Test 2 - Hepatic, Pancreatic, Respiratory Flashcards
(223 cards)
1
Q
Define Hepatitis
A
Widespread inflammation of the liver cells, resulting in enlargement of the liver
2
Q
What types of causes are there for Hepatitis?
A
- Viral
- Bacterial
- Toxic Substances (ETOH, drugs, etc.)
- Immune
3
Q
How is Hepatitis A transmitted?
A
Fecal-orally
4
Q
What does it take to kill Hepatitis A on surfaces/objects?
A
Bleach or very high temperatures
detergents and acids don’t work
5
Q
What type of symptoms are seen with Hepatitis A?
A
Mainly GI symptoms
6
Q
What is Hepatitis A pre-exposure treatment?
A
Hep A Virus Vaccine (2 doses, 6 months apart)
7
Q
What is Hepatitis A post-exposure treatment?
A
Immune globulins within 2 weeks PLUS vaccination
Healthy pts (12 months - 40 years): only need vaccine post-exposure
8
Q
How is Hepatitis B transmitted?
A
Blood and Body Fluids (semen, vaginal secretions, and perinatal exposure during birth)
9
Q
Which Hepatitis do most adults develop immunity to if exposed?
A
Hepatitis B
10
Q
What are patients with chronic hepatitis at increased risk for?
A
Cirrhosis and Liver Cancer
11
Q
Who should be tested for Hepatitis B?
A
Pregnant women with each pregnancy
12
Q
What is pre-exposure care for Hepatitis B?
A
Vaccination
13
Q
What is post-exposure care for Hepatitis B?
A
Immune globulin (IG) + vaccination
- Perinatal Exposure: treat within 12 hours
- Exposure: treat within 2 weeks
14
Q
How is Hepatitis C transmitted?
A
Blood
15
Q
What activity results in the highest incidence of Hepatitis C?
A
IV drug abuse
16
Q
Is breastfeeding allowed with Hepatitis C?
A
Only if nipples aren’t cracked and/or bleeding
17
Q
Is there a vaccine for Hepatitis C?
A
No vaccine available, chronic condition if not cured
18
Q
Who should be screened for Hepatitis C?
A
Anyone older than 18 (once), and pregnant women
19
Q
How is Hepatitis D contracted?
A
It is contracted with Hepatitis B as a co-infection or superinfection
20
Q
How does the Hepatitis D fatality compare with Hepatitis B?
A
Hepatitis D is much more fatal
21
Q
Which variants of Hepatitis can a person be vaccinated for?
A
Hepatitis A, B, D (through B vaccination)
22
Q
What are the functions of the liver?
A
- Formation of Albumin
- Formation of clotting factors such as Prothrombin
- Convert ammonia to urea (BUN)
- Vitamin Storage (A, D, E, K, B12)
- Drug metabolism, breakdown, and excretion
- Formation of Bile
- Hormone homeostasis
- Immunity through phagocytic cells
23
Q
What is Bile used for?
A
Bile is used in fa metabolism and fat soluble vitamins
24
Q
What does ammonia result from?
A
Protein metabolism results in a waste product of ammonia
25
Why is Vitamin K important?
It's a key component for clotting factors
26
What are clinical manifestations for Liver Failure?
- Mostly asymptomatic/flu-like, until the end stages
- Abdominal pain
- Joint/muscle pain
- Lethargy/Malaise
- Fever
- Nausea/Vomiting
- Pruritus
- Jaundice (Icterus) - only in late stages
27
Hepatitis A Testing
IgM ant-HAV antibodies: current infection
IgG anti-HAV antibodies: immunity/recovery
28
Hepatitis B Testing
HBcAB (Core antibody) - exposure to virus/natural infection "presumptive infectious"
HBsAG (Surface antigen) - acute or chronic (after 6 months) infection
29
Hepatitis C Testing
HCV Antibody (+) - presumptive: past/current infection
HCV RNA (+) - currently infected
30
What are the diagnostic tests for assessing the degree of liver injury?
- ALT
- AST
- ALT/AST Ratio
- Albumin
- Ammonia
- BUN
- PT, PTT, INR times
- Bilirubin: conjugated ( cirrhosis) and unconjugated (obstruction and hepatitis)
31
What is the lifespan of RBCs?
120 days
32
Liver Biopsy Care: Before
- NPO for 6 hours
- Check clotting times
- Admin "-phyton" PRN
- Informed consent
- V/S
33
Liver Biopsy Care: During
- Instruct to exhale and hold
| - DON'T move during procedure
34
Liver Biopsy Care: After
- R side position
- V/S
- Assess for S/S of hemorrhage
35
Safety for Liver Failure Patients
- Bleed risk: electric razor, no sticks
- Vitamin supplements (Thiamine, B vitamins)
- Diet: small, frequent, high carb meals
36
What can cause cirrhosis of the liver?
Hepatitis and alcohol (mainly), also any liver disease
37
What is Cirrhosis of the Liver?
A chronic, destructive course resulting in end-stage liver disease
38
What is a possible side-effect of Liver Cirrhosis?
Gynecomastia
39
What are the 4 basic types of Cirrhosis?
Laennec's: r/t alcohol intake
Post Necrotic: r/t infectious or toxic hepatitis (most common world wide)
Biliary Cirrhosis: biliary obstruction or destructrion
Cardiac Cirrhosis: secondary to CHF
40
What are common assessment findings for Cirrhosis?
- Jaundice
- Ascites
- Edema
- Vitamin deficiency
- Petechiae
- Ecchymosis
41
What are complications of Cirrhosis?
- Portal Hypertension
- Bleeding esophageal varices
- Coagulation defects
- Jaundice
- Ascites
- Hepatic encephalopathy (leads to ammonia in the brain)
- Gynecomastia
42
What is Portal Hypertension?
Increased pressure within the portal vein due to cirrhosis (liver scarring)
43
What can Portal Hypertension cause?
- Splenomegaly
- Varices (dilated veins)
- Ascites (peritoneal fluid build-up and swelling)
44
How much blood flows through the liver?
1,500 mL/min
45
Where do varices commonly occur?
- Distal esophagus
- Stomach
- Rectum
46
Why are varices a problem?
They are prone to leakage and rupture
47
What could cause rupture of varices?
- Coughing
- Strenuous exercise
- Trauma
48
What does high levels of Ammonia cause?
Decreased LOC
49
What is the recommended treatment for Variceal Hemorrhage?
- Maintain the airway
- Replace volume (caution with LR - may elevate ammonia in sever liver disease)
- Prep for emergent endoscopy
- Insert NGT: assess new bleeding and lavage
- Reduce hepatic blood flow (use "-pressin", but nitro to counteract around the heart)
50
What is a common symptom of variceal hemorrhage?
Projectile vomiting
51
Long-term Varices Management
- Screening endoscopies
- Beta Blockers ("-lol")
- Monitor Hgb and Hct, anemia, melena (bloody stool), and coffee ground emesis
- TIPS (Transjugular Intrahepatic Portosystemic Shunt): reduces portal venous pressure
52
Symptoms for Excess Bilirubin
- Jaundice: skin, sclera, mucuos membranes
- Pruritis (itching)
- Clay colored stools: no bile in GI tract
- Dark colored urine
- Need to avoid high temperature = increased itch
- Keep skin clean and moisturized
- Use antihistamines
- Keep nails short
53
What are the fat soluble vitamins?
- A
- D
- E
- K
54
Nursing Considerations for a Coagulation Defect
- Monitor PT, PTT, INR
- Monitor for s/s bleeding, coagulation studies
- Vitamin K PRN (SubQ, IM, PO) "-phyton"
55
Where is Albumin produced?
The liver
56
What is ascites?
Fluid accumulation in the peritoneum
57
What does low albumin cause?
A fluid shift into the interstitial space
58
What is the best/most reliable way to assess ascites?
Ultrasound
59
Nursing Care for Ascites
- Diuretics (lasix, aldactone)
- Limit Na (0.5 - 2 g/day)
- Limit PO and IVF (1,000 - 1,500 mL/day)
- Check electrolytes
- Elevate HOB
- Check abdominal girth
- Input/Output and daily weight
60
What is the purpose of a paracentesis?
To relieve abdominal pressure and to evaluate the peritoneal fluid
61
Paracentesis pre-procedure care
- Consent form
- Void prior to procedure
- Upright position
- Albumin IV
62
Paracentesis post-op care
- V/S, including weight
- Monitor for s/s hypovolemia
- Albumin replace if ordered (for larger amount drained)
63
Long-term Management for Ascites
- PleurX Drainage system (q 1-2 days)
- Shunt Placement
High complication rate:
-Infection, Bleeding, Shunt Failure
64
What is a result of Portal-Systemic Encephalopathy (PSE)?
Altered mental capacity d/t high serum ammonia
65
What are the common precipitating factors for PSE?
- Excessive protein intake and GI bleeds (protein digestion = higher ammonia)
- Constipation (GI flora change increases ammonia)
- Drugs (opioids, sedatives, analgesics)
- Infection
- Electrolyte imbalance (low K)
66
Symptoms of PSE
- Restlessness, short attention span, LOC change
- Asterixis "wrist flap" (unable to hyperextended wrist)
- Fetor hapticus (liver breath)
- Comatose
67
Treatment of PSE (Supportive care)
- Protein restriction (plant proteins)
- Avoid electrolyte imbalances and dehydration
- Fall precautions
- Vulnerable to over-sedation
68
Treatment of PSE (To lower ammonia)
-Administer "lactulose" (titrate to 2-4 stools/day)
-Lower colonic pH
S/E: Abd cramps, hyperglycemia, diarrhea -> hypokalemia and dehydration
-Antibiotics
69
What are the two types of Liver Cancer?
- Primary Hepatic Cancer: originates in the liver
| - Metastatic Hepatic Tumor: originates outside the liver
70
What are the main causes for Primary Hepatic Cancer?
- Chronic Hepatitis B or C (most common)
| - Cirrhosis
71
What are the symptoms of Liver Cancer?
They depend on the amount/size of damage
- Early S/S: vague, until large tumor
- Jaundice, ascites, hepatic encephalopathy
- Elevated (AFP) alpha-fetoprotein levels
72
Treatment for Liver Cancer
- Surgical management if contained to only 1 lobe, may increase survival by up to 5 years
- Chemotherapy
- Cryotherapy
73
Organ Transplants
- Obesity leads to fatty liver = unable to donate
| - Prioritized on a waiting list
74
Liver Transplant Considerations
Transplant not an option for:
- Malignant cancer
- Severe CVD
- Inability to follow instructions about drug therapy or self-care
75
Post Transplant Care
-Monitor s/s of rejection
-Infection risk
-Hepatic or Renal complications
Bleeding
Petechiae
Ecchymosis
Elevated liver and renal function tests
76
What are the types of Pancreatitis?
- Acute
| - Chronic
77
What is Acute Pancreatitis?
Exocrine disorder
| -Premature activation of pancreatic enzymes which leads to auto-digestion
78
What are symptoms of Pancreatitis?
- Severe epigastic, L quadrant pain (most common)
- Nausea/Vomiting
- Abdominal distention
- Jaundice
- Low grade fever
- Hypovolemic shock: tachycardia, hypotension r/t inflammation
- Grey turner's sign: flank
- Cullen's sign: belly button
79
Pancreatitis pain
- "Boring" pain
- Worsened in supine
- Lessened in fetal position
80
Where is Cullen's Sign found?
The belly button
81
Where is Grey Turner's Sign found?
The flank
82
At what Hgb do you transfuse blood?
Hgb <9
83
Potential Complications of Pancreatitis
- Jaundice
- Hyperglycemia
- Hypocalcemia (HALLMARK of pancreatic/fat necrosis)
- Pulmonary complications (ARDS, pleural effusion, atelectasis, pneumonia)
- Paralytic ileus d/t peritoneal irritation
- Hypovolemic shock d/t fluid shift and/or hemorrhage
- DIC (deactivated clotting factors)
- Renal failure d/t hypovolemia
84
What are diagnostic tests for Pancreatitis?
- Elevated serum Amylase
- Elevated serum Lipase
- Elevated WBC
- Decreased Hgb and Hct
- Elevated ALT
- Elevated glucose r/t insulin production stopping
- Decreased potassium r/t N/V
- Decreased calcium r/t lipolysis
85
Pancreatitis Interventions
```
-A,B,C
ICS, Cough and Deep Breathe
Fluid replacement
-Pain control - morphine (demerol by old HCPs)
-Input and Output
-Monitor labs
-Nutrition: TPN, enteral or PO feeds (assess peristalsis)
-Histamine blockers/PPI
```
86
Invasive Pancreatitis Treatments
- Drain pancreatic abscess to remove necrotic tissue
| - ERCP to remove gallstones
87
How survivable is Pancreatitis?
90% recover with just supportive care in 5-7 days
10% die from acute pancreatitis r/t severe respiratory issues -> left lower lung issues
"Ranson criteria" to evaluate chance of outcome
88
What is Chronic Pancreatitis?
A progressive, destructive disease that goes through phases of remission and exacerbation
89
What is the primary risk factor for Chronic Pancreatitis?
Alcoholism
90
What (besides alcoholism) causes Chronic Pancreatitis?
Autoimmune issues, obstruction of the sphincter of oddi
91
What affects the sphincter of oddi?
Alcohol - causes spasms
92
What are symptoms of Chronic Pancreatitis?
-Abdominal pain (lower amount than acute)
-Insufficient enzyme production
Malnutrition (decreased fats and proteins)
Steatorrhea (fatty stools)
-Diabetes
-Ascites
93
What is steatorrhea?
fatty stool
94
What do you focuss on for Chronic Pancreatitis interventions?
Pain, nutrition, and prevention of reoccurrences
Don't assume pancreatitis = alcoholism
95
What are specific interventions for Chronic Pancreatitis?
-Nutrition (main focus)
High caloric intake: 4,000 - 6,000 calories (high protein and carbs, low fat)
-TPN (or J Tube)
-Insulin (even for non-diabetic patients)
-Enzyme Replacement Therapy
96
What drugs can enhance PERT (Pancreatic Enzyme Replacement Therapy)?
H2 Blockers or PPIs
97
When should you not take PERT?
- On an empty stomach
- With drinks that contain <1/2 milk = tea, squash, fizzy drinks
- If you eat only small quantities of food
98
Enzyme Replacement Therapy (PERT)
- Take with food at meals, follow PERT with glass of water
- Take after H2 blockers or antacids
- Don't chew
- If can't swallow pill, use with applesauce
- Don't mix with protein foods
- Wipe lips after
- Don't crush
- Follow up
99
When might it be appropriate to alter own dose of PERT?
If experiencing loose stools or failing to gain weight
100
Education for PERT
- Monitor uric acid levels
- Monitor for fatty stools
- Prevent exacerbations of pancreatitis (avoid ETOH and caffeine)
101
What is a risk from PERT?
PERT = increased uric acid = chance of gout
102
Pancreatic Carcinoma
- Survival is extremely rare
| - Cause is unknown
103
What is the purpose of a "Whipple"?
Redirects the body's pancreatic enzymes when part of the pancreas has to be removed
104
Whipple Post-op Care
-NPO, NGT with contiuous suction
| expect serosanguineous drainage (pink/yellow)
105
What are Whipple Post-op complications?
- Hemorrhage
- Diabetes
- Wound infection, dehiscence
- Bowel obstruction
106
How o you know when NGT can be removed?
- Turn off suction and listen for BS
| - Stool or gas passage
107
Total Pancreatectomy Diet
- Lentils
- Chick peas
- Garbanzos
108
Will a total pancreatectomy resolve a carcinoma?
- No, the cancer often returns
| - A successful surgery only adds 5-6 more years
109
Lung Sounds: Crackles
- Air passing through fluid
- Clear by suctioning
- Heard on inspiration
110
Lung Sounds: Wheezes
- Narrowed airway
- High pitched
- Whistling sound
111
Lung Sounds: Rhonchus
- Coarse, snoring
- Larger Airway
- Air passing over solid, thick sputum
- Heard on expiration
- Cleared by coughing
112
Lung Sounds: Stridor
-Louder noise of the neck than over the chest wall
113
Lung Sounds: Bronchial
- Trachea
| - Main stem brochi
114
Lung Sounds: Bronchovesicular
-Branching bronchi
115
Lung Sounds: Vesicular
-Small bronchi
116
What are risk factors for Lung Cancer?
- Smoking (90% of cases)
- Second hand smoke
- Radon exposure
- Occupational pollutants
- Asbestos
117
Tobacco Use Calculation
packs per day x years of smoking = pack years
118
How long does it take for lungs to fully recover and cancer risk to be normal again?
15 years post-cessation of smoking
119
What are the two classifications for Lung Cancer?
Non-small cell (NSCLC)
Small Cell (Oat cell)
120
Non-Small Cell Lung Cancer (NSCLC)
85% of all Lung Cancers
| -3 types
121
Small Cell (Oat Cell) Lung Cancer
Most Malignant
- 5 year survival is 5-10%
- Causes paraneoplastic syndrome (endocrine issues)
122
Clinical Manifestations of Lung Cancer
- New chronic cough
- Hemoptysis
- SOB
- Wheezing
- Hoarse
- Chest pain
- Unexplained weight loss
- Frequent respiratory infections
- Headache
- Bone pain
123
Common sites for lung cancer metastasis
- Bone
- Liver
- Adrenal Glands
124
Diagnostics for Lung Cancer
- Sputum Cytology
- X Ray, CT, MRI, PET
- Fiber optic bronchoscopy with biopsy**
- Thoracoscopy
- Percutaneous lung biopsy
- Thoracentesis with fluid evaluation
125
**Fiber Optic Bronchoscopy with Biopsy - post op care**
- Monitor for respiratory distress
- Keep the patient NPO until gag reflex returns
- Monitor for s/s bleeding
126
Lung Cancer Screening for at risk population
Yearly "low-dose" CT scans
127
What is a lobectomy?
Removal of a lobe of the lung
128
What is a pneumonectomy?
Removal of an entire lung
129
What is decortication of a lung?
Surgical removal of the surface layer of a lung
130
Which needs chest tubes: Lobectomy or Pneumonectomy?
Lobectomy
131
Where will chest tubes be post-lobectomy?
Apex and Base of the lung
Apex- little drainage
Base- most of the drainage d/t gravity
132
Lobectomy Post-op Care: Pain Managing
- PCA
- Epidural
- On-Q Soaker
133
What is Crepitus?
Subcutaneous Emphysema: air between skin layers "Rice Krispies"
- Common immediately post-op
- Mark the area to track size
134
Positioning of Patient: Pneumonectomy
Operated side or supine
135
Positioning of Patient: Lobectomy
Non-operated side or supine
136
Post-op Care: Pneumonectomy/Lobectomy
- Maintain chest tube patency
- Monitor for complications
- Exercise affected arm & shoulder (no heavy lifting 6 months)
137
What are complications from a Pneumonectomy or Lobectomy?
- Sudden SOB
- Trachea shift (mediastinal shift)
- Pain
- Low CO
- Cardiac herniation (RARE)
138
Order of Steps to Address with Patients Who Smoke
- Ask
- Advise
- Assess willingness
- Refer
Help arrange follow-up
139
Options to Help Quit Smoking
-Replace smoking with healthy habits
-Nicotine patches
-Nicotine gum
-Zyban (wellbutrin), bupropion)
-Chantix
S/E:
Anger
Nightmares
Etc.
140
Lung Cancer = end of life care
- Overall 5 year survival is only 14%
| - Requires palliative and/or hospice care
141
What can a clamped chest tube cause?
Tension pneumothorax
142
What is the purpose of a chest tube?
To re-inflate the lung; removal of air (pneumothorax) or fluid (hemothorax) from pleural space
143
Chest Tube System - Chamber #1: Drainage
- Collects fluids
- Assess for sudden increase/cessation of output
- Normal: 100 ml/hr
- Output decreases as healing occurs
- After first day, check q8h
144
Chest Tube System - Chamber #2: Water Seal
- Prevents air from entering pleural space "one-way valve"
- Bubbles during forceful expiration or cough = draining air
- Contiuous bubbling = broken system
- Bubbling completely stops = healed or tube kinked
145
Tidaling in the Water Seal Chamber
Water level ^/v with respiration
146
Chest Tube System - Chamber #3: Suction Control
-Wet or Dry Suction Control
| Recommnded Suction: 20 cm H2O
147
Wet Suction Control
Suction controlled by water level
| -water will gently bubble when connected to wall suctioning
148
Dry Suction Control
Suction controlled by dial
149
Chest Tube Care Principles
- Call HCP if sat <90%
- Document drainage per protocol, Intake and Output
- Avoid vigorous stripping
150
What do you do if Chest Tube is pulled from the chest wall?
Cover with sterile dressing and tape of 3 sides*
151
What do you do if chest tube is disconnected from the drainage system?
Submerge the tube in H20 (temporary water seal); call for help
152
Nursing Actions for Chest Tube
- Monitor for Crepitus
- Encourage cough and deep breathing
- Secure all connections
- Monitor for complications
153
Removal of Chest Tube
Cover with vaseline gauze (controversial) or Tegaderm
154
What is the purpose of an ET Tube?
To maintain a patent ariway
155
What is the purpose of a mechanical ventilator?
To breathe for the patient when they aren't able to
156
Define Tidal Volume
The amount of air moved by each respiration
157
PEEP vs. CPAP
PEEP is only pressure during expiration. CPAP is constant pressure through inspiration AND expiration
158
What are possible complications from a Ventilator?
- Hypotension
- Aspiration
- Infection
- Ventilator Associated Pneumonia (VAP)
- Barotrauma (overdistention of alveoli)
159
What are some nurse care examples for a Ventilator?
- HOB 30 to 45 degrees
- Suction PRN
- Monitor for S/S of infection (VAP, aspiration pneumonia, etc.)
- DVT Prevention
- NPO, TPN
160
What are risk factors for Acute Respiratory Failure?
- Pulmonary edema
- Pneumonia
- Pulmonary embolism
- Hypercapnic respiratory failure
- Asthma
- Narcotics overdose
- Myasthenia gravis
161
Types of Acute Respiratory Failure
-Impaired ventilation/hypoventilation
Airway obstruction, OD
-Ventilation perfusion mismatch (lungs functioning, but not perfused)
Pulmonary embolism
-Impaired O2 diffusion at alveolar level
ARDS, pulmonary edema, fluid in alveoli
162
What are clinical manifestations of Acute Respiratory Failure?
Main Symptoms: dyspnea, orthopnea or DOE (dyspnea on exertion)
-Hypercapnia/ Hypercarbia (high CO2)/ Hypoxia (low O2)
Changes in RR, HR, BP
HA, confusion, decreased LOC
163
Cyanosis vs. Clubbed Fingers
Cyanosis - acute hypoxia
| Clubbbing - chronic hypoxia
164
Acute Respiratory Distress Syndrome (ARDS)
Criteria:
- Acute onset (<7 days)
- Refractory hypoxemia (doesn't respond to noninvasive O2 therapies
- Bilateral infiltrates on X Ray (white out)
- No evidence of CHF
165
Precipitating Factors for ARDS
- Shock
- Trauma
- Pancreatitis
- Sepsis
- Pulmonary Aspiration
- Toxin Inhalation
- Multiple blood transfusions (within 6 hrs of transfusion time)
166
What causes ARDS?
Release of chemical inflammatory mediators leads to lung injuries (increased capillary permeability = fluid into alveoli)
167
What are clinical manifestations of ARDS?
- Rapid onset of sever dyspnea
- Increased alveolar deadspace
- Hypoxemia that doesn't respond to supplemental O2
- Abnormal lung sounds
- Altered LOC
- Cyanosis
- Intercostal and/or substernal retractions
- Tachycardia
- Hypotension
168
Nursing Implications for ARDS
- Strict infection control
- Intubation and ventilation with PEEP, CPAP< or APRV
- Corticosteroids = decreased inflammation
- Prone positioning (controversial)
- Nutrition
- Fluids as ordered
- Inhaled Nitric Oxide
- Surfactant Replacement
169
What is the functino of Nitric Oxide?
Vasodilation
170
Extra-Corporeal Membrane Oxygenation (ECMO)
Oxygenates the blood and allows lung rest and healing (lung dialysis)
171
Pulmoary Embolism
Obstruction of the pulmoary artery or one of its branches, (by solid, liquid, air) usually by a blood clot
Pts. may die within 1 hr of onset
172
Pulmonary Embolism Predisposing Factors
- Prolonged immobility (venous stasis)
- CVC
- Surgery (vessel damage, clotting)
- Obesity
- Age
- Increased clotting conditions (pregnant, sickle cell, estrogen tx)
- History of thromboembolism
173
Symptoms of Pulmonary Embolism - Classic
- Sudden dyspnea
- Pleuritic chest pain
- Tachypnea
- Anxiety
- Feeling of impending doom/unwell
- New cough
- Hemoptysis
174
Symptoms of Pulmonary Embolism - Severe
- Tachycardia
- JVD
- Hypotension d/t no right side circulation
175
Any idiopathic: SOB, Chest Pain, and/or hypotension
Call HCP immediately
176
Prevention for a PE
```
-Prevention of DVT
Homan's sign - can't rely on
Notice unilateral swelling
-Passive, active ROM
-Ambulate ASAP
-Antiembolism, compression stockings/device
-Anticoagulants/Antiplatelets
-Avoid smoking
```
177
Diagnostics for PE
-CT scan
Know kidney function (BUN/Cr, UOP >30 ml/hr)
-Ventilation perfusion scan (VQ scan)
-D dimer
178
PE Drug Therapy
Anticoagulants
- Heparin: PTT 1.5-2.5 x normal
- Coumadin (Warfarin): INR 2-3
- Lovenox (enoxparin): SubQ q12h
- Xarelto (rivaroxaban):
Thrombolytics: "-ase"
179
Presentation for Laryngeal Trauma
- Hoarseness
- Difficulty swallowing
- Dyspnea
- Hemoptysis
- Hematoma/edema of neck
180
Nursing Interventions for Laryngeal Trauma
- Monitor airway patency
- Trach tray and emergency equipment at bedside
- Humidified air
- HOB >45 degrees
- Aspiration precautions
- Voice rest
181
Laryngeal Trauma: Prep for Surgery
- Evacuation of hematoma
- Repair lacerations
- Stabilization of fractures
- Total laryngectomy (won't be able to speak after)
182
PaO2 in acute care
>60 mmHg
183
CPAP Modes
- Invasive
| - Noninvasive
184
Invasive interventions for Acute Respiratory Failure
ET Tube (Invasive, last resort) - Advantages
- Decreased airway resistence
- Decreased work of breathing
- Improved oral care
- Improved suctioning
- Improved patient comfort
185
ET Intubation
Provide O2 if attempt >30 seconds
Monitor for:
- V/S
- Signs of hypoxia or hypoxemia
- Dysrhythmias
- Aspirations
186
Verification of ET Tube Placement
Clinical Assessment:
- Chest Rise
- Bilateral Breath Sounds
- Gurgling in Stomach (misplacement into esophagus)
- Waveform capnography**
Stabilize the ET tube
187
Waveform Capnography - ETCO Value
35 - 45 mmHg
188
Pressure Alarms with ETT (Low/High)
Low Pressure: leakage; pt stopped breathing (if on CPAP or SIMV)
High Pressure: Blockage; biting/couhging/mucus plug/kink/water collection -> fix with suction
189
Mechanical Ventilator Complications
- Hypotension (especially PEEP): increased intrathoracic pressure = decreased CO
- Aspiration: epiglottis not functioning
- Infection
- VAP (48 hr or more after intubation)
- Barotrauma: alveolar rupture
- Friable lungs
190
What can chronic use of corticosteroids cause?
Decreased healing
191
Weaning of Mechanical Vent/ETT
Criteria:
- Individualized
- Ability to breathe spontaneuously
- Ability to maintain adequate O2
- Hemodynamically stable
Must DC sedation, assess VS and LOC
192
Extubation
Monitor:
- VS
- S/S resp. distress: SOB, coughing, stridor, inability to cough up secretinos, aspiration
- Limit speaking
- Semi Fowler's
- ICS
193
Modes of Ventilator
- Tidal Volume: amount of air in each respiration
- Rate: bpm
- FiO2: oxygen concentration to patient (RA is 21%)
194
Side Effects of PEEP
- Additional intrthoracic pressure = decreased CO
- Pneumothorax
- Barotrauma in friable tissue
- Low CO
195
Controlled Mechanical Ventilation (CMV)
Machine completely controls all aspects of breathing
-severe spinal injury, sedation/paralytic agent
196
Synchronized Intermittent Mandatory Ventilation (SIMV)
Pt can take sponteaneous b/w ventilator breaths
As patient is able to take more spontaneous breaths, resp. alk. risk increases
197
Assist-Control Ventilation
SIMV but pressure support added on spontaneous breaths
Ideal for respiratory muscle recovery
198
CPAP
Invasive or Noninvasive
Keeps alveoli open; patient breathes spontaneously
199
Allen's Test before obtaining ABG from ______ Artery
Radial Artery
Occlude one side, then the other and check blood return
Firm pressure of site: Radial = 5 min, Femoral = 10 min
200
Symptom of Aortic damage
cough d/t laryngeal nerve stimulation
201
Primary Assessment
To rule out or identify life-threatening conditions
202
ABCDE of Primary Assessing
A - Airway (C4 & C5 innervate diaphragm = C-spine precautions)
B- Breathing (equal/ breath sounds/ chest wall movement)
C- Circulation (HR, BP, IVF)
D- Disability (GCS or AVPU scales)
E- Expose (Remove clothing to get clear visualisation, but prevent hypothermia)
203
What would a pulse at only: radial, femoral, or carotid, indicate?
Radial - BP >80
Femoral - BP >70
Carotid - BP >60
204
What 3 components make up the Triad of Death?
Hypothermia, Metabolic Acidosis, Coagulopathy
These all are positive feedback looped resulting from hemorrhage
205
Secondary Assessment: AMPLE
```
A - Allergies
M - Medication Use
P - Past Medical History
L - Last Meal
E - Events/Environment b4 injury
```
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Clues for Potential Injuries: Diminished Breath Sounds, Bowel Sounds in Lower Mid Chestr, Bruit, Muffled Heart Sounds
Diminished Breath Sounds: pneumothorax
Bowel Sounds in Chest: ruptured diaphragm
Bruit: vascular injury
Muffled Heart Sounds: cardiac tamponade, pericardial bleed
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When is the only time that a bruit is a good thing?
In assessing a fistula
208
What can JVD indicate?
Tension pneumothorax
| Paricardial tamponade
209
What can Flat JV indicate?
Hypovolemia
210
What does a shifted trachea indicate?
Tension pneumothorax
| Massive hemothorax
211
What is the most common blunt chest injury?
Rib fx
212
What is a Flail Chest?
Ribs are broken in two places, resulting a free-floating piece of the ribcage
213
What can 1st and 2nd rib fx injure?
Blood vessels and nerves
214
What can fractures of ribs 9-12 injure?
Liver, Spleen or Diaphragm
215
S/S of Flail Chest
- Paradoxical respirations
- Chest wall pain
- Respiratory complication (r/t pain on respiration)
216
Interventions for Rib fx
Pain meds (carefully) to lessen pain and improve ventilation ability
217
What is a Pulmonary Contusion?
Hemorrhage b/w alveoli resulting in pulmoary edema and respiratory failure (may develop over time)
218
Nursing Care for Pulmonary Contusion
- O2
- Chest Tube if pneumo/hemo-thorax
- GCS <8 requires intubation
219
S/S of pneumothorax
- Dyspnea
- Tachycardia
- Hyper resonance on INJURED side
- Decreased breath sounds on INJURED side
- Pleuritic chest pain
- Subcutaneous emphysema (crepitus)
- Tracheal deviation
220
S/S of Tension Pneumothorax (order)
- Tachycardia
- Severe respiratory distress
- Hypotension
- JVD
- Angina
- Tracheal Deviation
- Cyanosis
221
S/S of Hemothorax
Dullness on INJURED side (with percussion)
222
Thoracotomy/Chest Tube
Pneumothorax: 2nd or 3rd intercostal space at midclavicular line
Hemothorax: 4th to 8th intercostal space at midaxillary line
223
5 P's
- Pain
- Parasthesia
- Pallor
- Pulse
- Paralysis
