Adult quiz 1 lecture note PDF

Preview

Summary

lecture notes study guide adults quiz...

Description

Med-Surg I Quiz #1 1. Identify the early findings in ARDS; identify implications for nursing care Acute respiratory distress syndrome (ARDS) is a sudden and progressive form of acute respiratory failure in which the alveolar capillary membrane becomes damaged and more permeable to intravascular fluid resulting in severe dyspnea, hypoxemia and diffuse pulmonary infiltrates Alveolar damage S/SX: tachypnea, dyspnea, retractions, hypoxia, tachycardia, decreased pulmonary compliance (stiff, rigid, loss of elasticity), decreased PO2, increased dyspnea ///// s/sx similar to pneumonia “My heart is racing and I can’t catch my breath” Results from: trauma, pulmonary infection/aspiration, prolonged cardiopulmonary bypass, shock, fat emboli, sepsis Medical management: treated in ICU, no specific therapy exists, supportive measures (supplemental O2, mechanical respirator, positioning strategies from supine to prone and lateral rotation therapy), fluid therapy *SUPPORTING BODY TO REPAIR ITSELF Medications: antibiotics, anti-inflamm drugs (corticosteroids), diuretics, drugs to raise BP, anti-anxiety, muscle relaxers, inhaled drugs (bronchodilators)

2. Identify manifestations of impending airway obstruction; identify implications for nursing care S/SX: hypoxemia (tachycardia, restless, tachypnea), cough, mucus, SOB, wheeze, prolonged expiration, inc CO2 retention, chest tightness, retractions Implications: management of asthma= bronchodilators (beta sympathomietrics, methylxanthines, anticholinergics), leukotriene antagonists, mast cell stabilizers, corticosteroids, anti-IgE antibody 3. Identify teaching for the patient with COPD Exercise training (10-45 min per session at least 6 weeks Smoking cessation Nutrition counseling Get pneumonia + flu vaccine

4. Identify the criteria indicating client is in respiratory failure; (ABGs; s/sx); identify management of respiratory and implications for nursing care pneumonia complication = respiratory failure Respiratory failure PO2 of 60 = pt @ 60 = need intubated Ventilatory failure = V/Q mismatch -> perfusion normal, ventilation inadequate, PaCO2 > 45mmHg Oxygenation failure = V/Q mismatch -> ventilation normal, perfusion decreased, PaCO2 < 60mmHg V/Q Mismatch = ventilation doesn’t match with perfusion Ventilation = moving the air Depends which side is not working = different interventions to help fix it Causes of resp failure= NEUROLOGICAL: resp center (opioids, anesthetics, brain injury) cervical nerves C3,4,5 (spinal injury) phrenic nerves (chest trauma, surgery) neuromuscular junction (neuromuscular blockers & myas grav) MUSCULAR: Myopathy (steroids, myas grav, polyneuropathy polymyopathy of critical illness) FAILURE TO MAINTAIN AIRWAY: Airway obstruction (teeth, tongue, laryngeal edema, laryngospasm, inhaled objections, bronchospasm) Chest wall- Flail chest Pneumothorax, hemothorax, pleural effusion Ascites/hemoperitoneum, surgical packs FAILURE TO OXYGENATE DIFFUSION ABNORMALITY Pulmonary fibrosis, interstitial lung disease NORMAL, V/Q = 1 DEAD SPACE VENTILATION, V/Q>1 (pulmonary embolism, excessive PEEP) SHUNT V/Q air leak Suction control -> no bubbling unless attached to suction Water seal chamber tidaling (fluctuation) w/ respiration Listen to breath sounds, RR, O2 Sat, cardiac (BP/tachy,etc) Have 2 clamps on bedside!! Put cup of water at tube when it accidentally d/c to prevent pneumo (air going into lungs) Interventions= - after insertion monitor V/S q 15minx2, 30min x2, 1hr x4 - monitor amount/type of drainage by marking drainage level on outside of collection chamber q1hr. report anything > 100ml/hr, sudden inc/dec drainage, change in characteristics - assess pt and drainage system for an air leak. Air leak is present if air bubbles are observed in water-seal chamber or going from L to R in air leak detector zone. Assessing air-leak chamber, ask pt to take deep breaths in and out. if no leak, ask pt to cough. If leaking air, you will notice intermittent bubbling parallel to respirations. Locate source by pinching tubing for a moment...