test 2 Flashcards
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
Frail chest
Results of blunt force trauma
Fractures of a leas two neighboring ribs in two or more places causing paradoxical chest wall movement
Assess for paradoxical chest movements, dyspnea, cyanosis, tachycardia, increased work of beating and hypotension
Frail chest interventions
Humidified oxygen, pain management, promote deep breathing with positioning, encourage deep breathing and coughing, tracheal auctioning
Mechanical ventilation with peep for respiratory failure or shock
ABG and vital capacity monitoring while ventilated
Monitor vitals fluid and electrolyte balances pain sa02
Offer psychosocial due to fear anxiety and pain
Pneumothorax
Any injury that allows air to enter the pleural space, increase chest pressure and reduces vital capacity(lung collapse)
Often caused y blunt chest trauma or medical procedure
Can be open or closed
-reduced breath sounds on auscultation on affected side
-Hyperresonance on percussion
-Lack off chest wall movement on affected side
-deviation of trachea away from side of injury
-pleuritic pain, Tachypnea and subcutaneous emphysema
Pneumothorax interventions
Chest X-ray Chest tube Pain control Pulmonary hygiene Continuous assessment for impeding respirator failure
Tension pneumothorax
Rapidly developing and life threatening complication of blunt chest trauma resulting from an air leak in the lung or chest wall
-cause complete collapse of affected side
-air entering pleural cavity upon inspiration does not exit upon expiration
-air under pressure collapses blood vessels and decreases blood return
-without prompt detection and treatment, quickly becomes fatal
Cause: blunt force trauma, mechanical ventilation with PEEP, chest tubes, insertion of central venous access devices
Tension pneumothorax finding
Asymmetry of the thorax
Tracheal movement away from midline toward the unaffected side
Extreme respiratory distress
Absence of breath sounds on one side
Distended neck veins
Cyanosis
Hyper tympanic sounds on percussion over the affected side
Hemodynamics instability
Abg reveal hypoxia and respiratory alkalosis
Chest X-ray reveal collapsed lung and shifting of internal organs away from affected side
Tension pneumothorax treatment
Needle thoracostomy with large bore needle inserted in 2nd intercostal space midclavicular line of affected side
Chest tube in forth intercostal space to water seal
Pain control
Pulmonary hygiene
Psychosocial
Hemothorax
Common after blunt chest trauma or penetrating injuries
-simple or massive
-bleeding from injury to lung tissue
-bleeding from trauma to heart, great vessels or intercostal arteries
Finding:
Respiratory distress with decreased breath sounds on affected side
Percussion on affected side is dull
Blood in plural space
Hemothorax management
Redoing blood to improve breathing and recent infection Chest tube to drain Chest X-ray Pain management Vital signs I&O Transfusion and fluid replacement Open thoracostomy for large initial blood or persistent bleeding Mechanical ventilation
Automaticity
(Pacing function) is the ability of cardiac cells to generate an electrical impulse spontaneously and repetitively
Excitability
Ability of non-pacemaker heart cells to respond to an electrical impulse that begins in pacemaker cells and to depolarize
Depolarization
Occurs when the normally negatively charged cells within the heart muscle develop a positive charge
Conductivity
The ability to send an electrical stimulus from cell membrane to cell membrane
Contractility
The ability of atrial and ventricular muscle cells to shorten their fiber length in response to electrical stimulation, causing sufficient pressure to push blood forward through the heart
(Mechanical activity of the heart)
P wave
representing atrial depolarization
PR segment
Represents the time requires for the impulse to travel through the AV node, where it is delayed , and though the bundle of HIS, bundle branches, and purkinje fiber network, just before ventricular depolarization
PR interval
Represents the time requires for atrial depolarization as well as impulse travel through the conduction system and purkinje fiber network, inclusive of the p wave and PR segment
Measures from the beginning of the P wave to the end of the PR segment
Normal measure 0.12-0.20 seconds five small blocks
QRS complex
Ventricular depolarization and is measured from the beginning of the Q(or R) wave to the end of the S wave
