Week 3 Material Part 2 Flashcards
1
Q
tracheostomy: risk factors
A
- Trauma, either during intubation or to upper airway structures
- Long term intubation with mechanical ventilation
- Cervical cancer resulting in loss of part of airway
- Also an emergency procedure to secure an otherwise difficult airway with sedation or airway obstruction through trauma, collapse, or foreign body
2
Q
tracheostomy: assessment
A
- Absent lung sounds to auscultation
- Decreased SpO2
- S/S of hypoxia
3
Q
tracheostomy: diagnostics
A
- ABGs
- CXR
4
Q
tracheostomy: interventions
A
- Monitoring
- Ensure tubing does not pull on tracheostomy, adequate water in humidification chamber
- Medications
- Able to deliver aerosolized respiratory medications through trach
- suctioning
5
Q
tracheostomy: complications
A
- LRI
- confirm with CXR
6
Q
tracheostomy: client edu
A
- will require routine care–changing of trach mask
7
Q
Pneumothorax: patho
A
- Presence of air or gas in the pleural space that causes the lung to collapse
-
Tension Pneumothorax occurs when air enters the pleural space during inspiration through one-way valve and is not able to exit upon expiration
- Trapped air causes pressure on heart and lungs → compresses blood vessels and limits venous return → decrease CO
- Tx immediately
- As pressure continues to rise causes mediastinal shift
8
Q
Pneumothorax: risk factors
A
- Blunt chest trauma
- Penetrating chest wound
- closed/ occluded chest tube
- Older adults have dec pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli
- COPD
9
Q
Pneumothorax: expected findings
A
- Signs of respiratory distress
- Tracheal deviation to unaffected side (tension pneumo)
- Reduced or absent breath sounds on affected side
- Asymmetrical chest wall movement
- Hyperresonance on percussion due to trapped air (pneumothorax)
- Dull percussion (hemothorax)
- Subcutaneous emphysema (air accumulation in subq tissue)
10
Q
Pneumothorax: lab tests and diagnostics
A
- ABGs - Hypoxemia (PaO2 <80mmHg)
- Chest X ray
- Confirm pneumo or hemo
11
Q
Pneumothorax: nursing care
A
12
Q
list the classes of meds used for a pneumothorax
A
- benzodiazepines (sedatives)
- opioid agonists (pain meds)
13
Q
what are the benzodiazepines used for pneumothorax?
A
- lorazepam
- midazolam
14
Q
nursing considerations for benzodiazepines used for pneumothorax
A
- Monitor vitals - can cause hypotension and respiratory distress
- Meds have amnesiac effect
- Monitor for paradoxical effects
15
Q
client ed for benzodiazepines for pneumothorax
A
- Amnesic effects and cause drowsiness
16
Q
what are the opioid agonists used to treat pneumothorax?
how do they work, and what are the effects they produce?
A
- morphine sulfate and fentanyl
- act on mu and kappa receptors that alleviate pain
- produces: analgesia, respiratory depression, euphoria, sedation, dec in GI motility
17
Q
nursing considerations for opioid agonists used for pneumothorax
A
- Use cautiously for asthma and emphysema pt
- Assess pain q4h
- Patch - takes several hours to take effects, short acting pain med should be administered for breakthrough pain
- Monitor RR, stop meds if under 12/min
- Monitor vitals for hypotn and bradypnea
- Assess for N/V
- Monitor constipation
- Assess LOC
- Encourage fluid intake and activity
- Monitor intake and output and fluid retention
18
Q
client ed for opioid agonists for pneumothorax
A
- Drink plenty of fluids if not on restrictions to prevent constipation
- Teach about PCA if applicable
- Ventilation education can vary
19
Q
interdisciplinary care for pneumothorax
A
- Respiratory services - ABG, breathing tx, suctioning of airway
- Pulmonary - chest tube management and pulmonary care
- Pain management - if pain persists or is uncontrolled
- Rehab - prolonged weakness and needs assistance with increasing level of activity
20
Q
therapeutic procedures for pneumothorax
A
- Chest tube insertion
- To drain fluid, blood or air
- Reestablish negative pressure
- Facilitate lung expansion
- Restore normal intrapleural pressure
21
Q
list the possible complications of a pneumothorax
A
- dec CO
- respiratory failure
22
Q
explain decreased CO as a complication of pneumothorax
A
- Amount of blood pumped by heart decreases as intrathoracic pressure rises
- HypoTN develops
- Administer IV fluids, blood products, watch HR and rhythm, monitor I&O of chest tube
23
Q
explain respiratory failure as a complication of pneumothorax
A
- Inadequate gas exchange due to lung collapse
- Prepare for mechanical ventilation and continue respiratory assessment
24
Q
hemothorax: patho
A
- Accumulation of blood in the pleural space
- Spontaneous hemothorax can occur when there has been no trauma
- A small bleb on the lung ruptures and air enters the pleural space
25
hemothorax: diagnostic procedures
* CXR
* can confirm pneumo/hemothorax
* thoracentesis
* can confirm hemothorax
26
explain nursing actions for a thoracentesis to diagnose hemothorax
* Informed consent needed
* Client understands remaining still
* Assist client positioning and specimen transport
* Monitor status (vitals, SaO2, injection site)
* Assist to edge of med and lean over on bedside table
* Inform client of feeling discomfort when the local anesthetic solution is injected
* When needle going into lung, some pressure may be felt
27
flail chest: patho
* Occurs when at least 2 neighboring ribs, usually on one side of the chest, sustain multiple fx causing instability of the chest wall and paradoxical chest wall movement
* Results in significant limitation in chest wall expansion
* Inability of the injured side of the chest to expand adequately upon inhalation and contract upon exhalation
* One side typically affected due to multiple rib fx
28
flail chest: risk factors
* Unequal chest expansion
* Paradoxical chest wall movement
* Tachycardia
* Hypotension
* Dyspnea
* Cyanosis
* Anxiety
* Chest pain
29
flail chest: nursing care
* Admin humidified O2
* Monitor vitals and SaO2
* Review findings of pulmonary fx tests, x rays and ABGs
* Assess lung sounds, color and capillary refill
* Promote lung expansion by encouraging deep breathing and proper positioning
* Maintain mechanical vent in the event of severe injury
* Suction trach and endotrach
* Administer pain meds
* Administer IV fluids
* Monitor I and O
* Offer support and reassurance
30
pulmonary embolism: patho
* Occurs when a substance (solid, gas, liquid) enters venous circulation and forms a blockage in the pulmonary vasculature
* Originate from:
* DVT: most common
* Tumors
* Bone marrow
* Amniotic fluid
* Air
* Foreign matter
* Inc hypoxia to pulmonary tissue and impaired blood flow can result from a large embolus
* Medical emergency: must try to prevent, recognize rapidly, and treat
31
pulmonary embolism: risk factors
* Long term immobility
* Oral contraceptive use and estrogen therapy
* Pregnancy
* Tobacco use
* Hypercoaguability (elevated platelet count)
* Obesity
* Surgery (esp ortho surgery of lower extremities or pelvis)
* Central venous catheters
* HF or chronic afib
* Autoimmune hemolytic anemia (sickle cell)
* Long bone frxs
* Cancer
* Trauma
* Advanced age
32
pulmonary embolism: why is advanced age a risk factor?
* Older adults have dec pulmonary reserves due to normal lung changes (dec lung elasticity, thickening alveoli)--\>decompensate quicker
* Certain conditions and procedures that predispose a client to DVT (peripheral vascular dz, HTN, hyp and knee arthroplasty) are more common in older adults)
* Usually lower activity levels--\>predisposed to DVT and PE
33
pulmonary embolism: health promotion and dz prevention
* Smoking cessation
* Maintain appropriate weight for height and body frame
* Encourage healthy diet and physical activity
* Prevent DVT by:
* Doing leg exercises
* Wearing compression socks
* Avoid sitting for long periods
34
pulmonary embolism: expected subjective findings
* Anxiety
* Feelings of impending doom
* Pressure in chest
* Pain on inspiration and chest wall tenderness
* Dyspnea and air hunger
* Cough
* Hemoptysis
35
pulmonary embolism: physical assessment findings
* Pleurisy
* Pleural friction rub
* Tachycardia
* hypoTN
* Tachypnea
* Adventitious breath sounds (crackles) and cough
* Heart murmur in S3 and S4
* Diaphoresis
* Low grade fever
* Dec O2 sats, cyanosis
* Petechiae over chest and axillae
* Pleural effusion
* Distended neck veins
* Syncope
36
pulmonary embolism: lab tests
* ABG Analysis:
* CBC analysis: monitor H&H
* D-Dimer: elevated above normal range in response to clot formation and release of fibrin degradation products (expected reference 0.43-2.33 mcg/mL)
37
pulmonary embolism: ABG results
* PaCOs low (due to initial hyperventilation--\>resp alkalosis)
* As hypoxemia progresses, resp acidosis occurs
* Further progression leads to metabolic acidosis due to buildup of lactic acid from tissue hypoxia
38
pulmonary embolism: diagnostic procedures
* CXR and CT scan
* ventilation perfusion (V/Q) scan
* pulmonary angiography
39
CXR and CT scan used to diagnose PE
* Provide initial ID of a PE
* CT scan is most common
* Chest x-ray: can show large PE
40
V/Q Scan used to diagnose PE
* Show circulation of air and blood in the lungs and can detect a PE
41
pulmonary angiography used to diagnose PE
* GOLD STANDARD and most thorough test but invasive and costly
* Catheter inserted into vena cava to see a PE
* Higher risk than V/Q scan
* Nursing Actions:
* Verify informed consent is obtained
* Monitor V/S, anxiety, bleeding during and after
42
PE: nursing care
* Administer O2 therapy to relieve hypoxemia and dyspnea
* Position pt in high Fowler’s to maximize ventilation
* Obtain IV access
* Administer meds
* Assess respiratory status every 30 min by:
* Auscultate lung sounds
* Measure rate, rhythm, and ease of respirations
* Inspect skin color and cap refill
* Examine for trachea position
* Assess cardiac status by:
* Compare BP in both arms
* Palpate pulse quantity
* Check for dysrhythmias
* Examine neck for distended veins
* Inspect thorax for petechiae
* Provide emotional support
* Monitor changes in LOC and mental status
43
PE: name the classes of meds used
* anticoagulants
* direct factor Xa inhibitor
* thrombolytic therapy
44
name the anticoags used to tx PE and how do they work
* Ie heparin, enoxaparin, warfarin, fondaparinux
* Used to prevent clots from getting larger or new clots forming
45
anticoagulants: nursing considerations
* Assess for contraindications: active bleeding, peptic ulcer dz, hx of stroke, recent trauma
* Monitor bleeding times:
* PT and INR for warfarin
* PTT for heparin
* CBC
* Monitor for SEs: thrombocytopenia, anemia, hemorrhage
46
name the direct factor Xa inhibitor used to tx PE and how it works
* Ie. rivaroxaban
* Binds directly with factor Xa to inhibit production of thrombin
47
direct factor Xa inhibitor: nursing considerations
* Assess for bleeding from any site
* Risk for spinal or epidural hematoma
* Should d/c med for 18 hour prior to removal of epidural catheter and wait another 6 hr to restart
48
name the thrombolytic therapy used to tx PE and how it works
* Ie. alteplase, reteplase, tenecteplase
* Used to dissolve blood clot and restore pulmonary blood flow
* Similar SE and contraindications to anticoags
49
thrombolytic therapy: nursing considerations
* Assess for contraindications
* Monitor for bleeding, thrombocytopenia, anemia
* Monitor BP, HR, RR, O2 sats
50
PE: interdisciplinary care
* cardio/pulmonary services: consulted to manage and tx PE
* Respiratory services: for O2 therapy, breathing tx, and ABGs
* Radiology: for diagnostics
51
PE: therapeutic procedures
* embolectomy
* vena cava filter
52
explain embolectomy as a therapeutic procedure for PE
* surgical removal of embolus
* Nursing Actions:
* Prepare client: NPO, consent
* Monitor post op V/S, SaO2, drainage, pain
53
explain vena cava filter as a therapeutic procedure for PE
* insertion of a filter in the vena cava to prevent further emboli from reaching pulmonary vasculature
* Nursing Actions:
* Prepare client: NPO, consent
* Monitor post op V/S, SaO2, drainage, pain
54
PE: client education
* If client is homebound, set up services to perform weekly blood draw
* Set up referral to supply portable O2 to clients with severe dyspnea
* Educate about tx and prevention of PE:
* Monitor intake of foods high in vit K (green, leafy veggies) if taking warfarin b/c can reduce effects of warfarin
* Adhere to schedule to monitor PT and INR, adhere to weekly blood draw
* Remind client of inc risk for bruising and bleeding
* Avoid aspirin
* Check mouth and skin for bruising/bleeding
* Use electric shavers and soft bristled toothbrushes
* Avoid blowing nose hard, and apply gentle pressure if nose bleed occurs
* If traveling, use measures to prevent PE
55
what should you educate client about to tx and prevent PE?
* Smoking cessation
* Avoid long periods of immobility
* Encourage physical activity
* Wear compression socks
* Avoid crossing legs
56
what are measures the client can use to prevent a PE while traveling?
* Arise from sitting position for 5 min out of every hour
* Wear support hose
* Remain hydrated
* Perform active ROM exercises
57
what are the 2 possible complications of a PE?
* dec CO: blood volume is dec
* hemorrhage: risk for bleeding inc due to anticoag therapy
58
explain nursing actions used to manage dec CO as a complication of PE
* Monitor for hypoTN, tachycardia, cyanosis, JVD, syncope
* Assess for presence of S3 and 4 heart sounds
* Obtain IV access
* Monitor urinary output (should be 30 mL/hour or more)
* Administer IV fluids (crystalloids) to replace volume
* Monitor ECG
* Monitor pulmonary pressures,
* IV fluids can contribute to pulmonary HTN for clients who have RHF
* Administer inotropic agents (milrinone, dobutamine) to inc contractility
* Vasodilators can be needed if pulmonary A pressure is high enough to interfere with contractility
59
explain nursing actions used to manage hemorrhage as a complication of PE
* Assess for oozing, bleeding, or bruising from injection and surgical sites at least every 2 hour
* Monitor CV status (BP, HR, rhythm)
* Monitor CBC and bleeding times
* Administer IV fluids and blood products
* Test stool, urine, vomit for occult blood
* Monitor for internal bleeding (measure abdominal girth and abdominal/flank pain) at least every 8 hour
60
what is cor pulmonale?
* RHF
* Air trapping, airway collapse, and stiff alveoli lead to increased pulmonary
* Blood flow through the lung tissue is difficult → increased workloads → enlargement and thickening of rt atrium and ventricle
61
cor pulmonale: manifestations
* Low oxygenation levels
* Cyanotic lips
* Enlarged and tender liver
* Distended neck veins
* Dependent edema
62
cor pulmonale: nursing actions
* Monitor respiratory status and O2 therapy
* Monitor HR and rhythm
* Meds as prescribed
* IV fluids and diuretics to maintain fluid balance
