Exam 3 - Study Material Flashcards

Question

What are the manifestations of acute prerenal failure and how would you treat the patient?

Answer 1

**Manifestations:** * Oliguria (UO \< 30 mL/hr, \< 400 mL/24 hr) * Hyperkalemia (K+ \> 6.5 mEq/L) * ↑ serum creatinine, ↑ BUN **Treatment:** * IV glucose & insulin (carries K+ intracellularly) * IV NaHCO3- (shifts K+ intracellular for H+) * dialysis/CRRT (clean out BUN & Creatinine)

Answer 2

1. Ischemia induced acute tubular necrosis 2. Nephrotoxic induced acute tubular necrosis

Answer 3

* It kidney failure caused by direct damage to the kidneys by inflammation, toxins, durgs, infection, or reduced blood supply * **Can be due to parenchymal damage to glomeruli or tubules** * Prolonged renal ischemia from ◦Myoglobinuria (trauma) ◦Hemoglobinuria (transfusion reaction) * Nephroxic agents ◦ aminoglycosides (gentamicin, tobramycin) ◦ radiopaque contrast ◦ heavy metals, chemicals ◦ NSAIDS, ACE inhibitors * Infections (acute pyelonephritis, glomerulonephritis)

Answer 4

**Antibiotics:** * Aminoglycosides (gentamicin & tobramycin) * Amphotericin B * Vancomycin * **MONITOR KIDNEY FUNCTION BEFORE GIVING DRUG** **Other Drugs:** * NSAIDS * Radiocontrast * prehydration with saline * admin of N-acetylcysteine + sodium bicarbonate

Answer 5

* It is a sudden obstruction of urine flow due to an enlarged prostate, kidney stones, bladder tumor, or injury * Problems below the kidneys that result in increased pressure due to problems with urinary tract outflow: * **Urinary tract obstruction:** * calculi (stones) * tumors * benign prostatic hyperplasia * Strictures * blood clots

Answer 6

1. Initiation 2. Oliguria-↑ in serum concentration of urea, creatinine, uric acid, potassium, magnesium 3. Diuresis-gradual ↑ in UO; watch for dehydration 4. Recovery

Answer 7

**Monitor fluid & electrolyte status:** * **Hyperkalemia!** * VFs-use smallest amt possible * UO, daily weight, edema * heart and lung sounds * Breathing effort **Help reduce metabolic rate:** * Bed rest (so need help turning, coughing, deep breathing) * Prevent/treat fever **Prevent infection:** * Invasive lines * Catheters **Skin care:** * Dry and edematous skin – moisturize * Tissue toxins – use measures to minimize itching * **RUB don't scratch**

Answer 8

**It is:** * The progressive loss of renal function associated with systemic diseases **Causes:** * **Diabetes mellitus (#1)** * **Hypertension (#2)** * Systemic lupus erthematosus * Intrinsic kidney disease * Acute kidney injury

Answer 9

**Progression:** 1. Progressive kidney damage → 2. Loss of nephron mass → suriving nephrons to sustain kidney function → 3. Nephron hypertrophy and hyperfunction in their rates of filtration, reabsorption, and secretions → 4. Maintainance of solute and H2O regulatin in presence of ↓ GFR → 5. Until Kidney function \< 25% → 6. Loss of nephrons → ↑ Angiotensin II 7. **Destruction of the remaining glomeruli →** 1. ↓ erythropoietin → ↓ RBCs → **Anemia** 2. Retention of urine → **edema** → **Hypertension** 3. Retenion of blood, urea, creatinine, K+ & P (-3) → **hyperkalemia & hypocalcemia → bone growth arrest** 8. Capillary hypertension → 9. ↑ Glomerular permeability and filtration → **proteinuria** 10. ↑ Tubular protein reabsorption → 11. Tubulointerstitial inflammation & fibrosis → 12. **Renal scarring**

Answer 10

* **↓GFR & creatinine clearance** * **↑serum creatinine & BUN** * serum creatinine-more sensitive indicator of renal function than BUN * Sodium & water retention * **Metabolic acidosis** * Anemia * **↓calcium & ↑ phosphorus**

Answer 11

**Medications:** * Calcium & phosphorus binders * Antihypertensive & cardiovascular agents * Antiseizure agents * Erythropoietin (Epogen) * **Give all of these meds with food** **Diet:** * **protein restriction; allowed protein must be of high biologic value (e.g., dairy, eggs, meats)** * **fluid restriction**-500-600 ml/day more than previous day’s UO * carbs, fats, vitamin supplements * monitor potassium intake **Dialysis **

Answer 12

**It Is:** * An infection of one or both upper urinary tracts, that is the ureter, renal pelvis, and kidney interstitium * Common in young adult women **Most common causes:** 1. Urinary obstruction 2. Reflux of urine from the bladder (vesicouretral reflux) * Problem occurs from: **E. Coli**, *Proteus, Pseudomonas (from urethral instrumentation or urinary tract surgery)*

Answer 13

**Progression:** 1. Microorganisms spread by ascending uropathic ureters → 2. Infection → 3. Local Inflammation (affects the pelvis, calyces, and medulla) → 4. Medullary infiltration of WBCs → 5. Renal edema → Purulent urine 6. Healing → scar tissue → fibrosis → atrophy of affected tubules **DOES NOT USUALLY EFFECT THE GLOMERULUS**

Answer 14

**Manifestations:** * Acute fever, chills, and flank/groin pain (similar to UTI) * Polyuria * N/V * leukocytosis, **WBC casts** * **Frequecy, dysuria (pain when peeing), CVA tenderness, may precede systemic signs and symptoms**

Answer 15

**Diagnostics:** * CT or US - to locate obstructions in the urinary tract * IV pyelogram - to identify functional or structural renal abnormalities * Urine C&S to identify causative organisms * Two weeks after antibiotic tx completed, urine is re-cultured, then monthly for several months **Treatment:** * Antibiotics (for 2 weeks) and hydration

Answer 16

1. **Kidney stones -** Obstruction and statis of urine contributing to bacteriuria nad hydronephrosis, irritation off epithelial linning with entrapement of bacteria 2. **Vesicouretral reflux -** Chronic reflux of urine up the ureter and into the kidney during micturition contributing to bacterial infection 3. **Pregnancy -** Dialation and relaxation of ureter with hydroureter and hydronephrosis, partly caused by obstrution from enlarged uterus and partly from ureteral relaxation caused by higher progesterone levels 4. **Neurogenic bladder -** Neurologic impariment interfering with normal baldder and urethral sphincter contraction with residual urine and ascending infection 5. **Instrumentation -** Intoduction of organisms into urethra nad bladder by catheters and endoscopes introduced into the urinary tracy for diagnositc purposes 6. **Femal sexual trauma -** Movement of organisms from the urethra into the bladder with infection and retrograde spread to kidney.

Answer 17

**It Is:** * Persistent or recurrent infection of one or both kidneys leading to **scarring, which can leadto kidney failure.** **Causes:** * Idiopathic * May be associated with vesicoureteral reflux or renal stones. * Drug toxicity (NSAID's) * Ischemia * Immunecomplex diseases

Answer 18

**Progression:** 1. Urinary tract obstruction (kidney stones) or Vesicoureteral reflux → 2. Presistent infections → 3. Progressive inflammation in interstitial spaces between tubules→ 4. Alterations of the renal pelvis and calyces → 5. Destruction of the tubules, atrophy or dilation and diffuse scarring → 6. impaired urine concentrating ability → 7. Chronic kidney failure → 8. Inability to conserve sodium → hyperkalemia → metabolic acidosis

Answer 19

* no symptoms of infection unless acute exacerbation * fatigue * headache * poor appetite * polyuria * excessive thirst * weight loss ## Footnote **Persistent, recurring infection can produce scarring of kidneys leading to renal failure**

Answer 20

**Diagnostics:** * IV urogram * BUN and Creatinine levels * Creatinine clearance **Complications:** * End-stage renal disease (ESRD) * Hypertension * Formation of kidney stones **Treatment:** * Long-term prophylactic antimicrobial therapy * Forced fluids, antipyretics, antibiotics, bedrest

Answer 21

**It is:** * The formation of kidney stones * Formation not clearly understood; dehydration? **S/S:** * No symptoms vs. excruciating pain * Hematuria, pyuria, N/V/D * Confirmed by KUB or US **Medications / treatment:** * Opioid analgesics & NSAIDs; hydration * Procedures for stone removal + stent **Nursing interventions:** * Encourage ambulation; strain urine * Have the Pt report ↓UO, bloody/cloudy urine, fever, pain

Answer 22

* Risk for Fluid Volume Deficit * Acute pain * Ineffective Renal Tissue Perfusion * Impaired Urinary Elimination * Hyperthermia

Answer 23

* Hemodialysis * Continuous renal replacement therapy (CRRT) * Peritoneal dialysis

Answer 24

* It is the removal of waste products such as [creatinine](http://en.wikipedia.org/wiki/Creatinine) and [urea](http://en.wikipedia.org/wiki/Urea) and free water from the [blood](http://en.wikipedia.org/wiki/Blood), and can be short or long term * Chronic hemodialysis * 3X/week for 3-4 hours as outpatient * home hemodialysis

Answer 25

* Hemodialysis (HD) goal: toxic nitrogenous substance removal from blood + H2O removal * HD based on principles of diffusion, osmosis, and ultrafiltration

Answer 26

* heart failure, CHD, angina, stroke, PVD * anemia * gastric ulcers, nausea/vomiting, malnutrition * bone pain & fractures * HTN, **hypotension** * itching * sleep disturbances * SOB * Muscle cramping

Answer 27

Dialyzer-artificial kidney (replaces glomeruli & tubules)

Answer 28

* Diffusion & osmosis occur as waste products move from an area of higher concentration (blood stream) to an area of lesser concentration (dialysate fluid) through a semipermeable membrane (peritoneum) * **Dialysate should be warmed via dry heat- heating cabinet, incubator, or heating pad** * Exchange-infusion, dwell, & drainage of dialysate

Answer 29

**Peritonitis:** * most common & most serious complication of PD * first sign-cloudy dialysate drainage; abdominal pain & rebound tenderness occur much later * hypotension **Leakage:** * of the dialysate through catheter site * avoid by use of small dialysate volumes **Bleeding:** * bloody effluent (drainage) may be seen w/ menstruating women * expected after newly inserted catheters

Answer 30

**Protect vascular access:** * Check patency-bruit or thrill * No BPs on vascular access extremity * Take precautions w/ IV therapy: slow, minimal **Detect cardiac & respiratory complications:** * fluid overload, HF, pulm edema→crackles * pericarditis→chest pain, low-grade fever, frict rub **Control electrolyte levels:** * monitor daily labs * blood transfusions during HD **Manage discomfort & pain:** * itching-antihistamine (diphenhydramine/Benadryl) * pain-analgesics **Monitor BP:** * HTN common b/c of fluid overload + renin oversecretion * withhold daily antihypertensives until after dialysis **Prevent infection:** * ESRD pts have low WBCs, low RBCs, & impaired plt func * wash hands **Care for catheter site:** * Do not submerge PD catheter in water * Catheter site care w/ soap & water-during showering **Watch out for nephrotoxic meds** **Avoid meds with potassium & magnesium**

Answer 31

* Acts on ascending loop of Henle to block reabsorption of Na+ and Cl- * This also inhibits potassium recycling = ↓ in potassium * Loss of volume * Relaxation of venous smooth muscle

Answer 32

* ↓ Pulmonary edema r/t congestive heart failure (CHF) * Edematous states – of hepatic, cardiac, or renal origin that has been unresponsive to other diuretics * ↓ Hypertension not controlled by other diuretics – but can add a thiazide diuretic (no benefit to combining furosemide with another high-ceiling/loop agent)

Answer 33

* Hyponatremia * hypochloremia * Hypocalcemia * hypomagnesemia * dehydration * Hypokalemia * If serum K+ falls below 3.5 mEq/L tx with K supplements or use K-sparing diuretic * Hypotension * Ototoxicity * Hyperglycemia * Hyperruricemia (a lot of peeing)

Answer 34

* Digoxin [hypokalemia from loops produces ↑ risk of dig-induced toxicity (ventricular dysrhythmias) * Ototoxic drugs * Lithium – in general, diuretics result in decreased renal lithium clearance = ↓ lithium excretion, so it can accumulate to toxic levels in the blood * Antihypertensive agents – lower BP already, now add loss of fluid volume and relaxation of venous smooth muscle * NSAIDs (Nonsteroidal anti-inflammatory drugs) – \*blunts efx of furosemide

Answer 35

* Increase renal excretion of sodium, chloride, potassium, and water * Elevate levels of uric acid and glucose * Promote renal calcium retention * Loss of volume * Relaxation of venous smooth muscle

Answer 36

Not effective when urine flow is low = GFR is \< 15-20 mL/min

Answer 37

early segment of the distal convoluted tubule

Answer 38

* **To treat essential hypertension – 1st line choice for most people** * **To treat edema** – preferred drug for mild to moderate HF and hepatic & renal edema * To treat diabetes insipidus – don’t know how it works * May protect from post menopausal osteoporosis

Answer 39

* Hyponatremia * Hypokalemia * If serum K+ falls below 3.5 mEq/L tx with K supplements (or eating K rich foods) or use K-sparing diuretic * Hypomagnesemia * hypochloremia * dehydration * Promotes renal calcium retention * **NO OTOTOXICITY** * Hyperuricemia * Hyperglycemia * usually only in DM pts...who may need larger doses of insulin or oral hypoglycemic drug * Impact on lipids - ↑ LDL, cholesterol, total cholesterol & trigs

Answer 40

* Digoxin - If combined will further lower K+ lvls * NSAIDs may blunt diuretic effect * Lithium supplements - If combined can increase lithium levels due to retained lithium in kidneys * **Can be combined with ototoxic agents without increased risk of hearing loss**

Answer 41

* Aldosterone antagonist (blocker) * Spironolactone * Nonaldosterone antagonists (blockers) * Triamterene * Amiloride

Answer 42

* Blocks aldosterone in the distal nephron * Retention of potassium * (hyperkalemia \>5 mEq/L – mostly if used alone) * **Increased excretion of sodium & passive loss of water** * Slows myocardial remodeling & fibrosis * **Reduces Baroreceptor activatio**n * gynecomastia in men **NOTE: this is a Aldosterone antagonist **

Answer 43

* Pts w/ with Hypertension -- ↓ BP * Pts w/ with Edematous states -- ↓ BP * Pts w/ Heart failure -- decreases mortality in severe failure * Pts w/ primary hyperaldosteronism -- blocks aldosterone from being formed * **Potent antagonist of the androgen (testosterone) receptor as well as an inhibitor of androgen production **

Answer 44

* Hyperkalemia -- possible fatal dysrhythmias; cell uptake of insulin could ↓ K+ levels by K+ uptake into cells * Endocrine effects – gynecomastia, menstrual irregularities, impotence, hirsutism, & deepening of the voice

Answer 45

* Thiazide and loop diuretics – counteract K-wasting * Agents that raise potassium levels (because this drug ↑ K+ lvls), such as: * K supplements * Salt substitutes (KCl) * Or other K-sparing diuretic * ACE-inhibitors * ARBs * Direct renin inhibitors

Answer 46

* Block actions/access\* of angiotensin II * Cause dilation of arterioles and veins * Prevent angiotensin II from inducing pathologic changes in cardiac structure * Decrease release of aldosterone: * ↑ renal excretion of Na & water * Hyperkalemia – K retention (more from ARBs than ACE-I) * Increase renal excretion of sodium and water * **Do not increase levels of bradykinin (no blocking of enzyme)** * **no cough**

Answer 47

* Hypertension, **heart failure**, myocardial infarction, stoke & death * **improves LV ejection fraction, reduce HF symptoms, increase exercise tolerance** * ↓ bradykinin lvls -- no cough * Diabetic nephropathy - mitigates progression * If unable to tolerate ACE inhibitors: protection against MI, stroke, and death from cardiovascular (CV) causes in high-risk patients * Migraine headache – prophylactically (candesartan) * Slowed development of diabetic retinopathy (losartan)

Answer 48

Hypotensive efx with other anti-HTN meds (similar to ACI-Is)

Answer 49

A condition in which the kidneys are unable to conserve water due to problems with ADH.

Answer 50

* Polyuria (increased production of urine) & polydipsia (increased thirst) * Low urine specific gravity ( less than 1.010) * Low urine osmolality (less than 200mOsm/kg) * Hypernatremia * High serum osmolality (greater than 300mOsm/kg) * Continued diuresis diuresis despite serum sodium levels greater than 145

Answer 51

**Normal range is between 0.6-1.2 mg/dL** * Creatine clerance is a natural substance produced by muscle breakdown and is released into the blood at a relatively constant rate * It is freely filtered at the glomerulus and is not reabsorbed by the renal tubules * Creatine clerance overestimates the GFR but it is within tolerable limits, therefore creatine clerance provides a good estimate of GFR. * **As renal function declines, creatinine clearance decreases** *

Answer 52

* BUN is the concentration of urea nitrogen in the blood, and it reflects the GFR and urine-concentrating capacity * **Because urea is filtered at the glomerulus, BUN lvls ↑, when GFR ↓** * **Dehydration &/ acute/chronic renal failure → ↑ BUN lvls** * **Normal range is 10-20 mg/dl** * BUN is affered by altered protein intake and protein catabolism and is **a poor measure of GFR**

Answer 53

1.010 to 1.025

Answer 54

increased amounts of nitrogenous wastes in the blood

Answer 55

Clouded urine due to pus formation in the urinary tract

Answer 56

Difficult and/or painful urination

Answer 57

* **Arteriovenous fistula (AVF) is preferred for perm access** * in a fistula you want to hear a bruit, feel the thrill * **Complications: Watch out for hypovolemia, hypotension,**

Answer 58

* Slowly progressive disease of airflow obstruction, associated with an abnormal inflammatory response of the lungs that is not completely reversible * Includes emphysema and chronic bronchitis * Preventable and treatable, but difficult to reverse damage **Usually due to:** 1. Inflammation of airway 2. Parenchyma damage 3. Decrease of elastic recoil

Answer 59

* **_Chronic_ _bronchitis-_** mucus production & persistent cough * **_Emphysema_-** Over distention of air spaces & alveolar walls destroyed * May have one or combination **_Asthma is considered a distinct, separate disorder, not a type of COPD._**

Answer 60

**Primary symptoms:** * Cough * Sputum production * Dyspnea **Additional symptoms:** * **Wheezing and crackles** * Weight loss * Pale to cyanotic * **Barrel chest (emphysema)** * **Use of accessory muscles** * Prolonged expiration * Orthopnea * Cardiac dysrhythmias * Congestion and hyperinflation on CXR * **Polycythemia** * Hypoxemia

Answer 61

* Occurs when the Hct in the blood is above reference range values * With COPD there is an increase in RBC from chronic low O2 levels * Polycythemia indicates a disease or disorder

Answer 62

* Respiratory failure * Pulmonary hypertension with consequent heart failure * Cor Pulmonale, one of the complications of emphysema, is right-sided heart failure brought on by pulmonary hypertension. * **Monitor heart failure – BP/HR, BNP, Lung sounds, edema, CXR, EF** * Pneumothorax * Infection * Other comorbidities related to smoking and aging which include ischemic heart disease and lung cancer

Answer 63

* Defined as an acute worsening of symptoms characterized by increased dyspnea, mucous production, hyperinflation and air trapping which may be triggered by infection or environmental pollutants * Mortality increases as the frequency of exacerbations occur. * They can be caused by medicine noncompliance

Answer 64

* Advancing age - strong predictive risk factor of COPDE * Pulmonary secretion clearance is reduced with age which puts the patient at increased risk for infection * Declines in immunity may also be partially responsible

Answer 65

* Spirometry * Chest X-ray: increased bronchovascular markings * Sputum sample for culture and sensitivity * ABGs: respiratory acidosis * CBC: increased RBCs * Pulmonary Function Tests: decreased forced expiration, decreased vital capacity * EKG

Answer 66

* Breath sounds/ capillary refill & skin color / hydration status, sputum * Pulse oximetry/ABG * Spirometry (FEV not accurate in COPDE) * Labs - ABG’s CBC, Chemistry panels * Cardiac status as needed * Other physical symptoms (see complications) * Holistic assessment: physical, psychosocial, cognitive, spiritual

Answer 67

**Ineffective airway clearance related to:** * bronchoconstriction * increased sputum production * ineffective cough * fatigue/ lack of energy * bronchopulmonary infection **Ineffective breathing pattern related to:** * shortness of breath * mucus * bronchoconstriction * airway irritants **Impaired gas exchange r/t** * Ventilation perfusion inequality **Activity intolerance r/t** * Imbalance between oxygen supply with demand **Imbalanced Nutrition: less than body requirements r/t** * Anorexia **Disturbed sleep pattern r/t** * Discomfort * Sleeping position **Self-care deficit (hygiene) r/t** * Fatigue secondary to inc. respiratory effort & ventilation & oxygenation insufficiency

Answer 68

* Fowler’s; forward-leaning positions * O2 as ordered (supplemental O2 to mechanical ventilation) * If give too much O2, then O2 suppresses the hypoxic drive to breathe. The hypoxia is the stimulus to breathe * Pulse oximetry / ABGs / cardiac monitor as needed * Respiratory therapy (breathing treatments) * Start IV/ give meds as ordered (bronchodilators, antibiotics, steroids, anxiolytics, antidepressants) * Nicotine patch * Decrease patient’s anxiety- psychosocial support

Answer 69

* Quit smoking * Supplemental oxygen, ventilator support, walker, wheelchair, nebulizer * Home Health/SNF * Meds/Inhalers/Nebs - bronchodilators, antibiotics, steroids, anxiolytics, antidepressants * Pulmonary Rehab - maintaining functional ability * Fall prevention * Prevent respiratory infections * Proper nutrition to prevent muscle wasting * Crucial to prevent exacerbations * May need: * Lung Transplantation * Lung volume reduction surgery

Answer 70

* Defined as the presence of cough and sputum (with no other known cause) **_for at least 2 months in each of two consecutive years._** * It is caused by Inflammation of the airways due to irritants (smoking, bacteria, virus…) and results in increase mucous production (d/t increase in number of goblet cells) * Mucous plugging results in reduction of ciliary function, thickened bronchial walls (narrowing), alveolar damage and fibrosis. * Patient becomes more susceptible to infection, exacerbations are more likely during the winter when viral and bacterial infections more prevalent.

Answer 71

* Cyanotic apperance * **Recurrent cough & sputum production** * Hypoxia * **Hypercapnia** * Acidosis * **Edematous** * **Increased RR** * Exertional dyspnea * Cor Pulmonale * **Use of accessory muscles to breathe**

Answer 72

**Impairment of O2 and CO2 exchange results from destruction of walls of over distended alveoli which leads to:** * O2 unable to diffuse through capillaries * Permanent over inflation of alveoli * Increased airway resistance * Loss of elastic recoil * Dead space: lung area where no gas exchange can occur and impaired oxygen diffusion à hypoxemia * Impaired elimination of CO2àhypercapnia, respiratory acidosis * Increased anterioposterior diameter increases: barrel chest; air gets in, but cannot get out.

Answer 73

* ↑ CO2 retention (this leads to the pink apperance) * Minimal cyanosis * **Purse lip breathing** * Dyspnea * **Hyperresonance on cheast percussion** * Orthopenic * **Barrel chest** * **Exertional dyspnea** * Prolonged expiratory time * Speaks in short jerky sentences * Anxious * **Use of accessory muscles to breathe** * Thin apperance

Answer 74

It is a _reversible_ chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and and mucus production. **Causes:** * Triggers; genetic component: +25 genes associated with asthma * Respiratory infections and colds * Cigarette smoke; 2nd hand smoke * **Allergens such as pollen, mold, animal dander, feathers, dust, food & cockroaches** * Exercise * Exposure to cold air or sudden temperature change * Odors and fumes * Excitement or stress

Answer 75

* Diffuse airway inflammation and narrowing * Bronchoconstriction of smooth muscles * Increased vascular permeability * Increased mucous gland secretion * Increased airway resistance from spasm * Increased lung compliance * Impaired mucociliary function * **Altered gas exchange: respiratory acidosis**

Answer 76

1. Allergens/triggers → 2. production of IgE → 3. IgE attach to mast cells and basophils → 4. Activates release of histamine, bradykinin, prostanoids, cytokines, leukotrienes → 5. Swelling, airway constriction **Airway “remodeling” may occur in response to chronic inflammation, causing further airway narrowing.**

Answer 77

* Dyspnea, breathlessness, chest tightness, cough * Wheezing (inspiratory and/or expiratory) * Increased P, R, BP; Pallor * Anxiety, restlessness * Use of accessory muscles, nasal flaring, retractions * **If uncorrected leads to status asthmaticus: s/s continue despite treatment à air trapping & V/Q mismatch à respiratory distress, cyanosis**

Answer 78

1. Frequent cough, especially at night 2. Losing your breath easily or shortness of breath 3. Feeling very tired or weak when exercising 4. Wheezing or coughing after excercise 5. Feeling tired, easily upset, grouchy, or moody 6. Decreases or changes in lung function as measured on a peak flow meter 7. Signs of a cold or allergies 8. Trouble sleeping

Answer 79

1. ‘STEP’ therapy for asthma (see link in previous slide) 2. Know the triggers for asthma & chronic bronchitis 3. Do not delay professional treatment for any breathing problems; controlled breathing techniques 4. Staying hydrated (follow any fluid restrictions if have heart disease); take meds as prescribed 5. Know home equipment- peak flow meter, O2, spacer, & inhalers

Answer 80

* It is a Medical emergency, which has a sudden or gradual onset, and is not responsive to usual therapy. * Triggered by viral infection, stress, D/C meds, etc. **Leads to:** * Severe bronchospasms/air trapping * Hypoxemia * Expiratory flow/volume decrease * Fatigue * Respiratory failure

Answer 81

* Absence of a wheeze is called a “silent chest” and is an emergency * Hyperinflated chest * Hypoxemia * Hypocapnia initially, followed by hypercapnia * Marked respiratory distress * Marked wheezing * Use of accessory muscles * Extreme anxiety * Fear of suffocation * Diaphoresis * Tachycardia

Answer 82

Correct hypoxemia to achieve PaO2 \> 60 - may require intubation **This will require the use of:** * β-adrenergic agonist nebulizer * Arterial line placement * IV corticosteroids * IV mag sulfate

Answer 83

* Subjective data, if appropriate; brief history * Breath sounds/ capillary refill & skin color / hydration status * Pulse oximetry/ ABGs * Cardiac status, as needed * Other physical symptoms (see manifestations) * Holistic assessment: physical, psychosocial, cognitive, spiritual

Answer 84

* Ineffective airway clearance * Anxiety * Impaired gas exchange * Ineffective breathing pattern * Ineffective therapeutic regimen * Imbalance nutrition: less than body requirements * Disturbed sleep pattern * Risk for infection/actual infection * Decrease cardiac output * Activity intolerance

Answer 85

* Fowler’s; forward-leaning positions * O2 as ordered; usually cannula at first * Pulse oximetry / ABGs / cardiac monitor as needed * Respiratory therapy (breathing treatments) * Start IV/ give meds as ordered * Decrease patient’s anxiety / work with family

Answer 86

* Acute inflammation of lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses. * The edema associated with inflammation stiffens the lung, decreases lung compliance, and vital capacity, and causes hypoxemia.

Answer 87

* **Community-acquired (CAP)** * Steptococcus, Mycoplasma, Haemophilus influenzae * Occurs within \< 48 hours of admission * **Healthcare-associated (HCAP)** * Often multi-drug resistant organisms * Occurs within \> 48 hours of admission * **Hospital-acquired (HAP)** * Enterobacter, E.Coli, H.influenzae, Klebsiella, Pseudomonas * Occurs within \> 48 hours of admission * **Ventilator-associated (VAP)** * Subtype of HAP; most common infection seen in the ICU * **Immuno-compromised** * Pneumocystis pneumonia (PCP), fungal, and mycobacterium tuberculosis * **Aspiration**

Answer 88

* **Older adult** * Immobility * Chronicity/ decreased immune system * Exposure to foreign materials * Nosocomial factors (tracheal intubation, feeding techniques) * Not following health professionals’ advice (hand washing, vaccines, immediate attention for meds)

Answer 89

* Dry or wet cough * Tired, body aches * Fever, chills * Short of breath * **Wheezes, rhonchi** * Chest pain * Tachycardia * Dyspnea, Syncope, cyanosis * **Older patients: Mild fever, confusion and/or tachypnea might be the only sign**

Answer 90

* Establish adequate ventilation/ perfusion * Empiric antibiotics; Treat the organism based on sputum C & S * Bronchodilators * Antipyretics * Analgesics * Nutrition, hydration, pulmonary hygiene * Patient teaching & concept of prevention (hand washing)

Answer 91

**Vital signs: ** * respiratory rate, pulse oximetry, temperature, cyanosis, lung sounds - wheezing, rales or diminished breath sounds **Sputum color, amount, consistency** **Assess for exposure of tuberculosis**

Answer 92

* Encourage coughing and deep breathing and use of incentive spirometer * Change pts. position frequently and ambulate to mobilize secretions * Semi-Fowler’s position to facilitate lung expansion * Nasotracheal suction if pt. unable to clear secretions * Encourage fluids, unless contraindicated * Provide balance of rest and activity * Provide CPT * **Health Promotion** * Prevention * Immunizations: Pneumococcal

Answer 93

**_Ineffective Airway Clearance_** a. Assess resp status, SpO2, VS, breath sounds, skin color b. Assess cough & sputum c. Monitor ABGs, as ordered; report abnormal values d. Position in Fowler’s/high-Fowler’s e. Assist with C & DB f. Provide fluids g. Assist with chest physiotherapy h. Administer medications/assess effectiveness **_Ineffective Breathing Pattern_** a. Provide for rest b. Assess for pain/provide analgesia c. Administer O2 as ordered. **_Activity Intolerance_** a. Assess effect of activity b. Assist with ADLs c. Schedule activities/rest d. Provide emotional support/encourage family presence & help

Answer 94

* Oxygen assessment documentation * Blood culture before 1st antibiotic * Initial antibiotic within 6 hours of triage time * Appropriate antibiotics given * Influenza/Pneumococcal vaccination given/or documented * Documentation of smoking cessation * Nicoderm patch if patient refuses to quit smoking

Answer 95

* Acute viral infection of respiratory tract; highly contagious * Different viral strains, usually known as types A, B, and C * Symptoms: acute onset of myalgia, fever, cough, sore throat, head aches, and can progress to pneumonia symptoms (esp in older adult) * **Patients are contagious 1 day before symptoms start and 7 days after they start**

Answer 96

* Diagnosis early to receive anti-viral medication: need to be given within 48 hours of intial symptoms for effectiveness * Treatment targeted at symptom relief: antipyretics and antitussives * Rest, hydration, nutrition * Prevent pneumonia * Teaching: hand washing, avoid crowds, annual influenza vaccination

Answer 97

* Highly communicable disease caused by Mycobacterium tuberculosis * **M. tuberculosis is an aerobic bacterium, primarily affecting the pulmonary system, especially the upper lobes where oxygen content is highest.** * **Granulomas develop in the lung tissue** * It can also affect other areas of the body, such as brain, intestines, peritoneum, kidney, joints, and liver. * Major public health concern- globally, every second someone infected

Answer 98

* Spread by droplet nuclei * Microorganisms usually lodge in upper lobe * Multiply & cause inflammation * Can migrate through lymph system * Tubercle= granulomatous lesion * Bacilli in tubercles can be dormant or become active * Compromised immune system or live bacilli can spread through to other organs

Answer 99

1. Infectiousness of person 2. Environment of exposure 3. Duration of exposure 4. Virulence of organism: * Multidrug-resistant (MDR-TB) * Extensively (CDC) drug-resistant (XDR-TB); “extreme”- lay term

Answer 100

* Foreign-born: e.g., Asia, Africa, Russia * Close contacts: same living environment * Health care workers: high-risk patients * Substance abusers: e.g., injection/ inhalation * Other high-risk populations: e.g., homeless persons, migrant farm workers, prisoners * Immunocompromised individuals ie. HIV/AIDS, diabetes mellitus, cancer * International travelers

Answer 101

* **Cough for several weeks** * **Fever for more than a week** * **Night sweats** * Weight loss * Weakness * Chest pain/pleurisy * **Coughing up blood** * Fatigue * Anorexia

Answer 102

* Mantoux test: simple skin test * QuantiFERON-TB Gold (OFT): blood test * Direct microscopic exam of sputum: acid-fast bacilli (AFB) * Radiographic evidence: CXR * Culture of specimens * History & clinical findings

Answer 103

* Nursing care plan: education/ prevention * Directly Observed Therapy Strategy (DOTS) * Drug therapy * Monitoring of drug therapy * Notify MD of side effects * BCG vaccine – efficacy questioned

Answer 104

* Airborne infection: coughing, sneezing * Droplet nuclei- 3 feet; family members * Classic symptoms * Encourage health care & compliance-incentives * Medication side effects – jaundice, bleeding, N/V, aches/pains (monitor LFTs) * Social support; social stigma- Holistic approach * Mandatory reporting

Answer 105

* Treatment of identified lesions depends on whether the patient has active disease or hs only be exposed to the disease * Treatment is difficult because the bacterium has a waxy substance on the capsule that makes penetration and destruction difficult * Multidrug regimen most effective to destroy organism quickly and minimize drug-resistant * Individuals with active TB are treated for 6-9 months; HIV patients treated for longer period * After 2-3 weeks of treatment, the risk of transmission is greatly reduced * Individuals exposed to active TB are treated with preventative Isoniazid for 9 to 12 months

Answer 106

* Importance of teaching: * Side effects * ETOH intake * Drug interactions * Routine monitoring: e.g., kidneys, liver, eye exams * Use in pregnancy * **Encourage relationship with practitioner**

Answer 107

* Isoniazid * Rifampin * Ethambutol * Pyrazinamide * Rifabutin * Rifapentine Many TB meds can cause toxic effects such as hepatotoxicity, nephrotoxicity, neurotoxicity, optic neuritis, or ototoxicity. Teach the client about the signs of toxicity and to notify HCP if signs arise.

Answer 108

* Second-line Agents * Used in combo with 1st line meds; more toxic * Amikacin * Cipro, Levofloxacin * Cycloserine * Capreomycin sulfate * Streptomycin Many TB meds can cause toxic effects such as hepatotoxicity, nephrotoxicity, neurotoxicity, optic neuritis, or ototoxicity. Teach the client about the signs of toxicity and to notify HCP if signs arise.

Answer 109

* Be educated * Independent actions- ISOLATION & infection control nurse * Use \*Negative air-flow rooms/HEPA filters \* * Be aware: coughing, risk factors, read chart * Wash your hands- always for any infection control! * Call the practitioner if patient has symptoms

Answer 110

* Patients taught to cover their mouth & nose when coughing, using a tissue. * Private room with air exchange - air exchange at least 6 times per hour and two of the exchanges being fresh air from outside. Air exhausted to the outside. * When patient leaves their room, must wear a particulate respirator (PR) mask. * Air pressure in patient’s room, must be negative. * High-energy particulate air (HEPA) filters in rooms. * Ultraviolet lights. * **_3 consecutive negative smears for TB, patient does not have to wear a mask._** * HCWs using PR mask - refitted annually. * HCWs tested annually with PPD. * If exposed to TB, then have PPD 8 to 12 weeks after exposure. * If work in area where exposure is possible (ie, tracheal suctioning or bronchoscopy) - then have PPD every 6 months. Determined by CDC. * If convert from negative PPD status to positive, must have exam to rule out active TB. Consider INH therapy or annual CXR.

Answer 111

* Air accumulation in pleural space * Rupture of visceral or parietal pleura * Air destroys negative pressure; lung collapses * Can be Spontaneous * Rupture of bleb **Types of pnuemothorax include:** 1. traumatic 2. tension 3. simple

Answer 112

* **Depend on size & cause** * Sudden pleural pain * Tachypnea, tachycardia * Increased oxygen demand * Dyspnea (degree depends on size) * Absent or decreased breath sounds affected side * Air movement thru open wound (open pneumothorax) * Subcutaneous emphysema * Confirmed by CXR

Answer 113

* Oxygen therapy * Vented dressing (stabilize impaled object) with open pneumothorax * Chest tube insertion * Surgical intervention

Answer 114

**Physical assessment:** * Degree of respiratory distress * Evidence of chest trauma * Vital signs * SpO2 * Skin color * LOC * Breath sounds & respiratory excursion * Position of trachea * Neck vein distention

Answer 115

**Impaired gas exchange, Ineffective breathing pattern, Ineffective airway clearance:** * Maintain open airway * Assess VS, Breath sounds, SpO2 (q4hrs) * Position in Fowler’s or semi-Fowler’s * Administer oxygen/assess effectiveness * Administer analgesia/assess effectiveness * Maintain/monitor chest tube function (q2hrs) * Provide for adequate rest * Increase patient mobility (once stabilized) **Decreased cardiac output (tension pneumothorax, hemothorax):** * Monitor VS * Administer fluids (crystalloids, colloids) * Monitor I&O * Monitor H&H, RBCs, platelets **Risk for infection:** * Chest tube care/site care * Wound care (open pneumothorax) * Monitor/interpret labs * Monitor VS * Administer antibiotics

Answer 116

* Fractured rib (blunt trauma) * Closed pneumothorax * Open (penetrating trauma) * Sucking chest wound * Iatrogenic (central line, thoracentesis, mechanical ventilation)

Answer 117

**Site of the pleural rupture acts as one-way valve:** * Air enters on inspiration * ***_Air does not escape during expiration_*** * More & more air enters pleural space * Pressure builds & compresses lung tissue & mediastinum (heart & great vessels)

Answer 118

**Clinical Manifestations:** * Severe dyspnea/hypoxemia * Hypotension * Absent breath sounds affected side * Tracheal deviation * Neck vein distention **Collaborative Care-Emergency Situation:** * Oxygen * Needle thoracotomy/Chest tube insertion * Monitor EKG, VS * Possible intubation

Answer 119

**Accumulation of blood in intrapleural space caused by:** * Blunt/penetrating trauma * Rib fractures * Lung parenchymal (pulmonary contusion) **Clinical Manifestations:** * Decreased/absent breath sounds * Decreased chest expansion * Decreased percussion noted

Answer 120

Refers to the extravasation of fluid from the pulmonary vasculature into the interstitium & alveoli of the lung **Causes:** * Increased capillary hydrostatic pressure * Increased capillary permeability * Decreased oncotic pressure * Lymphatic obstruction

Answer 121

Stage I – fluid transfer is increased into the lung interstitium because lymphatic flow increases Stage 2 – The capacity of the lymphatics to drain excess fluid is overwhelmed and fluid begins to accumulate in the interstitial space that surrounds the bronchioles & lung vasculature Stage 3 – as fluid continues to build up, increased pressure causes it to track into the interstitial space around the alveoli & disruption to the alveolar membrane occurs. Gas exchange becomes impaired

Answer 122

* Infectious pulmonary edema (viral or bacterial) * Inhaled toxins * Circulating toxins * Vasoactive substances (histamine, kinins) * Disseminated intravascular coagulation * Immunologic reactions * Radiation pneumonia * Uremia * Near-drowning * Aspiration pneumonia * Smoke inhalation * **ARDS**

Answer 123

Can develop slowly or acutely **Early signs:** * Shortness of breath on exertion * Sudden respiratory distress after sleep * Difficulty breathing unless sitting upright * Cough

Answer 124

* Labored & rapid breathing (leads to respiratory alkalosis) * Frothy or bloody sputum * Tachycardia * Cardiac arrhythmias * Cold, clammy, sweaty, bluish skin * Decreased blood pressure * Thready pulse * Anxiety * Pulse oximetry is commonly less than 85% & arterial Po2 of 30-50 mmHG

Answer 125

**Medical treatment:** * Find and treat underlying cause * O2 via nasal cannula or mask * Intubation & mechanical ventilation maybe necessary * **Furosemide (Lasix) –** increases urine output and works quickly to remove excess fluid from the body * **Morphine –** decreases anxiety & work load of breathing * **Dobutamine –** dilates the peripheral vessels to decrease the work load of left ventricle * **Aspirin -** helps decrease blood viscosity for easy delivery

Answer 126

* Identify type of artificial airway or supplemental oxygen * Check respirations for rate, depth, rhythm, symmetry, accessory muscle use * Sputum – if present, note color, consistency, & odor of sputum * Pink Frothy is usually noted with pulmonary edema * **Auscultate breath sounds for equality and/or adventitious breath sounds (would hear crackles)**

Answer 127

* **Monitor for symptoms of heart failure/decreased cardiac output** * **Monitor vital signs** * Observe for confusion, restlessness, agitation * Monitor for chest pain, discomfort (note severity, radiation, and duration) * Cardiac monitor for dysrhythmias * **Monitor I & O** * Note results of EKG, chest x-ray, & other diagnostic exams * Monitor lab work such as ABGs, CBC, electrolytes * Place patient in semi-Fowlers of upright position * Activity/rest balance * **Diet sodium restricted, low cholesterol, limit caffeine** * Serve smaller more frequent meals * Monitor bowel and bladder function * Minimize environmental stimuli * **Daily weights** * Refer appropriately (heart failure programs, cardiac rehab., support groups)

Answer 128

* s/s of heart failure * Importance of smoking cessation/ avoidance of alcohol * Stress reduction * Diet restrictions * Assist patient to understand need for lifestyle changes * Side effects of medications * Early reporting of SOB or other respiratory difficulty * Provide specific self-care & disease process information to patient prior to discharge

Answer 129

**It is a collection of fluid in pleural space:** * vSource: blood vessels or lymphatics; lesions * Fluids _compress_ lung tissue (atelectasis occurs) * Lung does not collapse **Types:** * Transudative: watery; low in protein * Exudative: high amount of WBCs & proteins

Answer 130

**Clinical Manifestations:** * Dyspnea * Pleuritic pain * Dullness to percussion, decrease breath sounds (hyperressonance) * CXR **Collaborative Care:** * Treat underlying cause * Thoracentesis

Answer 131

* Dyspnea with activity and/or rest * Tachycardia, dysrhythmias, S3 heart sound, hypo or hypertension * Fear, anxiety * Pain aggravated by inspiration, possibility of spread to neck, shoulders, abdomen * Tachypnea, use of accessory muscles in chest, intercostal retraction, decreased breath sounds, decreased fremitus (effected side * Skin – pale, cyanosis, sweating

Answer 132

**Transudative effusions usually form as a result of excess capillary fluid leakage into the pleural space, and can be caused by:** * Congestive heart failure * Nephrotic syndrome * Cirrhosis of liver * Pulmonary embolism * Hypothyroidism

Answer 133

**Exudative effusions are often more serious than transudative effusions. They are formed as a result of inflammation of the pleura caused by:** * Pneumonia * Lung Cancer; other cancers * Connective tissue diseases * Pulmonary embolism * Asbestosis * Tuberculosis * Radiotherapy

Answer 134

**Ineffective breathing pattern:** * Identify etiology or trigger factor * Assess respiratory function (changes in vital signs, O2 sat, cyanosis) * Auscultation for breath sounds * Note position of the chest & trachea * Comfortable position – usually HOB up * Give oxygen and monitor * Monitor chest tube if inserted **Chest Pain:** * Assess for presence of pain, the scale and intensity of pain * Teach patient about pain management & relaxation with distraction * Secure chest tube to restrict movement and avoid irritation * Provide analgesics as indicated * Evaluate effectiveness of pain reduction measures

Answer 135

* Informed consent * Position pt upright, leaning forward * Obtain equipment * Monitor pulse, color, SpO2 * Apply dressing over site * Monitor closely after procedure; I & O

Answer 136

* Promote ventilation & re-expansion of the lung * Pneumonectomy – should not be turned on unoperative side * Maintain a clear airway * Maintain a closed drainage system (if used) * **Promote arm exercises on affected side (PROM)** * Promote nutrition * Monitor incision for bleeding & subcutaneous emphysema * Remain in ICU until extubated & hemodynamically stable * Then O2 at 6L/min via NC

Answer 137

1. Stasis - decreased blood flow 2. Endothelial injury - damage to the inside of the blood vessel 3. Hypercoagulability - blood clots likely

Answer 138

* Careful assessment including risk factors, physical exam * **Ambulation, active & passive leg exercises** * Do not sit or lie in bed for prolonged period * **Do not cross legs; wear constrictive clothing; dangle or place feet in dependent positions for long periods of time** * Sequential compression devices * Prophylactic heparin or lovenox

Answer 139

* Venous stasis * Hypercoagulable states * Immobilization * Surgery & trauma * Pregnancy * OCPs & estrogen replacement * Malignancy * Acute medical illnesses * IV drug abuse * Heparin-associated thrombocytopenia * Varicose veins * Venous pacemakers * Inflammatory bowel disease * Lupus

Answer 140

* Travel of 4 hours or more in the past month * Surgery within the last 3 months * Malignancy, especially lung cancer * Current, or past hx of thrombophlebitis * Trauma to lower extremities & pelvis during past 3 months * Smoking * Central venous instrumentation in past 3 months * Stroke, paresis, or paralysis * Prior pulmonary embolus * Heart failure * COPD

Answer 141

* Tachypnea (RR \> 16/min) * Rales * Accentuated 2nd heart sound * Tachycardia (HR\>100) * Fever (temp \> 37.8C) * Diaphoresis * S3 or S4 gallop * Clinical S/S suggesting * Thrombophlebitis * Lower extremity edema -- DVT

Answer 142

* Monitor vital signs, ABGs * Position patient in high Fowler’s position * Administer oxygen as ordered * Bedrest * Medications - anticoagulants

Answer 143

**_Anticoagulants:_** * Heparin – weight based protocols * Monitoring PTT, INR; therapeutic range 2.0-2.5 * S/E – bleeding; antidote = Protamine Sulfate * Warfarin (Coumadin) * Monitoring PT, INR * Important to keep the same brand of coumadin * Enoxaparin (Lovenox) * High doses SC * Require less frequent monitoring

Exam 3 - Study Material Flashcards

(168 cards)