Powerpoints and Notes Flashcards
(222 cards)
1
Q
Describe the function of the skin. (6)
A
Provide protection for underlying tissues
Control body temperature
Provide sensory perception of pain, touch, cold and heat
Assist in the maintenance of the fluid and electrolyte balance
Use sunlight to synthesize vitamin D, which is necessary to Ca and Ph metabolism
Major component in self and body image
2
Q
What are normal characteristics of skin?
A
Intact with no abrasions
Feels warm when palpated
Turgor is elastic and firm
Usually smooth and soft
Color varies from part to part
3
Q
What is moisture in the skin related to and what is the normal state of skin?
A
Moisture in the skin is directly related to the degree of hydration and the condition of the outer lipid of the skin.
Moisture refers to the wetness and oiliness.
Skin folds like axilla are normally moist
Skin is normally smooth and dry.
4
Q
What is temperature dependent on?
A
Temperature within the body depends on the amount of blood circulating through the dermis.
5
Q
What are reasons for temperature changes within the body?
A
Temperature changes occur at the site of infection, sites of inflammation, stage 1 pressure sores, and coldness r/t decreased circulation.
6
Q
Describe turgor.
A
Turgor represents the skin’s elasticity and is an indication of hydration.
Turgor decreases with age
Decrease in turgor predisposes the client to skin breakdown.
7
Q
What are factors that affect skin integrity?
A
Genetics and heredity
Age
Chronic Illnesses
Medications
Poor nutrition
8
Q
What are pressure ulcers?
A
________ __________ are defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue
9
Q
What are pressure ulcers also known as?
A
Decubitus ulcers or pressure sores.
10
Q
Describe the etiology of pressure ulcers.
A
Pressure ulcers are due to localized ischemia (a deficiency in the blood supply)
The tissue is caught between two hard surfaces, usually the surface of the bed and the bony skeleton. Prolonged unrelieved pressure damages small blood vessels.
Usually occur over bony prominences, after skin has been compressed it will appear as if the blood has been squeezed out of it.
11
Q
Describe reactive hyperemia.
A
When pressure is relieved, the skin takes on a bright red flush, which is the body’s mechanism for preventing pressure ulcers. The flush is due to vasodilation.
12
Q
What two other factors frequently act in conjunction with pressure to produce ulcers?
A
Friction: the force acting parallel to the skin.
example-pulling pt up in bed. Use drawsheet so it won’t slide skin.
Shearing: a combination of friction and pressure
example- sliding down in bed. Support patient, lower head of bed, provide pillows
13
Q
What are risk factors of developing pressure ulcers?
A
Immobility and Inactivity
Inadequate Nutrition
Hypoproteinemia (abnormally low protein in the blood)
Fecal and Urinary incontinence (will become worse if laying in urine)
Decreased mental status: Pt may not know that they have to move.
Diminished sensation: might not feel the pressure. Decreased circulation/sensation in paralysis, stroke, nerve damage, diabetes
Excessive Body Heat
Advanced age
14
Q
What is the Braden Risk Scale and what factors are measured?
A
The Braden Risk Scale is a method used to predict pressure ulcer risk.
Factors included are sensory perception, moisture, activity, mobility, nutrition, friction/shear
15
Q
Describe stage 1 and 2 of pressure ulcer development and state the difference between them.
A
Stage 1: nonblanchable erythema signaling potential ulceration
Stage 2: Partial thickness skin loss (abrasion, blister)
Difference: blister or abrasion in stage 2
16
Q
Describe 3 and 4 of pressure ulcer development and state the difference between them.
A
Stage 3: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.
Stage 4: Full thickness skin loss with tissue necrosis of damage to muscle, bone, or supporting structure.
Difference: Stage 3 does not affect bone.
17
Q
What are nursing interventions that can prevent or promote healing of pressure ulcers?
A
Assess risk factors
Assess hygiene and skin care
Keep area clean and dry
Use a protective skin barrier if needed
Reposition every two hours and check for reactive hyperemia or blanching
Provide adequate nutrition, monitor nutrition and weigh patient
Follow doctors orders for treatment plan
18
Q
What are the phases of wound healing?
A
Inflammatory phase, Proliferative phase, Remodeling phase.
19
Q
Describe the inflammatory phase.
A
Inflammatory phase:
- immediate to 2-5 days - Hemostasis-vasoconstriction - Inflammation-vasodilation, phagocytosis
20
Q
Describe the proliferative phase.
A
Proliferative phase:
- 2 days to 3 weeks - granulation- fibroblasts lay bed of collagen - contraction- wound edges pull together to reduce defect - epithelialization
21
Q
Describe the remodeling phase.
A
Remodeling phase:
- 3 weeks to 2 years - new collagen forms - scar tissue is only 80 percent as strong as original tissue.
22
Q
During a physical assessment of a pressure ulcer, what are we assessing and documenting?
A
- Location of the lesion-be as specific as possible
- Size of the lesion in centimeters-length, width, and depth
- Stage of ulcer
- Color of the wound bed and location of necrosis
- Undermining- look for skin that overhangs the wound edges.
- Conditions of the margins (macerated? mushy? look at outside borders.)
- Integrity of the surrounding skin
- Clinical signs of infection (redness, warmth, swelling, pain, odor, color and exudate) serous, purulent, sanguineous.
23
Q
What are further factors that nurses need to document when assessing pressure ulcers?
A
Presence of undermining or sinus tracts
Amount of time the lesion has been known to exist
Note any past treatments and any change in products
Current treatment-document the type of irrigation, products, and secondary dressing used.
24
Q
What changes to the skin occur due to age?
A
Reduction in skin turgor
Reduced thickness and vascularity of dermis
Degeneration of elastin fibers
Thinning and graying of hair on scalp, pubic and axilla areas
Thickening of hair in nose and ears
Slower growth of fingernails, more brittle nails
Reduction in number of sweat glands
25
What are measures to prevent pressure ulcers?
Provide nutrition- fluid intake, protein, vitamins, weight, lab data
Maintaining skin hygiene- mild cleansing agents, avoid hot water, moisturizers, skin protection
Avoiding Skin trauma- semi fowlers position, lifting devices, reposition every 2 hrs, smooth firm surfaces
Providing supportive devices-matress, beds, wedges, pillows
26
How do we care for patients with stage 1 or 2 pressure ulcers?
Prevent further breakdown
Apply decubitus mattress
Apply transparent film dressing (tegaderm) or hydrocolloid dressing (duoderm)
27
What are ways to manage stage 3 and stage 4 pressure ulcers?
Wounds may be cleansed wih normal saline if indicated
May cover with dry gauze
Obtain doctors orders or protocols established for pressure ulcers
28
What are different types of wound dressings?
```
Transparent film- Tegaderm
Hydrocolloids - Duoderm
Hydrogels
Polyurethane Foams
Alginates-Kaltostat
Vacuum-assisted closure (VAC)- use of suction equip. to apply negative pressure to wound
```
29
What are factors that affect wound healing?
```
Diabetes
Infection
Drugs
Nutrition
Tissue Necrosis
Hypoxia
Excessive tension
Another wound
Low temperature
```
30
Describe the etiology for feeling pain.
Receptor nerve cells in and beneath your skin sense heat, cold, light, touch, pressure, and pain
When there is an injury-these tiny cells send messages along nerves into your spinal cord and then up to your brain.
31
What happens to the body in response to pain?
1st the sympathetic nervous system responds (fight or flight response)
Increase BP and Pulse, reflexive movements
Over time (minutes or hours) pulse and BP return to baseline despite persistence of pain
Vital signs adapt but pain fibers do not
32
Describe acute, chronic, referred, and radiating pain.
Acute-may have sudden or slow onset, it is protective, patient seeks help
Chronic- lasts 6 months or longer and often limits normal functioning
Referred- felt in a part of the body that is considerably removed from the tissues causing the pain
Radiating- is perceived at the source of the pain and extends to nearby tissues
33
Describe intractable, phantom, and neuropathic pain.
Intractable- pain that is highly resistant to relief
Phantom- painful sensation perceived in a missing body part, or in a body part paralyzed from a spinal cord injury. Can last for a long time and you still treat the patient for the pain they are feeling.
Neuropathic- results as a disturbance of the peripheral or central nervous system that results in pain, which may or may not be associated with an ongoing tissue damaging process. It is described as sharp and shooting.
34
Describe pain reaction, pain threshold, and pain tolerance.
Pain reaction- includes the autonomic nervous system and behavioral responses to pain.
Pain threshold- the amount of pain stimulation a person requires in order to feel pain. High threshold means you can tolerate pain well. Everyone's threshold is unique.
Pain tolerance- the amount and duration of pain that an individual is willing to endure
35
What are factors that affect our pain experience?
Ethnic and cultural values
-Some tolerate making noise while in pain, others do not.
Developmental stage
Environment and Support Persons
Past pain experiences
-Can cause greater anxiety than necessary
Anxiety and Stress
-Can make pain worse
36
What questions do we ask while assessing pain?
Take a thorough history about the patient's pain
Ask about:
- location
- intensity
- quality
- pattern
Further questions:
- Pain to touch?
- Is Pt walking with/without difficulty?
- What activity were you doing before the pain started?
- What makes the pain go away?
- What helped last time with this pain? Was it medication?
37
When we assess pain, what are all the factors to take into consideration?
Precipitating factors
Alleviating factors
Associated symptoms
Effects on ADL's
-Can they walk? Go to the shower? Bathe themselves?
Past pain experiences
Meaning of pain
Coping resources
Affective responses
38
What implementation is included for pain management?
Acknowledge patient's pain
Assist support persons
Reduce misconceptions
Reduce fears and anxiety
39
What are nonpharmacologic ways to manage pain?
Physical interventions
-Repositioning pt.
Cutaneous stimulations
- Massage
- Heat and cold
- Accupressure
40
What are ways to administer nonpharmacologic practices?
Immobilization
TENS- Transcutaneous electrical nerve stimulation
Distraction- Tv, talking to them, family/visitors, relaxation channels on tv.
Hypnosis
41
What are analgesics?
Drugs which relieve pain without causing loss of consciousness.
42
What factors affect the selection of an appropriate analgesic?
1. The severity of pain
2. Duraiton of action
3. Desired duration of therapy (how quickly will it go into effect and how long will it last)
4. Ability to cause drug interactions
5. Hypersensitivity of the patient
6. Available routes of administration
43
Describe opioid analgesics.
Opium's major component is morphine
-Morphine can cause respiratory depression, constipation
It is controlled substance used to treat moderate to severe pain
Opioids relieve pain by binding to opiate receptors and activating endogenous pain suppression in the CNS.
44
What are common side effects of opiates?
All opiates result in some initial drowsiness when first administer, but with regular administration, thi side effect tends to decrease.
May cause nausea, vomiting, constipation
Respiratory depression is common side effect to monitor
Dependence can result
45
What is the most popular analgesic antipyretic used?
Aspirin is the most popular, most widely used of this group, used for mild to moderate pain. High doses can cause an anti-inflammatory effect.
Some adverse effects are GI hemorrhage, Tinnitus, and Reyes Syndrome.
46
Describe acetaminophen.
Acetaminophen decreases pain and fever, but not inflammation.
Side effects include hepatotoxicity and nephrotoxicity and more.
Cough/cold medicines usually already have Tylenol
so overdose is unfortunately common.
47
Describe NSAIDS.
NSAIDS:
- drugs such as Ibuprofen (Advil, Motrin)
- Have anti-inflammatory, analgesic, and antipyretic effect.
- They relieve pain by acting on peripheral nerve endings at the injury site and decreasing the level of inflammation mediators generated at the site of injury.
48
What are examples of multi-purpose adjunctive medications?
Steroids: used in metastatic bone pain, mood elevation, and increased appetite. Also useful to relieve pain associated with liver metastasis and other visceral pain syndromes.
Capsaicin: diabetic neuropathy, posherpetic neuralgia, arthritis, Kaposi's sarcoma lesions.
Vanlafaxine: SNRI: proved to be effective in diabetic neuropathy and treating depression.
49
Describe some treatments for neuropathic pain.
-Topical lidocaine/Lidoderm
-Capsaicin
Tricyclics antidepressants
-Anticonvulsants
50
Describe some treatments of muscle and visceral pain.
Baclofen-muscle spasms
| Ditropan-bladder spasms, visceral pain
51
What does WHO stand for and how many steps are included in the analgesic ladder?
WHO= World Health Organization and there are three steps included in this ladder model
52
Describe what is included within the three steps on the analgesia ladder.
Step 1-Mild pain
-Tylenol, ASA (Aspirin), NSAIDS
Step 2-Mild to Moderate pain
- Combo drugs like Vicodin, Lortab, Percocet, Tylenol #3, Ultram
- Hydrocodone, Codeine
Step 3- Moderate to Severe pain
-Morphine, Methadone, Dilaudid, Fentanyl, Oxycontin.
53
When administering pain medications, what are nursing interventions that are important to remember?
Assessment and planning must precede treatment
Use a pain scale before and after administration of medication
Question location, duration, intensity, and character of pain and other factors discussed
Monitor signs and symptoms of pain
(verbal statements, facial grimace, perspiration, nausea, anxiety, restlessness, vital sign changes, guarding)
Reassess patient's pain within 30 minutes of giving med and then in 2 hrs.
54
Which is included in our documentation about a patient's pain?
What patient describes (in own words if possible)
-"My head hurts, can I have my pain medication?"
The pain scale from 1-10: 4/10
```
Nursing assessment (be specific)
-Pt c/o headache that increases in bright room...etc.
```
55
Describe rest. What does it imply/not imply?
Rest implies calmness, relaxation without emotional stress, and freedom from anxiety.
Rest does not always imply inactivity
-Some people find some activities such as walking in fresh air restful
56
Describe the physiology of sleep.
Thought to be controlled by the centers located in the lower part of the brain.
The RAS (reticular activating system) is thought to control the sleep-wake cycles to some degree.
57
Describe NREM sleep. How many stages are included within NREM sleep?
NREM:
- Most sleep during the night is NREM sleep.
- It is a deep, restful sleep and brings a decrease in some physiological functions.
- Accounts for about 75-80% of sleep during the night
Four stages total
58
Describe stage 1 of NREM sleep.
Stage 1 of NREM sleep:
- Profound restlessness
- Usually lasts only a few minutes
- Floating sensation
- Eyes roll from side to side
59
What happens in stage 2 of NREM sleep?
During stage 2 of NREM sleep:
- Lightly asleep
- Easily aroused
- Constitutes 40-45% of total sleep time
60
Describe stage 3 of NREM sleep.
Stage 3 of NREM sleep:
- Less easily aroused
- Medium-depth sleep
- Blood pressure lowers
- Body temperature lowers
- Muscles totally relaxed
*This is the stage where sleep helps restore physiologic factors
61
What happens in stage 4 of NREM sleep?
During stage 4 of NREM sleep:
- Deepest sleep stage
- Rarely moves
- Muscles completely relaxed
- Difficult to arouse
- Occurs 30-40 minutes following onset of sleep
62
Describe REM sleep.
REM sleep:
- About 25% of the sleep of a young adult
- Usually recurs about every 90 minutes and lasts 5-30 minutes.
- REM sleep is not as restful as NREM sleep
- Most dreams take place during REM sleep
- Active dreaming occurs and dreams are remembered
- The sleeper may be difficult to arouse or may wake spontaneously
- Muscle tone is depressed
- Heart rate and respiratory rate are often irregular
63
What is the order of stages within our sleep cycle?
```
NREM Stage 1
NREM Stage 2
NREM Stage 3
-Stages 1-3 last about 20-30 minutes
NREM Stage 4
-Stage 4 lasts about 30 minutes
NREM Stage 3
NREM Stage 2
REM Sleep
-REM lasts about 10 minutes
NREM Stage 2
-Another cycle is repeated excluding stage 1
```
64
What are factors that affect our sleep?
Age
-Elderly don't often sleep as long...up during the night...etc.
Environment
Fatigue
Life Style
Psychologic Stress
Alcohol and Stimulants
Diet
Smoking
Motivation
Illness
65
What are medications that affect sleep?
```
Alcohol
Amphetamines
Antidepressants
Beta-blockers
Bronchodilators
Caffeine
Decongestants
Narcotics (stop the sleep cycle
Steroids
```
66
What are some comfort measures that are used to promote sleep?
Administer analgesics or sedatives about 30 minutes before bedtime
Encourage clients to wear loose-fitting nightwear
Remove any irritants against the client's skin such as moist or wrinkled sheets or drainage tubing
Position and support body parts to protect pressure points and aid muscle relaxation
Offer a massage just before bedtime
Provide caps and socks for older clients and those prone to cold
Administer necessary hygiene measures
Keep bed linen clean and dry
Provide a comfortable mattress
Encourage client to void before going to sleep
67
What is pain?
Pain-An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
68
Before continuing to treat an ulcer, what are necessary steps you should take?
The nurse needs to look at it, describe it, measure it, etc. BEFORE continuing to treat the ulcer and dress it.
69
Define purulent, sanguineous, and serous.
Purulent: Containing discharge or production of pus
Sanguineous: Of, containing, relating to, or associated with blood
Serous: Thin and watery (can be clear)
70
What is a good way to remember whether to apply wet or dry dressings?
If wound is wet then you want to dry it
| If wound is dry then you want to wet it
71
What is a sinus tract and how do we measure it?
A _______ ________ is a depression or cavity formed by a bending or curving.
Can be measured with a sterile Qtip
72
If a patient is not doing a lot of moving, then what kind of beds can be used?
Clinatron beds: Excellent yet expensive and doctor has to order it
Air mattresses: Effective and much cheaper
73
Describe hydrocolloids.
Hydrocolloids keep wounds moist, don't get changed daily, sticks well, and depending on the doctor's orders they can stay on for several days.
74
Describe wound vacs.
- Excellent for wounds that have a lot of drainage. --The tube goes into the wound bed with the dressing on top, where it then works as a suction, with negative pressure, to drain the wound.
- Can change dressing every 3-4 days
75
Define eschar and slough
Eschar: A dry scab or slough formed on the skin as a result of a burn or by the action of a corrosive or caustic substance.
Slough: A layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation.
76
What is an example of radiating pain?
Sciatic pain
77
What is a PCA pump and how does it work?
PCA stands for a patient controlled analgesic pump, which is a method of pain control that gives patients the power to control their pain.
This pump is prescribed by a doctor and is connected directly to a patient's intravenous (IV) line.
78
Describe the normal, average, bradycardia, and tachycardia guidelines for heart rate.
Normal: 60-100 bpm
Average: 60-80 bpm
Bradycardia: Under 60 bpm (can be normal in athletes)
Tachycaria: Over 100 bpm
79
What are examples of blood vessels and what are the functions?
Examples of blood vessels:
Arteries, arterioles, capillaries, veins, venules
Function:
Transport 02 and nutrients
80
What are the components included in blood?
```
Platelets
Plasma
RBC's
Hgb (hemoglobin)
Hct (hematocrit)
WBC's
```
81
Describe the rule associated with oxygenated/deoxygenated blood for arteries and veins. What is the exception to this rule?
Arteries carry oxygenated blood
Veins carry deoxygenated blood
Exception to the rule:
Pulmonary arteries carry deoxygenated blood and pulmonary veins carry oxygenated blood.
82
Describe the path of blood within the heart.
Blood from back portion of body goes into the inferior vena cava.
Blood from anterior portion of body goes into superior vena cava.
Both go into right atrium, tricuspid valve, right ventricle, pulmonary valve, pulmonary arteries, lungs, pulmonary veins, left atrium, mitral/bicuspid valve, left ventricle, aortic valve, aorta.
83
Keeping in mind that normal ranges change dependent on the institution, what are considerable lab value ranges for RBC's, Hgb's, Hct's, and WBC's?
RBC:
- Female: 3.6-5
- Male: 4.2-5.4
Hgb (Hb):
- Female: 12-16 g/dl
- Male: 14-17.4 g/dl
Hct:
- Female: 36-48%
- Male: 42-52%
WBC:
- Adult: 4.5-10.5
- Black adult: 3.2-10
84
Describe RBC's.
RBC's are major components of circulation
They carry oxygen & iron throughout the body
85
Describe Hct.
Hematocrit is the percentage of RBC's combined with plasma.
Hct should be 3x the value of Hgb.
Useful for assessing hydration status and fluid status.
Hct values will be higher during dehydration due to combination of plasma.
Hct will drop with blood loss or with too much fluid in the body.
Bone marrow suppression will cause a drop in Hct.
86
What are the effects of aging on the circulatory system?
Arteriosclerotic plaques narrow the arterial walls
By 80 years of age, cardiac output will have decreased by 1/2. (1% drop each year after age 25)
Heart takes longer to respond to stress or exertion
Arteries lose the ability to stretch
Vein walls thin due to loss of subcutaneous tissue (will lead to bruising very easily)
87
Describe cardiac output.
___________ ____________ is the amount of blood ejected by the heart with each ventricular contraction.
Roughly 4-8 Liters each minute
88
What are the benefits of exercise?
Improved cardiovascular fitness
Greater lean body mass and lesser body fat
Improved strength and muscular endurance
Improved flexibility
Increased ability to use O2
Quicker recovery after hard work.
89
What is included during a circulatory status assessment?
General observations: color, etc.
Interview (this will be where you find abnormalities)
Vital signs are important!!
90
What are examples of abnormalities when assessing the circulatory status?
Weakness and fatigue (can be sign of anemia)
SOB- especially at night or when lying down.
Chest pain
Pain in legs- ischemia
Claudication- pain in lower extremities due to lack of circulation
Edema
Behavior signs like increased irritability, forgetfulness, and confusion (not getting enough O2 and blood to the brain...take BP to confirm)
91
What is the pitting edema scale and what are its values?
Pitting edema is graded on a scale from 1 to 4, which is based on both the depth the "pit" leaves and how long the pit remains.
```
1+ = 2mm (disappears rapidly)
2+ = 4mm (disappears within 15 seconds)
3+ = 6mm (can last longer than a minute)
4+ = 8mm (can last longer than 2 minutes)
```
May see weeping at stages 3 and 4
92
What is included within a physical assessment?
Vital signs
Assessment of extremities
- skin color, temperature, integrity
- hair and nail growth
- capillary filling (should occur in less than 3 seconds)
- quality of peripheral pulses
- edema
Assessment of neck
- carotid pulse
- jugular vein distention (JVD)
93
What is the normal range for BP now considered to be?
110-115 systolic /60-70 diastolic
94
What is jugular vein distention indicative of?
JVD is a sign that patient has congestive heart failure (specifically the right side)
95
Describe what heart failure is and what the effects are.
________ __________ is an often recurring condition, usually develops chronically in association with the retention of Na+ and water by the kidneys.
Heart muscle has weakened, cannot pump effectively, and cardiac output decreases
Circulatory congestion is caused by cardiac disorders
Most common dx > 65 years of age
1/2 will die within 5 years of dx
Heart failure is a progressive disease and cannot be reversed.
96
What are the risk factors for heart failure?
Coronary artery disease and myocardial infarction are the most common causes
- HTN
- Valvular heart disease
- Congenital heart disease
- Chronic ETOH abuse, smoking
- Diabetes Mellitus
- Obesity and age
97
Describe the four stages of heart failure.
Stage A- Patient has established risk factors for developing HF but has no cardiac structural disorder. (could be smoker, drinker)
Stage B-Patient has cardiac structural disorder but is asymptomatic (aortic valve could be stiffened, but no symptoms have occurred.)
Stage C- Patient has past or present HF symptoms associated with structural disorder (heart will bunch up and enlarge, not pumping effectively)
Stage D- Patient has end-stage heart disease and requires specialized care (managed the symptoms but heart continues to fail. Need a heart transplant or LVAD)
98
What are the symptoms of left-sided HF?
Lungs: (mostly noninvolvement)
- SOB
- Rales or crackles
- Orthopnea
- Increased difficulty sleeping lying supine
- dyspnea
99
What are the symptoms of right-sided HF?
Systemic:
- Dependent edema
- JVD
- Ascites
100
What are symptoms that can be either left-sided or right-sided HF?
- Confusion
- Insomnia (having trouble breathing and nocturia)
- Depression
- Chronic cough
- Weight gain (2-4 pounds is an issue)
- Night wandering
- Weakness
- Anorexia
Left is the most common cause of Right (the patient would exhibit pulmonary AND systemic signs/symptoms.
101
What happens at night for the heart and kidneys?
Heart relaxes at night while sleeping so kidneys can finally excrete urine and fluid output
102
Describe the seven treatment options for heart failure.
- Bedrest with head of bed elevated (not always total bed rest)
- TEDS (help with circulation in lower extremities)
- Decreased Na+ intake (sodium pulls in fluid and we don't want extra fluid)
- Oxygen, prn
- Pt Education
- Medications
- Surgery
103
What is included under patient education for heart failure treatment?
```
Signs/symptoms
Medication information
Disease information
Daily weights
Fluid restriction
```
104
What kinds of medications are used for patients with heart failure?
Diuretics: Get rid of fluid in lungs and extremities (have to be able to breathe first)
ACE inhibitors: Used to try to lower bp so heart doesn't have to work so hard (side effect is coughing)
Beta blockers: Help decrease work load in heart (decrease heart rate and bp)
Digoxin: A cardiac glycoside that helps with pumping action of heart, increases cardiac output and lowers work load.
BiDil: Combination drug
105
What are surgical options for patients with heart failure?
Cardiac splint
Cardiac jacket
Left ventricular assist devices
106
Describe what an LVAD is.
LVAD stands for left ventricular assist device, which is an artificial pumping mechanism for the heart. It is used when waiting for a heart transplant or can be used toward the end to help sustain life.
107
List the medications that may increase digoxin levels.
```
Oral aminoglycosides
Amiodarone
Anticholinergics
Benzodiazepines
Calcium channel blockers
Erythromycin
Ondomethacin
Intaconazole
Omeprazole
Quinidine
Tetracycline
```
108
Hypokalemia will increase risk for dig toxicity, what are the signs and symptoms that will point you to this?
```
Diarrhea
Vomiting
Dehydration
Poor fluid intake
Diuretic use
Corticosteroid use
Laxatives
```
Caffeine increases potential for hypokalemia especially with diuretic use
Hypokalemia can cause digoxin toxicity EVEN IF serum digoxin level is WNL
Look at serum AND potassium level
109
What is hypokalemia?
___________ is deficiency of potassium in the blood plasma.
110
What is the normal potassium level?
Normal potassium level= 3.5-5.0
111
What are signs and symptoms of digoxin toxicity?
```
N/V
Anorexia
Diarrhea
Confusion
Excessive salivation
Lethargy
Headache
Blurred or colored vision
Bradycardia
Change in mental status
```
112
What are treatment options of digtoxicity?
Hold drug
Administer K+
Antiarrythmics if needed
Digibind-if life threatening, binds with digoxin and pulls it out of the cells
113
What are nursing implications r/t digoxin?
Assess apical pulse for 1 full minute, if < 60 bpm hold med and notify prescriber
Chart pulse on MAR, with initials
Monitor serum Digoxin levels, pt can be toxic even though levels are WNL
Assess I&O
Do not administer with food, antacids, fiber
Pt Ed- instruct how to take pulse, provide rationale for taking pulse, s/s toxicity, empty stomach
114
What is venous insufficiency?
__________ ____________ is a disease resulting from the incompetency of venous valves in the legs.
115
What causes venous insufficiency?
Valves in veins have weakened resulting in backward flow of blood, which then leads to pooling of blood.
Example: Deep vein thrombosis
-Can be superficial or deep (like in leg veins)
116
What are ways to avoid blood pooling within the body?
Elevate the feet!
Avoid crossing legs, sitting with feet down all the time, and standing for long periods of time.
117
What is included in an assessment for venous stasis?
Pedal edema
Darkened color of extremities which may eventually lead to ulcer formation
Venous ulcer-located on lower leg area
Distended veins
Does not affect pulse!!!
Heavy, dull, or aching pain in legs
118
What is the goal of nursing care for patients with venous stasis?
Goal is to avoid amputation, with client returning to previous level of functioning.
119
What education should nurses use for patients with venous stasis?
```
Provide education about:
Exercise
Weight control
Avoiding tight clothing (prevents circulation)
Avoid tobacco (nicotine causes veins to constrict)
Correctly using TEDS
Avoiding prolonged sitting or standing
Avoiding pressure points
Protect BLE (bilateral lower extremities) from trauma
Good lower leg and foot care
Elevate legs at frequent intervals
FOB elevated to sleep
Walking
```
120
If an ulcer appears due to venous stasis, what happens?
If an ulcer forms then it can't be healed and amputation can occur.
121
What are complications of venous insufficiency?
Varicose veins-tortuous, dilated vein with incompetent valves, bulge out
Venous Thromboembolism-traveling blood clot. Don't massage (could dislocate blood clot)
Venous Stasis Ulcer-located lower leg/ankle area. Color changes, edema, shape often irregular
122
What are risk factors associated with varicose veins?
- Immobility
- Lack of exercise
- Standing
- Aging
- Crossing legs
- Wearing constrictive clothing
123
What are symptoms of varicose veins?
- Dull pain/cramping of legs
- Interferes with sleep
- Dizziness when standing
- Leg heaviness
- Tingling, burning, or pulling sensation
124
What are treatment options for varicose veins?
Elevate affected limb to facilitate blood return
Exercise (will increase circulation)
TEDS, which fit properly, otherwise they will decrease circulation
125
What are risk factors for venous thromboembolisms?
- Hx of varicose veins
- Genetics
- Obesity
- CA
- Recent surgery (don't move as much)
- Fractures/injury
- Prolonged inactivity
- Use of oral contraceptives/HRT (esp + smoking)
126
What is the Homan's sign?
The _________ ___________ is a way to check if there is a clot in the calf muscle. The patient can dorsiflex the floot and if extreme pain occurs in the calf, then there is usually a clot.
127
What are the symptoms of a venous thromboembolism?
Depends on vessel involved; veins in calf are most frequent.
Edema
Warmth and redness over affected area
+ Homan's sign
*Dr/Nurse practitioner should be notified immediately for the above symptoms*
128
What can occur form a traveling clot?
A traveling clot can go to the lungs and lead to a pulmonary embolism.
129
What are treatment options for venous thromboembolism?
```
Bed rest (to avoid dislodging)
Elevate affected limb
Analgesics
TEDS
Warm, moist compress
Surgery
Anticoagulants
Do not massage!!
```
The goal of treatment is to prevent progression to embolism, to limit damage to the leg vein, and to prevent future clot development.
130
What are preventative measures against venous thromboembolisms?
Avoid immobility
| Education regarding risk factors
131
Describe a venous stasis ulcer.
A ________ __________ _________ is the most serious complication of chronic venous insufficiency.
Typically develops near medial ankle or lower leg
Extremely difficult to heal
Difference between venous and arterial insufficiency
132
Describe the etiology of a venous ulcer.
As the venous pressure rises and venous stasis occurs, capillaries are stretched and become more permeable. Protein (esp fibrinogen) leaks out of the vascular bed into the surrounding tissues. Fibrinogen is converted to fibrin and coats the capillaries, interfering w/ the exchange of oxygen and nutrients. Tissue breakdown begins and venous ulceration occurs.
133
Describe Hypertension.
Persistent levels > 140/90
- 70% of 70 yo have dx of HTN
- 80% of 80 yo have dx of HTN
Major organ damage if uncontrolled (nearly 3/4 of treated patients are not well-controlled) and kidneys will start to shut down.
Can be controlled, never cured (a woman with well-controlled HTN still has double the cardiovascular risk of one who never had HTN)
Diet and exercise can help maintain bp
Should do combination of drugs and changes in lifestyle like diet and exercise
134
What are risk factors of HTN?
```
Obesity
Lack of exercise
Increased Na+ intake
Family hx
Heavy ETOH consumption
NSAID"s
Excessive caffeine/stimulatory drugs
High cholesterol
Diabetes Mellitus
High stress (+/-)
Emotional disturbances
Smoking
Age
African American
```
135
What are modifiable/nonmodifiable risk factors for HTN?
Nonmodifiable-cannot change no matter what you do (age, gender, etc)
Modifiable-includes factors you can change like smoking, alcohol, sodium intake
136
What are symptoms of HTN?
None (silent killer): high bp could be their normal, pt does not know, symptoms can arise when meds lower bp
If symptomatic: dizziness, confusion, restlessness, drowsiness, elevated BUN.
Severe: awakening with a dull H/A, impaired memory, disorientation, epistaxis, slow tremors
Appearance of symptoms usually indicates vascular damage.
Stroke, slurred speech, drooping of face
137
What does BUN reflect?
BUN reflects kidney function.
Kidneys regulate BP
BUN and creatine will measure dehydration
138
What is the treatment for HTN?
Goal is to prevent mortality and morbidity
Monitor BP (ambulatory monitor)
DASH diet
Control weight
Exercise
Restriction of Na+, ETOH, nicotine
Relaxation
Medications (~50% will stop taking meds within 1st year due to side effects, even though body will eventually adjust)
139
Describe ACE inhibitors.
________ _________ block the enzyme angiotensin, which cause dilation and constriction of the vessels, thus allowing the bp to drop.
_pril suffix
Most common side effect-dry, hacking cough
Observe for hyperkalemia, digoxin toxicity, lithium toxicity
Administer po 1 hour ac
Avoid caffeine, NSAID's
Decreases effectiveness of tetracycline
140
Describe Beta-blockers.
Beta blockers cause vasodilation for arteries, which allows the bp to come down
_olol suffix
May cause bronchoconstriction (watch for bronchospasms if pt is wheezing)
Initial tx of HTN, reduce cardiac workload associated with cardiac ischemia, MI, HF, and cardiomyopathy.
Do not stop taking drug abruptly
Hold if SBP < 90, pulse <60
May cause ^ in serum glucose levels
May mask sx of hypoglycemia
Avoid caffeine
Rebound hypertension will occur if you stop taking the drug abruptly
If patient is diabetic and on a beta blocker we want to monitor their sugars and avoid caffeine.
141
Describe Ca Channel Blockers.
Primary tx:
1. slow heart rate
2. dilate vessels
3. reduce the heart's oxygen needs
_pine suffix
Accumulative effect: beta blockers and Ca channel blockers
Decreased CO and hypotension when administered with grapefruit juice, quinidine, cimetidine.
Dilantin and Tegretol may reduce the effectiveness of Ca channel blockers
Ca channel blockers may alter the metabolism of theophylline, digoxin, cyclosporine.
142
Describe some examples of diuretics.
Can be a loop: Lasix- ascending loop of henle
Thiazide: HCTZ (hydrochlorothiazide) - distal renal tubules
K+ sparing: Aldosterone
**Caution should be used with older adults**
143
Describe loop diuretics.
Lasix (furosemide)
- Assess for ototoxicity (hearing loss, tinnitus, dizziness)
- Monitor potassium levels (low)
- Monitor glucose levels (high)
- Monitor sodium levels (low)
Excessive diuresis can lead to formation of plaques, if you pull out too much fluid, it thickens the bld and can lead to clotting.
144
Describe Thiazide diuretics.
Hydrochlorothiazide (HCTZ) pulls out potassium
Monitor potassium levels (low)
Monitor glucose levels (high) due to fluid coming out of cell, therefore higher concentration of glucose in the cell.
145
Describe Potassium-sparing diuretics.
Aldactone (spironolactone)
- With ACE inhibitors, may cause hyperkalemia
- Pt ed- low potassium diet
- ASA decreases diuretic action
- Monitor glucose levels (high)
- May cause erectile dysfunction
146
What is the effect of caffeine on diuretics?
________ exacerbates the hypokalemic effect of diuretics.
147
What is the effect of nicotine to these types of antihypertensive medications?
Decreased effectiveness of beta blockers and calcium channel blockers (alters metabolism)
Increased peripheral ischemic effect of beta blockers
Decreased effectiveness of diuretics
Decreased anticoagulant effectiveness of heparin and warfarin.
148
Describe Vasodilators.
```
Nitrates:
-Nitroglycerin comes in
po: isosorbide dinitrate
sl: keep in original container tightly capped
oral spray: in mouth
topical: paste (wear gloves)
SR: rotate sites.
```
Also one of the first things given for chest pain and repeat every 3 minutes for five doses.
Gives the effect of hanging upside down
Used for erectile dysfunction.
149
What are the side effects of NTG?
Tolerance develops, it is common for patients to take a vacation from the med
Headache
Postural hypotension (deals with position changes)
May increase intraocular and ICP (esp for pts with head injuries, glaucoma, etc)
Dizziness, lightheadedness, from bp coming down.
150
What is included under the nursing process for NTG?
Assess frequency, duration, and precipitants of use
Assess knowledge of med
Assess risk for falls- hypotension may last 1/2 hour
Pt Ed: avoid ETOH (increases vasodilation and will make bp drop even more) and smoking, don't stop med abruptly, flushed or warm feeling is expected after taking med
Viagra
151
What is included in the nursing process for HTN?
Noncompliance is common due to horrific SE of medications
Pt Ed: lifestyle changes, med schedule, BP monitoring, drug-drug interactions, SE – erectile dysfunction.
Limit damage to organs: limit activities which stress the CV system, avoid heavy meals, don’t strain w/ BM, wt control, smoking cessation, aerobic exercise
152
What is included in the upper respiratory system?
Mouth, nose, pharynx, larynx
153
What is included in the lower respiratory system?
Trachea, lungs with the bronchi, bronchioles, alveoli, pulmonary capillary network, and pleural membranes.
154
What are the four processes of the respiratory system?
Pulmonary ventilation (breathing)
Alveolar gas exchange
Transport of O2 and CO2
Systemic diffusion
155
Describe what pulmonary ventilation depends on.
Clear airways
An intact CNS and respiratory center
(pons and medulla control breathing)
An intact thoracic cavity capable of expanding and contracting
Adequate pulmonary compliance and recoil
156
Describe alveolar gas exchange.
After the alveoli are ventilated, then diffusion of oxygen from the alveoli into the pulmonary blood vessels occurs.
157
Describe the transport of O2 and CO2.
O2 needs to be transported from the lungs to the tissues, and CO2 must be transported from the tissues back to the lungs.
About 97% of oxygen combines loosely with hemoglobin in the RBC's and is carried to tissues as oxyhemoglobin
Factors that affect the rate of oxygen transport from lungs to tissues:
Cardiac output
Number of erythrocytes and blood hematocrit
Exercise
158
Describe systemic diffusion.
________ _________ is the process where diffusion of O2 and CO2 between capillaries and the tissues and cells occur.
159
In healthy people, what stimulates breathing?
CO2 concentrations.
160
In clients with COPD, emphysema, bronchitis, etc., what becomes an important stimulant and what is this called?
O2 concentrations become an important stimulant called hypoxic drive.
For some, decreased O2 are the main stimuli for respirations.
Increasing oxygen levels will actually depress the respiratory rate.
This is why we only administer 2-3 L initially
161
An older adult c/o weakness, has loss of appetite, becomes increasingly confused, and has elevated pulse and respirations, therefore what should the nurse suspect?
Pneumonia
162
What physiological factors affect respiratory function?
Age: Less elasticity, more rigidity of wall, less air exchanged through alveoli, difficulty coughing, decrease in immune system, osteoporosis.
Health status: acid reflux (potentially aspirate), cold, COPD, allergies, emphysema, atelectasis
Medications: Benzodiazepine sedative (hypnotics), antianxiety, narcotics.
163
What sociocultural factors affect respiratory function?
Environment: altitude, heat, cold, air pollution
Lifestyle: physical activity increases rate and depth of respirations.
164
What psychological factor affects respiratory function?
Stress: increases risk for infection.
165
What are factors that increase the respiratory rate?
Exercise
Stress
Increased environmental temperatures
Lowered oxygen concentration
166
What are factors that decrease respiratory rate?
Decreased environmental temperature
Medications (narcotics)
ICP (intracranial pressure)
167
Respiratory function can be altered by conditions that affect what?
Patency (open airway)
The movement of air into or out of the lungs
The diffusion of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries
The transport of oxygen and carbon dioxide via the blood to and from the tissue cells.
168
A patient is on a PCA pump with morphine. What are the most important things for the nurse to assess?
Respiratory depth
Respiratory rate
Pulse ox
169
What are signs/symptoms of complete/partial obstruction of the upper airway?
Upper airway: Nose, pharynx, or larynx.
Completely obstructed airway: s/s= no chest movement, inability to cough or speak
Partially obstructed airway: s/s= low-pitched snoring sound during inhalation.
170
What are signs/symptoms of lower airway obstruction?
Involves partial or complete occlusion of the passageways in the bronchi and lungs most often due to increased accumulation of mucus or inflammatory exudate. (asthma)
s/s= not always easy to observe, stridor may be heard on inspiration. Client may have altered ABG levels, restlessness, dyspnea, and adventitious breath sounds.
171
What does the term breathing patterns refer to?
_____________ ______________ refers to the rate, volume, rhythm, and relative ease or effort of respiration.
172
Describe eupnea, tachypnea, bradypnea, and apnea, which all affect the respiratory rate.
Eupnea: normal respiration that is quiet, rhythmic, and effortless.
Tachypnea: Rapid respirations. Seen with fevers, metabolic acidosis, pain, and hypoxemia.
Bradypnea: abnormally slow respiratory rate. Seen in clients who have taken drugs such as morphine or sedatives, who have metabolic alkalosis, or who have ICP.
Apnea: the absence of any breathing.
173
Describe hypoventilation, hyperventilation, and Kussmaul's breathing.
Hypoventilation: very shallow respirations
Hyperventilation: very deep, rapid respirations
Kussmaul's breathing: hyperventilation that accompanies metabolic acidosis in which the body attempts to compensate (give off excess body acids) by blowing off carbon dioxide through deep and rapid breathing.
174
Define Cheyne-Stokes respirations and Biot's (cluster) respirations, which are associated with the rhythm of breaths.
Cheyne-Stokes respirations: rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure, increased intracranial pressure, or brain damage.
Biot's (cluster) respirations: shallow breaths interrupted by apnea
175
Define orthopnea and dyspnea, which are related to the ease or effect of respirations.
Orthopnea: ability to breathe only when in an upright position (sitting or standing)
Dyspnea: difficult or labored breathing.
176
Hypoxemia, or reduced oxygen levels in the blood, my be caused by what two conditions that impair diffusion?
Alveolar capillary level: such as pulmonary edema or atelectasis
Low Hemoglobin levels.
Cardiovascular system compensates for hypoxemia by increasing heart rate and cardiac output, to attempt to transport adequate oxygen to the tissues.
177
Once O2 moves into the lungs and diffuses into the capillaries, the cardiovascular system transports the O2 to all body tissues, and transports CO2 from the cells back to the lungs where it can be exhaled from the body. What conditions decrease cardiac output and affect this transport?
Congestive heart failure
Hypovolemia
Fluid Volume Deficit
Both affect tissue oxygenation and the body's ability to compensate for hypoxemia.
178
There are bibasilar rales in a 76 year old client. What is the nurse's next best action?
Have patient cough forcefully and repeat assessment.
179
What is included in the nursing assessment of the patient's medical history?
Current and past respiratory problems
History of COPD? Asthma?
Lifestyle
Any pain with coughing?
Presence of cough and/or sputum
Exercise
O2 at home?
Medications for breathing
Smoke?
Presence of risk factors for impaired oxygenation status
Alcohol
Weight
180
What is included within the physical assessment of the respiratory system?
Inspection: rate, rhythm, depth, quality, position for breathing, shape of thorax, resting respirations, chest movements.
Palpation: bulges, tenderness, abnormal movements, tactile fremitus
Percussion: not commonly done
Auscultation: breath sounds
-Normal -Adventitious
Bronchial Rales/crackles
Bronchovesicular Rhonchi
Vesicular Wheezes
Stridor
Friction rub
181
Describe tactile fremitus for patients with pneumonia, pleural effusion, and a pneumothorax.
Pneumonia: Tactile fremitus increases because water amplifies the vibration
Pleural Effusion:Tactile fremitus will be decreased due to barrier.
Pneumothroax: Tactile fremitus will be decreased or not present at all.
182
When we are assessing a patient's cough and sputum, what are we looking for?
Cough: dry vs moist, non productive vs productive (sputum), timing (day, night, during meals), frequency, pain
Sputum: color, consistency, odor, presence of blood.
183
The HCP may order various diagnostic tests to assess respiratory status, function, and oxygenation. What kinds of tests are done?
Sputum specimens
Throat cultures
Pulse oximetry-for normal/healthy= SaO2 > 95%
Blood work- venous and arterial
Venous - CO2 -23-30 mmHg
ABG's- PaO2= >80
Visualization procedures
- Bronchoscopy
- Laryngoscopy
- CXR-AP & lateral, portable
- Arteriograms
- Perfusion/ventilation scans
- CT scans
- MRI
- Thoracentesis
184
Describe pulmonary function tests, sputum specimens, and skin tests.
Pulmonary function tests: determine the presence, nature, and extent of pulmonary dysfunction caused by obstruction (increase in airway resistance), restriction (limitation in chest wall excursion), or both.
Sputum specimens: best to obtain early in AM after arising but before breakfast. Don't collect saliva! Must be sent to lab within 1/2 hour of obtaining. May use sputum trap if client is being suctioned.
Skin tests: TB-preffered PPD (purified protein derivative) intradermal-if positive then follow with chest x-ray.
185
Describe diagnosing labels for patients with oxygenation problems.
Ineffective airway clearance: Can't clear secretions or obstructions
Ineffective breathing patterns: Inspiration and/or expiration that does not provide adequate ventilation.
Impaired gas exchange
Activity intolerance: insufficient physiological or psychological energy to endure or complete required or desired daily activities.
These can result in anxiety, fatigue, fear, powerlessness, insomnia, and social isolation.
These may be related to
- Airway obstruction
- Copious secretions
- Cough discomfort
- Painful respirations
- Nasal congestion
186
What are common AEB phrases related to the respiratory system?
Impaired gas exchange related to copious secretions AEB intermittent cyanosis and Pulse Ox of 88%
Ineffective airway clearance r/t painful respirations AEB rhonchi heard in upper airways
Activity intolerance r/t dyspnea AEB inability to complete ADL's without resting every 2 minutes
187
During the planning stage of the nursing process, what are goals/outcomes that we want to do?
Maintain a patent airway
Improve comfort and ease of breathing
Maintain or improve pulmonary ventilation and oxygenation.
Improve the ability to participate in physical activities
Prevent risks associated with oxygenation problems such as skin and tissue breakdown, syncope, acid base imbalances, and feelings of hopelessness and social isolation.
188
Shallow respiration and inadequate chest expansion may result in what?
Pooling of respiratory secretions
Infection
Alveolar collapse
189
In reference to deep breathing and coughing, a patient with COPD may be prescribed special breathing exercises as part of their pulmonary rehabilitation. What are they?
Huff cough
Pursed lips breathing.
190
What is included in the implementation phase of the nursing process?
- Ensuring a patent airway
- Positioning
- Encouraging CDB (huff coughing or huff breathing)
- Ensuring adequate hydration
- Suctioning
- Lung inflation techniques
- Administration of analgesics
- Postural drainage, percussion, and vibration
- Oxygen therapy as ordered
- Patient Education for all of above
191
List the medications that facilitate respirations.
- Bronchodilators
- Antiasthmatics
- Anti-inflammatory drugs/steroids
- Expectorants
- Antitussives
- Antihistamines (tend to dry out mouth)
- Decongestants
- Mucolytics
- Narcan (naloxen)
192
List the medications that inhibit respirations.
- Narcotics/opioids
- Benzodiazepines
- Barbiturates
193
List examples of bronchodilators.
B2 Agonist
- albuterol
- metaproterenol
- terbutaline
- salmeterol
Xanthine Derivative
- theophylline
- dyphylline
- oxtriphylline
194
List examples of antiasthmatics.
Inhaled corticosteroids
- beclomethasone
- dexamethasone
- fluticasone
- triamcinolone
Leukotriene Antagonist
- montelukast
- zafirlukast
- zileuton
Anticholinergics
-ipratropium
195
If you get a respiratory infection while take flonase, what should you do?
Call HCP before taking any more flonase.
196
Because of the short duration & rapid effect, nasal decongestants...?
May become habit forming
197
A 76 year old client has been prescribed Benadryl, Which of the following statements, if made by the client, would cause the nurse to intervene?
I need to limit my fluids while taking benedryl
198
What are examples of antitussives?
Antitussives (cough suppressants, can cause repiratory depression
- Opioids: Codeine, hydrocodone
- Nonopioids: Benzonatate, Dextromethorphan
199
What are examples of decongestants?
Decongestants (rebound effect, can become dependent)
- ephedrine
- naphazoline
- phenylephrine
- pseudoephedrine
200
What are examples of expectorants?
Expectorants
| -guaifenesin
201
What are examples of mucolytics?
Mucolytics
-acetylcysteine
Mucolytics help liquify mucus
Can cause bronchospasms, asthma like symptoms, can be used against Tylenol poisoning.
202
What are examples of first and second generation antihistamines?
First generation (can cause sedation)
-Alkylamines
chlorpheniramine
-Ethanolamines
demastine
diphenhydramine
-Piperidines
cyproheptadine
Second generation
- fexofenadine
- loratidine
- desloratdine
- cetrizine
203
Describe an incentive spirometer.
Improves pulmonary ventilation
Counteract effects of anesthesia or hypoventilation
Loosen respiratory secretions
Facilitate respiratory gaseous exchange
Expand collapsed alveoli
Do not need Dr's order for this
Put in mouth, used during inspiration, set a target goal
Helpful after surgery, good for elderly, use every hr practice 4-5x
204
What client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?
He should inhale slowly and steadily to keep the balls up.
205
Describe percussion, vibration, postural drainage, and mucus clearance devices
Percussion (clapping): mechanically dislodges tenacious secretions
Vibration: frequently performed after percussion to loosen thick secretions
Postural drainage: drainage by gravity, sequence = positioning, percussion, vibration, coughing or suction.
Mucus clearance devices: used for clients with excessive secretions, device causes vibrations that loosen mucus from airways and assist its movement up the airways to be expectorated.
206
Describe oxygen therapy.
Oxygen therapy is considered to be a process similar to that of administering medications and requires similar nursing actions.
Order: specifies concentration, method of delivery, and depending on the method, liter flow per minute. (In an emergency the nurse may initiate oxygen therapy and then contact HCP for the order)
Respiratory distress: put pt on 2-3 L nasal cannula and immediately get an order from Dr.
Humidifiers: add water vapor to inspired air and are essential for L flows over 4 L/minute. Prevent mucous membranes from drying, becoming irritated, and loosen secretions.
Wall-outlet O2/Portable Cylinders: Have to be careful not to knock down
Safety Precautions: Fire precautions, no smoking!
207
Describe the nasal cannula, the face tent, and the noninvasive positive pressure ventilation.
Cannula: Most common & inexpensive device. Delivers relatively low concentration of oxygen (24-45%) at flow rates of 2-6 L/min.
Face tent: Can replace O2 masks when masks are poorly tolerated by clients. (30-50%) concentration of oxygen at 4-8 L/min.
Noninvasive Positive Pressure Ventilation: Delivery of air or O2 under pressure without the need for an invasive tube such as an endotracheal tube or tracheostomy tube. Conditions include acute and chronic respiratory failure, pulmonary edema, COPD, and obstructive sleep apnea.
Examples: CPAP & BiPAP
208
Describe the different masks used for oxygen delivery.
Simple face mask: Delivers O2 concentrations from 40-60% at liter flows of 5-8 L/min, respectively
Partial rebreather mask: Delivers O2 concentrations from 40-60% at liter flows of 6-10 L/min, respectively. O2 reservoir bag-rebreathe O2
Nonrebreather mask: Delivers O2 concentraions from 95-100% at liter flows of 10-15 L/min, respectively. O2 reservoir bag-one-way valves so only O2 is inhaled. (HAVE to see bag inflating/deflating properly, if not then O2 flow meter is not up all the way)
Venturi Mask: Delivers varying concentrations and liter flows depending on color-coded jet adapters that represent different percentages. (24-40 or 50%) at liter flows of 4-10 L/min
209
The nurse is planning to perform percussion & postural drainage. What is an important aspect of planning the client's care?
Percussion & postural drainage should be done before lunch.
You do not want to do on a full stomach because pt could aspirate.
Order is position, percussion, coughing, suctioning.
210
If the partial rebreather bag becomes totally deflated during inspiration, then the nurse should do what?
Increase the liter flow of oxygen.
211
What are the pros and cons of a nasal cannula, a face mask, a partial rebreather mask, and a nonrebreather mask?
Nasal Cannula: Pros-lightweight, comfortable, inexpensive, continuous use with meals and activity. Cons-Nasal mucosal drying, variable FiO2
Face Mask: Pros- simple to use, inexpensive.
Cons-Poor fitting, variable FiOs2, must remove to eat.
Partial Rebreather Mask: Pros-Moderate O2 concentration. Cons-Warm, poor fit, must remove to eat
Non-Rebreather Mask: Pros-High O2 concentration. Cons- Poor fit, risk of O2 toxicity, risk of suffocation. Use less than 24 hours.
212
Describe oxygen conserving devices.
Oxygen conserving devices: pulse or demand dose 10-40 mL/breath. Delivers O2 only on inspiration. For portable use in O2 dependent patients.
213
Describe pros and cons of a venturi mask, a blender mask, a tracheostomy collar, a T-piece, and a face tent.
Venturi Mask: Provides precisely controlled levels of O2, additional humidity available. Colors provide accuracy.
Blender Mask: good humidity, accurate FiOs2. Uncomfortable for some. Loud!
Tracheostomy collar: Good humidity, comfortable, fairly accurate FiOs2
T-Piece: Same as tracheostomy collar. Pulls on tracheostomy tube because it is heavy.
Face tent: Good humidity, fairly accurate FiO2. Less claustrophobic for some. Bulky and cumbersome.
214
Describe what happens for oxygen toxicity, what the symptoms are, and what prevention is included.
PaO2 levels > 300 mmHg for longer than 48 hours can cause overproduction of free radicals, severely damaging cells. Alveolar cells actually begin to disintegrate.
Symptoms: Substernal discomfort, cough, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, atelectasis, and alveolar infiltrates on x-ray.
Prevention: Use lowest effective concentrations of oxygen. PEEP, CPAP, or Bi-PAP prevents or reverses atelectasis and allows lower oxygen percentages to be used.
215
What are examples of methods for noninvasive positive pressure ventilation?
Use of mask or other device to maintain a seal and permit ventilation
Continuous positive airway pressure (CPAP) for sleep apnea.
Bi-level positive airway pressure (Bi-PAP) for ventilation in patients who can't get enough O2 from non-rebreather or blender masks and aren't ready to be intubated.
216
What are examples of diagnostic tests.
- Pulmonary function tests
- ABG
- Sputum tests
- Chest x-ray
- CT with & without IV contrast
- MRI
- Fluoroscopic studies and angiography
- Bronchoscopy
- Thoracoscopy
- Thoracentesis
- Biopsies
217
What is the rationale for bronchoscopy?
- Check for blockage
| - Find tumors
218
List pre-procedure nursing interventions for a bronchoscopy.
- Don't eat (patient could aspirate)
| - Could sedate (help with anxiety)
219
What is the rationale for the administration of atropine pre-procedure?
Atropine and anticholinergics reduce secretions and dilate the vessels.
220
For what post-procedure complications should the nurse assess the post-bronchoscopy patient?
```
Respiratory status!
Respiratory distress
Difficulty breathing
Swallowing ok?
Irritation
Swelling
```
221
Define endoscopic thoracoscopy.
A thoracoscopy uses an endoscope to visually examine the pleura, lungs, and mediastinum and to obtain tissue for testing purposes.
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Describe the normal values of Arterial Blood Gases.
```
pH 7.35-7.45
PaO2 80-100 mmHg
PaCO2 35-45 mmHg
HCO3- 22-26 mEq/L
Base excess -2 to +2 mEq/L
O2 saturation 95-98%
```
