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Adult Health I Test I > Week 3 Material Part 2 > Flashcards

Week 3 Material Part 2 Flashcards

1
Q

tracheostomy: risk factors

A
  • Trauma, either during intubation or to upper airway structures
  • Long term intubation with mechanical ventilation
  • Cervical cancer resulting in loss of part of airway
  • Also an emergency procedure to secure an otherwise difficult airway with sedation or airway obstruction through trauma, collapse, or foreign body
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2
Q

tracheostomy: assessment

A
  • Absent lung sounds to auscultation
  • Decreased SpO2
  • S/S of hypoxia
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3
Q

tracheostomy: diagnostics

A
  • ABGs
  • CXR
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4
Q

tracheostomy: interventions

A
  • Monitoring
    • Ensure tubing does not pull on tracheostomy, adequate water in humidification chamber
  • Medications
    • Able to deliver aerosolized respiratory medications through trach
  • suctioning
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5
Q

tracheostomy: complications

A
  • LRI
    • confirm with CXR
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6
Q

tracheostomy: client edu

A
  • will require routine care–changing of trach mask
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7
Q

Pneumothorax: patho

A
  • Presence of air or gas in the pleural space that causes the lung to collapse
  • Tension Pneumothorax occurs when air enters the pleural space during inspiration through one-way valve and is not able to exit upon expiration
    • Trapped air causes pressure on heart and lungs → compresses blood vessels and limits venous return → decrease CO
    • Tx immediately
    • As pressure continues to rise causes mediastinal shift
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8
Q

Pneumothorax: risk factors

A
  • Blunt chest trauma
  • Penetrating chest wound
  • closed/ occluded chest tube
  • Older adults have dec pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli
  • COPD
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9
Q

Pneumothorax: expected findings

A
  • Signs of respiratory distress
  • Tracheal deviation to unaffected side (tension pneumo)
  • Reduced or absent breath sounds on affected side
  • Asymmetrical chest wall movement
  • Hyperresonance on percussion due to trapped air (pneumothorax)
  • Dull percussion (hemothorax)
  • Subcutaneous emphysema (air accumulation in subq tissue)
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10
Q

Pneumothorax: lab tests and diagnostics

A
  • ABGs - Hypoxemia (PaO2 <80mmHg)
  • Chest X ray
    • Confirm pneumo or hemo
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11
Q

Pneumothorax: nursing care

A
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12
Q

list the classes of meds used for a pneumothorax

A
  • benzodiazepines (sedatives)
  • opioid agonists (pain meds)
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13
Q

what are the benzodiazepines used for pneumothorax?

A
  • lorazepam
  • midazolam
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14
Q

nursing considerations for benzodiazepines used for pneumothorax

A
  • Monitor vitals - can cause hypotension and respiratory distress
  • Meds have amnesiac effect
  • Monitor for paradoxical effects
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15
Q

client ed for benzodiazepines for pneumothorax

A
  • Amnesic effects and cause drowsiness
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16
Q

what are the opioid agonists used to treat pneumothorax?

how do they work, and what are the effects they produce?

A
  • morphine sulfate and fentanyl
  • act on mu and kappa receptors that alleviate pain
  • produces: analgesia, respiratory depression, euphoria, sedation, dec in GI motility
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17
Q

nursing considerations for opioid agonists used for pneumothorax

A
  • Use cautiously for asthma and emphysema pt
  • Assess pain q4h
  • Patch - takes several hours to take effects, short acting pain med should be administered for breakthrough pain
  • Monitor RR, stop meds if under 12/min
  • Monitor vitals for hypotn and bradypnea
  • Assess for N/V
  • Monitor constipation
  • Assess LOC
  • Encourage fluid intake and activity
  • Monitor intake and output and fluid retention
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18
Q

client ed for opioid agonists for pneumothorax

A
  • Drink plenty of fluids if not on restrictions to prevent constipation
  • Teach about PCA if applicable
  • Ventilation education can vary
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19
Q

interdisciplinary care for pneumothorax

A
  • Respiratory services - ABG, breathing tx, suctioning of airway
  • Pulmonary - chest tube management and pulmonary care
  • Pain management - if pain persists or is uncontrolled
  • Rehab - prolonged weakness and needs assistance with increasing level of activity
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20
Q

therapeutic procedures for pneumothorax

A
  • Chest tube insertion
    • To drain fluid, blood or air
    • Reestablish negative pressure
    • Facilitate lung expansion
    • Restore normal intrapleural pressure
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21
Q

list the possible complications of a pneumothorax

A
  • dec CO
  • respiratory failure
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22
Q

explain decreased CO as a complication of pneumothorax

A
  • Amount of blood pumped by heart decreases as intrathoracic pressure rises
  • HypoTN develops
  • Administer IV fluids, blood products, watch HR and rhythm, monitor I&O of chest tube
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23
Q

explain respiratory failure as a complication of pneumothorax

A
  • Inadequate gas exchange due to lung collapse
  • Prepare for mechanical ventilation and continue respiratory assessment
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24
Q

hemothorax: patho

A
  • Accumulation of blood in the pleural space
  • Spontaneous hemothorax can occur when there has been no trauma
  • A small bleb on the lung ruptures and air enters the pleural space
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25
Q

hemothorax: diagnostic procedures

A
  • CXR
    • can confirm pneumo/hemothorax
  • thoracentesis
    • can confirm hemothorax
26
Q

explain nursing actions for a thoracentesis to diagnose hemothorax

A
  • Informed consent needed
  • Client understands remaining still
  • Assist client positioning and specimen transport
  • Monitor status (vitals, SaO2, injection site)
  • Assist to edge of med and lean over on bedside table
  • Inform client of feeling discomfort when the local anesthetic solution is injected
  • When needle going into lung, some pressure may be felt
27
Q

flail chest: patho

A
  • Occurs when at least 2 neighboring ribs, usually on one side of the chest, sustain multiple fx causing instability of the chest wall and paradoxical chest wall movement
  • Results in significant limitation in chest wall expansion
  • Inability of the injured side of the chest to expand adequately upon inhalation and contract upon exhalation
  • One side typically affected due to multiple rib fx
28
Q

flail chest: risk factors

A
  • Unequal chest expansion
  • Paradoxical chest wall movement
  • Tachycardia
  • Hypotension
  • Dyspnea
  • Cyanosis
  • Anxiety
  • Chest pain
29
Q

flail chest: nursing care

A
  • Admin humidified O2
  • Monitor vitals and SaO2
  • Review findings of pulmonary fx tests, x rays and ABGs
  • Assess lung sounds, color and capillary refill
  • Promote lung expansion by encouraging deep breathing and proper positioning
  • Maintain mechanical vent in the event of severe injury
  • Suction trach and endotrach
  • Administer pain meds
  • Administer IV fluids
  • Monitor I and O
  • Offer support and reassurance
30
Q

pulmonary embolism: patho

A
  • Occurs when a substance (solid, gas, liquid) enters venous circulation and forms a blockage in the pulmonary vasculature
  • Originate from:
    • DVT: most common
    • Tumors
    • Bone marrow
    • Amniotic fluid
    • Air
    • Foreign matter
  • Inc hypoxia to pulmonary tissue and impaired blood flow can result from a large embolus
  • Medical emergency: must try to prevent, recognize rapidly, and treat
31
Q

pulmonary embolism: risk factors

A
  • Long term immobility
  • Oral contraceptive use and estrogen therapy
  • Pregnancy
  • Tobacco use
  • Hypercoaguability (elevated platelet count)
  • Obesity
  • Surgery (esp ortho surgery of lower extremities or pelvis)
  • Central venous catheters
  • HF or chronic afib
  • Autoimmune hemolytic anemia (sickle cell)
  • Long bone frxs
  • Cancer
  • Trauma
  • Advanced age
32
Q

pulmonary embolism: why is advanced age a risk factor?

A
  • Older adults have dec pulmonary reserves due to normal lung changes (dec lung elasticity, thickening alveoli)–>decompensate quicker
  • Certain conditions and procedures that predispose a client to DVT (peripheral vascular dz, HTN, hyp and knee arthroplasty) are more common in older adults)
  • Usually lower activity levels–>predisposed to DVT and PE
33
Q

pulmonary embolism: health promotion and dz prevention

A
  • Smoking cessation
  • Maintain appropriate weight for height and body frame
  • Encourage healthy diet and physical activity
  • Prevent DVT by:
    • Doing leg exercises
    • Wearing compression socks
    • Avoid sitting for long periods
34
Q

pulmonary embolism: expected subjective findings

A
  • Anxiety
  • Feelings of impending doom
  • Pressure in chest
  • Pain on inspiration and chest wall tenderness
  • Dyspnea and air hunger
  • Cough
  • Hemoptysis
35
Q

pulmonary embolism: physical assessment findings

A
  • Pleurisy
  • Pleural friction rub
  • Tachycardia
  • hypoTN
  • Tachypnea
  • Adventitious breath sounds (crackles) and cough
  • Heart murmur in S3 and S4
  • Diaphoresis
  • Low grade fever
  • Dec O2 sats, cyanosis
  • Petechiae over chest and axillae
  • Pleural effusion
  • Distended neck veins
  • Syncope
36
Q

pulmonary embolism: lab tests

A
  • ABG Analysis:
  • CBC analysis: monitor H&H
  • D-Dimer: elevated above normal range in response to clot formation and release of fibrin degradation products (expected reference 0.43-2.33 mcg/mL)
37
Q

pulmonary embolism: ABG results

A
  • PaCOs low (due to initial hyperventilation–>resp alkalosis)
  • As hypoxemia progresses, resp acidosis occurs
  • Further progression leads to metabolic acidosis due to buildup of lactic acid from tissue hypoxia
38
Q

pulmonary embolism: diagnostic procedures

A
  • CXR and CT scan
  • ventilation perfusion (V/Q) scan
  • pulmonary angiography
39
Q

CXR and CT scan used to diagnose PE

A
  • Provide initial ID of a PE
  • CT scan is most common
  • Chest x-ray: can show large PE
40
Q

V/Q Scan used to diagnose PE

A
  • Show circulation of air and blood in the lungs and can detect a PE
41
Q

pulmonary angiography used to diagnose PE

A
  • GOLD STANDARD and most thorough test but invasive and costly
    • Catheter inserted into vena cava to see a PE
  • Higher risk than V/Q scan
  • Nursing Actions:
    • Verify informed consent is obtained
    • Monitor V/S, anxiety, bleeding during and after
42
Q

PE: nursing care

A
  • Administer O2 therapy to relieve hypoxemia and dyspnea
  • Position pt in high Fowler’s to maximize ventilation
  • Obtain IV access
  • Administer meds
  • Assess respiratory status every 30 min by:
    • Auscultate lung sounds
    • Measure rate, rhythm, and ease of respirations
    • Inspect skin color and cap refill
    • Examine for trachea position
  • Assess cardiac status by:
    • Compare BP in both arms
    • Palpate pulse quantity
    • Check for dysrhythmias
    • Examine neck for distended veins
    • Inspect thorax for petechiae
  • Provide emotional support
  • Monitor changes in LOC and mental status
43
Q

PE: name the classes of meds used

A
  • anticoagulants
  • direct factor Xa inhibitor
  • thrombolytic therapy
44
Q

name the anticoags used to tx PE and how do they work

A
  • Ie heparin, enoxaparin, warfarin, fondaparinux
  • Used to prevent clots from getting larger or new clots forming
45
Q

anticoagulants: nursing considerations

A
  • Assess for contraindications: active bleeding, peptic ulcer dz, hx of stroke, recent trauma
  • Monitor bleeding times:
    • PT and INR for warfarin
    • PTT for heparin
    • CBC
  • Monitor for SEs: thrombocytopenia, anemia, hemorrhage
46
Q

name the direct factor Xa inhibitor used to tx PE and how it works

A
  • Ie. rivaroxaban
  • Binds directly with factor Xa to inhibit production of thrombin
47
Q

direct factor Xa inhibitor: nursing considerations

A
  • Assess for bleeding from any site
  • Risk for spinal or epidural hematoma
    • Should d/c med for 18 hour prior to removal of epidural catheter and wait another 6 hr to restart
48
Q

name the thrombolytic therapy used to tx PE and how it works

A
  • Ie. alteplase, reteplase, tenecteplase
  • Used to dissolve blood clot and restore pulmonary blood flow
  • Similar SE and contraindications to anticoags
49
Q

thrombolytic therapy: nursing considerations

A
  • Assess for contraindications
  • Monitor for bleeding, thrombocytopenia, anemia
  • Monitor BP, HR, RR, O2 sats
50
Q

PE: interdisciplinary care

A
  • cardio/pulmonary services: consulted to manage and tx PE
  • Respiratory services: for O2 therapy, breathing tx, and ABGs
  • Radiology: for diagnostics
51
Q

PE: therapeutic procedures

A
  • embolectomy
  • vena cava filter
52
Q

explain embolectomy as a therapeutic procedure for PE

A
  • surgical removal of embolus
  • Nursing Actions:
    • Prepare client: NPO, consent
    • Monitor post op V/S, SaO2, drainage, pain
53
Q

explain vena cava filter as a therapeutic procedure for PE

A
  • insertion of a filter in the vena cava to prevent further emboli from reaching pulmonary vasculature
  • Nursing Actions:
    • Prepare client: NPO, consent
    • Monitor post op V/S, SaO2, drainage, pain
54
Q

PE: client education

A
  • If client is homebound, set up services to perform weekly blood draw
  • Set up referral to supply portable O2 to clients with severe dyspnea
  • Educate about tx and prevention of PE:
  • Monitor intake of foods high in vit K (green, leafy veggies) if taking warfarin b/c can reduce effects of warfarin
  • Adhere to schedule to monitor PT and INR, adhere to weekly blood draw
  • Remind client of inc risk for bruising and bleeding
    • Avoid aspirin
    • Check mouth and skin for bruising/bleeding
    • Use electric shavers and soft bristled toothbrushes
    • Avoid blowing nose hard, and apply gentle pressure if nose bleed occurs
  • If traveling, use measures to prevent PE
55
Q

what should you educate client about to tx and prevent PE?

A
  • Smoking cessation
  • Avoid long periods of immobility
  • Encourage physical activity
  • Wear compression socks
  • Avoid crossing legs
56
Q

what are measures the client can use to prevent a PE while traveling?

A
  • Arise from sitting position for 5 min out of every hour
  • Wear support hose
  • Remain hydrated
  • Perform active ROM exercises
57
Q

what are the 2 possible complications of a PE?

A
  • dec CO: blood volume is dec
  • hemorrhage: risk for bleeding inc due to anticoag therapy
58
Q

explain nursing actions used to manage dec CO as a complication of PE

A
  • Monitor for hypoTN, tachycardia, cyanosis, JVD, syncope
  • Assess for presence of S3 and 4 heart sounds
  • Obtain IV access
  • Monitor urinary output (should be 30 mL/hour or more)
  • Administer IV fluids (crystalloids) to replace volume
  • Monitor ECG
  • Monitor pulmonary pressures,
    • IV fluids can contribute to pulmonary HTN for clients who have RHF
  • Administer inotropic agents (milrinone, dobutamine) to inc contractility
  • Vasodilators can be needed if pulmonary A pressure is high enough to interfere with contractility
59
Q

explain nursing actions used to manage hemorrhage as a complication of PE

A
  • Assess for oozing, bleeding, or bruising from injection and surgical sites at least every 2 hour
  • Monitor CV status (BP, HR, rhythm)
  • Monitor CBC and bleeding times
  • Administer IV fluids and blood products
  • Test stool, urine, vomit for occult blood
  • Monitor for internal bleeding (measure abdominal girth and abdominal/flank pain) at least every 8 hour
60
Q

what is cor pulmonale?

A
  • RHF
  • Air trapping, airway collapse, and stiff alveoli lead to increased pulmonary
  • Blood flow through the lung tissue is difficult → increased workloads → enlargement and thickening of rt atrium and ventricle
61
Q

cor pulmonale: manifestations

A
  • Low oxygenation levels
  • Cyanotic lips
  • Enlarged and tender liver
  • Distended neck veins
  • Dependent edema
62
Q

cor pulmonale: nursing actions

A
  • Monitor respiratory status and O2 therapy
  • Monitor HR and rhythm
  • Meds as prescribed
  • IV fluids and diuretics to maintain fluid balance

Adult Health I Test I (5 decks)

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