test 2 Flashcards
(106 cards)
Pulmonary embolism
Collection of particulate matter that enters venous circulation and lodges in the pulmonary vessel.
Large emboli obstructs pulmonary blood flow
Reduced gas exchange, oxygenation
Pulmonary tissue hypoxia
Decreased perfusion
Potential death
PE Cause
Inappropriate blood clotting forms a venous thromboembolism in vein or legs, pelvis
Risk factors for PE
Prolonged immobility Central venous catheters Surgery Obesity Advanced age History Pregnancy, estrogen therapy, contraceptive therapy Cancer Trauma Smoking
Prevention of PE
Start PROM, AROM ambulate Ted hose Prevent compression in popliteal space Avoid constricting clothing Change patient every 2 hours Frequent physical assessment of circulation Patient/family teaching Encourage smoking cessation
PE physical assessment
Displeasure Pleuritic chest pain on inspiration Auscultation: crackles or clear, hemoptysis Tachycardia, low grade fever JVD syncope Cyanosis, diaphoreses Hypotension Abnormal heart sound Shock and death
PE Signs
Tachypnea, crackles Pleural friction rub Tachycardia Petechia over chest and axillae Anxiety, restlessness, fear of impending doom
Assessment of PE
Pulmonary angiography
CT-PA
chest x-ray
Nursing diagnosis PE
Hypodermic r/t mismatch of lung perfusion and alveolar gas exchange
Hypotension r/t inadequate circulation to left ventricle
Potential for inadequate clotting and bleeding r/t anticoagulant or fibrinolytic therapy
Anxiety r/t hypoxemia and life threatening illness
PE intervention
Elevate the HOB, apply o2, call RRT
Reassurance
Telemetry and continuous pulse ox
Maintain adequate venous access
Assess respiratory and cardiac status at least every 30 min
Administer prescribed anticoagulants
Heparin,lovenox, fibrinolytic a, warfarin
Reversing agents heparin-protamine sulfate
Warfarin-vitamin k
PE Laboratory
aPTT, PTT
*measures heparin therapy
*common range:20-30 sec
* therapeutic range:1.5-2.5 times normal value
PT, prothrombin time
*measures effectiveness or Coumadin therapy
*normal range: 11-12.5 sec
*therapeutic range: 1.5-2.0 times normal range
INR
* common range
* therapeutic range for PE 2.5-3.0, 3.0 -4.5 for recurrent PE
Managing hypotension
Iv fluid Ecg monitor I&O Drug therapy and vasopressors Vitals
PTT, aPTT
Normal 20-30 seconds
PE 1.5-2.5 times normal value
Therapeutic times:means that the clotting time is increased from normal but this increase is indicated in the case of PE
Prolonged times: patients with PE >75 sec indicates the pt is at risk for serious bleeding. Heparin is usually stopped until PTT is normal
PT
Normal range 11-12.5 sec
PE 1.5-2.0 times the normal
Therapeutic: pro time is increased from normal but this increase is indicated in the case of PE
Prolonged: at risk for bleeding, warfarin decreased or stopped until it is normal
INR
Normal 0.8-1.1
Therapeutic:INR is increased from normal but the increase is indicated in the case of PE
Prolonged: at risk for bleeding, stop warfarin, instructed to eat food in vitamin k
Minimize bleeding
Have antidote available
Asses for bleeding every 2 hours
Check emissions, stools and urine for blood
Avoid im injection, apply ice to site of trauma avoid nose blowing, use soft tooth brush and electric razor
Hold pressure on needle stick for 10 minutes
Monitor lab
The client diagnosed with dvt suddenly complains of chest pain and feeling of impending doom.
Pulmonary embolus
Nurse is preparing to administer warfarin an oral anticoagulant to a client diagnoses with a PE. which data should the nurse questions?
INR is 5
Client is suspected of having a PE, which diagnostic test confirms the diagnosis?
Plasma d-dimmer
Which nurse intervention should the nurse implement for a client diagnose with PE who is undergoing thrombolytic therapy
Keep protamine sulfate readily
Assess for overt and covert signs of bleeding
Avoid invasive procedures and injections
Ad mister stool softeners
Thoracic trauma
First emergency approach to all chest injuries is BAC
Breathing, airway, circulation, a rapid assessment and treatment of life threatening conditions
Pulmonary contusion
Occurs most often by rapid deceleration during car crashes
Potential life threatening
Respiratory Failure can develop
Hemorrhage and edema in and between alveoli reducing lung movement and available area for gas exchange
May present or develop hypoxia and dyspnea over time
Note brushing over chest , cough, tachycardia, Tachypnea, a auscultate decreased breath sounds wheezing or crackles
Pulmonary contusion management
Maintenon of ventilation and oxygen.
Provide o2, give it fluids and place patient in a moderate fowler so position. When side lying the good lung down position
Rib fracture
Often results of blunt force trauma to the chest
Increase the risk for deep chest injury such as pulmonary contusion, pneumothorax and hemothorax
Presents with pain on movement and splints the affected side
Pre existing lung conditions increase the risk for atelectasis and pneumonia
Fx of 1st or 2nd ribs, frail chest, multiple rib fractures and low expired volumes [15mg] have poor prognosis
Focus of treatment is analgesics to reduce pain and promote normal ventilation