Notes for Exam 1 CH 21 23 25 27 29 PDF

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keiser university 3rd semester exam 1 for advanced adult health care...

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EXAM 1 (21,23,25,27,29) 1. Review

S/S of impaired oxygenation Early: Restlessness (can’t sit still), fatigue, HA, Dyspnea, air hunger, tachy (increased RR- quiz answer for early sign of ARDS), hypertension, pale skin and mucous membranes, S/S of resp distress: use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. (EVERYTHING ^^^^) decreased LOC

Late: Confusion, stupor, lethargy, clubbing, Brady(cardia/pnea), hypotension, central cyanosis, diaphoresis, resp arrest, cardiac dysrhythmias (EVERYTHING DECREASES)

decreased / inffective breathing

Turn, Cough, Deep Breathe

abnormal sweating

Interventions: Sit up, O2, TCDB, IS use, positioning, monitor spO2, increase fluid, mucolytic and resp tx Dx: ABG (hypoxemia more accurate than hypoxia which uses pulse ox), CBC, BC, CXR Pt with chronic resp changes  Due to age (>50 years alveoli loses elasticity/compliance)  Chronic bronchitis and emphysema: CO2 drives breathing. Their normal is lower SP02. Lower TV and VC*

NORMAL LUNG SOUNDS Are specified by their location

Tracheal Bronchial

I=E E>i

EXAMPLES Bronchovesicular I=E Pleural effusion= Flatness Lung fields dull to VesIcular  (smpercussion, and big I) Absent breath sounds, and a Pleural friction rub (TB)  L.A.P. Consolidation Dullness (pneumonia)& Atelectasis Resonance Asthma, Bronchitis, and pulmonary edema Emphysema (Faint Hyperbreath sounds with Resonance prolonged expiration (TB), asthma, and pneumothorax Large pneumothorax Tympany

Trachea Manubrium (top part of the sterum) INTENSITY, PITCH, Over the main DURATION nd bronchus (1st and I: soft; P: high; D: 2 interspaces) short Entire lung field

Tidal Volume

Abnormal Lung sounds: Crackles *AKA Rales*

I: med; P: med; D: med

WhEEzing

I: loud; P: low; D: long I: very loud; P: lower; D: longer

I: loud; P: high; D:

Volume Capacity

Rhonchi

Popping on inspiration. Noncontinuous NOT cleared by a cough Whistle heard louder on expiration

Due to Fluid

Deep low pitch rumbling on inspiration or expiration

Due to narrowed passageway from

Heard in pts w/ HF* (TB) Due to bronchoconstriction; Narrowed airway! Or heard during Bronchospasm

Normal Lung PERCUSSION= resonance. Dullness is heard over organs (liver&❤). Flatness is heard over bones. Tympany heard over stomach.

secretions or foreign body

V/Q: Ventilation is the air that reaches the alveoli and perfusion is the blood the reaches the alveoli. Not an equal proportion but close to equal (4 liters of air a min/5 liters of blood a min or 0.8) Resp failure consists of (imbalanced V/Q ratio)  Impaired Ventilation due to issues with CNS, MG, COPD, CF, and asthma. (Can’t breathe because you’re in a C.C.C.C.O.M.A.A) Tutoring= overdose, ALS, CVA  Impaired Qerfusion due to pneumonia, ARDS, HF, COPD, PE, and pulmonary HTN (C.C.A.P.P.P on gas) Tutoring= chest hematoma, pulmonary edema/embolism, ARDS PE pts suffer from inadequate flow of blood 2. Pulmonary Edema

Definition: Abnormal accumulation of fluid in the lung tissues, alveoli, or both d/t increased micro vascular pressure from abnormal cardiac function or fluid overload. (neg pressure draws fluid from pulmonary capillaries causing pulmonary edema). Whereas, pleural effusion is in the pleural space. -Fluid overload happens from administering blood too quickly. “flash pulmonary edema” is when blood backs up quickly from LV failure which leads to pressure buildup in left atrium. Could also be d/t renal problems. Tx: furosemide IV to get rid of interstitial fluid and slow down blood. S/S: Dyspnea, rales, coughing, (when fluid within alveoli mixes with air) or blood tinged secretions. Confusion and advances to resp failure. Pt is literally drowning in their own secretions. Mx: Correct cause, O2, Diuretics (furosemide), vasodilators (nitro) for symptom relief, intubation, resp therapy, decreased fluid intake Position pt upright with legs dangling over the side of the bed (this decreases venous return, Right vent SV, and lung congestion).

Dx: CXR

3. Acute Resp Distress syndrome (ARDS)

Watch https://www.youtube.com/watch?v=cVCvYxVxSt4

Definition: sudden pulmonary edema, infiltrates and hypoxemia which injures/inflammation alveolar capillary. Damage to the alveolar capillary membranes causes a shunt in the blood which leads to hypotension. Results in pulmonary edema (fluid in alveoli). Starts off as fluid surrounding the lungs in early stage, then late stage it starts filling the alveoli, by day 10 the alveoli is filled completely. Patho: Inflammation causes V/Q mismatch  Alveoli are damaged  clogs up and oxygen can’t get through  Airway is narrow  Possible atelectasis  Decreased compliance  Refractory hypoxemia: unreactive to oxygen bc of so much fibrosis in their lungs. Also, no left atrial pressure Cx: (anything that damages alveoli) Aspiration pts such as stroke, drug overdose (OD), prolonged high O2 concentration, Smoke, infections, metabolic disorders, shock, trauma, surgery, fat or air embolism and sepsis

*PEEP: extra pressure at end of normal breath to keep alveoli open. SE when too much: pneumothorax, hypoTN, uncomfortable (may need sedatives.. if that doesn’t work then neuromuscular blocking agents) ^Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy.

S/S: rapid dyspnea and tachypnea (*INCREASED RR* on quiz). PaO2 not responding to O2 therapy: later sign. Mx: tx cause, supportive care, O2, intubation w/ PEEP, hood, prone position to get back of lungs to expand, daily CXR/ABG. VS every hour and PRN. Monitor for pneumothorax and hypotension (tx for hypoTN= NS/vasopressors) 1. NC  2. SFM  3. Venturi  4. NRB (100%)/ PNRB (75%)  5. BiPAP  6. Intubate w/ PEEP (uncomfortable so use sedation and titrate to affect, BP will decrease so NS then vasopressor) Meds: NS, vasopressors, diprivan (propofol), morphine, and… succinylcholine if needed.

4. Pulmonary Hypertension

Definition: Elevated pulmonary arterial pressure and secondary right heart failure. Making it hard for liquid to flow through the vessel. This can cause back up to the heart’s RV and not enough blood getting oxygenated in the lungs because the pulmonary artery

delivers blood to the lungs. Cx: Genetic, hypoxemia from COPD, collagen vascular disease, congenital system shunts, portal HTN, Alteration in immune function, capillary/venous disease, chronic thrombus/emboli, sarcoidosis, fen-phen (anorectics), liver disease, low O2 conditions. S/S: Dyspnea with exertion w/o other clinical S/S (QUIZ); Other: chest pain, weakness, syncope and signs of right sided HF (swelling, portal HTN), cough, anxiety, fatigue, SOB, h/a Dx: History and physical (H + P), CXR, PFT, EKG, BNP (to check for heart problem), CMP, ESR, ABG, V/Q scan, Echo and right heart cath, ANA (antibody test to check for inflammation) Meds: Can only help S/S. O2, CCB (to decrease squeeze on muscles), Sildenafil (helps dilate the blood vessels to relieve pressure), endothelin antagonists (bosentan=vasodilator) and Prostanoids (Relaxes smooth muscle)  on 24/7 IV medication hooked on central dedicated line, if meds stop then they stop breathing, they are used for end stage. Possible lung transplant. C(ccb).O(o2).P(rostanoid).S(-fil). ON ASSESSMENT EXPECT LOW BPs Very Nice Drugs= Verapamil, Nifedipine, and Diltiazem  CCBs 5. Cor Pulmonale AKA right sided heart failure

TALK ABOUT THIS MORE LATER ON. Definition: Enlarged right ventricle d/t stenosis and increased pressure eventually fails from disease of the lung. Alteration in the structure and function of the RV caused by a primary disorder of the respiratory system. Cx: May be secondary to chronic pulmonary problems (pulmonary HTN). Vascular or lung disease (because if the lungs aren’t properly working then it will cause backflow to the ❤) Lungs aren’t able to push out the blood systemically so it backups and causes systemic effects of fluid overload. S/S: SOB, cough, wheeze, edema, JVD, Liver failure, pleural effusion, heart murmurs, HA, AMS (Altered mental status) Mx: O2, bed rest, ECG monitoring, Na

6. Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE)

restriction, RT (no albuterol bc increases heart rate), diuretics and digoxin Definition: blood clot that forms in vein (DVT) breaks off and travels to heart and blocks blood vessel in the lung (PE) S/S of DVT: warmth, redness, tender, swelling S/S of PE: Dyspnea, sudden chest pain, anxiety, tachycardia/tachypnea, hemoptysis (bloody sputum), pink frothy sputum, hypoTN (bc of shock), diaphoresis, cyanosis. Dx: **Pulmonary angiography** (inject dye and checks for blockage), Spiral CT (takes longer than normal CT bc need to inject dye=20 mins instead of 3 mins) and D-Dimer (for clotting, + indicates abnormally high level of fibrin) Tx: O2, fluids, ECG monitor, vasopressors (vessel constriction to increase BP but give NS 1st; vasopressors given for ARDS & intubation as well ), percutaneous mechanical thrombectomy, anticoagulation/ thrombolytic treatment (USE pneumatic compression devices for pts w/ contra to anticoags such as a bleeding ulcer). Vena Cava filter umbrella placement and warfarin to prevent new clots.

7. Anticoagulants

1. Heparin 2. Heparin Drip 3. Pill (warfarin) to wean off heparin

LMWH Heparin

Monitor Platelets aPTT (25-35 sec) 

Reversal agent Protamine Sulfate Protamine Sulfate

therapeutic level is 1-2x baseline

Vitamin K/FFP PT (11-14 sec)/INR (0.8-1.2) TPA, streptokinase, alteplase (activase) Warfarin

8. Thrombolytics

Teaching: Bleeding precautions, avoid too much vitK intake, S/S of bleeding, labs, avoid invasive procedures (on quiz), Avoid IM injections, avoid straining to defecate (give stool softener- on QUIZ), and consult HCP before any OTC meds (no Antihistamines or Aspirin while taking warfarin). GI is most susceptible to bleeding,

9. Sarcoidosis

dark tarry stools. Contra alteplase: Elongated INR (>1.2), kids, stroke, bleeding disorders. *Abdominal bruising is OK because that’s expected. Worry more about a low BP, especially low diastolic such as 90/40 mmHg  QUIZ Q Definition: multisystem granulomatous inflammatory disease. Inherited and predisposition to disorder. Causes cells to clump (granulomas) which leads to fibrosis (scarring of the lungs). S/S: Depends on organ affected. Mainly the lungs. Also LN, liver, spleen, CNS, skin, eyes, fingers, parotid gland, and any organ. Mx: Steroids  ae: ^ BS, immunosuppressed Dx: CXR, CT, PFTs, ABGs

10. Occupational lung disease

Lungs= normal  inflammation  granuloma  fibrosis Lung disease caused by occupation (firefighters, miners, construction). Caused by inhalation of mineral dusts: Silicosis, asbestosis, smoke, coal dusts Px:  Monitor air levels to eval exposure (OSHA)  Not curable  Wear protective equipment like masks  Clean and mop to prevent dust transfer

11. Lung Cancer

Leads to lesions in the lungs which turn into… Definition: Small cell carcinoma (fast growing and linked to cigarette Smoking) or non-small cell carcinoma (more common, surgical resection) ^can metastasize to brain, bone, and liver by lymph system Cx: Smoke!!, carcinogens, radon gas, diet and genetics, COPD, male S/S: Cough that doesn’t go away, dyspnea, chest pain, fever, hoarseness Dx: Bronchoscopy (Lung biopsy), CT guided biopsy, CT, PET, MRI and open lung BX (if can’t get a piece through bronchoscopy then open up chest [thoracotomy] and get)

^Complications from dx tests: pneumothorax and hemorrhage. Mx: depends on stage and type, will pt survive surgery, functional reserve (PFTs), adv direc.  Chemo: methotrexate. Pt has dedicated line. Ae- n/v, decreased cells (rbc, wbc, and plt)  know neutropenic precau.  Radiation: uses beam of radioactive isotopes. Patient has private room with sign on door. Radioactive material excreted in urine (double glove and discard). Monitor for skin integrity because adverse effects is dry, burned skin. Wash/dry skin. No ointments. Tattoo used to show where isotope goes or radioactive beads.  Surgery: side effects: pain (Give morphine**QUIZ) & infection Lobectomy, pneumonectomy (entire Lung), wedge resection (peripheral part of lung is removed to allow more lung expansion), segmentectomy, bronchioplastic or sleeve resection, lung volume reduction. Post op: Chest Tube B4 surgery check: allergies and PFTs 12. Chest Trauma

Cx: Blunt, motor vehicle accident, bike crash and penetrating foreign objects or nonpenetrating S/S: Hypoxemia, hypovolemia, dec lung sounds, tracheal shift, tachycardia/pnea and HF Dx: CXR, ABG, CT, labs Tx: surgery or chest tube

Closed pneumothorax can happen from sharp rib puncturing lung Ex: more of a hit to the chest that’s non-penetrating

Complication of chest trauma: *flail chest, *pneumothorax (air between pleurae), cardiac tamponade (compression of heart by fluid surrounding) pulmonary contusion, aortic rupture, airway obstruction, tracheobronchial/diaphragmatic injury, hemothorax (concern about amount of bleeding in lung) and contusions.

**Flail chest: 3+ free floating ribs from fracture causing abnormal breathing appearance during inspiration and expiration (ON QUIZ) ^ suction the patient’s airway secretions***** & control pain

*Open pneumothorax: wound in chest that allows air to pass freely in and out of thoracic cavity; Ex: stab wound Tension pneumothorax: WILL KILL. Air enters the pleural space from lung or airway and has no way out. Most dangerous if patient is on PEEP. No breath sounds will be observed on affected side. This will cause a shift in mediastinal pushing the heart, vessels AND trachea to the unaffected side. Blood flow is then compromised. Late sign is when the trachea shifts to unaffected side.

HYPERRESONANCE!!!!!!!! 13. Chest Tubes

Definition: Tube inserted in pleural space to drain fluid, blood or air from chest. Put in emergent, planned or after open chest surgery. QUIZ IND= spon. Pneumothorax, thoracotomy. Removed when lungs re-expand. May see air leak and some blood post insertion but should go away with time. Drainage system must be sealed so that air/liquid cannot enter the pleural space. Dry vs. Wet seal= personal preference. Materials: bottle of saline, drainage system, occlusive dressing, tape, 4x4 sterile gauze. 3 chambers:  1st: Collection chamber (fluid/air)  2nd: Water seal- an airleak here will stop with time. Tidaling goes away as pneumothorax resolves.  3rd: Suction chamber- continuous bubbling normal. Amount of suction is controlled by amount of water (more water= higher suction). Gentle bubbling (vigorous could cause evaporation too quickly); -20=pressure. Very PAINFUL! Pain is normal Assessment:  Resp status: Look out for resp distress. Are there changes from baseline resp assessment? ABC.  Look out for tension pneumothorax from obstructed tubing (assess tubing and notify MD). NO dependent loops (which result in stagnation & slow drainage) and don’t have under bed where it can get crushed  SubQ emphysema (Crepitus): rice

krispie on skin. Fluid migrates under skin. Usually higher up because of gravity. Maybe tube isn’t in right place. If suspected mark area with marker and observe for expanding. Notify MD.  Watch of signs of recurring pneumothorax and pleural effusion  Is pt hypotensive from loosing too much blood? Hemoglobin of 7 is the hard fast number for a blood transfusion or 8 with S/S. If given 2 bags postop… should expect 9, if it was 8 you would know they’re still loosing blood. Diastolic decreases by a larger amount. Ex: 96/40  BIG concern (QQ) Maintenance:  Suction control (CAN bubble)  Water seal chamber and air leak monitoring (CAN’T bubble)  Recording drainage volume/sampling  Titling: Not tilting the drainage system is crucial to prevent drainage from moving into all chambers and making it difficult to maintain accurate drainage output.  Do not clamp or milk tubes (milking tubes increases negative pressure)  If there is an air leak. Start by observing pt, dressing, loops and connections  Chest tube system must be lower than pt always and secured in place. Chest tube removal:  Daily CXR to check for lung expansion  As drainage slows, suction is d/c  Removed by primary care provider  Pain management 30 min before  Supplies: suture removal scissors, gauze, Vaseline gauze, tape and drape  Instruct pt to perform Valsalva maneuver: forced exhalation and bear down (QQ) to decrease air entry by increasing intrathoracic pressure.  Assess for resp distress, SOB, tachypnea. Get STAT CXR call PCP  After removal apply a dressing (PETROLATUM gauze= occlusive) and BED REST!!  Pleurodesis: technique to stick pleura to chest wall to prevent liquid there (pleural effusion).

If accidentally comes out: 1. Tube is still in chest: place end in sterile saline, bed rest, stat CXR, call PCP 2. Tube no longer in chest: occlusive dressing on site, gauze, Vaseline gauze, tape on 3 sides so air can get out or 4 sides to px infection. 14. Oxygen Therapy Non-invasive low flow  Nasal cannula FiO2 1-6L/min add 3-4% FiO2 per liter. Dries out nares but more http://www.atitesting.com/ati_next_gen/skillsmodules/content/oxygentherapy/equipment/delivery-devices.html comfortable (use water soluble gel to px dry nares). Pt can eat and drink.  Simple face mask: 40-50% FiO2 (5-8L) Adv: comfortable Dis: poorly tolerated in pts who have claustrophobia; moisture collects under mask causes skin breakdown.  Partial RB (75%) and NRB (100%) Adv: has reservoir bag; rebreathes exhaled air with room air. Dis: complete deflation of bag during inspiration causes CO2 buildup.  Non RB (100%): delivers the highest amount of O2 possible w/o intubation. Adv: The valves on the side ports of the mask allow exhalation but close on inspiration to px inhalation of room air.  Venturi (ATI says high flow, Lindgren says low flow; 4-10 L) Adv: humidification is not required; specific o2 delivery (good for COPD pts) Dis: $$$$ N.S.V.P.N.  BiPAP  intubate w/ PEEP Non-invasive high flow: humidifier for >4L  Aerosol mask and Trach collar F.A.T. Face tent: 28-100% and 8-12L Adv: useful for pts who have facial trauma, burns, or thick secretions  BiPAP: Bi-level positive airway pressure. 30-100% O2. Gives inspiratory&expiratory airway pressure  CPAP (continuous positive airway pressure): prevent alveolar collapse DOESN’T give O2 just keeps airway open. IND: sleep apnea  Trach collar or T-piece fits on a tracheostomy (10L) (T-piece and trach collar are used when weaning from ventilator!!) Invasive: endotracheal or tracheostomy

Chapters 21,25,27,29 15. Intubation and ventilation

What does it feel like? Painful and traumatic despite analgesics. Decreased memory of experience but felt like drowning and fighting the tube. Being told what happened during the process is most important and nurses have to communicate w/ a calm and confident tone esp the use of touch because pt hears EVERYTHING that going on. How do we communicate with them? Blink, thumbs up, board, pictures. Indication  Problems with Gas exchange, Lung disease, Neuromuscular diseases, general Anesthesia, Obesity, Trauma. Grandma TOLAN Administration 1) Put down the tube w/ the laryngoscope 2) Pull out the stylet 3) Put on end tital CO2 detector (and it will turn YELLOW if CO2 is present). Purple  yellow color change indicates correct intubation and open airway. Yellow is Mellow � 4) Then hook up to an ambu bag w/ a vent. 5) If it was to go too far, it’s tends to go to the right main stem. If breath sounds are diminished on the left side after intubation, the right main bronchus has probably been intubated. 6) Then really c...