Respiratory Case Studies Flashcards
(145 cards)
1
Q
Pulmonary Embolism s/s
A
dyspnea
hypoxemia
cyanosis
tachypnea
chest pain
cough
crackles
hemoptysis
wheezing
shallow respirations
edema in lower extremities
2
Q
pulmonary embolism onset s/s
A
pleuritic chest pain
SOB
hypoxemia
3
Q
Pulmonary embolism vitals
A
tachycardia
hypotension
low grade fever
pulse oximetry low
4
Q
Pulmonary Embolism tests
A
- EKG
- Coagulation studies : PT / PTT and INR
- CXR
- Spiral Chest CT
- V/Q mismatch
- pulmonary angiography
- Duplex Ultrasonography
- D-dimer
- BNP
- ABG
- CBC
5
Q
PE spiral chest CT
A
need large IV for contrast
BUN and Creatinine levels need to be assessed before contrast is given
6
Q
V / Q scan
A
identifies areas of lungs that are ventilation but not perfused efficiently
-low / medium / high probability
7
Q
d-dimer
A
fibrin degradation products or fragments produced during fibrinolysis
+ test = thrombus formation
***NOT recommended in dx PE because is nonspecific
8
Q
BNP test
A
measures overstretching of the ventricles , peptide is released
> 100 is indicative of HF
9
Q
Pulmonary Embolism Risk Factors
A
- advanced age
- smoking
- reduced activity
- clotting disorder
- air travel
- obesity
- hx of a-fib
- oral contraceptives
- hx of DVT
- cancer
- trauma or recent surgery
10
Q
Pulmonary Embolism Meds
A
- Lovenox
- Heparin
- Warfarin
- tPA
- Oral Xa inhibitors
11
Q
what labs to monitor on Heparin
A
aPTT
normal is 25-35 seconds
heparin = 1.5 - 2.5 times that
12
Q
heparin antidote
A
protamine sulfate
13
Q
what labs to monitor on warfarin (coumadin)
A
INR
range = 2-3 or 2.5 - 3.5
14
Q
antidote for warfarin
A
vitamin K
15
Q
Pulmonary Embolism teaching
A
exercise : strengthen patients heart
cardiac diet
adequate fluid intake : 8oz glasses / day
med education : FOLLOW UP LABS
bleeding precautions
limit vit K intake on Warfarin
16
Q
Acute Respiratory Failure
A
one or both gas exchange functions of lungs are compromised
-leads to hypercapnia and hypoxemia
-not a disease but condition CAUSED by another disease
17
Q
Respiratory Failure level
A
PaO2 < 60 mmHg despite increased oxygen with normal PaCO2
18
Q
hypercapnia s/s
A
headache
confusion
decreased LOC
tachycardia
tachypnea
dizziness
flushed / pink skin
19
Q
hypoxemia s/s
A
tachycardia
tachypnea
elevated BP
decreased cerebral perfusion
20
Q
decreased cerebral perfusion s/s
A
restlessness
confusion
anxiety
cyanosis
–> eventual coma
21
Q
Acute Respiratory Failure Tests
A
ABG
Venous Oxygenation
CBC
CXR
Sputum Culture
22
Q
type 1 ARF , ABG
A
initial respiratory alkalosis –> eventual respiratory acidosis
23
Q
type 2 ARF , ABG
A
pH < 7.35 and PaCO2 > 45 mmHg
24
Q
venous oxygen saturation ARF
A
amount of oxygenated blood returning to heart
normal = 60-80%
decreased = inadequate cardiac output
25
CBC , ARF
Hct. and Hgb should be analyzed to ensure enough oxygen binding sites
26
CXR, ARF
reveal underlying patho
27
sputum culture , ARF
rule out pathogenic cause of failure
28
ARF management
1. high flow O2 with non-rebreather
2. non-invasive positive pressure ventilation
3. endotracheal intubation, tracheostomy, mechanical vent with PEEP
29
non-invasive positive pressure vent , ARF
used in severe V/Q mismatch
1. BiPAP
2. CPAP
30
ARF medications
-bronchodilators
-inhaled steroids
-diuretics
-sedatives
-antibiotics
31
ARF bronchodilators
opens airway by stimulating beta-2 receptors
ex: albuterol, levalbuterol, salmeterol
32
ARF inhaled steroids
decrease inflammatory response , combination of bronchodilators and steroids provide more therapeutic response
ex: flovent, pulmicort, aerobid, qvar
33
ARF IV steroids
solu-medrol and solu-cortef
34
ARF diuretics
used to decrease pulmonary congestion , esp. when pulmonary edema is underlying cause
ex : lasix
35
ARF sedatives
used to control agitation and anxiety that increase work of breathing , esp with mechanical ventilation
ex: propofol and versed
36
ARF antibiotics
treat suspected pneumonia , initially broad spectrum and adjusted
37
ARF priority actions
1. patent airway
2. vitals and O2 Sat.
3. cardiac monitoring
4. neuro assessment
5. med administration
6. breath sounds
7. skin color
8. elevate HOB
9. administer IV fluids
10. nutrition
11. prepare for invasive or noninvasive vent support
38
ARF vitals
BP / pulse / RR increased to attempt to increase oxygenation
39
ARF O2 goals
maintain SpO2 > 94%
PaO2 of 80mmHg
40
ARF cardiac monitor
hypoxia and increased oxygen demand due to tachycardia --> dysrhythmias
41
ARF neuro assessment
early indication of impending respiratory failure
42
ARF breath sounds
crackles : pulmonary edema
rhonchi : pneumonia , COPD
diminished breath sounds : hypoventilation
43
ARF skin color
cyanosis in nailbeds and around mouth
deep pink color indicates HIGH CO2 levels
44
ARF education
1. disease process
2. medication administration
3. infection prevention : HAND WASHING
4. smoking cessation
5. diet and hydration
6. breathing technique
7. energy conservation
45
ARF breathing techniques
pursed lip breathing, diaphragmatic breathing allowing for better alveolar ventilation
46
ARF energy conservation
determine priorities and daily living, aerobic exercise improves respiratory status
47
Acute Respiratory Distress Syndrome
sudden / advanced progression of acute respiratory failure
48
ARDS s/s
hypoxemia
dyspnea
decreased lung compliance
49
ARDS treatment
1. mechanical ventilation
2. ECMO
50
ARDS mechanical vent
primary tx of refractory hypoxemia
-lung compliance decreases
-work of breathing increases
-oxygenation continues to be refractory
51
ARDS ventilation setting
reduced tidal volume and PEEP
-lower tidal volumes
-high PEEP
52
ARDS ECHMO
uses a pump to circulate blood through an artificial lung outside of the body
53
PEEP
keeps alveoli from collapsing
54
using lower tidal volumes
volume of air moved with one breath , helps improve oxygenation while also reducing occurrence of ventilator induced lung injury
55
ARDS assessments
1. vital signs
2. neuro assessment
3. respiratory assessment
4. monitor UO
5. monitor mechanical ventilation
6. monitor EKG
7. skin assessment
56
ARDS vitals
increased HR
increased RR
decreased BP
low O2
decreased CVP
decreased PA pressure
57
ARDS neuro assessment
LOC and pupillary assessment every 1-2 hours
neuro compromise d/t refractory hypoxemia and PaCO2 increase
58
ARDS respiratory assessment
crackles r/t fluid buildup
later stage : diminished lung sounds r/t atelectasis and fibrotic changes
59
ARDS urine output
decreased UO is early sign of poor oxygen delivery
60
ARDS mechanical ventilation
increase airway pressure (PIP) could mean secretions
decrease in airway pressure could mean a leak
61
ARDS priority test
1. CXR
2. ABG
3. CBC w/ diff
4. sputum / blood culture
5. serum lactate level
6. liver and renal function
62
ARDS chest x-ray
done to monitor improvement and progression, identify the bilateral infiltrates
-ground glass appearance, snow screen effect, whiteout effect
63
ARDS ABGs
initially sho hypoxemia / hypocapnia
later = respiratory acidosis
metabolic acidosis b/c of hypoxemia
64
ARDS CBC w/ diff
determine cause of ARDS is an infection
> 10,000 is infection
65
ARDS sputum culture
early = cause of ARDS
later = complication
66
ARDS serum lactate
elevated confirms anaerobic metabolism
67
ARDS liver fxn
abnormal test indicates progression of ARDS to MODS
68
ARDS medications
1. Antibiotics
2. Corticosteroids
3. Furosemide (Lasix)
4. Neuromuscular blocking agents
5. Dopamine / dobutamine / norepinephrine
69
ARDS antibiotics
used for if cause of ARDS is infection
-broad then narrow after pathogen identified
70
ARDS corticosteroids
used to decrease inflammatory response
-controversial use
71
ARDS lasix
to decrease pulmonary hypertension and edema
72
ARDS neuromuscular blocking agents
reduce risk of barotrauma
-vecuronium
-used with severe ARDS
73
ARDS dopamine / dobutamine / norepinephrine
increase and maintain BP / organ perfusion
74
ARDS action
1. suctioning
2. positioning
3. administer medications
4. infection prevention
75
ARDS suctioning
presence of secretions in ETT , secretions bring infection
76
ARDS positioning
PRONING allows for better oxygenation
elevate HOB
77
ARDS infection prevention
hand washing
monitor care of central line
foley cath care
increase risk for ventilator assisted pneumonia
78
ARDS teaching
-provide family education and support
-understand medications, lines, vent
-provide family with visiting hours
-spiritual needs
79
Tracheostomy
used when pt has been on mechanical ventilation for 7-14 days
-provide long term vent support, access for lower airway suctioning, relieve upper airway obstuction
80
what is ordered after trach placement to ensure proper placement ?
CXR
81
outer cannula
tube that holds tracheostomy open
82
neck plate
extends from sides of outer cannula
83
inner cannula
can be removed for cleaning and disposable
84
obturator
used to insert a trach tube
**KEEP AT BEDSIDE
85
inflated cuff
used for pt with continuous mechanical ventilation or pt at aspiration risk
86
trach cuff pressure setting
20-30 cm H2O to decrease injury to esophageal tissue and aspiration
87
uncuffed tube
used for patients who are ready for decannulation or are not getting mechanical vent
88
fenestrated trach tube
has removable inner cannula and plastic plug , pt is able to speak through natural airway
89
trach care
provided each shift : once every 12 hours and as needed
-provide patent airway and prevent infection
90
trach suctioning
1-2 hours or less
assess breath sounds : wheezing , crackles, rhonchi
coughing, audible secretions, increase in pulse or RR or restlessness
91
trach complications
1. decannulation !!
2. obstruction
3. bleeding
4. pneumothorax
5. subcutaneous emphysema
6. infection
7. tracheoesophageal fistula
8. tracheal stenosis
92
decannulation
within first 72 hours is considered MEDICAL EMERGENCY
-greater risk for tissue damage and unsuccessful ventilation
93
Decannulation actions
stay with the patient and call for assistance , provide manual ventilation using a manual resuscitation bag w/ 100% oxygen
94
what needs to be at the bedside for trachs ?
OBTURATOR
tube in equal size and one smaller
intubation tray
95
Trach obstruction
caused by secretions
encourage deep breathing / coughing , suctioning, humidification
air needs humidification
96
Trach bleeding
small about expected first few days
report moderate to large amounts of bleeding, continuous oozing
97
trach pneumothorax
collection of air in pleural cavity, occur during trach procedure if lung is pierced
chest X-ray always ordered after the procedure
98
trach subcutaneous emphysema
occur if puncture or tear in the trachea
-moves to neck, chest, face area
**FEELS LIKE CRACKLING (rice krispies)
notify provider immediately
99
trach infection
use aseptic technique , teach patient and caregiver
100
trach tracheoesophageal fistula
overinflation of tracheostomy cuff causes a hole to occur between trachea and esophagus
MAINTAIN CUFF PRESSURE
101
trach tracheal stenosis
narrowing of trachea due to scar tissue
MAINTAIN CUFF PRESSURE , prevent pulling of trach tube
102
obstructive sleep apnea
caused by upper airway obstruction , narrowing of upper airway leading to intermittent breathing pattern
-collapsing of upper airway
103
OSA risk factors
a-fib
nocturnal dysrhythmias
type II DM
HF
pulmonary HTN
male
obesity
smoking
hyperlipidemia
menopause
104
OSA s/s
loud snoring
snorting
witnessed apnea
gasping during sleep
choking during sleep
recurrent waking up
daytime sleepiness
taking intentional naps
105
OSA dx
15 or more obstructive sleep events / hour
POLYSOMNOGRAPHY
106
polysomnography
EKG
pulse ox
respiratory airflow
eye / skeletal muscle movement
electroencephalogram
**key is apnea-hypopnea index value
107
OSA tx
CPAP : delivers continuous positive pressure keeping airway open and provide unobstructed airway
108
OSA surgery
remove excessive tissue in airway interfering with adequate airflow
-bariatric surgery
-tonsillectomy
-adenoidectomy
-uvulopalatopharyngoplasty
-nasal polypectomy
-tongue reduction
-epiglottoplasty
109
OSA complications
1. cardiovascular disease : recurrent hypoxemia
2. endothelial damage / atherosclerosis : release of inflammatory mediators
3. cardiac ischemia : nocturnal hypoxemia
110
OSA assessment
1. Vitals : HTN , dysrhythmias
2. height and weight
3. sleep , rest , activity hx
111
OSA action
1. administer meds
2. dx testing : polysomnography
112
OSA teaching
1. disease process
2. medication use
3. no smoking
4. CPAP instructions
5. weight reduction
113
small cell lung cancer
grows quickly and metastasizes to other organs in body, poor prognosis
114
lung cancer tests
1. CXR
2. CT of chest
3. sputum for cytology
4. bronchoscopy
5. mediastinoscopy
6. bone scans , abd CT
7. PET scan
115
lung cancer bronchoscopy
tells number of lesions, assesses trachea and bronchi
-biopsy may be performed
116
lung cancer mediastinoscopy
surgical procedure allowing direct visualization of mediastinum
-scope inserted through incision in chest to visualize lesions
117
lung cancer tests when concerned for spreading
PET and CT scans
118
lung cancer surgery
used when there is no metastasis of cancer
used for non-small cell tumors
-chemo can be used before and after surgery
119
lobectomy
removal of entire lobe of lung
120
pneumonectomy
removal of entire lung
121
wedge resection
removal of small section from lobe of lung
122
lung cancer non-surgical
chemotherapy and radiation
123
chemotherapy
may be used in conjunction with surgery
-primary tx option for more advanced cancers or if pt cannot undergo surgery
124
radiation
versatility, used in situations where surgery is not an option
-used palliatively for pain management
125
lung cancer s/s
persistent cough
dyspnea
wheezing
hemoptysis : bloody cough
chest pain
episodes of pneumonia / bronchitis
126
lung cancer assessments
1. oxygen sat. : SpO2 < 90% indicates poor gas exchange
2. temperature : elevated = infection
3. breath sounds : wheezing, rhonchi
4. coughing : bloody?
5. pain
6. appetite / weight : appetite can be decreased , SE of chemo
127
lung cancer actions
1. provide O2
2. pain / anxiety meds
3. small frequent meals
4. semi-folwers positition
128
lung cancer pain meds
NSAIDS
opioids : oxycodone, hydrocodone, morphine, codeine
129
lung cancer bronchodilators
open airway to decrease WOB
-albuterol, theophylline, ipratropium bromide
130
lung cancer teaching
breathing technique : PURSED LIP BREATHING !!
pacing activity to conserve energy
no smoking
nutrition
pain medications around the clock : keeps pain controlled instead of unbearable
131
pulmonary hypertension
1. Primary Pulmonary HTN : rare and rapid progressive form
2. Secondary Pulmonary HTN : forms overtime , increase in pulmonary pressure
132
pulmonary HTN s/s
dyspnea on exertion
SOB
fatigue
exertional chest pain
dizziness
exertional syncope
133
pulmonary HTN complications
1. R sided heart enlargement and HF
2. PE
3. arrhythmia
4. OSA
134
HTN R sided heart enlargement and HF
heart tries to compensate by thickening walls and expanding chamber to increase amount of blood it can hold but actually increases strain on heart
135
HTN PE
increases likely to develop clots in small arteries in lungs
136
HTN arrhythmias
cause irregular heartbeats leading to pounding heartbeats , dizziness and fainting
137
pulmonary HTN dx
1. CBC for polycythemia
2. CXR
3. EKG
4. CT scan
5. echocardiogram
6. R heart cath
7. ABG for hypoxemia
6. Pulmonary function test
138
HTN CXR
can show enlargement of R ventricles
139
HTN CT scan
show heart size, blood clots, look for lung disease (COPD and pulmonary fibrosis)
140
HTN R heart cath
directly measure pressure in main pulmonary arteries and R ventricle
*** > 25 mmHg at rest and > 30 with exercise = HTN !!!!
141
HTN medications
1. CCB : Diltiazem
2. Sildenafil
3. Prostacyclins
4. Bosetan
5. Digoxin
142
diltiazem
should not be used with R sided HF
-vasodilates to reduce pressure in PA
143
sildenafil
do not take with nitroglycerin = HYPOTENSION
144
bosetan
monitor liver function
145
HTN education
medications
portable oxygen
diet, activity, lifestyle
