Zoey Unit 2 Study Guide Flashcards
Where can a Pulse Oximetry be placed? (4)
- ear
- finger
- toes
- bridge of nose
what kind of disease is TB? (pg 465 table 24.4)
- Air born
2. Mycobacterium tuberculosis (bacteria)
Medication management with TB
it is important to make sure that client and family understands that all medication regiments should be completed.
what could a positve smear of TB after a client has been taking the regimen for several weeks indicate? (Pg 473)
noncomplience
why is a two step PPD used?
PDD is sone in a two step process for people who work in long term health care facilities because of the risk of false- negative responses
S/S of TB (SATA) (5)
- manifestations of tuberculosis often develop insidiously and are initially nonspecific.
- fatigue
- weight loss
- hemoptysis
- nigh sweats- this is the stage where the patient seeks medical attention
What is the nursing resposibility on reporting TB?
TB MUST be reported to state health care agencies
How do you read a TB test?
By induration
Induration is measured based on size of induration, NOT REDNESS.
How do you read a tb test on a HIV patient
When an HIV patient has a > 5 mm positive test is important to investigate over other risk factors
What is the care of a patient admitted with active TB (SATA) (pg 465 table 24.4)
- Single patient room/ roommate
- Use PPE
- Droplet precautions
- Airborne precautions
When do you use a beta-2 adrengic agonist?
What is the purpose and use of beta-2 adrengic agonist (bronchodialator)? (3)
You use it during fight or flight response,
- beta2- adrenergic receptor of the sympathetic nervous system are simulated,
- bronchiolar smooth muscle relaxes.
- bronchodilation occurs.
how will you instruct a patient on how to use Atrovent
only take the prescribed number of doses each day to prevent drug overdose.
What are the insturction of medication use with acute asthma attack
the patient who is experiencing wheezing and an impending attack is best treated with
- inhaled beta- 2 adrenegic such as albuterol (ventolin).
- oxygen corticosteroid may also be used
what are bronchiodoalatos called? how do they work? (2)
called= Beta-s adrengic agnist
- relax the bronchial muscle
- help open the airway and decrease obstruction.
define pneumonia
Altered alveolar gas exchange.
remember in assesmet that agitation, restless, axiety, lethargy, and fatigue are the result of decreased tissue perfusion from altered alveolar gas exchange and require immediate action by the nurse
schedule for the pneumonia vaccine (470
How many times is the vaccine administered?
When is revaccination recommended?
the pneumococcal vaccine is administered once.
revaccination is only recomended in persons with
- renal failure
- splenectomies
- malignancies
- HIV/AIDS
How do you position the patient with bacterial pneumonia (470)
patient positioning;
- side to side with turning assist
- Teach them recruitment strategies to ensure maximum ventilation perfusion.
What is a gerontological considerations with pneumonia patients
A consideration is that \manifestations of pneumonia are similar to the average adult, including anorexia, lathargy, hemoptysis
how would you teach an older patient how to manage COPD? (3)
- remember it is important to pace activities
- short walks are best
- walk 15-20 min a day at least 3 X a week
What are the risk for COPD (SATA)
(pg 504, table 26.1) (3)
- environmental exposure is being exposed continuously
- smoking history
- occupational exposure
* 4. (emphysema= alpha- 1 antitrypsin deficiency)
How would you teach nutriton to some one who has COPD?
nutritional teaching with COPD
they should have small meals and snaks, and foods that are soft and easy to chew.
assessment of a client with COPD (CH 7 pg 83) (4)
- contradictions to O2 therapy w/ COPD pts,
- their drive for breathing is hypoxia so giving too much O2 may interfere with the hypoxic drive for breathing and lower their respiratory rate.
- also with core pulmonale you see JVD, dependent edema, enlarged liver, ascited.
- Remember tachypnea is an assessment priority due to the possible respiratory arrest
How do you identify orthopneic position aka tripod position?
a patient will sit up and lean over with there arms suported on their legs or over a table.
what is the purpose of the orthopeic position aka tripod position?
this allows for lung expansion and enables COPD patient to breath easier.
what is another name for the orthopeic position?
tripod position
what delegation can a UAP not perform?
- asses
- instruct
- Teach
- administer
s/s of sleep apnea (2)
- morning head aches related to hypercapnia
2. increased blood presure that causes vasodilation of cerebral blood vessels
How do you teach how to use a CPAP
(continuous positive airway pressure)
(3)
- proper fitting and size a
- keeping the straps tight
- teaching client to relax can reduce claustrophibic feelings.
what is the effect of CPAP on lower airway
CPAP doe snot give the patient oxygen, it keeps the alveoli from collapsing in the lower air way
Nursing diagnosis of ineffective airway clearance
inability to clear secretions or obstructions from the respiratory tract to maintain a clear air
distinguishing diffrent coughs; Hemoptysis
hemoptysis often occurs with tuberculosis
does not indicate airway irritation
distinguishing diffrent coughs; dry, hackingcough
indicated the patient is expiriencing airway irritation or obstruction
distinguishing diffrent coughs; harsh, barkey cough
suggest upper airway obstruction
distinguishing diffrent coughs; loose- sounding cough
indicated secreations
AAP what zone has no cough, wheeze, chest tightness/ shortness of breath during the day or night?
Green
AAP in what zone can you do casual activities?
green
AAP in what zone is the PFM 80
green
AAP in what zone do you take LABA wich include anti-inflamitory?
Green
AAP what zone do you have cough, wheeze, chest tightness/ shortness of breath?
yellow
AAP what zone do you have waking at night due to asthma?
yellow
AAP what zone can you do some but not all activities?
yellow
AAP what zone is the PFM 50-79?
yellow
AAP in what zone do you take Quick Relief medication?(SABA)
yellow
AAP when you are in yellow how long should it take to go back to green?
1 hr.
AAP what zone do you have very short/shortness of breath
red
AAP what zone do quick relieve medications not work?
red
AAP what zone can you not do usual activities?
red
AAP what zone do symptoms stay the same or get worse after 24 in yellow zone?
red
AAP what zone is the PFM 50>
red
AAP treatment for green zone
take LABA 2 or 4 puffs 5 min before exercise
AAP treatment for yellow zone
- take SABA 2-4 puffs every 20 min or nebu.
*SABA to get you back up to green zone - take SABA 2-4 puffs or nebulizer
take oral steroid
AAP treatment for red zone
- take SABA 4, 6 puffs or nebulizer
2. take oral steroid
AAP Danger signs
- trouble walking and talking due to shortness of breath
2. lips/ fingernails blue
what does a Pulse Oximetry do?
- mesures oxygen saturation.
2. uses wavelengths of light to measure the saturation of hemoglobin with oxygen
what is a normal Pulse ox level?
95%-99%
What conditions affects the bronchial airways NOT the alveoli?
Asthma.
What is asthma? (pathophysiology)
What does it result from?
It is a chronic lung disease characterized by intermittent, reversible air way obstruction.
It results from inflammation of the lung’s airways and tightening of the muscles that surround the airways
how do you treat a patient who is having an asthma attack? (2)
- with a inhaled beta-2 agonist like albuterol (ventolin)
2. Or oxygen and corticoid steroids.
how do you use an aerochamber? (10)
- remove cap from MDI
- shake and insert in back of aerochamber
- breath out completely, place mothpice of chamber in mouthand tighly seal lips around it.
- press cannister once to release a dose of medication
- take deep slow breath in.( no whisteling sound should be heard)
- hold breath for 10 seconds, then breath our through th emouthpiece
- breath in again but do not press canister
- remove mouth piece from mouth and breath out
- wait 1 min or adbyhcp then repeate steps 2-8(rinseout mouth)
- replace the cap on MDI
what are the discharge teachings/ avoidance risk factors for a patient with asthma? (8)
- Asthma Action Plan
- avoid risk factors
- pursed lip breathing
- medication education
- PFM
- smoking cessation
- proper inhaler technique
- clean respitory equipment
what is pursed lip breathing?
keeps the airways open longer and it prolongs exhalation.
what does pursed lip breathing allow for?
increased time for oxygen and carbondioxide to exchange.
how do you do pursed lip breathing? (5)
- sit up right w neck an shoulders relaxed
- inhale trough the nose count 1-2
- exhale through pursed lips count 1-2-3-4
- exhalation should be 2X as long as inhalation
- continue until shortness of breath is controlled
when assessing the affect that COPD has on the patient nutrition-metabolic pattern. what is the appropriate question to ask?
ask if they have experienced weight loss
What can a UPA NOT do (4)
- assess
- teach
- instruct
- adminester
what are the assessments of a client with COPD (5)
- cough
- increased mucus production
- tripod positioning
- pursed lip breathing
- changes in skin color
With COPD what assessment is a priority due to the possibility of respiratory arrest?
If you see that the have Tachypnea rapid breathing
what is a contraindication to oxygen administration?
- delivering too much oxygen may interfere with the hypoxic drive for breathing, this will lead to decreased respiratory effort and ultimately
nursing diagnosis of Impaired gas exchange
relates to a deficit in oxygenation (low O2 “oxygen”saturation) or impaired elimination of CO2 “carbon dioxide”
nursing diagnosis of ineffective airway clearance
inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
when is tracheostomy care provided?
- in each shift as needed or indicated by facility.
why is tracheostomy care provided?
to maintain airway and prevent infection.
What occurs as a result of decreased tidal volume and apnea?
acidosis and increased sympathetic vasoconstrictive activity.
Manifestations of OSA (8)
- loud snoring
- gasping during sleep
- waking during sleep
- choking during sleep
- day time sleepiness
- naps
- falling asleep
how many osbstruvtive sleep events per hr diagnose OSA?
15 or more
what test is used to diagnose OSA?
what does this test consist of? (2)
polysomography
1 electrocatdiogram
2. pulse oximetry
Surgical Management of OSA (7)
- tonsillectomy
- adenoidectomy
- uvulopalatophraryngoplasty
- septoplasty
- nasal polypectomy
- toung reduction
- epiglottoplasty
instruction for treatment of OSA (4)
- CPAP- prevents collapse of the upper airway through the use of pressure delivered through the use of a nasal, oral, or oronasal mask during sleep.
- weight managment/ loss
- positioning during sleep
- avoid alchohol and sedatives before bed
Management of OSA; what test is used to diagnose OSA? what does this test consist of? (5)
polysomography 1 electrocatdiogram 2. pulse oximetry 3. respiratory air flow 4. eye and skeletal muscle movement 5. electroencephalogram
name some complications of OSA (8)
- cardio vascular disease
- cardiac ischemia
- myocardial infraction
- erectile dysfunction
- stoke
- arterial fibtillation
- hear failure
- sudden cardiac death
what are the respiratory assessment techniques? (4) and in what order?
- Inspection
- palpation
- percussion
- auscultation
Where are oxygen and carbon dioxide exchanged?
alveoli
Describe Inspection of respitory air ways(5)
- is there Hypoxia? - mucus membrane pale/cyanotic
- abnormalities in level of consciousness & orientation
- level of speach
- clubbing
- nose, mucusmembrain, mouth, neck, trachea, thorax
Describe palpation of the lungs (2)
- listening for crepitus- air is trapped under skin; described as a crackling feeling
- equal expansion of the lungs
Describe percussion of the lungs
done between the ribs
listen for for resonance=normal
Describe auscultation of the lungs
listening to right and left lungs
listen for wheezes, ronchi, pleural friction rubs
when a cough produces thick sputum what is it?
pnemonia
when a cough is dry wha it is?
asthma
what is PaCo2
carcon dioxide
what is HcO3
biocarbonate
what is PaO2
partial pressure of oxygen
AP diameter
Normal=
Abnormal =
normal= 1:2 abnormal= 1:1
Nursing implications: what does the allen test asses for?
adequacy of ulnar artery circulation.
Diagnostic Studies Nursing implications: what does capnography do?
continuously monitors the PaCo2 in the airway during inhalation and exhalation and provides a written tracing.
Diagnostic Studies Nursing implications: what is a bronchoscopy
allow for visualization down to the second level of the bronci
Diagnostic Studies Nursing implications: what is sputum analysis
check for migroorganisims and abnormal cell growth
what does a positive sputum analysis indicate?
Tb or pneumonia
Diagnostic Studies Nursing implications:
Bronchospy
Flexible=
Ridgid=
flexible= take tissue specimensn or replace an endotracheal tube rigid= remove obstruction or large amounts of secreations from the respiratory tract
Diagnostic Studies Nursing implications: what is thoracentesis?
used as a diagnostic test or treatment depending on the disease process. a needle is inserted into the pleural space to remove fluid/air
Diagnostic Studies Nursing implivations: Pulmonary Function test, what does it do?
evaluate lung volumes to determine the functioning of the lungs.
do not smke or eat for 8 hrs before the test
What type of room is appropriate fo a TB patient?
- Single patient room because of droplet precautions.
2. Placed together in the same room with other patients that have the sad symptoms/disease.
