Week 1 Material Flashcards
what is a thoracentesis?
- Procedure involving surgical perforation of chest wall and pleural space for specimen collection, diagnostic evaluation, medication instillation into pleural space, and fluid removal
- Performed under local anesthesia using large bore needle
- Best practice - ultrasound guidance
- Performed under local anesthesia using large bore needle
indications for a thoracentesis
- Transudates (HF, cirrhosis, nephritic syndrome, hypoproteinemia)
- Exudates (inflammatory, infectious, neoplastic)
- Empyema
- Pneumonia
- Chest trauma (blunt, penetrating, crushing) or invasive thoracic procedures
assessment findings for a thoracentesis
- Large amounts of fluid in pleural space
- SOB, chest pain, cough
- Abnormal breath sounds
- Dull percussion sounds
- Decreased chest wall expansion
diagnostics and labs involved with a thoracentesis
- COCA of fluids aspirated
- Cell counts, protein/glucose content, abnormal cells
- Enzymes
- Lactate dehydrogenase, amylase
- Culture
Pre-Procedure Nursing Interventions for a Thoracentesis
- May be necessary for nurse to assist client into and to maintain position necessary for thoracentesis
- Ensure client signed consent form
- Gather required supply
- Obtain pre-procedure CXR (locate pleural effusion, ID needle site)
- Client positioning
how to position a client for a thoracentesis?
Sitting upright with arms and shoulders raised and supported on pillows or overbed table, feet and legs well supported
client education to be done before a thoracentesis
- Client to remain absolutely still
- Client not to speak or cough
- Mitigate risk of accidental needle damage
intraprocedure nursing actions for a thoracentesis
- Assist provider with procedure
- Maintain strict surgical aseptic technique
- Prepare client for feeling of pressure
- Monitor VS, skin color, O2 saturation for changes
- Measure and record amount of fluid removed
- Label specimens at bedside and send to lab
post procedure nursing interventions for a thoracentesis
- Apply dressing over puncture site
- Monitor VS and Resp status (hourly for several hours post procedure)
- rate/rhythm, breath sounds, oxygenation status
- Auscultate for reduced breath sounds on side of procedure
- Encourage client to deep breathe
- Assists with lung expansion
- CXR post-procedure
- Resolution of pleural effusion
- R/O pneumothorax
list possible complications of a thoracentesis
- mediastinal shift
- pneumothorax
- bleeding
- infection
explain mediastinal shift as a complication of a thoracentesis
- shift of thoracic structures to one side of body
- Diagnostics
- Monitor VS
- Auscultate lungs for decrease/absence of breath sounds
explain pneumothorax as a complication of thoracentesis
- collapsed lung (injury to lungs during procedure)
- Diagnostics
- Monitor for Pneumothorax manifestations
- Diminished breath sounds, distended neck veins, respiratory distress, cyanosis, chest wall asymmetry
- CXR
- Monitor for Pneumothorax manifestations
- Education: educate client on S/S pneumothorax, which can occur up to 24 hours post procedure
explain bleeding as a complication of peumothorax
- from client movement during procedure, esp. w/ increased risk for bleeding
- Diagnostics
- Monitor for coughing, hemoptysis
- Assess thoracentesis site for bleeding
- Monitor VS/labs
- Hypotension, decreased HGB levels
explain infection as a complication of thoracentesis
- compromised surgical asepsis
- Diagnostics:
- Monitor client temperature
Pathology of Rhinitis
- Inflammation of the nasal mucosa and often the mucosa in the sinuses that can be caused by infection (viral or bacterial) or allergens)
- Common cold (coryza) is caused by viruses spread from person to person in droplets from sneezing and coughing or direct contact
- Often coexists with other such as asthma and allergies
- Presence of allergen causes histamine release and other mediators from WBC in nasal mucosa - mediators bind to blood vessel receptors causing capillary leakage → edema and swelling
expected findings of rhinitis
- Excessive nasal drainage, runny nose, nasal congestion
- Purulent nasal discharge
- Sneezing and pruritus of the nose, throat and ears
- Itchy, watery eyes
- Sore, dry throat
- Red, inflamed, swollen nasal mucosa
- Low grade fever
- Diagnostic testing can include allergy tests to identify possible allergens
nursing care for rhinitis
- Encourage rest and increased fluid intake
- Encourage use of humidifier or breathing steamy air
- Promote proper disposal of tissues and cough etiquette
name the classes of medications used to treat rhinitis
- antihistamines
- leukotriene inhibitors
- mast cell stabililzers
- decongestants
- intranasal glucocorticoid sprays
- antipyretics
- antibiotics
name the antihistamines, leukotriene inhibitors, and mast cell stabilizers used to treat rhinitis
How do they work?
- antihistamines: bromepheniramine/pseudoephedrine
- leukotriene inhibitor: montelukast
- mast cell stabilizers: cromolyn
- Used to block the release of chemicals from WBC that bind with receptors in nasal tissues which prevent edema and itching
nursing considerations for antihistamines, leukotriene inhibitors, and mast cell stabilizers (used to treat rhinitis)
- Older adults ADRs - vertigo, hypertension and urinary retention
name the decongestant used to treat rhinitis
how does it work?
nursing considerations?
- phenylephrine
- Constrict blood vessels and decrease edema
- Nursing considerations - use as prescribed to avoid rebound nasal congestion
what is the most effective prevention and treatment of seasonal and perennial rhinits?
intranasal glucocorticoid sprays
when to use antipyretics for rhinitis?
when to use antibiotics for rhinitis?
- Antipyretics - use if fever is present
- Antibiotics - if bacterial infection can be identified
client education for rhinitis
- Hand hygiene
- Complementary therapies such as echinacea, larger dose of vit C, and zinc preparations can be useful to promote immune response
- Limit exposure to others
epistaxis
- Often a complication of a HTN crisis, coagulation disorder
- need to stop the bleeding!
- have pt lean forward and apply pressure to nose for 10 min
- should investigate:
- use of blood thinners (coumadin, aspirin)
- drug use
- can utilize nasal tampons or silver nitrate
deviated septum
Can often be associated with sinusitis
what is seasonal influenza?
- “flu”
- Epidemic, usually in the fall or winter months
- Highly contagious acute viral infection
- Population: children and adults of all ages
- Can be caused by several virus families–varies yearly
when are adults contagious with seasonal influenza?
- 24 hours before manifestations begins
- Up to 5 days after manifestations begin
pandemic influenza
- viral infection among animals or birds that has mutated and is becoming infectious to humans
- H1N1: swine flu
- H5N1: avian flu
assessment for influenza
- Severe HA and muscle aches
- Chills
- Fatigue, weakness
- fever
- Severe diarrhea and cough (avian flu)
- Hypoxia (avian flu)
diagnostic procedures for influenza
AV Avantage A/H5N1 Flu Test
nursing care for influenza
- Maintain droplet and contact precautions for clients with pandemic influenza
- Give saline gargles
- Monitor hydration, I&O
- Administer fluid therapy (as prescribed)
- Monitor respiratory status
name the antivirals to treat and prevent influenza
Amantadine, Rimantadine, Ribavirin
name the antivirals to shorten the duration of influenza infection
- Zanamivir (oral inhalant)
- Oseltamivir (oral tab)
client education for antivirals to treat influenza
- tell clients to begin antiviral meds w/in 24-48 hours after onset of manifestations
trivalent vaccines for influenza
- prepared yearly depending upon the suspected strain of influenza expected to appear
- IM injection of Fluvirin or Fluzone
- Live attenuated influenza vaccine by intranasal spray
- DO NOT use for patients with co-morbidities, immunocompromised
- Client Education:
- Vaccination encouraged for everyone older than 6 mos
- Higher risk and require vaccination: clients with hx of pneumonia, chronic medical conditions, and those over 65, pregnant, and health care providers
H1N1 vaccine
for general population
H5N1 vaccine
stockpiled for distribution if pandemic occurs
interdisciplinary care involved with influenza
- Respiratory services: consulted for respiratory support
- Community health officials: notified of outbreaks
- Public health officials: containment and prevention of directives during pandemic influenza
client education for clients with influenza
- Encourage annual vaccines
- Wash hands and follow cough etiquette
- Avoid places where ppl gather, avoid close contact
- If develop flu manifestations: inc fluid intake, rest, stay home
- Avoid travel to areas where pandemic flu is identified
- Be aware of public health announcements
complications of influenza
- Pneumonia:
- especially affecting older adults and clients who are debilitated or immunocompromised
patho for sinsuitis
- AKA rhinosinusitis
- Patho: inflammation of the mucous membranes of 1 or more of the sinuses (usually maxillary or frontal sinuses)
- Swelling of the mucosa can block the drainage of secretions–>sinus infection
- Commonly caused by: Streptococcus pneumoniae, Haemophilus influenzae, diplococcus, bacteriodes
risk factors for sinusitis
- Often occurs after rhinitis
- Deviated nasal septum
- Nasal polyps
- Inhaled air pollutants or cocaine
- Facial trauma
- Dental infections
- Loss of immune fcn
assessment findings for sinusitis
- Nasal congestion
- HA
- Facial pressure or pain (worse when head is tilted forward)
- Cough
- Bloody or purulent nasal drainage
- Tenderness to palpation of forehead, orbital and facial areas
- Low grade fever
diagnostic procedures for sinusitis
- CT scan or sinus x-rays: confirm diagnosis
- Endoscopic sinus cavity lavage/surgery: relieve obstruction and promote drainage
nursing care for sinusitis
- To relieve sinus congestion/pain: use steam humidification, sinus irrigation, saline nasal sprays, hot/wet packs
- Inc fluid intake and rest
- Discourage air travel, swimming, and diving
- Encourage cessation of tobacco
- Teach client how to correctly irrigate sinuses and administer nasal sprays
list the medication classes used to treat sinusitis
- nasal decongestants
- broad spectrum antibiotics
- pain relief medications
nasal decongestants to treat sinusitis
- Ie. Phenylephrine
- Used to reduce swelling of mucosa
- Nursing Considerations:
- Begin OTC decongestant at first sign of sinusitis
- If decongestants used more than 3-4 days, may develop rebound nasal congestion
broad spectrum antibiotics to treat sinusitis
- Ie. Amoxicillin
- Used on a limited basis for a confirmed causative bacterial pathogen
pain relief meds to treat sinusitis
NSAIDs, acetaminophen, aspirin
client education for sinusitis
- Sinus irrigation and saline nasal sprays: alternative to antibiotics for relieving nasal congestion
- Contact provider if experience severe HA, neck stiffness (nuchal rigidity), and high fever
complications of sinusitis
- Meningitis and Encephalitis:
- Can occur if pathogens enter the bloodstream from the sinus cavity
patho pneumonia
- An inflammatory process in the lungs that produces excess fluid
- Triggered by infectious organisms or by the aspiration of an irritant such as fluid or foreign object
- Inflammatory process in the lung parenchyma results in edema and exudate that fills the alveoli
- Can be primary or complication
risk factors of pneumonia
- Young and old
- Immunocompromised
- Immobility and inactivity
- Recent exposure to viral, bacterial or influenza infections
- Lack of current immunizations
- Exposure to plant pollen, molds, animal dander, foods, medications and enviro contaminants
- Tobacco smoke
- Substance abuse
- COPD
- Presence of a foreign body
- Conditions that increase risk of aspiration (dysphagia)
- Mechanical ventilation
- Impaired ability to mobilize secretions
Community Acquired Pneumonia (CAP)
Most common
Usually a complication of the flu
Health Care Associated Pneumonia (HAP)
Higher mortality rate
More likely resistant to antibiotics
Expected Findings of Pneumonia (Subjective Findings)
- anxiety
- fatigue
- weakness
- chest discomfort due to coughing
- confusion from hypoxia
what is the most common manifestation of pneumonia in older adults?
- confusion from hypoxia
Physical Assessment findings of Pneumonia
- fever
- chills
- flushed face
- diaphoresis
- shortness of breath or difficulty breathin
- tachypnea
- pleuritic (sharp) chest pain
- sputum production (yellow tinged)
- crackles and wheezes
- coughing
- dull chest percussion over areas of consolidation
- dec O2 sats
- purulent blood tinged or rust colored sputum (not always present)
laboratory tests necessary for pneumonia
- sputum culture and sensitivity
- CBC
- ABGs
- blood culture: to rule out organisms in the blood
- serum electrolytes: to identify causes of dehydration
sputum culture and sensitivity test for Pneumonia
- obtain specimen before starting antibiotics
- obtain specimen by suctioning if the client is unable to cough
- older adult clients have a weak cough reflex and dec muscle strength
- so may have trouble expectorating–>can lead to difficulty breathing and make specimen retrieval difficult
what are the expected results of a CBC and ABGs when client has pneumonia?
- CBC: elevated WBC count (not always present in older adults)
- ABGs: hypoxemia (dec PaO2 less than 80 mmHg)
diagnostic procedures for pneumonia
- chest x ray
- pulse oximetry: if have pneumonia, SpO2 <95%
what are the expected findings for a chest x-ray on a client with pneumonia?
- will show consolidation
- might not indicate pneumonia for a few days after manifestations
- important to use b/c early manifestations of pneumonia are often vague in older adults
nursing care for a client with pneumonia
- put pt in High Fowler’s (to maximize ventilation)
- encourage coughing or suctioning
- administer breathing tx and meds
- administer O2 therapy
- monitor for skin breakdown from O2 device
- encourage use of incentive spirometer to prevent alveolar collapse
- determine clients physical limits and include periods of rest during activity
- promote adequate nutrition and fluid intake
what is important to remember about promoting adequate nutrition and fluids for a client with pneumonia?
- inc work of breathing (WOB) requires additional calories
- proper nutrition aids in prevention of secondary respiratory infections
- encourage fluid intake of 2-3 L/day to promote hydration and thinning of secretions, unless contraindicated
name the classes of medications used to treat pneumonia
- antibiotics
- bronchodilators
- anti-inflammatories
antibiotics for use in tx of pneumonia
- given to destroy infectious pathogens
- esp. penicillins and cephalosporins
- often given IV then switched to oral form
- important to obtain culture specimens prior to giving 1st dose of antibiotics
nursing considerations for antibiotics given for pneumonia
- observe clients taking cephalosporins for frequent stools
- monitor kidney function, esp in older adults taking penicillins and cephalosporins
client education for clients taking antibiotics for pneumonia
- encourage clients to take penicillins and cephalosporins with food
- some penicillins should be taken 1 hour before meals or 2 hours after
why are bronchodilators given for use in tx of pneumonia?
- given to reduce bronchospasms and reduce irritation
what are the 3 types of bronchodilators used for pneumonia tx?
- short acting beta 2 agonists
- cholinergic antagonists/anti-cholinergic meds
- methylxanthines
short acting beta 2 agonists taken for pneumonia
- type of bronchodilator
- ie. albuterol
- provide rapid relief
-
nursing considerations:
- watch for tremors and tachycardia
-
client education:
- encourage inc fluid intake
anticholinergic medications taken for pneumonia tx
- type of bronchodilator
- ie. ipratropium
- block the parasympathetic NS and allow for inc bronchodilation and dec pulmonary secretions
-
nursing considerations:
- observe for dry mouth
- monitor HR
- ADRs: HA, blurred vision, palpitations
-
client edu:
- suck on hard candies to moisten mouth
- encourage inc fluid intake
methylxanthines taken for pneumonia tx
- type of bronchodilator
- ie. theophylline
-
nursing considerations:
- monitor serum med levels closely
- ADRs: tachycardia, nausea, diarrhea
-
client edu:
- encourage inc fluid intake
-
nursing considerations:
anti-inflammatories for use in the treatment of pneumonia
- dec airway inflammation
- glucocorticosteroids (like fluticasone and prednisone)
- prescribed to reduce inflammation
- ADRs: immunosuppression, fluid retention, hyperglycemia, hypokalemia, poor wound healing
nursing considerations for clients taking anti-inflammatories for pneumonia
- monitor for dec immune function
- monitor for hyperglycemia
- report black, tarry stools
- observe for fluid retention and weight gain
- monitor throat and mouth or aphthous lesions (canker sores)
client education for clients taking anti-inflammatories for pneumonia
- drink plenty of fluids
- take glucocorticosteroids with food
- avoid d/c glucocorticosteroids abruptly
interdisciplinary care involved with pneumonia
- respiratory services: consult for inhalers, breathing tx, suctioning
- nutritional services: contacted for weight loss or gain related to meds
- rehab care: consult if client has prolonged weakness
client education for those with pneumonia
- educate client on importance of continuing pneumonia tx
- maintain hand hygiene
- avoid crowded areas
- tx and recovery can take time
- encourage immunizations for influenza and pneumonia
- promote smoking cessation
list the possible complications of pneumonia
- atelectasis
- bacteremia (sepsis)
- acute respiratory distress syndrome
explain atelectasis as a complication of pneumonia
- airway inflammation and edema lead to alveolar collapse and inc the risk of hypoxemia
- client reports shortness of breath and exhibits findings of hypoxemia
- client has diminished or absent breath sounds over affected areas
- chest x ray shows area of density
explain bacteremia (sepsis) as a complication of pneumonia
- occurs if pathogen enters the bloodstream from infection in the lungs
explain acute respiratory distress syndrome as a complication of pneumonia
- hypoxemia persists despite O2 therapy
- dyspnea worsens as bilateral pulmonary edema develops that is non cardiac related
- chest x ray: shows area of density with a ground glass appearance
- blood gas findings demonstrate high arterial blood levels of CO2 (hypercarbia) even though pulse ox shows dec saturation
what is pleural effusion?
- Abnormal accumulation of fluid in the pleural space
- often an indication for a chest tube
- may be a sign of a PE
- must obtain a chest x-ray to verify resolution of pleural effusion
assessment findings for pleural effusion
- Dyspnea
- Distended neck veins
- Pleuritic chest pain
- Cough
- Absent or reduced breath sounds on affected side
- Dullness or flatness on percussion of affected side
- Asymmetrical chest wall motion
diagnostic procedure for pleural effusion
- thoracentesis
- must obtain a preprocedure x ray to locate the pleural effusion and determine needle insertion site
what puts a patient at increased risk for the flu?
- presence of a co-morbidity such as DM (even if well controlled)
what color sputum indicates a viral or bacterial infection?
yellow-green sputum
what color sputum indicates allergies
white sputum
what does having a cough that worsens at night indicate?
post nasal drip (PND)
nasal turbinates in allergies vs. infection
- allergies: swollen, pale, boggy, bluish
- infection: red, swollen, inflamed
use of Afrin
- used as a nasal decongestant (it is a nasal spray)
- should not used for more than 3 days
- longer use can cause rebound nasal congestion and make symptoms worse
