chest pain - Antipyretics for fever - Adjuvant drugs - Individualize rest and activity Treatment: - Response generally occurs within 48 to 72 hours -- Decreased temperature -- Improved breathing -- Decreased Chest discomfort - Repeat chest x-ray in 6 to 8 weeks - Viral pneumonia—no definitive treatment -- Antivirals: influenza and herpes

Answer 35

Initial empiric therapy - Gram-negative and gram-positive organisms - Likely infecting organism (Table 27-2) and risk factors for MDR organisms; varies with local and institutional prevalence and resistance patterns - Should see improvement in 3 to 5 days or need to reevaluate - Antibiotics: IV, proceed to oral when stable; at least 5 days; afebrile 48 to 72 hours

Answer 36

*small, frequent, high calorie, nutritious meals; monitor weight* adequate hydration; monitor intake - prevent dehydration - thin and loosen secretions - adjust for older adults, patients with heart failure, or those with preexisting respiratory conditions

Answer 37

- impaired gas exchange - impaired breathing - fluid balance - hyperthermia - activity intolerance

Answer 38

Goals: - clear breath sounds - normal breathing patterns - no signs of hypoxia - normal chest x-ray - normal WBC count Implementation - health promotion - monitor assessment parameters, provide treatment, monitor response - prevent aspiration pneumonia - medical asepsis and infection control

Answer 39

- Emphasize need to take full course of antibiotics - Drug-drug and drug-food interactions - Adequate rest - Adequate hydration - Avoid alcohol and smoking - Cool mist humidifier or warm bath - Chest x-ray, vaccinations - Takes several weeks (or more) to recover

Answer 40

- effective respiratory rate, rhythm, and depth of respirations - lungs clear to auscultation - absence of infection

Answer 41

- Infectious disease caused by Mycobacterium tuberculosis - Lungs most commonly infected - 1/3 of world’s population has TB - Prevalence in the United States decreasing

Answer 42

Poor, underserved, and minorities - Homeless - Residents of inner-city neighborhoods - Foreign-born persons - Living or working in institutions - IV injecting drug users - Overcrowded living conditions - Poverty, poor access to health care - Immunosuppression

Answer 43

- Gram-positive, aerobic, acid-fast bacillus (AFB) - Spread via airborne droplets, 1 to 5 m -- Can be suspended in air for minutes to hours - Transmission requires close, frequent, or prolonged exposure -- NOT spread by touching, sharing food utensils, kissing, or other physical contact -- Number, concentration, length of time for exposure and immunity influence transmission Once inhaled, droplets lodge in bronchioles and alveoli Local inflammatory reaction occurs Only 5% to 10% of people with dormant TB will develop active TB; may take months or years

Answer 44

0 = No TB exposure 1 = Exposure, no infection 2 = Latent TB, no disease 3 = TB, clinically active 4 = TB, not clinically active 5 = TB suspect

Answer 45

- Takes 2 to 3 weeks to develop symptoms - Characteristic initial: dry cough that becomes productive - Other symptoms: fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats - Late: dyspnea and hemoptysis - Acute, sudden presentation of TB - High fever - Chills, generalized flulike symptoms - Pleuritic pain - Productive cough - Crackles and/or adventitious breath sounds Complications: - large numbers of organisms spread via bloodstream to distant organs

Answer 46

- tuberculin skin test (TST) -- mantoux test - INF-gamma release assays (IGRAs): screening tool - chest x-ray - bacteriologic studies

Answer 47

Aggressive drug therapy used to treat active disease and prevent MDR-TB; monitor adherence - Active TB disease - Two phases of treatment: -- Initial (8 weeks to 3 months): 4 drugs (below) -- Continuation (18 weeks): 2 drugs (isoniazid and rifampin) - Initial 4-drug regimen: -- Isoniazid (hepatitis) -- Rifampin (hepatitis; orange body fluids) --- always asked about on boards; will turn urine orange -- Pyrazinamide (hepatitis) -- Ethambutol (ocular toxicity)

Answer 48

- impaired breathing - impaired airway clearance - risk for infection - lack of knowledge

Answer 49

- have normal pulmonary function - adhere with therapeutic regimen - take appropriate measures to prevent spread of disease - have no recurrence of disease

Answer 50

- Health promotion - Acute Care - Teach patient to prevent spread -- Cover nose and mouth with tissue when coughing, sneezing, or producing sputum; dispose in trash or flush -- Hand washing after handling sputum-soiled tissues - Patient wears face mask if outside of negative-pressure room - Identify and screen close contacts - Ambulatory care - Evaluation -- Expected outcomes *airborne precautions, negative-pressure room*

Answer 51

- environmental or occupational inhalation of dust or chemicals - lung damage depends on: -- toxicity -- amount and duration of exposure -- susceptibility of individual

Answer 52

- leading cause of cancer-related deaths in US - high mortality rate, low cure rate - advances in treatment improving response Primary 2 subtypes: - Non–small-cell lung cancer (NSCLC); 85% - Small-cell lung cancer (SCLC); 15%

Answer 53

- smoking - pollution - radiation/radon - asbestos - industrial agents (nickel, uranium, chromium, formaldehyde, arsenic)

Answer 54

Metastasis: direct extension; blood and lymph system Common sites: lymph nodes, liver, brain, bones, and adrenal glands

Answer 55

Squamous cell carcinoma - Slow growing - Early symptoms: cough and hemoptysis Adenocarcinoma - Moderate growing - Most common in nonsmokers Large-cell carcinoma - Rapid growing - Highly metastatic

Answer 56

- very rapid growth - *most malignant* - early metastasis - associated endocrine disorders - chemotherapy and radiation - poor prognosis

Answer 57

- symptoms nonspecific and appear late in disease - may be masked by chronic cough - depend on type of primary lung cancer, location, and metastatic spread - persistent cough with sputum (most common) - hemoptysis - dyspnea - wheezing - chest pain

Answer 58

- Anorexia, nausea/vomiting, fatigue, weight loss - Hoarseness - Unilateral paralysis of diaphragm - Dysphagia - Superior vena cava obstruction - Palpable lymph nodes - Mediastinal/cardiac involvement

Answer 59

- T denotes tumor size, location, and degree of invasion - N indicates regional lymph node invasion - M represents presence/absence of distant metastases

Answer 60

- chest x-ray - CT scan - sputum cytology - lung biopsy (definitive diagnosis) - pleural fluid analysis - metastasis: bone and CT scans: brain, abdomen, pelvis - H&P - CBC with differential - chemistry panel - liver, renal, and pulmonary function tests - MRI

Answer 61

- annually in adults ages 55-77 with a history of smoking -- 30 pack-year history -- current smoker -- quit less than 15 years ago - completed with low dose CT

Answer 62

- surgical care - radiation therapy - stereotactic body radiotherapy (SBRT) - chemotherapy - targeted therapy - immunotherapy

Answer 63

- Assess patient’s and family’s understanding of current medical condition, diagnostic tests, diagnosis, treatment options, and prognosis - Patient’s level of anxiety - Support systems - Subjective - Objective

Answer 64

- impaired airway clearance - impaired breathing - impaired gas exchange - anxiety

Answer 65

- adequate airway clearance - effective breathing patterns - adequate oxygenation of tissues - minimal to no discomfort - realistic outlook about treatment and prognosis

Answer 66

- traumatic injuries to chest contribute to many traumatic deaths - range of injuries: simple rib fractures to cardiorespiratory arrest - emergency management (respiratory distress, CV compromise, ABCs, oxygen, 2 large bore IVs)

Answer 67

- caused by blunt trauma - most common with ribs 5-9 -- can damage pleura, lungs, heart and other internal organs Manifestations: - pain with inspiration and coughing - splinting - shallow respirations Complications (atelectasis, pneumonia) Treatment (pain)

Answer 68

- three or more consecutive fractured ribs in 2 or more places; or fractured sternum and several consecutive ribs - causes unstable chest wall and paradoxical movement with breathing -- *flail segment moves opposite* -- inspiration: sucks in -- expiration: bulges out -- inadequate ventilation, increased work of breathing

Answer 69

- caused by air entering pleural cavity - positive pressure in pleural space causes lung to partially or fully collapse - increased air in pleural space equals reduced lung volume -- open: opening in chest wall -- penetrating trauma: sucking chest wound -- closed: no external wound suspect pneumothorax with chest wall trauma

Answer 70

Small pneumothorax: mild tachycardia and dyspnea Large pneumothorax: - respiratory distress - absent breath sounds over affected area Diagnostic study: chest x-ray

Answer 71

- spontaneous: rupture of blebs (me) - iatrogenic: medical procedures - tension: accumulation of air in pleural space that cannot escape; medical emergency - hemothorax: blood in pleural space - hemopneumothorax - chylothorax: lymphatic fluid in pleural space

Answer 72

- Dependent on severity, underlying cause and hemodynamic stability - Emergency treatment—Cover wound with dressing secured on 3 sides - Treatments -- *Chest tubes with water-seal drainage -- Other: partial pleurectomy, stapling, or pleurodesis - Tension pneumothorax -- Needle decompression— immediate -- Chest tube and water-seal drainage

Answer 73

chest tubes drain pleural space reestablish negative pressure allow lung to expand - 20 inches long - 12 to 40 F -- small: air -- medium: fluid -- large: blood - pigtail tubes (10-14F)

Answer 74

- Removes air from pleural space -- Small to moderate-sized pneumothorax - Rigid plastic tube with one-way rubber valve inside - Attached to external end of chest tube - Two nozzles -- Inlet nozzle: allows air to pass in the valve through chest drainage tube -- Outlet nozzle—air passes to environment or colleting device during expiration

Answer 75

Collection device for fluid, air, or blood from chest cavity Three basic compartments - 1st compartment or collection chamber -- Fluid stays in; air vents to 2nd compartment - 2nd compartment or water-seal chamber -- Contains 2 cm of water; acts as one-way valve; air goes in, bubbles out, but can’t go back to patient - 3rd compartment or suction control chamber -- Uses column of water to control suction from regulator Bubbling in water-seal chamber - Brisk at first, eventually disappears as lung expands - Intermittent with exhalation, coughing, or sneezing Tidaling in water-seal chamber - Fluctuation of water with pressure changes during respiration - Disappears as lung re-expands - If stops suddenly, check for occlusion Suction control chamber - Wet suction -- Amount of water in chamber (20 cm) controls suction -- Excess suction from source vented -- Usual suction order = −20 cm H2O -- Adjust suction until gentle bubbling in third chamber - Dry suction—no water (less noise) -- Dial regulator to pressure; visual alert

Answer 76

Set-up and Insertion - Consent/Aware of procedure - Gather and set-up equipment as per order Drainage system - Keep tubing loosely coiled - Keep connections tight; taped - Observe: tidaling, bubbling, air leak, fluid levels 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 tubes Wet suction chest drainage Monitor: Water levels Suction at—20 cm H2O Gentle bubbling Dry suction chest drainage Turn dial to ordered amount If decrease suction; depress high-negativity vent and check water level in water-seal chamber

Answer 77

Assess: - Vital signs, lung sounds, pain - Drainage amount - Drainage site infection - Subcutaneous emphysema Encourage: - Deep breathing/Incentive spirometry - Range-of-motion exercises

Answer 78

- Change according to agency policy and procedure -- Petroleum gauze - Aseptic technique - Monitor for infection - Document

Answer 79

Clamping chest tubes - Not advocated during transport or disconnection due to risk for tension pneumothorax - May clamp briefly to change drainage unit Monitor for Complications - Reexpansion pulmonary edema - Hypotension - Severe subcutaneous emphysema

Answer 80

- When lungs reexpanded and drainage minimal - Premedicate prior to removal - Valsalva maneuver during removal - Apply occlusive dressing - Chest x-ray - Monitor for respiratory distress

Answer 81

Aspiration of intrapleural fluid for diagnosis and treatment - 1000 to 1200 mL - Larger volumes result in hypotension, hypoxemia, re-expansion pulmonary edema - Chest x-ray: pneumothorax - Monitor VS, pulse ox, and respiratory distress

Answer 82

Disorders that impair movement of the chest wall and diaphragm Three categories: - Extrapulmonary—Lung tissue normal but caused by CNS, neuro-muscular or chest wall disorders - Intrapulmonary— Abnormal pleural or lung tissue disorders Hallmark characteristic: reduced forced expiratory volume (FEV1) on PFTs

Answer 83

Collapsed, airless alveoli - Decreased or absent breath sounds - Dullness on percussion - Caused by: secretions obstructing small airways - At risk: bedridden and postop abdominal and chest surgery patients - Prevention and treatment: -- Deep breathing exercises, incentive spirometry, early mobility

Answer 84

Inflammation of the pleura Etiology: infection, cancer, autoimmune disorders, chest trauma, GI disease, and some medications Manifestations - Pain—sharp, worse with inspiration - Breathing shallow—reduced movement - Pleural friction rub—peak of inspiration Treatment—underlying cause and pain management

Answer 85

purulent fluid in pleural space

Answer 86

Abnormal amount of fluid in pleural space; sign of disease Caused by: increased pulmonary capillary pressure, decreased oncotic pressure, increased pleural membrane permeability, or lymph flow obstruction Types: (depend on protein content) - Transudative—noninflammatory diseases - Exudative—inflammatory diseases - Empyema—purulent fluid in pleural space -- Antibiotics and/or drainage or other procedures

Answer 87

- Dyspnea, cough, sharp chest pain - Decreased chest movement; dullness, decreased breath sounds on affected side - Chest x-ray and CT—location and volume - Empyema: above manifestation and fever, night sweats, cough, weight loss

Answer 88

Diffuse parenchymal lung disease - Greater than 200 disorders caused by inflammation or scarring (fibrosis) between air sacs - Two most common: -- Idiopathic pulmonary fibrosis -- Sarcoidosis - Treatment—reduce exposure or treat underlying disease -- Corticosteroids, immunosuppressants; transplant

Answer 89

Chronic, progressive disorder; chronic inflammation and scar tissue in connective tissue; poor prognosis Risk factors: smoking; wood & metal dust Manifestations: exertional dyspnea; dry, nonproductive cough, clubbing, crackles Progression: weakness, anorexia, weight loss Diagnostic Studies: - PFTs: reduced vital capacity and impaired gas exchange - * Open lung biopsy (VATS)—“gold standard”

Answer 90

Treatment -Corticosteroids and other immune suppressants - Kinase inhibitor drugs - Oxygen - Pulmonary rehabilitation - Lung transplant 5 year survival—30s% to 50% after diagnosis

Answer 91

Chronic, granulomatous disease - Primary affect on lungs Dyspnea, cough, chest pain Other: skin, eyes, liver, kidney, heart, lymph nodes At risk: blacks and family history Treatment—suppress inflammation Follow 3 to 6 months: PFTs, chest x-ray, and CT scan for progression

Answer 92

Abnormal accumulation of fluid in alveoli and interstitial spaces - Complication of heart and lung diseases - Most common cause: left-sided HF

Answer 93

Etiology and Pathophysiology - Blockage of one or more pulmonary arteries by thrombus, fat or air embolus, or tumor tissue - Clot in venous system into pulmonary circulation then lodges in small blood vessel and obstructs alveolar perfusion - Most often affects lower lobes

Answer 94

- immobility or reduced mobility - surgery within 3 months (especially pelvic and lower extremity) - history of VTE - cancer - obesity - oral contraceptives/hormone therapy - smoking - prolonged air travel - heart failure - pregnancy - clotting disorders

Answer 95

Manifestations - Depend on type, size, and extent of emboli - Dyspnea most common (85%); mild-moderate hypoxemia - Other: tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, tachycardia, syncope, pulmonic heart sound - *Massive PE: change in mental status, hypotension, impending doom, death* Complications - Pulmonary infarction - Pulmonary hypertension

Answer 96

- D-dimer - spiral (helical) CT scan/ CT angiography (CTA) - ventilation-perfusion scan (V/Q) important but not diagnostic: - ABG - chest x-ray - EKG - troponin levels - BNP

Answer 97

Adequate tissue perfusion and respiratory function Prevent: - Further growth or extension of lower extremity thrombi - Prevent embolization from upper or lower extremities to pulmonary vascular system - Prevent further recurrence of PE Support cardiopulmonary status - Oxygen: intubation/mechanical ventilation - Pulmonary hygiene: prevent atelectasis - Shock: fluids, vasopressors - HF: diuretics - Pain: opioids

Answer 98

Anticoagulation - immediate - Low-molecular-weight heparin (LMWH) - Unfractionated IV heparin - Warfarin (Coumadin) or alternative—admission: 3 months (or longer) Fibrinolytic agents—dissolve clot - Tissue plasminogen activator (tPA) - Alteplase (Activase)

Answer 99

Prevention - Intermittent pneumatic compression devices - Early ambulation - Anticoagulation Immediate treatment - Bed rest in semi-fowler’s position - Assess cardiopulmonary status - Administer: oxygen, IV fluids and medications - Monitor: coagulation and complications

Answer 100

Patient support - Anxiety, pain, dyspnea, fear of death Patient education - Regarding long-term anticoagulant therapy - Measures to prevent VTE - Importance of follow-up exams

Answer 101

Elevated pulmonary artery pressure due to an increase in resistance to blood flow through the pulmonary circulation. Mean pulmonary artery pressures - Normal 12 to16 mm Hg - Greater than 25 mm Hg at rest - Greater than 30 mm Hg with exercises May be primary disease or secondary complication

Answer 102

Enlarged right ventricle secondary to disorder of respiratory system; COPD - Pulmonary hypertension preexists; HF

Answer 103

- Exertional dyspnea, tachypnea, cough, fatigue, RV hypertrophy (ECG), increased intensity in S2 heart sound, polycythemia - HF: peripheral edema, weight gain, distended neck veins, full, bounding pulse, enlarged liver

Answer 104

Early identification before irreversible heart changes - Determine and treat underlying cause Long-term oxygen Other individualized therapies

Answer 105

Option for end-stage lung disease - Treat diseases: COPD, idiopathic pulmonary fibrosis, cystic fibrosis, IPAH, alpha1-antitrypsin deficiency Preoperative Care - Evaluation - Contraindications - Able to adhere and cope with postoperative regimen United Network for Organ Sharing (UNOS) - Lung Allocation Score (LAS)