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
2
Q
tracheostomy: assessment
A
- Absent lung sounds to auscultation
- Decreased SpO2
- S/S of hypoxia
3
Q
tracheostomy: diagnostics
A
- ABGs
- CXR
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
5
Q
tracheostomy: complications
A
- LRI
- confirm with CXR
6
Q
tracheostomy: client edu
A
- will require routine care–changing of trach mask
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
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
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)
10
Q
Pneumothorax: lab tests and diagnostics
A
- ABGs - Hypoxemia (PaO2 <80mmHg)
- Chest X ray
- Confirm pneumo or hemo
11
Q
Pneumothorax: nursing care
A
12
Q
list the classes of meds used for a pneumothorax
A
- benzodiazepines (sedatives)
- opioid agonists (pain meds)
13
Q
what are the benzodiazepines used for pneumothorax?
A
- lorazepam
- midazolam
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
15
Q
client ed for benzodiazepines for pneumothorax
A
- Amnesic effects and cause drowsiness
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
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
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
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
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
21
Q
list the possible complications of a pneumothorax
A
- dec CO
- respiratory failure
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
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
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
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
