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FinalExamABGArterial Blood Gases Hypoxemia with O2 not diffusing through fluidfilled alveoli Respiratory Alkalosis: hyperventilation Respiratory Acidosis: CO2 retention Metabolic Acidosis: accumulation of lacticacidpCO2 35- 45 mmHg Opposite of pH, respiratoryHCO3 21- 28 mEq/L Same as pH, metaboli...

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Final Exam

ABG Arterial Blood Gases

pCO2 HCO3 pH Uncompensated Partially compensated Full compensated

35- 45 mmHg 21- 28 mEq/L 7.35- 7.45

Hypoxemia with O2 not diffusing through fluid filled alveoli  Respiratory Alkalosis: hyperventilation  Respiratory Acidosis: CO2 retention  Metabolic Acidosis: accumulation of lactic acid Opposite of pH, respiratory Same as pH, metabolic pH & only one other value is normal All values are abnormal pH is normal, but PaCO2 and HCO3 are abnormal

Respiratory Acidosis pH 45 Causes  Hypoventilation caused by:  Overdose of narcotics/alcohol  Tumor  COPD and other respiratory conditions (severe asthma & emphysema)  Neuromuscular diseases that affect respiratory movement (Myasthenia Gravis, Guillian-Barre syndrome)  Pulmonary edema  Airway obstruction  Chest trauma Symptoms  Dyspnea  Cyanosis  Muscle twitching  Sweating  Hypertension  Decreased LOC  Peripheral vasodilatation  Cardiac dysrhythmias Treatments  Reversal of underlying pathology, and mechanical ventilator support to help “blow off” CO2. Focus is on increasing ventilation: C&DB, reverse sedation, bag/intubate  *Oxygen administration will not fix respiratory acidosis

Metabolic Acidosis pH 7.45 and HCO3 > 28 Causes Body loses acids, or gains bases by • Prolonged vomiting • NG suctioning • Diuretic abuse • Sodium bicarb overdose • Overuse of antacids • Hyperaldosteronism • Cushing’s syndrome • IV administration (blood products or TPN) Symptoms • Mental confusion, stupor • Apathy • Muscle weakness (secondary to low potassium) • Dizziness • Tetany • Convulsions • Hypoventilation (secondary to compensation) Treatments • Treat primary cause • Potassium replacement • Saline infusion

Dehydration Symptoms •

• •

Cardiovascular Changes o ↑ Heart rate o Weak peripheral pulses o ↓ BP (greater decrease in SBP) o Orthostatic hypotension o Light-headedness o Dizziness Respiratory Changes: o ↑ respiratory rate Skin Changes o [less reliable in elderly due to normal ↓ in skin elasticity] o Poor skin turgor o Dry, scaly skin o Dry mucous membranes possibly with a thick, paste-like coating

Dehydration in the elderly • • • •

Poor skin elasticity Disorientation Constipation Tachycardia

Fluid Overload Cardiovascular changes: • ↑ HR • Bounding pulse quality • Full peripheral pulses • ↑ BP • ↓ Pulse pressure • ↑ Central venous pressure • Distended hand & neck veins • Engorged varicose veins • Weight gain (often rapid) Respiratory changes:  ↑ Respiratory rate  Shallow respirations  ↑ Dyspnea with exertion or in supine position  Moist crackles present with auscultation Skin and Mucous Membrane Changes:  Pitting edema in dependent areas  Skin pale & cool to the touch Neuromuscular Changes  Altered level of consciousness  Headache  Visual disturbances

Skeletal Muscle  Weakness  Parasthesias Gastrointestinal Changes  Increased motility  Enlarged liver

ELECTROLYTES Magnesium

1.3-2.1 mg/dL

Potassium

3.5-5.0 mEq/L

Calcium

9.0- 10.5 mg/dL

Sodium

136- 145 mEq/L

Phosphorus

3.0- 4.5 mg/dL

Nerve, muscle, enzyme function – cardiac impact; extracellular Mg regulates blood coagulation Nerve, muscle, enzyme function – cardiac impact; hypo OR hyper can lead to cardiac dysrhythmias  ↓ levels reduce cell tissue excitability leaving them less responsive to normal stimuli.  ↑levels result in excitable tissues respond to less intense stimuli and may discharge spontaneously; the heart is very sensitive to potassium level ↑ Activates enzymes allowing skeletal & cardiac muscle contraction – cardiac impact; blood clotting Major cation in extracellular fluid maintaining ECF osmolarity, sodium levels should be high in the ECF and low in the ICF – this is vital for skeletal muscle contraction, cardiac contraction, nerve impulse transmission, and volume in the ECF (fluid balance) Major anion in ICF, activates vitamins and enzymes, forms ATP for energy supply, assists in cell growth and metabolism, acid-base balance function, maintains calcium homeostasis

Hyponatremia Symptoms: apprehension, anxiety, muscular twitching, muscle weakness, headache, tachycardia, hypotension Nursing: Tx will include po water restriction, IV NaCL or 3% saline. Urine specific gravity 1.030 can indicate high Na.

Hypokalemia Symptoms: vertigo, hypotension, cardiac dysrhythmias, nausea, vomiting, diarrhea, abdominal distension, decreased peristalsis, muscle weakness, leg cramps, behavioral changes (confusion, irritability, mental depression) Nursing: Overhydration can dilute K levels. Prolonged and depressed ST segment and a flat or inverted T wave can indicate low K. Corticosteroids and potassium-wasting diuretics can cause sodium retention and potassium excretion. A low K level enhances Dig effects, leading to Dig toxicity. Never give K via IV push. K via IVPB is irritating to heart muscle and veins.

Hyperkalemia Symptoms: bradycardia, abdominal cramps, oliguria or anuria, extremity tingling, twitching or numbness Nursing: Dehydration can concentrate K levels. A wide QRS and peaked T waves can indicate high K. Kayexelate (ion exchange resin) can be given to promote K excretion.

Hypocalcemia Symptoms: tetany (muscular twitching, tremors, larynx spasms, facial spasms, spasmodic contractions), increased peristalsis, positive Chvostek’s and Trousseaus’s Nursing: Dig toxicity can occur if calcium supplements are given to the point of too high Ca while taking Digoxin. Avoid the overuse of antacids and prevent chronic laxative habit – both can lower Ca levels. Calcium IV should be administered slowly and in D5W; NS contains sodium which promotes calcium loss

Hypercalcemia Symptoms: lethargy, headaches, weakness, muscle flaccidity, cardiac dysrhythmias including heart block, anorexia, nausea, vomiting, decreased peristalsis Nursing: Promote active or passive ROM for bedridden patients to prevent calcium loss from bone. Thiazide diuretics inhibit calcium excretion and promote high Ca.

Hypophosphatemia Symptoms: anorexia, pain in muscle and bones, generalized skeletal muscle weakness that can lead to breakdown (rhabdomyolysis) or decreased respiratory function, decreased stroke volume and CO Nursing: Low PO4 should result in high Ca levels. Do not take antacids that contain aluminum hydroxide – phosphorus binds with it lowering the PO4 levels.

Hyperphosphatemia Symptoms: no effects seen Nursing: High PO4 should result in low Ca levels. Decreased urine output of 15 min and not relived by rest or nitroglycerin  Often radiates to the left arm, shoulder, and jaw and sometimes described as “crushing”  Dyspnea and cyanosis due to ↓ cardiac output  Poor organ perfusion due to an insufficient amount of O2 being pumped to the body  Watch for urine output 600 mg/dL]  Insulin deficiency and profound dehydration  Kidney impairment causes the increased blood glucose levels – normally the kidneys act as a safety valve to eliminate excess glucose [above 180 mg/dL]  Decreased blood volume caused by osmotic diuresis [or underlying kidney disease] resulting in furthering kidney function deterioration o Decreased GFR results in increased blood glucose levels Symptoms: confusion, coma, seizures, myoclonic jerking, reversible paralysis, severe dehydration, tachycardia, lethargy  The extent of the symptoms are based on serum osmolarity levels – coma occurs with levels >350 mOm/L

Diabetes insipidus patho Water metabolism problem caused by an antidiuretic hormone [ADH] deficiency resulting in excretion of large amounts of dilute urine  Either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH  Without ADH, the distal kidney tubules & collecting ducts do not reabsorb water into the body – this lead to polyuria [excessive water loss through urination] and dehydration o DI is diagnosed with urine output >4L/24hrs and more than intake [UO may be 4-30 L/day] Nursing Diagnosis Priority:

Diabetes Insipidus Water metabolism problem caused by an antidiuretic hormone [ADH] deficiency resulting in excretion of large amounts of dilute urine  Either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH  Without ADH, the distal kidney tubules & collecting ducts do not reabsorb water into the body – this lead to polyuria [excessive water loss through urination] and dehydration  DI is diagnosed with urine output >4L/24hrs and more than intake [UO may be 4-30 L/day] Nursing Diagnosis:

Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Vasopressin [ADH] is secreted even when plasma osmolarity is low or normal causing water to be retained resulting in dilutional hyponatremia and fluid overload  Also known as Schwartz-Barter syndrome  Increased plasma volume results in increased glomerular filtration rate [GFR] and inhibits the release of renin and aldosterone o This results in an increased sodium loss in urine, leading to a greater hyponatremia  Free water [not retained] is retained and dependent edema is not usually present Symptoms  GI: loss of appetite, nausea, vomiting  CNS: lethargy, headaches, hostility, disorientation, change in LOC o In the later stages: decreased responsiveness, seizures, coma, decreased deep tendon reflexes  Vital Signs: full and bounding pulse, hypothermia  Urinary: ↓ urine volume, ↑ urine osmolarity, ↑ plasma volume, ↓ plasma osmolarity, ↑ urine sodium levels, ↑ urine specific gravity indicating ↑ urine concentration, ↓ serum sodium levels [often as low as 110 mEq/L]

Gestational Diabetes Mom risks: Mom is at risk hyperglycemia and the risks that accompany high blood glucose levels Baby risks:  Increased glucose causes the baby’s pancreas to produce  more insulin to combat against the extra glucose  Extra glucose for energy is transformed to fat leading to  higher birth weight = “Macrosomia” [fat baby] o Damage to shoulders during birth  Extra insulin in the baby’s system can lead to hypoglycemia after birth – may need sugar water to combat low blood sugar levels o Higher risk for breathing problems with hypoglycemia  Babies with excess amounts of insulin at birth have increased chances of overweight childhood & type 2 DM in adulthood

Pneumothorax A pneumothorax is a partial or complete collapse of a lung with a chest injury that allow air to enter the pleural space resulting in a rise of chest pressure and a reduction of vital capacity Nursing Interventions:  Maintain safety  Monitor lung sounds, VS, oxygenation, and LOC  Encourage ambulation, cough & deep breathing, upright positioning if dyspneic

Pulmonary Embolism A pulmonary embolism [PE] is a collection of particulate material [solid, liquid, air] that enters the pulmonary vessels venous circulation and lodges, obstructing blood flow “below” the area of the embolism  Large emboli can obstruct pulmonary blood flow, decreasing oxygenation and resulting in pulmonary tissue hypoxia and possible death  Most often a PE derives from a venous thromboembolism [VTE], especially a DVT in the legs or pelvis o Platelets collect onto the embolism causing further constriction of the vessel and increasing blockage, leading to pulmonary HTN which impairs gas exchange – deoxygenated blood moves into the arterial system leading to systemic hypoxemia Nursing Interventions Post-op PE preventative interventions:  Apply TEDS/SCDs  ROM [passive/active]  Ambulate ASAP  Elevate legs Impaired Gas Exchange  Interventions: o Monitor VS [including O2 sats] o Administer IV fluids [to increase CO & maintain BP] o Monitor LOC o Position the patient in high Fowler’s to maximize lung expansion o Maintain a calm environment

Croup Symptoms  Normal or slightly elevated temperature  Loud, barking cough  Raspy, hoarse voice  Varying degrees of high-pitched crowing sounds with inspiration  Difficulty breathing Treatment  Glucocorticoids and Epinephrine [↓ inflammation]  Oxygen  No antibiotics [not effective]  Cool mist tent over the crib o Let parents hold the child if the child is scared or agitated and focus the cool mist over the child’s face [this can also be done at home]

RSV Education  Educate on the importance of handwashing to prevent spread of illness  Educate parents on when to seek medical treatment: o High fever – thick nasal discharge – worsening in cough or cough that produces yellow, green, or gray mucous – signs of dehydration – trouble breathing Treatment  No antibiotics – VIRUS  If severe, hospitalization with fluids and oxygen may be necessary  Humidifier – cool mist to keep secretions moist [winter air can be dry air which will make the mucous stickier and more difficult to expel]  Bulb syringe to aspirate mucous if unable to expel on their own Medications:  Non-aspirin fever reducers [Acetaminophen or Ibuprofen] since children can develop Reye syndrome when Aspirin is administered with a viral illness  Bronchodilator nebulizer [Proventil, Ventolin]  Ribavirin [Rebetol] – antiviral in nebulizer form  Nebulizer epinephrine may relieve RSV symptoms

Epiglottitis  Epiglottitis infection leads to inflammation

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

that can prevent any air flow – Medical Emergency! Most common organism to cause this is the past was Haemophilus influenza type B [Hib] before this became part of routine vaccinations – most common in 2-7-yearolds o Can also be caused by Streptococcus, varicella, herpes simplex, and staphylococcus FYI: George Washington is believed to have died from this

Priority secure the airway!

Lung Cancer Post-surgical Priorities  The patient will likely have a chest tube post-op – encourage coughing & deep breathing; encourage the use of a pillow to splint to ease the pain; encourage early ambulation Potential Complications  Superior vena cava syndrome o Facial and upper body edema present due to blockage of venous return from the head, neck, and upper trunk – medical emergency Treatment Surgical treatment:  Wedge resection – peripheral portion of small, localized area removed  Lobectomy – entire lobe removed  Pneumonectomy – entire lung removed o The patient will likely have a chest tube post-op – encourage coughing & deep breathing; encourage the use of a pillow to splint to ease the pain; encourage early ambulation Medications: [for comfort only]  Bronchodilators  Corticosteroids  Mucolytics  Antibiotics [if infectious process is present since the patient is prone to these]

Lung Cancer Cont. Nursing Interventions  Provide comfort using oxygen therapy via cannula or mask  Pain management  Encourage a smoker to quit – the current damage cannot be undone; however, it can prevent further lung damage  Offer realistic hope and encouragement  Assess metastasis prone systems regularly o adrenal gland, bone, brain, liver, other lung [www.cancer.gov]  Palliative care is common due to late stage diagnosis [control pain, oxygenation, dyspnea] Activity Intolerance  Outcome goal: o Patient will maintain independence with activities as able  Interventions: o Plan activities and procedures with frequent rest periods to allow for rest o Monitor oxygenation during activity to ensure adequate oxygen levels are maintained o Provide assistance with activity when necessary to maintain safety  Maintain safety at all times

Cystic Fibrosis Nursing Interventions  Maintain safety at all times  Maintain respiratory treatment programs  Administer medications as prescribed  Monitor VS and O2 sats  Decrease risk of infections: handwashing, isolation if necessary, room placement, etc.  Education: a balanced diet is essential to maintain health; importance of maintaining treatments

Acute Respiratory Distress Syndrome (ARDS) Priority Nursing Diagnosis:

Respiratory Normal Assessment  Palpitation  Percussion  Auscultation Changes with aging  Alveolar surface area decreases, diffusion capacity decreases, elastic recoil decreases, bronchioles and alveolar ducts dilate, ability to cough decreases, airways to close early  Residual volume increases, vital capacity decreases, efficiency of oxygen and carbon dioxide exchange decreases, elasticity decreases  Muscles atrophy, vocal cords become slack, laryngeal muscles lose elasticity, and airways lose cartilage  Vascular resistance to blood flow through pulmonary vascular system increases, pulmonary capillary blood volume decreases, risk for hypoxia increases  Body’s response to hypoxia and hypercarbia decreases  Respiratory muscle strength, especially the diaphragm and intercostals, decreases  Effectiveness of the cilia decreases, immunoglobulin A decreases, alveolar macrophages are altered  Anteroposterior diameter increases, thorax becomes shorter, progressive kyphoscoliosis occurs, chest wall compliance (elasticity) decreases, mobility of chest wall may decrease, osteoporosis is possible, leading to chest wall abnormalities

Chest Tube Nursing Care  No bubbling means no air in lungs  Document type of drainage hourly  Notify surgeon if more than 70mL/hr occurs  After first 24 hours assess drainage at least every 8 hrs.  Bubbling is normal during forceful expiration or coughing; continuous bubbling indicates air leak Respiratory Diagnosis  Labs:  Chest X-rays: used to assess lung pathology such as with pneumonia, atelectasis, pneumothorax, and tumor  Computed tomography (CT): assesses soft tissues with consecutive cross-sectional views of the entire chest, can verify the identity of a suspicious lesion or clot  Pulse Oximetry: identifies hemoglobin saturation with oxygen  Capnometry and Capnography: measure the amount of carbon dioxide present in exhaled air, which is an indirect measurement of arterial carbon dioxide levels  Pulmonary Function Tests (PFTs): assess lung function and breathing problems, these tests measure lung volumes, and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation  Bronchoscopy: used to diagnose and manage pulmonary diseases  Thoracentesis: the needle aspiration of pleural fluid or air form the pleural space for diagnostic or management purposes  Lung Biopsy: to obtain tissue for histologic analysis, culture, or cytologic examination Respiratory Nursing Considerations

COMPLETE BLOOD COUNT (CBC) WBC 4.5-11 RBC

4.2-6.1 million/µL

Hemoglobin

12-18 g/dL

Hematocrit

37-52%

Platelets Neutrophils

150-450 cells/μL 40-80%

Eosinophils

1-6%

Basophils

101.5 degrees F [persistent with unknown cause]  Drenching night sweats  Unexplained weight loss [>10% body weight]

Multiple Myeloma – White Blood Cell Cancer Affecting Functioning Ability  WBC cancer affecting a mature lymphocyte (plasma cell) that secretes antibodies  Overgrowth of B-lymphocyte plasma cells in bone marrow – when the cells become cancerous, they overproduce antibodies (gamma globulins) – a disorder called gammopathy  An overproduction of myeloma cells results in ↓ functioning RBCs, WBCs and platelets (anemia, ↑ infection risk and bleeding)  Multiple myeloma cells also produce excess cytokines (↑ cancer cell growth & destroy bone) and excess antibodies (↑ serum protein levels and clogging blood vessels esp. in the kidneys)  Tumors form within the bone Symptoms Possible assessment findings:  Fatigue  Anemia  Easy bruising  Hypertension  Fluid imbalance  Bone pain  Pathologic fractures  Recurrent bacterial infections  Kidney dysfunction  Hypercalcemia (rare)  Hyperviscosity syndrome (rare)  20% patients have no symptoms when diagnosed  Without treatment – progressive bone destruction, bleeding problems, kidney failure, immunosuppression, and death

Anemia Nursing Diagnosis: Aplastic Anemia Symptoms  Bone marrow failure with poor oxygenation: o Weakness o Pallor o Bruising o Petechiae or...