T2 Respiratory Problems Ch.32 Flashcards
(75 cards)
1
Q
Gas exchange is the process by which oxygen is transported to cells and carbon dioxide is transported from CELLs
A
Gas exchange
2
Q
Adequate arterial blood flow through the peripheral tissues (peripheral perfusion) and organs (central perfusion) Act of blood flowing
A
Perfusion
3
Q
Gas exchange and perfusion -
Acute or chronic problems more common?
Which is worse ? Why?
How to prevent ?
A
Chronic problems are more common
but acute problems can cause issues with gas exchange and perfusion and cause death
Prompt recognition is critical in preventing serious long term complications to patients
4
Q
an inadequate blood supply to an organ or part of the body
A
Ischemia
5
Q
deficiency in the amount of oxygen reaching the tissues
A
Hypoxia
6
Q
an absence or deficiency of oxygen reaching the tissues; severe hypoxia
A
Anoxia
7
Q
the spreading of something more widely
A
Diffusion
8
Q
occurs when the diffusion of gases (oxygen and carbon dioxide) becomes impaired because of
Ineffective ventilation
Reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells)*
Increased need for oxygen
Inadequate perfusion
Prompt recognitions is essential!!
A
Impairment of gas exchange
9
Q
Slide 6
A
6
10
Q
Slide 7
A
7
11
Q
Causes of impaired gas exchange
A
Pulmonary embolism
Acute respiratory failure
Acute respiratory distress syndrome
Chest trauma
12
Q
Collection of particulate (blood clot, fat, air, oil etc) that enters the venous circulation and becomes lodged in the pulmonary vessels*
If large enough can Cause: emboli obstruct pulmonary blood flow and leads to impaired gas exchange, hypoxia
Any substance can form an embolism but blood clot is most common*
Common preventable death!- often with decreases mobility after surgery
A
Pulmonary embolism
13
Q
Collection of particulate matter—solids, liquids, air—that enters venous circulation and lodges in pulmonary vessels usually occurs when a blood clot from a venous thromboembolism in leg or pelvic vein breaks off and travels through the vena cava into the right side of the heart.
Clot then lodges in pulmonary artery or one if its branches causing impaired gas exchange. Unoxygenated blood travels through body causing hypoxemia.
May be most common preventable death but often misdiagnosed
A
Pulmonary embolism with infarction.
14
Q
Risk factors for pulmonary embolism
A
Prolonged immobilization -Central venous catheters Surgery -Obesity -Advancing age Conditions that increase blood clotting History of thromboembolism
Also smoking, pregnancy, birth control (estrogen), heart failure, cancer and trauma
15
Q
long bone fracture (femur)**
Risks?
A
Fat embolism risk
Fat emboli don’t block blood flow but injure blood vessels and cause ARDS risk
Femur is most common
Can happen with humorous break
16
Q
A nurse is caring for an older adult client who had a femoral head fracture 24 hours ago and is in skin traction. The client has sudden onset of dyspnea, confusion, and tachycardia. The nurse suspects the client developed which of the following complications? A. Pneumothorax B. Pneumonia C. Fat embolism D. Mucoid plug in the airway
A
C.
Long bone fracture
17
Q
Pulmonary embolism prevention?
Tx
A
Smoking cessation
Weight reduction
Increased physical activity
Ambulate soon after surgery
If traveling or sitting for long periods, get up frequently and drink plenty of fluids
Refrain from massaging/compressing leg muscles
Stop smoking especially women on birth control
Patients at risk for VTE: preventative heparin, IVC filter
Chart 32-1 Prevention of PE*
18
Q
Pulmonary embolism s/s
Respiratory-
Cardiac-
Mental-
A
Respiratory:
Dyspnea, tachypnea, pleuritic chest pain (deep breaths hurts), dry cough-blood may be present, hemoptysis, crackles
Cardiac-
Tachycardia, distended neck veins, syncope(loc), cyanosis, systemic hypotension, abnormal heart sounds (S3 or S4), abnormal ECG, chest pain
Hypoxemia-can trigger anxiety, restlessness and sense of impending doom
Chart 32-2
PE patients are critically ill
Range from vague, nonspecific discomforts to hemodynamic collapse, cardiac arrest, and death
Symptoms relate to decrease gas exchange
19
Q
PE dx?
A
ABGs
Hyperventilation leads to resp alkalosis
Shunting causes increases PaCo2 leading to resp acidosis with out oxygen gas exchange.
Tissue hypoxia can cause metabolic acidosis
Labs: troponin(to rule out cardiac with chest pain symptoms), d-dimer- determines clotting factors in blood
Imaging assessment
Pulmonary angiography (gold standard)*
CT- (cat scan with contrast) next best
VQ Scan- if allergic to contrast dye
Chest X-ray- rule out other s/s
Doppler ultrasound-find source of blood clot
20
Q
- Pulmonary embolism
moving blood from right to left side of heart without picking up oxygen (decreased gas exchange)
____doesn’t diagnose PE but if its low, can usually be ruled out. If its high then more testing needs to be done
_______Is gold standard but not always available
_____is next best option
VQ scan is not commonly performed but is useful in some situations (allergy to contrast)
CXR can rule out other causes but not diagnose PE
Doppler: check for VTE
A
Shunting
D-dimmer
Pulmonary angio- gold standard
CT - next best
21
Q
Major complications of PE
______decrease exchange
_______inadequate blood circulation to left ventricle
_______from anticoagulation
_______due to hypoxemia
A
Hypoxemia
Hypotension
Potential for excessive bleeding
Anxiety
22
Q
Tx of PE?
A
Oxygen therapy (nasal cannula, mask, possible mechanical ventilation)
Continuous patient monitoring
Obtain adequate venous access
Continuous monitoring of pulse oximetry
Drug therapy*
Anticoagulants
Fibrinolytics- emergency situation - breaks down clots much faster.
PTT - lab to monitor with heparin before starting med. infusion - check frequently until reach goal level. While on patient is transfered to Coumadin or something more long term.
23
Q
PE nursing interventions
Antidotes for heparin, protamine sulfate, Coumadin
Lab to check before starting heparin
A
Notify rapid response, reassure patient, elevate head of bed, o2 therapy
Usually nonsurgical but in some cases invasive procedures are needed.
Monitor: assessment, vital signs, lung sounds, dysrhythmias, JVD, edema
Anticoagulants: heparin, lovenox, arixtra: check patients PTT before and during
Heparin 5-10 days then Coumadin or xarelto
Fibrinolytics: alteplase for use when patient in shock or hemodynamic collapse
Know antidotes:
Heparin-protamine sulfate
Warfarin vitamin K
fibrinolytics- clotting factors, FFP, and aminocaproic acid.
24
Q
PE-
Discuss assigned anticoagulation/ fibrinolytic medication and find answers to the following questions:
Benefits vs risks Monitoring Safety considerations Patient education Antidote
A
Heparin Warfarin Lovenox Xarelto Alteplase
25
How to manage hypotension in PE?
IV fluid
Medications to increase cardiac output
Medications to maintain blood pressure
Goals:
Normal pulse and BP
U/O of at least 0.5-1 mL/kg/hr - adequate perfusion
26
Manage risk for excessive bleeding in PE how?
At risk for bleeding due to anticoagulant or fibrinolytic therapy
Ensure antidotes to anticoagulant or fibrinolytic are available
Assess appropriate lab values
Assess for evidence of bleeding
Watch for Petechiae, bruising, oozing, etc
Great resources for bleeding precautions in book
27
Minimize anxiety in PE how?
Oxygen therapy
Therapeutic communication
Antianxiety medications
28
Surgical interventions for PE
Useful when patients are contraindicated for fibrinolytics-
Used in high risk patients and when anticoagulation can’t be used-
Embolectomy-
Useful when patients are contraindicated for fibrinolytics
Placement of IVC filter-
Used in high risk patients and when anticoagulation can’t be used
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Either ventilation or perfusion is mismatched, gas exchange reduced
Can be ventilator failure, oxygenation failure, or combination
Classified by ABG values
Patient is always hypoxemic
Acute Respiratory Failure
30
```
ABG values*
Pao2 <60 mm Hg
OR
Paco2 >45 mm Hg with pH <7.35
With
Sao2 <90%;
```
Either ventilation or perfusion is mismatch= reduced gas exchange
Acute respiratory failure -resp acidosis
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Physical problem of lungs or chest wall
Prevents adequate oxygen intake
Defect in respiratory control center in brain
Poor function of respiratory muscles, especially diaphragm
Extrapulmonary causes vs. Intrapulmonary causes (chart 32-2)
Ventilatory failure
32
Problem is oxygen intake (air movement) that cases a v/q (ventilation perfusion) mismatch (blood flow is normal and air flow is decreased)
Too little oxygen reaches alveoli and CO2 is retained
Extra pulmonary-outside of lung but effect respiratory?
Intrapulmonary?
Myasthenia gravis, GBS, spinal cord, opioids
disorder of respiratory tract: airway disease, COPD, asthma, PE, ARDS
33
Insufficient oxygenation of pulmonary blood at alveolar level
Ventilation normal, lung perfusion decreased
Right to left shunting of blood
V/Q mismatch
Low partial pressure of O2
Abnormal hemoglobin
Air moves in and out normally but lung blood flow (perfusion) is decreased (VQ mismatch)
Breathing air with low o2, low hgb, PE or ARDS
Oxygen gas exchange failure
34
Often occurs in patients with abnormal lungs-
Chronic bronchitis
Emphysema
Asthma attack
Cystic fibrosis
Diseased bronchioles and alveoli cause oxygenation failure; work of breathing increases; respiratory muscles unable to function effectively
Alveoli are diseased causing decrease oxygenation and the work of breathing increases until they can’t function
Leads to more profound hypoxemia that others
Combined ventilatory/oxygenation failure
35
Symptoms of ARF (acute respiratory failure)
What is the hallmark sign?
Slow progressing starts with what?
When is dyspnea more intense?
```
Related to systemic effect of hypoxia, hypercapnia, and acidosis
Dyspnea (hallmark sign)
Orthopnea
SpO2 decreases,
ETCO2 increases*
Others similar to PE
CO2 increases lead to lethargy,
confusion*
```
Dyspnea is more intense when it develops suddenly.
Slow progressing RF starts with dyspnea on exertion or orthopnea
36
Acute respiratory failure interventions
```
Oxygen therapy*
Position of comfort
Energy conserving measures
Relaxation, diversion, guided imagery
Energy-conserving measures (prioritizing care)
```
Medications:
nebulizers, inhalers to dilate bronchioles
corticosteroids
May need mechanical ventilation
37
Persisting hypoxia
Decreased pulmonary compliance*
Dyspnea
Noncardiac-associated bilateral pulmonary edema
Dense pulmonary infiltrates seen on x-ray
Ground glass*
Hypoxia persists despite 100% FiO2. May have refractory hypoxemia
Often occurs after acute lung injury (ALI): sepsis, burns, pancreatitis, trauma,
Trigger is systemic inflammatory response causing injury in alveolar-capillary membrane.
Membrane becomes more permeable to large molecules and allows debris, proteins, and fluid into the alveoli
Lung fluid increases
Surfactant: increases lung compliance prevents alveoli collapse. ARDS reduces surfactant activity. Alveoli become unstable and collapse. Edema then surrounds alveoli further decreasing gas exchange resulting in further decrease in lung volume and compliance
S/s of what?
ARDS - acute respiratory distress syndrome
38
What does surfactant sounds for ARDS?
When does ards usually occur?
Surfactant: increases lung compliance prevents alveoli collapse. ARDS reduces surfactant activity. Alveoli become unstable and collapse. Edema then surrounds alveoli further decreasing gas exchange resulting in further decrease in lung volume and compliance
Often occurs after acute lung injury (ALI): sepsis, burns, pancreatitis, trauma,
39
Causes of ARDS
Systemic inflammation causes injury in alveolar capillary membrane
Direct lung injury: aspiration, pneumonia, drowning, inhalants
Often occurs after acute lung injury (ALI): sepsis, burns, pancreatitis, trauma, transfusions
—————
Trigger is systemic inflammatory response causing injury in alveolar-capillary membrane.
Membrane becomes more permeable to large molecules and allows debris, proteins, and fluid into the alveoli
Lung fluid increases
Surfactant: increases lung compliance prevents alveoli collapse. ARDS reduces surfactant activity. Alveoli become unstable and collapse. Edema then surrounds alveoli further decreasing gas exchange resulting in further decrease in lung volume and compliance
TRALI sudden onset (within 6 hours) of hypoxemic lung disease.
No matter how high you turn up oxygen patients oxygen will stay low Or get lower
40
What to asses for ARDS?
What is key to recovery?
Assess work of breathing
Retractions
Early recognition is key!!!
Assess: increased work of breathing, abnormal breath sounds not heard due to edema in interstitial spaces and not airways
Lung sounds may be normal
Lower Pao2 value on ABG (cyanosis)
Refractory hypoxemia*- oxygen goes down after turning up oxygen
Whited-out” (ground glass) appearance to chest x-ray
No cardiac involvement on ECG
Low-to-normal PCWP
41
3 phases of ards
??? early changes result from alveoli becoming full of fluid, pulmonary shunting, and atelectasis. Support focuses on support and oxygen
??? increased lung injury leads to pulmonary hypertension. MODS can occur. Deliver adequate oxygen, prevent complications, and support lungs
??? after 14 days, fibrosis may or may not occur.
Exudate: early changes result from alveoli becoming full of fluid, pulmonary shunting, and atelectasis. Support focuses on support and oxygen
Fibroproliferative: increased lung injury leads to pulmonary hypertension. MODS can occur. Deliver adequate oxygen, prevent complications, and support lungs (may mean mechanical ventilation l)
Resolution: after 14 days, fibrosis may or may not occur.
42
Interventions for ARDS
Position?
Resp ?
Endotracheal intubation, conventional mechanical
ventilation with PEEP or CPAP
PEEP* ?? Amt of airflow as the patient is exhaling - positive pressure remaining in the ventilator which is helping their alveoli stay open. Don’t want lungs to collapse due to already high volume of surfactant
Lung protective ventilation: low tidal volume*
High setting of air can cause barro trauma to lungs- keep on low
Severe cases: ECMO
Medications: antibiotics if needed, conservative fluid therapy
Positioning
————
Pressure controlled ventilation is preferred over volume control
Side effect of high PEEP: tension pneumothorax
Positioning: possible prone position, turn and reposition every 2 hours
ECMO: extracorporeal membrane oxygentation (bypass)
Conservative fluid volume- don’t want to increase pulmonary edema
43
Drug and nutrition therapy for ARDS
Antibiotics to treat infections
Treat underlying cause
Conservative fluid therapy
Prevent malnutrition- adequate nutrition
44
Mr. Nguyen is a 58-year-old patient that had septic shock and developed Acute Respiratory Distress Syndrome. He is orally intubated and on a mechanical ventilator. He is paralyzed and sedated.
What manifestations might you observe for a patient with ARDS?
What complications can Mr. Nguyen develop from being mechanically ventilated?
List priority nursing interventions to prevent complications associated with ventilatory support.
What interventions can be implemented specifically to prevent the development of Ventilator Acquired Pneumonia (VAP)?
You are orienting in the ICU, the nurse you are working with is not implementing the VAP interventions. What would you do?
?
45
Correct placement of an oral endotracheal tube?
To reduce tracheal trauma?
How to verify placement of endo tube?
Endotracheal tubes. B,
Correct placement of an oral endotracheal tube 2 cm above carina (point where trachea divides into mainstem bronchi)
To reduce tracheal trauma consider trach after 10-14 days of intubation
Verify tube placement:
* *#1 gold standard way-End-tidal carbon dioxide levels- do at time of insertion and throughout
* *Chest x-ray
* Assess for breath sounds bilaterally, symmetrical chest movement, air emerging from ET tube
Can cause mouth breakdown. If longer than 10-14 days then may need tracheostomy
46
Assessment and other nursing safety care for endotracheal tube patients?
First measures?
If only hear breath sounds on right but not left?
Assess tube placement, End tidal CO2* and xray are first measures*, breath sounds, chest wall movement*
If only hear breath sounds on right but not left- pull back ET tube a few cm
Prevent movement of tube by patient- may need soft wrist restraints
Check pilot balloon
Mechanical sedation- with ARDs so their lungs can rest and heal. So lungs aren’t fighting against it
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Nursing priorities for intubation patient?
*#1Maintain patent airway
Assess lung sounds
```
DOPE:
Displacement
Obstruction- pe, mucus plug, etc
Pneumothorax
Equipment
```
Always focus on patient FIRST before the monitor/equipment *
48
Ventilator types?
Modes of ventilation?
Ventilator types?
Negative-pressure
Positive-pressure
Modes of ventilation?
Assist-control ventilation (AC)
Synchronized intermittent mandatory ventilation (SIMV)
Bi-level positive airway pressure (BiPAP)
49
Ventilator controls and settings
```
Tidal volume (Vt)
Rate: breaths/min
Fraction of inspired oxygen (Fio2)
PIP
CPAP
PEEP
Flow and other settings
```
Monitor these settings, control, and document on
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If patient on ventilator has respiratory distress?
Always assess patient first, ventilator second*
Assess respiratory status
Oral care q hour or 2 hr, suctioning, Hob above 30 degrees, repositioning PRN=VAP (ventilator associates pneumonia) prevention
Monitor patient response
Manage ventilator system
Prevent complications!* = VAP, pneumothorax)
Prevent ventilator associated events (VAEs)
If patient on ventilator has respiratory distress, first remove patient from ventilator, provide ventilation with BVM, then determine problem.
Alarms should be relevant and never silenced without further assessment.
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Ventilator associated events - VAEs?
Cardiac?
GI?
Infections?
Cardiac-
Hypotension
Fluid retention
Valsalva maneuver- tube can cause pt to gag and have lower heart rate
Gastrointestinal (GI)-
Nutritional
Infections: Ventilator-associated pneumonia (VAP)
Muscle deconditioning- while in bed
Ventilator dependence
52
Respiratory VAE?/ complications?
_______ (note air in the neck; arrow) as a consequence of ARDS in a patient receiving positive-pressure ventilation (PPV).
______damage to lungs by excess volume
_______shear injury to alveoli from opening and closing
________inflammatory response-mediated damage to alveoli
_______damage from prolonged ventilation
Barotrauma (note air in the neck; arrow) as a consequence of ARDS in a patient receiving positive-pressure ventilation (PPV).
Volutrauma damage to lungs by excess volume
Atelectrauma: shear injury to alveoli from opening and closing
Biotrauma: inflammatory response-mediated damage to alveoli
VALI: damage from prolonged ventilation
Acid base imbalances - watch ABGs
53
VAP ventilator associated pneumonia
What is key?
Prevention is key
Prevent by strict adherence to infection control and ETT care
```
Ventilator bundle:
HOB >30
Oral care
Suction so bacteria does not re enter lungs
Ulcer prophylaxis
Prevent aspiration
Turn/reposition
```
Artificial airways are colonized with bacteria within 48 hours.
54
Weaning from ventilator ?
Process of going from vent dependence to spontaneous breathing
Complications prolong weaning process
Various weaning methods (Table 32-7)
Wean as quickly as patient will tolerate
55
Extubation nursing interventions
Observe for dyspnea, coughing, inability to clear airway, stridor*- if stridor they are not maintaining airway well and may need to re intubate
Hyperoxygenate patient
Thoroughly suction ET and oral cavity- deep into fairings?
Rapidly deflate ET cuff
Remove tube at peak inspiration
Instruct patient to cough
Monitor patient every 5 minutes; assess ventilatory pattern for respiratory distress
Provide oral care post extubation
56
About ____%of traumatic deaths result from chest injuries
Pulmonary contusion
Rib fracture
Flail chest
Pneumothorax
Tension pneumothorax
Hemothorax
Tracheobronchial trauma
25%
Chest trauma
57
Bruise on lungs
Potentially lethal injury
May be asymptomatic at first, later develop respiratory failure
Bloody sputum, decreased breath sounds, crackles, wheezes
Pulmonary contusion
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Management of pulmonary contusion
Management of pulmonary contusion includes maintaining ventilation and gas exchange.
Provide oxygen, IV fluids, moderate fowlers position, coughing/deep breathing, noninvasive positive pressure as needed
59
Tx of pulmonary contusion
Treatment—Maintenance of ventilation and oxygenation
Position “good lung down”*
Air will follow path of least resistance- want to make sure oxygen is adequate/optimal for pt
60
Risk for deep chest injury/rib fracture:
Nursing intervention Main focus?
pneumo/hemo thorax
Patient reflexively splints chest with breathing or coughing.
Splinting reduces breathing depths and secretion clearance.
Chest usually not splinted by tape or other materials
**Main focus: Decrease pain so that adequate ventilation is maintained
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Paradoxical chest movement
—“Sucking inward” of loose chest area during inspiration, “puffing out” of same area during expiration
Multiple rib fractures in multiple areas - aren’t attached to anything
Emergent condition
Flail chest
Flail chest. Normal respiration: A, Inspiration; B, Expiration. Paradoxic motion: C, Inspiration —area of the lung underlying unstable chest wall sucks in on inspiration. D,
Expiration—unstable area balloons out. Note movement of mediastinum toward opposite lung during inspiration.
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Flail chest Interventions*:
Best intervention?
humidified o2, pain relief, deep breathing, positioning, positive pressure ventilation
Best intervention- Positive pressures ventilation-Et tube, bipap, cpap
63
.
Right: ? on the left with mediastinal shift to the right.
Prevents gas exchange and oxygenation, pressure on heart
Left: Pneumothorax.
Right: Tension pneumothorax on the left with mediastinal shift to the right.
64
Tension pneumothorax assessment
Assessment*
Asymmetry of thorax- one side doesn’t expand
Tracheal movement away from midline toward unaffected side- late sign
Respiratory distress
Absence of breath sounds on one side
Distended neck veins
Cyanosis
65
pneumothorax interventions
Small stable?
Severe unstable?
Emergent?
Small, stable: no treatment
Severe, unstable: chest tube
Emergent management is needle thoracostomy - inserted into third intercostal space to relieve air pressure
66
A 65-year-old woman is brought to the ED by her husband with new-onset shortness of breath. She had an abdominal hysterectomy 5 days ago. Her husband states that she stayed in bed since she was discharged from her surgery 48 hours ago, because she feels very short of breath when she gets up.
What risk factors are present for VTE?
ANS: Prolonged immobility; advancing age; recent surgery.
67
During triage, the following vital signs and assessments are noted
Temperature—99.6º F BP—80/44 mm Hg
P—126 (sinus tachycardia) R—28 and labored
O2 saturation—84% (room air) Crackles bilaterally
Petechiae across chest and in axillae
Based on these findings, what do you suspect might be happening with the patient?
ANS: The patient may have a pulmonary embolism. She could also have pneumonia based on her recent surgery and immobility. Further assessment should be performed to ascertain the specifics of her symptoms.
68
```
When the ED physician is notified of the patient’s manifestations, and she is moved immediately to a treatment room. The physician writes the following orders:
O2 at 2 L per nasal cannula
Stat CBC, BMP, d-dimer, aPTT, INR
Stat CT of the chest
Start a saline lock
```
Which order takes priority at this time?
ANS: Based on the patient’s pulse oximetry reading, the priority order is the administration of oxygen.
Next, the saline lock should be started. Once the vein is accessed, blood can also be obtained for the CBC, BMP, d-dimer, PTT, and INR. After the laboratory specimens are sent, the radiology department can be notified to perform the stat CT of the chest.
69
While in the treatment room, the patient says she needs to use the bathroom. The nurse delegates this task to the unlicensed assistive personnel (UAP).
What is the best approach for the nursing assistant to take?
A.Place the patient on a bedpan and stay with her until she is finished.
Ambulate her into the hall bathroom on room air and stand outside the door until she is done.
Ask the provider for an indwelling catheter because of her shortness of breath when she ambulates.
Tell her to try to wait until the shortness of breath subsides.
ANS: A
The nursing assistant should place the patient on a bedpan and stay with her. She is too short of breath to ambulate to the bathroom and she should remain on the oxygen at all times. The nursing assistant should not ask the provider about an indwelling catheter because this would only increase the possibility of a urinary tract infection (UTI). The patient should never be told to try to wait, because this could also increase the risk for UTI.
70
Two hours later, the patient is admitted to the medical unit where she is started on a continuous IV heparin weight-based protocol.
Which finding indicates that the heparin infusion is therapeutic?
INR is less than 1.
INR is between 2 and 3.
aPTT is the same as the control.
D. aPTT is 1.5 to 2.5 times the control.
ANS: D
When a patient is started on continuous heparin, the aPTT is drawn before therapy is started and then every 4 hours until a therapeutic range of 1.5 to 2.5 times the control is reached. Thereafter, the aPTT is checked daily.
71
Three days later, the provider prepares to discharge the patient on warfarin (Coumadin).
Which teaching points do you include about this therapy? (Select all that apply.)
“Be sure to have follow-up INR laboratory tests done.”
“Report any bruising or bleeding to your provider.”
“Consume lots of foods that are rich in vitamin K, such as green leafy vegetables.”
“Use a soft toothbrush to brush your teeth and an electric razor to shave your legs.”
“A skin rash is expected while you are taking this drug.”
AnS: A, B, D
It will be important for the patient to have follow-up INR laboratory tests done, reporting any bruising or bleeding, and use a soft toothbrush and electric razor while on warfarin therapy. Vitamin K is the antidote for warfarin, so patients should not consume a great deal of foods that are high in this vitamin. A skin rash is a sign of an adverse drug reaction and should be reported to the provider immediately.
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Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)?
A.24-year-old male admitted with blunt chest trauma and aspiration
56-year-old male with a history of alcohol abuse and chronic pancreatitis
72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells
82-year-old female on antibiotics for pneumonia
ANS: A
All patient scenarios create a risk for ARDS. However, the trauma patient with direct chest injury and known aspiration is at greatest risk. ARDS risk factors include direct lung injury (most commonly aspiration of gastric contents), systemic illnesses, and injuries. The most common risk factor for ARDS is sepsis. Other risk factors include bacteremia, trauma with or without pulmonary contusion, multiple fractures, burns, massive transfusion, near drowning, post-perfusion injury after cardiopulmonary bypass surgery, pancreatitis, and fat embolism.
73
A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse?
“I should limit my alcohol consumption.”
B. “I should eat more green leafy vegetables like spinach.”
“I should take the medication at the same time every day.”
“I should make a doctor’s appointment for weekly blood draws.”
ANS: B
Patients who experience a venothromboembolism/pulmonary embolism are frequently discharged on anticoagulant therapy (e.g., warfarin [Coumadin]). The patient should be educated to understand the risks and monitoring of this drug to include weekly monitoring for therapeutic levels, consistency in dosing regimens, and foods to avoid (e.g., leafy green vegetables, green tea, alcohol, cranberry juice).
74
A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure?
Pulmonary edema
Hypovolemic shock
Pulmonary embolus
D.Opioid analgesic overdose
ANS: D
Acute ventilatory failure is the type of problem in oxygen intake and carbon dioxide removal (ventilation) and blood delivery (perfusion) that causes a ventilation-perfusion (V/Q) mismatch in which perfusion is normal but ventilation is inadequate. It occurs when chest pressure does not change enough to permit air movement into and out of the lungs. As a result, too little oxygen reaches the alveoli and carbon dioxide is retained. Opioid analgesic overdose is a possible cause of ventilatory failure. The other choices listed are related to oxygenation failure.
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Path way to hypoxia or cell death
Reduce oxygen in blood or none
Deprived tissues - once this occurs it leads to cell death which is unable to regenerate
Cell death
