WEEK 2 : Altered gas exchange Flashcards
Gas exchange : recognize cues : pt history
true or false. women have high risk than men, why is that ?
this is true, women have smaller airway
highly populated areas increases the risk of what ?
infection
recall that it is important to aks for family hx and genetic risk that run in the family.
what type of genetic disease are we asking ?
cystic fibrosis and emphysema ( genetic component aat factor )
recall that patient history is important and current health problems is important, what undergoes this
cough, sputum, amount and color
any pain? what type?
dyspnea at rest or on exertion
what does blood tinged sputum indicate?
lung cancer
when it comes to pain, what do we have to watch ?
pain ?? watch how they breathe
what does shallow breathing indicate
it indicates retaining c02
at rest - check if dyspneic or walking or talking tells u how severe the situation is
gas exchange : recognize cues : physical assessment
what undergoes this section
nose, pharynx, larynx, trachea, thorax
- is there any lumps, asymmetry, hoarse throat ?
lungs and thorax
- auscultate for abnormal sounds
what other observations are we doing when it comes to physical assessment ?
skin color, nail beds, wt loss, dyspnea when walking or talking
what would be our pyschological assessment ?
is patient anxious or depressed?
it is important to analyze the data what undergoes this
physical assessment
abgs
cb ( rbc, hgb )
sputum culture
what does low hgb indicate?
polycothermici
if they have pneumonia, what goes high ?
wbc
sputum culture is used to determine what ?
what kind of abx they use
radiology imaging
what do we use ?
ct, mri, chest xray images are used to diagnose, show progression or response to treatment
what do we do pre procedure ?when it comes to ct scan, mri, chest xray ?
remove metal objects ( jewelry )
iv contrast can be nephrotoxic
true or false. if using contrast dye check for allergies ?
yes this is true
what should you check first when doing a radiology imaging ?
may check creatine level first to assess kidney function
(this is hard on kidneys, may deliver, with lots of hydration)
true or false. if on metformin drug , this is to be stopped before and held after procedure for 24- 48 hours. Why is this occurring ?
can cause kidney damage with contrast dye
true or false. contrast dye is hard on the kidney but sometimes it could be delivered with hydration ?
this is true
what do we check pre procedure for bronscopy ?
cbc, plt, ptt, lytes, cxr
NPO 4-8 hours ( depends on the doctor )
what is the post procedure for broncoscopy
monitor until sedation wears off
ensure gag prior to eating.drinking
what is the risk for post procedure after bronchoscopy ?
risk of bleeding, infection, hypoxemia
what could you do if the patient is bleeding after bronchoscopy ?
vital signs, if they are bleeding , get their baseline ( blood pressure ) call the doctor to fix it ( out of scope )
heart rate is high, blood pressure is low
why could hypoxemia be happening post procedure in bronchoscopy ?
inflammation in the tissue, interfering with airway complications
what is the pre procedure with thoracentesis ?
pre procedure
patient teaching is important: what undergoes this ?
will feel a sting when local anaesthetic injected and pressure when needle pushing through the chest
true or false. pre-procedure ( patient teaching important )
recall that the patient will feel a sting when local anaesthetic injected and pressure when needle pushing through the chest.
what else ?
do not move cough or deep breath during procedure
need to sign consent
what is the post procedure after thoracentesis ?
apply pressure to puncture site and sterile drsg
chest x ray to rule out pneumothorax
monitor for s and s of pneumothorax ( mediastinal shift, trachea moves to unaffected side, air hunger, rapid hr, pain on inspiration and expiration , cyanosis, cough )
why do u want chest xray after procedure – >
chest xray to rule out pneumothorax
what is the pulmonary function tests ?
used to evaluate lung function by measuring strength of air movement , can determine presence of disease and establish a baseline to evaluate improvement or decline
used to evaluate lung function by measuring strength of air movement , can determine presence of disease and establish a baseline to evaluate improvement or decline
what is this describing ?
pulmonary function tests
what is the pre procedure for pulmonary function tests ?
may be asked to hold bronchodilator 6 hrs before
what is the post procedure pulmonary function tests
monitor for dyspnea, bronchospasm
what is percutaneous lung bx ?
needle inserted to aspirate tissue sample using ct or fluoroscopy to guide placement of needle
needle inserted to aspirate tissue sample using ct or fluoroscopy to guide placement of needle
percutaneous lung bx
what is used before percutaneous lung bx ?
local anesthetic used before needle inserted
what does percutaneous lung bx provoking ?
anxiety provoking, help reduce the anxiety
what is pre procedure for percutaneous lung bx
teaching of what will happen to reduce anxiety
what is post procedure for percutaneous lung bx
monitor for pneumothorax ( same as post thoracentesis )
altered gas exchange : take action
1 to 5
- Optimize oxygenation
- Optimize ventilation
- Administer medication
- Manage secretions
- Optimize nutrition
* 6 small meals, increased protein, calories
1.* O2 as needed
2. * positioning
3. * Appropriate to problem
4.* Fluids, suction
5.* 6 small meals, increased protein, calories
what position, are we putting the pt in ?
tripod position
what type of medication do we give the pt ?
whatever appropriate to the problem
what do we manage secretions
easier to suction with fluid this is important
- lots of secretions with resp
what undergoes optimize nutrition
hard to chew, swallow, and make meals
this is a teaching we should do
meal preps
this is tumour that grows in larynx : good prognosis if diagnosed in early stages
laryngeal cancer
** cancer could also be in the tongue or the cheek **
what are the risk factors for laryngeal cancer ( recognize cues )
smoking and alcohol ( main )
voice abuse, exposure to chemicals, gerd
recognize/analyze cues : labs and diagnostics
what undergoes diagnostic tests
laryngoscope to visualize and take bx of tumor to determine ca cell type and stage
x rays, ct scan, mri ( to determine metastatic sites )
what undergoes lab assesments
electrolytes, hct, bun, hct, may be affected if nutritional and hydration status is poor
take action : laryngeal ca treatment
treatment depends on :
tumour type, size, and location
patient and surgeon preference
extensive traditional surgery often required with laryngeal cancer
true
what is partial laryngectomy
when only one vocal chord or no vocal cords are removed
can speak , can breathe normally
total laryngectomy with radical neck dissection
entire larynx/vocal cords removed
permanent stoma created in neck
require alternate method to talk
tracheostomy and laryngectomy
often they take off ( and suture things open and this is open permanently ). true or false.
this is true
just read
Take Action: Laryngectomy
Post -op care
MAINTAIN PATENT AIRWAY!
* Suction/ keep stoma clear
* Post-op VS
* Position Midline/ HOB elevated
* Suture lines/ stoma care
* Flap checks (if present)
* Nutrition is important
* Prevent Aspiration
* NPO for 24-48 hrs then Tube feed
* Must Re- learn how to swallow
* Physio (Prevent frozen shoulder)
* Emotional Support
what undergoes flap checks ?
they take out some vessels, ask doppler make sure the circulation is good
speech pathology and consulted to relearn how to swallow
if they had surgery we need physio involved ( scar tissue that causes frozen shoulder - cannot move )
is this true or false.
this is true
what is normal in laryngectomy ?
blood tinged is normal, dont worry typically little blood is okay
monitor document and carry on
alcohol abuse consider in laryngectomy patients
yes
what is transesophageal puncture and prosthetic voice device
puncture created between trachea and esophagus
when patient speaks air is rerouted through prosthesis to esophagus and vibration creates sound
define if these are true or false, when it comes to discharging a patient teaching laryngectomy
Psychological Support.
* Altered body image
* Different sounding speech
* Mucous from stoma embarrassing
* Cannot laugh or cry
true
what is the number one cause of lung cancer ?
what about number 2 ?
smoking
2nd hand smoke exposure
exposure to environmental carcinogens, asbestos, air pollution
what are the diagnostics when it comes to lung cancer ?
ct scan ( most effective non invasive method )
sputum for cytological studies
bx of cancer cells or plural fluid is definitive
lung cancer :
surgery is used for what stage of cancer in the lungs ?
what is a wedge resection ? segmental resection ? pneumonectomy ? lobectomy ?
tx of choice in stage 1 and stage 2 lung cancer
1. remove tumour plus margin around
2.a larger segment of lung is removed
3.entire lung removed
4.lobe of lung removed
what kind of taking action for lung cancer can we utilize ?
surgery
radiation
chemo
targeted therpahy
immunotherpahy
what is targeted therapy
drugs work to disrupt cancer cell division
what is chemo?
what is radiation ?
what is immunotherapy?
1.drugs that work systemically to kill ca cells
2.high energy rays or particles targeted to kill cancer cells
3.drugs prompt own immune system to better recognize and attack ca cells.
what is this describing : big incision on the side and retract the muscle and go in and cut and take out the tumour
this is a lot of healing
thoracotomy
what is video assisted thoracotomy
they are looking through a camera and see what they need to remove and scoop it out and pull it out in pieces
what is the post op care for thoracotomy
monitor resp status ( treat hypoxia with 02 as needed )
monitor chest tube and collection device ( placed in pleural space )
position changes ( semi fowlers )
assist with db and c
optimal pain management
monitor for s and s of infection or empyema ( pleural fluid )
what is incentive spirometry: recall that this helps with lung adequacy in breathing, measures volume of inspired air
what does it help with ?
bedside version, help with deep breathing and coughing
what type of pain management are we utilizing ? for lung cancer
lidocaine, morphine, and combination opoid
this is attach to the IV and push the button and get a woosh and only a certain amount they can only have certain amount
they have boundaries so they do not overdose
Take Action: Discharge Planning
lung cancer ( just read )
- Signs and symptoms of progression, recurrent disease, when to seek medical care
- Home oxygen – safe use
- Encourage smoking cessation (patient and family)
- Palliation (to relieve symptoms S0B) * Radiation
- Thoracentesis
- Pain management
true or false. oxyegn can ignite a flame but not explode ?
yes this is true
higher than 4 L of oxygen needs what ?
humidifier
pulmonary contusion
common chest injury that occurs in car crashes
what is this describing : can severely compromise gas exchange that rapidly leads to hypoxemia
flail chest
recall that with flail chest : if severe it may require icu and intubation ( mechanical ventilation )
what should we monitor ?
monitor abgs levels
vital signs
signs of poor gas exchange
what is a pneumothorax ?
presence of air in the pleural space
what is installed when a patient has a pneumothorax ?
chest tube - one of the reasons is accumulation of air that can cause the lung to collapse
pneumothorax
causes loss of negative pressure in the lung and lung
what is an open pneumothorax or closed pneumothorax ?
open pneumothorax - pleural cavity exposed to outside air such as penetrating wound ( knife stab )
closed pneumothorax - happened inside such as injury to lungs from broken ribs or mechanical ventilation or other med procedures
what is the cues for pneumothorax :
small
large
small : mild tachycardia and dyspnea
large : resp distress, including shallow, rapid resp; dyspnea ; air hunger; decreased oxygen sat.
no breath sounds on auscultation
what is this describing : this is like a pneumothorax but this is blood in the cavity
hemothorax
what is a hemothorax
accumulation of blood in the pleural space that can occur from trauma or med procedures
what can happen along with hemothorax ?
can happen along with pneumothorax
the cues for hemothorax are the as pneumothorax, but what else can occur if a large amount of blood is lost?
hypovolemic shock
define if this is true. For large hemothorax or tension pneumothorax will require immediate needle aspiration followed by chest tube insertion.for the treatment
yes this is true
define if this is true in terms of treatment : If small hemothorax and hemodynamically stable then supportive nursing care only. Will resolve spontaneously.
yes this is true
a chest tube drain placed in the pleural space allows what ?
allows lung re-expansion and prevents air and fluid from returning to the chest.
pulmonary embolism is the blockage of pulmonary vessels by thrombus ( dead space )
what can this be ?
solid, fatty deposit, air
what are the risk factors for PE
prolonged immobility, surgery, pregnancy, obesity, advancing age, genetic conditions, hx of thromboembolism, smoking, estrogen therapy, hf, fractures ( f.e ) foreign objects ( broken iv catheters )
if fat embolism is the cause what is the things you will recognize/analyze when it comes to the cues for PE
increase RR
increase HR
increase temp
decrease 02 sats
petechiae over chest
true or false. many patients do not present with classic symptoms so PE is often overlooked ( notice small things )
true
what are the lab assessments and diagnostics we are looking for when it comes to PE
ABG’s
general metabolic panel ( for underlying conditions that may affect clotting )
d dimer ( increases with fibrinolysis associated with PE )
troponin and brain natriutic peptide ( bnp ) – prognostic markers of R ventriuclar dysfunction associated with PE
ct scan
when does pe drug theraphy begin ?
Begins immediately with anticoagulants to prevent embolus enlargement
Type of Anticoag depends on severity of symptoms and size of embolus.
with massive PE ( mortality > 65 % ) pts what undergoes this description
- Fibrinolytic tx (tPA to dissolve clot) monitored in ICU while on this. Major risk of hemorrhaging.
Low risk PE (mortality 1-3%) what undergoes this description
- Heparin, low molecular weight heparin initiated and on this for 5-10 days.
- Warfarin initiated on day 1-2 of heparin tx.
- Treatment with both Heparin and Warfarin continues until INR reaches therapeutic level 2-3.
- Direct Thrombin inhibitors (riveroxiban apixaban) are becoming more common to use instead of Coumadin
- Usually on oral anticoags (Warfarin or Direct Thrombin Inhibitors for 3-6 mths.
Submassive PE
- Must weigh benefits of thrombolytic tx to risk of bleeding. Treatment controversial.
PE
General Nursing Care
Position to optimize ventilation (high fowlers)
- O2 therapy (Type and amount depends on severity)
- NP, Mask, Mechanical ventilation
- IV Line for drug therapy and fluids
- Emotional Support - it’s scary when you can’t breathe!
- Self care while on anticoags (next slide)
those are also essential when it comes to general nursing care on a pt who has PE
what are the ongoing Monitoring, we are going to be doing
- Resp status,
- VS, cardiac dysrhythmias, lung sounds,
- mental status, confusion
- DVTs
- Evidence of bleeding (could be gums, old IV sites, GI, brain)
what are the signs that a patient may have bleed in the brain ? gi ?
confusion
gi - they could have melena stools , blood pressure will drop
cardiac output is low
how can a patient be discharged for pe ?
especially if it is warfarin
Can be discharged once hemodynamically stable, hypoxia is resolved, and adequate anticoagulation is achieved.
a patient who had pe may be on anticoag therapy for weeks, months, years. Teach the following:
especially if it is warfarin
- Importance of taking take anticoagulants at same time each day
- Will require frequent regular appointments to monitor INR.
——- Vit K can alter effectiveness of anticoagulants (green leafy veggies)
- Teach to monitor for S&S of bleeding, bruising.
- Teach to use soft bristle toothbrush electric shaver.
- Non- contact sports, careful with ADLs
these are also very important to teach ur client who had PE
what is the most important ?
If bleeding occurs and does not stop within 15 min call EMS ( especially if nose bleed )
lose blood quicky- and probably pass out
Take Action: Pulmonary Embolus
surgical therapy
what is embolectomy ?
surgical removal, embolus when pt is not a candidate for tPA
what are the two surgical theraphy for pulmonary embolus ?
embolectomy
inferior vena cava filter
what is Inferior Vena Cava Filter
Insertion of a filter to vena Cava that traps emboli travelling to lungs from other veins.
who are the candidates for inferior vena cava filter
- Can’t take anticoags (i.e. pregnancy)
- Have a DVT not responding to anticoags
- Have a PE and are at high risk for reoccurrence
post procedure for inferior vena cava , what are we watching out for ?
monitor insertion site for bleeding (femoral site or jugular vein)
The nurse notes new onset confusion in an older-adult client in a long-term care facility. The client is normally alert and oriented. Which action should the nurse take first?
a. Obtain the oxygen saturation.
b. Check the client’s pulse rate.
c. Document the change in status.
d. Notify the health care provider.
a
The nurse is caring for a client with a possible pulmonary embolism who has symptoms of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60 mm Hg, and respirations of 42 breaths/minute. Which of the following actions should the nurse implement first?
a. Elevate the head of the bed to 45–60 degrees.
b. Administer the ordered pain medication.
c. Notify the client’s health care provider.
d. Offer emotional support and reassurance.
A
copd - what is it ?
what are the two kinds ?
airflow limitations - loss of elasticity of alveoli
airflow obstruction : mucous bronchitis
what are the risk factors for copd
asthma
aging
cigarette smoking
dust recurring infection
occupational chemicals
heredity ( AAT gene )
recognize/analyze cues : copd
chronic airflow limitation
emphysema and chronic bronchitis
what are the cues?
easily fatigued
frequent resp infections
use of accessory muscles to breathe
orthopenic
thin in appearance
recall that : easily fatigued
frequent resp infections
use of accessory muscles to breathe
orthopenic
thin in appearance
are signs and symptoms of copd what else ?
wheezing
pursed lip breathing
chronic cough
barel chest
dyspnea
prolonged expirtory time
bronchitis
– increased sputum
digital clubbing
what is the sign of a late disease in copd
cor pulmonale
what are the lab assessments are we looking at for COPD
ABGs
CBC
electrolytes
what undergoes ABGs
- Hypoxemia (low PA02)
- Hypercapnia (increase in PAC02) often chronically present if alveoli hyperinflated
- If chronic the body tries to compensate ( increase HC03)
how does the body compensate ? if chronic copd
body is gonna try to compensate in the kidney
retain bicarb to balance the pH
what undergoes cbc for copd
- Increased WBC (if infection present)
- Increased HGB and HCT (polycythemia –if body is trying to compensate for hypoxia
true or false. produces more blood cells so we have more carrying it, for copd
true
true or false. it is important to watch carefully for copd because resp acidosis can change electrolytes
true
other diagnostics we could use for copd patients
pulmonary function tests
chest xrays
what undergoes pulmonary function tests
- Breathing tests that measure how well the lungs are exchanging air.
- Spirometry measures how effective inhalation and exhalation is
- Diagnosis of severity based on FEV1 (Forced expiratory volume in 1st sec of exhalation)
what undergoes chest xrays
Show hyperinflation and flattened diaphragm
common measurement for copd and asthma patients
is what ?
forced expiratory volume in 1st sec of exhalation
copd stage
mild
moderate
severe
very severe
mild - SOB from copd , when hurrying on the lvel or walking ip slight hill
mod - SOB causing the pt to stop after walking approximately after a few mins on the level
severe - SOB resulting in pt being too breathless to leave the house, breathless when dressing , presence of chronic resp fail or right hf
what is the focus drugs for copd ?
focus in on long term control therapy with longer acting drugs and combination drugs
what system is used in copd ?
step up for exacerbation and step down once under control again
what are the different type of drugs we could utilized for copd ?
sabas ( salbutamol ) ventolin resuce drug
labas ( salmetrol ) serevent
cholinergi antagonists ( atrovent )
steroidal anti inflammatory ( fluticasone, prednisone)
cromones - nedcromil
what is labas -salmeterol ( serevent )
relax smooth muscle in airway allowing bronchodilaition
what is cholinergic antagonists ( atrovent )
bronchodilates, and decreases mucous
what is steroidal anti inflammatory
anti inflammatory and immunosuppresive effects
what is cromones - nedocromil ( inhaled )
stabilizes cell membrane and decreases inflammation
** treat infections promptly with abx **
what prevents exacerbations from happening
steroidal anti inflammatory
what are some action copd patients could utilize
?
pursed lip breathing
diaphragmatic breathing
positioning
fluids to thin secretions
Pursed Lip Breathing
* Inhale slowly through nose
* Pucker lips as if whistling
* Exhale through lips while counting
* Exhale longer than inhale
* Coughing after 3rd breath
just read
what is diaphragmatic breathing ?
breath from abd while keeping chest still
what is the positioning ?
upright position
elevating HOB allows for lung expansion
what is 02 therpahy used to
reduces work of breathing
maintain Pa02 reduce workload on the heart
true or false. sats should be between 88-92% or as prescribed
aim is to raise Pa02 with just enough 02.
true
- Various methods of delivery
- Should be humidified (thins secretions)
- Home Delivery Systems
- Portable systems (Can be used at home or when out)
when it comes to 02 theraphy
true
what is common in copd patients?
weight loss and malnutrition
pressure on diaphragm from a full stomach causes what ?
dyspnea
in copd patients : difficulty breathing while eating leads to what
inadequate consumption
to decrease dyspnea and conserve energy in copd patients what do we do ?
- Rest at least 30 minutes before eating.
- Use bronchodilator.
- Prepare foods in advance (4-6 small meals/day).
- High calorie high protein foods
what undergoes hydration therapy for copd patients
- Drink at least 2L/ day (thins thick secretions)
- Can use humidifiers if air is dry.
define if these are true.
rlly hard to chew when u cannot brethe
do not eat too much at a time - dipahragram - breathing problem
conserve energy - make their meals in advance
true when it comes to copd
pulmonary rehab programs are rlly good why ?
because they have that ability to connect
what are the two surgical management when it comes to copd
lung volume reduction surgery
lung transplant
LVRS results in
increased forced expiratory volume ( FEV ) and improved oxygenation
true or false. must meet criteria ( end stage emphysema but otherwise be in good health )
true
lungs transplant
Very difficult course of antirejection drugs to follow
what does this mean
body rejects it
copd : acute exacerbation
copd is a lifelong disease with remissions and excaerbations
what is acute exacerbation
what could trigger an acute exacerbation
worsening of symptoms and decrease in ability to do ADLs
respiratory infections, unhealthy air quality
what could resp rate be for acute exacerbation?
40-50 breaths per minute
immediate medical attention required
prevention of exacerbations
Avoid crowds
Up to date pneumonia and flu vaccines
Avoid triggers, stay indoors when air quality poor
back and forth if not control
triggered if they have resp infection - get to dr and get abx
this is true amongst acte exacerbation in copd pts.
yes
acute exacerbation copd
will require what ?
require hospitalization and increased monitored care
acute exacerbation COPD
increase the medication and add medication to get under control
what does this mean ?
Medication will be “stepped up”until stable.
o Increase Inhaled bronchodilators
o Antibiotics if infection present
o Oral systemic steroids
- Oxygen will be required and stepped up as needed
- Promote rest to allow energy for breathing and eating.
- Raise HOB
- Ventilation and intubation may be required if acute respiratory failure
are these true when it comes to acute exacerbation
yes
COPD : cor pulmonale
give a brief description
lungs are not working well - vasoconstriction
lead to resistance and pulmonary hypertension and end up right sided hf
what is cor pulmonale ?
air trapping and stiff alveolar walls increase lung tissue pressure and narrow blood vessels making blood flow and perfusion difficult
recall that cor pulmonale :
air trapping and stiff alveolar walls increase lung tissue pressure and narrow blood vessels making blood flow and perfusion difficult
what does this cause ?
causes right side of heart to work harder to pump the blood to lungs.
Right chamber of heart enlarges thickens and becomes inefficient.
Causes blood to back of to central venous system
* Distended neck veins
* Peripheral swelling
thicken and enlarged not pumping adequately can eventually cause what?
dysrhythmias
Cardiac Dysrhythmias define the description for cor pulmonale
Decreased oxygenation of heart muscle can cause dysrhythmias
copd patients could be prone to depression/anxiety/panic
high rates of depression anxiety : >40% report anxiety/depression
depression relates to ?
depression :
related to loss associated with disease
related guilt of smoking
convey understanding
support groups, counselling, mediation, hypnosis therapy
what can cause anxiety ?
dyspnea causes anxiety - scary when u cannot breathe
pt should have a plan for when systems flare
COPD: Discharge Teaching:
just read :
* Pace and plan ADLs with rest periods.
* Encourage smoking cessation
* Promote hand hygiene, stay away from crowds
* Encourage influenza, pneumonia vaccines
* Seek medical attention promptly if S&S of infection begin.
* Follow medication schedule, understand use, how to take inhalers properly.
* Take long-acting medications to prevent exacerbations. Take short acting inhalers before activity (exercise, eating) or when feeling SOB.
* Exercise using pursed lip breathing. Walking daily for 20 min is best.
* Home 0 2 if needed.
yuuuh
The nurse is caring for a client with (COPD) who has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which of the following interventions is best to address this problem?
a. Increase the client’s intake of fruits and fruit juices.
b. Have the client exercise for 10 minutes before meals.
c. Assist the client in choosing foods with a lot of texture.
d. Offer high calorie snacks between meals and at bedtime.
d
