exam 2 Flashcards by Callie Wanek

Respiratory complications=life threatening complications

Priority

What are common nursing diagnoses?
ineffective airway clearance
impaired gas exchange
eneffective breathing pattern

resp complications

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Cessation of breathing while sleeping due to upper airway obstruction
Interferes with ability to get adequate sleep
What else will this affect?
judgement, mood, weight, mental clarity (confusion, difficultly concentrating)

obstructive sleep apnea - upper airway

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At least 5 obstructive events / one hour of sleep –> hypoxia & hypercapnia –> sympathetic nervous system response
What can cause obstruction?
-Reduced diameter of upper airway or continuous changes in airway
Leads to HTN, MI, CVA, death, arrhythmias, vascular disease
More prevalent in patients with CAD, CHF, metabolic syndrome, DM
-Men
-Older
-Overweight
-Structural changes (inflamed tonsils or airway)

osa patho

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tachycardia, restlessness, anxious, tachypnea, sweating, cold and clammy

sympathetic nervous system response

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Snoring	
Breathing cessation for 10 sec or longer, 5 episodes or more/hour, abrupt awakening, blood oxygen levels drop
Need a sleep study + clinical symptoms to diagnose
Treatments
weight loss
oral appliances
CPAP
BIPAP (more inspiration than expiration)

s/s and treatment of osa

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CPAP
Positive pressure that keeps the alveoli open
Keeps the upper airway and trachea open during sleep
Patient must be able to breathe on own
BIPAP
Provides pressure support ventilation
2 different levels of positive airway pressure
Inspiratory
Expiratory
Used for severe COPD, severe sleep apnea
Hard to tolerate

CPAP and BIPAP

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Monitor skin - break down & pressure ulcers
Monitor for dryness of nasal passages, nasal congestion
Education
On OSA
On cpap/bipap, oxygen
On weight loss
Avoid alcohol, sedatives

nursing management for cpap

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Abnormal accumulation of fluid in the lung tissue and/or alveolar space
Due to fluid in alveoli, gas is not exchanged  hypoxemia
Manifestations
Respiratory distress
Anxiety
Frothy sputum - when air mixes with fluid leaked from aveoli, froth forms
Confusion
What will lungs sound like?
CXR-interstitial fluid
Tachycardia - sympathetic ns/ fight/flight increases heartrate
Decreased oxygen saturations

pulmonary edema

lower resp tract

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Fix the underlying problem!
Oxygen-what form of oxygen may be needed?
Morphine-vasodilator, reduces preload - preload: volume in ventricles at end of diastole (diastole = resting of heart)
Vasodilators - dilate and reflex
Inotropic medications-increase contractility and this increases cardiac output
Diuretics

pulmonary edema treatment

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Inflammation of the pleurae
Caused from
Pneumonia, URI, TB, chest trauma, PE, cancer
Severe, sharp pain worse on inspiration
Patients will often hold their breath or breath shallow to decrease the pain
Treat underlying cause
Analgesics
Anti-inflammatory medication
Steroids

Pleurisy

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Pleural effusion-collection of fluid in the pleural space
Complication of
Heart failure - due to poor pump –> backflow
TB
Pneumonia
Viral infections
PE
Tumors
Empyema-collection of pus like fluid within the pleural space (this is a type of pleural effusion)

pleural effusion and empyema

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Can be clear fluid, bloody fluid, purulent fluid
The size of the effusion will determine the severity of symptoms
Dyspnea
Fever, chills, pain, cough
Patient will have decreased or absent breath sounds over the effusion
Tracheal deviation
Hypoxemia
Hypotension
Tachycardia

pleural effusion

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Must find underlying cause of effusion
Relieve dyspnea
Thoracentesis - needle in chest 
-Removes fluid
-Ultrasound
-Blind
-- need to assess BP due to fast removal of fluid 
Chest tube
Surgery
What is the nurse’s role? Baseline assessments, immobilize, keep still, sit up, document fluid appearance/amount, set up equipment

pleural effusion management

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Sudden life-threatening deterioration of gas exchange
PaO2 <50 mmHg on RA
PaCO2 >50 mmHg, pH <7.35
Ventilation/perfusion mismatch: area in lung that receives blood flow or no oxygen or oxygen with no blood flow
*respiratory failure increases CO2, ven/perfus mismatch

acute respiratory failure

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Manifestations
Restlessness
Fatigue
Dyspnea
Headache
Tachycardia
Tachypnea
Cyanosis
Management
Intubation - for vent/perfus mismatch - give high concentration of oxygen 
Mechanical ventilation
Assess patient: what focused assessment is PRIORITY? - respiratory: work of breathing
Monitor O2 sats continuously
Assess vital signs
Assess underlying event

acute respiratory failure

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Obstruction of the pulmonary artery or one of it’s branches by a thrombus

Starts somewhere in the venous system or the right side of the heart

3rd leading cause of death in hospitalized patients. WHY? due to being immobile. Puts you at risk for DVT and PE so use SCD’s

What leads to PE?
Trauma
Arrhythmia (atrial fibrillation): irregular heart rate: ventricles pump, atria quivers, doesn’t pump like they should and blood pools - admin anticoagulant
Surgery
Pregnancy
Heart failure - inadequate pump pumping good blood flow –> risk for clots
Prolonged immobility

pulmonary embolism (PE)

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Thrombus obstructs pulmonary artery or branch –> decreases alveolar dead space –> impaired gas exchange

Clot causes vasoconstriction in surrounding bronchioles and blood vessels –> surfactant decreases –> atelectasis and hypoxemia

Increased pulmonary artery pressures increase workload on heart –> right ventricle fails –> decreased cardiac output –> hemodynamic instability

pulmonary embolism (PE) pathophys

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Manifestations
Acute dyspnea
Chest pain
Cough
Hemoptysis - coughing up blood/sputum
Palpitations
Tachypnea
Crackles
Tachycardia
Often associated with DVT….so what other physical assessment will you be looking for? - came from somewhere so check legs for swelling, redness, warmth in calf
*severity S/S depends on size/location of embolism

pulmonary embolism

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Chest X-ray
ABGs
Doppler studies
Spiral or contrast angiogram CT scan (contrast: 1. pt with kidney failure can't do this b/c it goes through kidneys 2. allergy to contrast dye/shell fish)
What patients cannot have CT scan?
D Dimer to detect clotting

pulmonary embolism (PE) diagnostic tests

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Must prevent DVT!
Leg exercises
Ambulation
TEDS/SCDs
Look at pg. 304 table 10-3
Meds
Heparin SQ
Enoxaparin
Arixtra

prevention of PE

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This is an emergency! So give Oxygen and Treat hypotension (due to decreased cardiac output)
-IVF, vasopressors, inotropic medications (give fluids)
Monitor EKG
Heparin-IV: look at PTT to ensure PTT is therapeutic. If it is then they’re blood is where we want it to be
Thrombolytics-if hemodynamically compromised
-Alteplase (TPA: clot buster; give if pt is hemodynamically compromised: low BP, increased heart rate)
Inferior vena cava (IVC) filters

management of PE

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Assess
Control pain
Manage oxygen
Relieve anxiety
Monitor vitals
Monitor for complications

PE: potential complication is right side heart failure - look and prepare for this

nursing management of PE

ADPIE and ABCs

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Either parietal or visceral pleura punctured positive pressure enters pleural space  lung collapses

Three types
Simple
Traumatic
Tension

Pneumothorax

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Also called spontaneous
Can happen in ‘healthy’ people
Also happens with emphysema or pulmonary fibrosis

simple pneumothorax

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Air escapes from a laceration in the lung and enters pleural space or when air enters the pleural space through a wound in the chest wall Blunt trauma Penetrating trauma Diaphragm tear Lung biopsy Insertion of subclavian line - they could have nicked it Barotrauma from mechanical ventilation pressure on chest Often will result in hemothorax (blood fills pleural space)

traumatic pneumothorax and reasons for it

Tension pneumothorax-air into pleural space that cannot escape. This will create a build up of positive pressure and will decrease the venous return to the heart This is life threatening! Both respiratory and circulatory issues will occur. Patient will experience immediate shortness of breath Cardiac output will decrease and cardiac arrest can occur - PEA: pulseless electrical activity: on heart monitor it looks good, but when you assess them they're dead (no pump or squeeze) Trachea will shift toward unaffected side-late sign What is this called?

Tension pneumothorax

``` Pain Shortness of breath Respiratory distress Anxiety Increased use of accessory muscles Tracheal shift (tension pneumo) Decreased breath sounds/absent breath sounds on affected side Cyanosis ```

pneumothorax manifestations

Chest tube Needle decompression - emergency needle decompression: blind stick between ribs into pleural space to drain and allow pressure back in Nursing management Respiratory assessment Oxygen assessment Assess tracheal alignment

pneumothorax management

Chest trauma -MVA Often leads to respiratory issues Often results in tension pneumothorax

chest trauma

Used to drain fluid or air Restores negative pressure needed to re-expand the lung Suction-will generally see dry suction used at CHI Gravity Tidaling: increase with inspiration and decrease with expiration -No tidaling means 1. lung rexpanded/fixed so take chest xray to verify 2. chest tube stuck on wall so xray to verify

chest tubes

Subcutaneous emphysema-air enters the tissues under the skin Crackling “rice krispies” - can feel/see if it's bad enough - edema is affected airway or xray Will spontaneously resolve when air leak stopped

chest tube - subcutaneous emphysema crepetis and subcutaneous air all mean it too

Monitor pain level Assess respiratory status Assess oxygen levels Assess chest tube! look for crepitus, air leak, drainage Monitor dressing for bleeding and s/s of infection Monitor for crepitus Assess insertion site of chest tube Document! What should you document? All that and is it to gravity/suction, tidaling, location, drainage What if it accidentally comes out? Cover with occlusive dressing* Maintain tube patency Keep below chest level Do not kink or clamp without MD order Why? never clamp/kink it due to positive pressure and backflow

chest tube nursing management

Fluid and electrolytes for intracellular space

2/3rd body fluid increase concentration of potassium, magnesium and phosphorus inside the cells

fluid and electrolyte extracellular space

1. intravascular: fluid within blood vessels - increased: increase BP and heart rate - decreased: decreased BP and heart rate 2. Interstitial: surrounds cells - increased: edema, crackles - decreased: dehydration

concentration of solutes Increase: blood increases, body released adh and urine gets concentrated decrease: blood decreases, suppresses adh and urine is more dilute

osmolality

movement of water caused by a concentration gradient lower solute concentration to area of increased solute equalize solutes of concentration

osmosis

natural tendency of a substance to move from an area of higher concentration to one of lower concentration ex: exchange between CO2 and O2

diffusion

the separation of a liquid from the undissolved particles floating in it Kidneys

filtration

located in the cell membrane and actively moves sodium from the cell into the ECF

sodium potassium pump

movement of molecules across a cell membrane from a region of lower concentration to higher concentration in the direction against a concentration gradient

active transport movement

measures kidneys ability to excrete/conserve water 1. 010-1.025 - larger volume of urine - lower specific gravity

urine specific gravity

end product of metabolism of protein 10-20 increase due to dehydration, fever, sepsis, diet

BUN

end product of muscle metabolism 0.7-1.4 best indicator of kidney function

creatinine

``` measure volume percentage of RBC in blood males: 42-52% females: 35-47% increase when dehydrated fluid overload --> decrease ```

hematocrit

assess volume status 200 meq/24 hrs changes with no intake and change in fluid volume used to diagnose hyponatremia and acute renal failure

urine sodium

Fluid and electrolyte balance Functions: Regulation of volume & osmolality -decrease in kidney function, volume in body goes up and osmolality goes down Regulation of electrolyte levels in the ECF Regulation of pH of the ECF Excretion of metabolic wastes and toxic substances

kidneys

Remove approximately 400ml of water daily via exhalation Acid-base balance What conditions increase the loss of water from lungs? coughing, rapid respirations What conditions decrease the loss of water from lungs? Humidity - will decrease water loss

lungs

``` posterior pituitary gland body conserves water regulates volume and osmolality by conservation of H20 Increased=volume increase Decreased=volume decrease ```

pituitary: adh

Increased secretion: sodium retention & water retention Decreased secretion: sodium & water loss; K+ retention regulates Na and K values and regulates BP and fluid balance

adrenal: aldosterone

Renin-enzyme that converts angiotensinogen to angiotensin I Angiotensin-converting enzyme (ACE) converts angiotensin I to II. Angiotensin II-vasoconstrictor (increases arterial perfusion) Aldosterone released when SNS activated because of increased renin in body Aldosterone-regulates volume and will increase reabsorption of sodium & water-increasing plasma volume

renin angiotensin aldosterone system

``` Expand the ECF volume Expand intravascular space Use cautiously in patients with Hypertension Heart failure Types D5W-limited ability to expand intravascular volume - treat hypernatremia 0.9% Normal saline-remains in ECF Lactated Ringers-contains K+, Ca++ - fluid replacement: does have electrolytes so use for GI distress ```

isotonic

Provide Na, Cl, and free water Treat hypernatremia Types 0.45% NS Use cautiously-can lead to intravascular fluid depletion due to a fluid shift

hypotonic

Increase ECF volume Critical situations-hyponatremia Administer slowly-can cause volume overload and pulmonary edema Assess respiratory and BP Types 3% NS 5% NS Both are only administered in intensive care

hypertonic s

``` Loss of ECF volume exceeds the intake of fluid Water and electrolytes are both lost at the same proportion Causes Inadequate intake Vomiting Diarrhea GI suctioning Sweating Diabetes Insipidus Hemorrhage Third-space shifts ```

hypovolemia or fluid volume deficit (FVD)

``` Rapid weight loss Decreased skin turgor Oliguria (low urine output) Concentrated urine Postural hypotension (low bp when stand) Tachycardia Cool, clammy skin, dry mucous membranes Altered LOC BUN increased not in proportion to creatinine Hematocrit increased (rbc get suspended and hemoconcentrated) Electrolytes: Sodium and Potassium Urine specific gravity increased Urine osmolality increased ```

manifestations of hypovolemia

Oral fluids IV fluids Isotonic (0.9% NS or lactated ringers) Rate & volume based on volume loss & hemodynamics Assessment I&O What will the output be? decreased <30 ml/hour What will the urine look like? very concentrated Weights Vital signs Skin turgor Mental status Prevention

nursing management of hypovolemia

Expansion of the ECF abnormal retention of sodium and water ``` Causes fluid overload heart failure renal failure cirrhosis: liver issue, decrease albumin and unable to excrete urine excessive salt intake ```

hypervolmia

``` Edema JVD Crackles in lungs Tachycardia, bounding pulse, S3 heart sounds Hypertension Increased weight Increased urine output Shortness of breath* very important BUN decreased Hematocrit decreased Urine sodium-increased Chest X-ray-pulmonary congestion ```

manifestations of hypervolemia

Diuretics Hemodialysis Sodium restriction and/or Fluid restriction ``` Assessment I & O Weight Lung sounds Edema ``` Prevention Teaching: fluid/na restriction

nursing management of hypervolemia

keeps water in extracellular space | 135-145

sodium

``` Salt loss that is greater than water loss Causes Diarrhea Diuretics NG tube suctioning manifestations -poor skin turgor -dry mucousa -headache -orthostatic hypotension -nausea ```

cause of hyponatremia | true salt loss / fluid volume deficit

``` Excess of water relative to total body sodium Causes CHF Cirrhosis Excessive H2O intake manifestations -edema -crackles -ascites -JVD ```

cause of hyponatremia | too much water / fluid volume excess

``` Neurological (especially when NA <115) Altered mental status Headache Lethargy Seizures * Coma ``` Due to water shifting from the ECF into the cell  increased ICF volume  cerebral edema

manifestations of hyponatremia

why are they? -true sodium loss = give sodium in diet -fluid overload = fluid restriction neurologic symptoms? critically low; give 3%/5% NaCl slowly to prevent volume OD and monitor lung sounds edema? sodium and fluids are restricted early detection? I/O, daily weight, assessments, especially confusion with elder, monitor labs

nursing management of hyponatremia

More sodium than water ``` Causes Dehydration Enteral feeding with no water flushes Diarrhea Burns manifestations water shifts from ICS to ESC and leaves cell dehydrated, give hypotonic to make cell swell and decrease NA levels neurologic S/S: restless, weak, hallucinations in severe increased deep tendon reflexes thirst = first sign ```

hypernatremia

``` excreted via kidneys 3.5-5 98% is in cells 80% excreted via kidney, 20% excreted in stool poor renal function = trouble excreting ```

potassium

cause: diuretics: especially Thiazide diarrhea vomiting GI suction NPO: poor nutrition (alcoholics/elderly) = low potassium insulin: pushes potassium in ICF cell, not to the blood

hypokalemia

``` S/S: Fatigue Anorexia Nausea Vomiting Muscle weakness Leg cramps Arrhythmias* Decreased tendon reflexes ``` Replacement - Oral - IV….be careful b/c burns/hurts at site - - worse pain in PIH, less in Central - Diet: bananas, leafy greens, milk, meats, pickle juice Watch kidney function* Assessment! Cardiac-monitor for arrhythmias Musculoskeletal-monitor for weakness

management of hypokalemia

Kidney function Cardiac arrest Causes K+ sparing diuretics: Spironalactone (K paring) Renal failure: dialysis to help excrete Acidosis: move K out of cell into ECF and cause increase serum -S/S: cardiac disturbances so watch EKG

hyperkalemia

S/S: -cardiac disturbances Restricting diet and K+ meds Meds Kayexalate: binds K in bowel and pts excrete it in the stool Calcium Gluconate: regulates cardiac muscles --> lowers effects of hyperkalemia Sodium Bicarbonate: give to acidosis pt: makes blood alkaline and pushes K back into cell Regular Insulin: push K intracellular to lower K levels Diuretics Dialysis Assessment Cardiac Muscle weakness Labs

management of hyperkalemia

Transmits nerve impulses Regulates muscle contraction and relaxation Absorbed from foods, excreted in feces & urine Inverse relationship with Phosphorous (so if Ph is up, Ca is down) 8.5-10.5

calcium

``` causes: Inadequate calcium intake Acute pancreatitis Medications Decrease in Vitamin D High phosphorous levels ``` S/S: Tetany: muscle spasm, tingle on mouth, finger tips and feet. monitor through these tests -Trousseau’s sign: pump BP all the way, fingers invert -Chvostek’s sign: tap on facial nerve, twitch -Chvostek's Sign and Trousseau's Sign due to Postoperative Acquired Hypoparathyroidism - YouTube Seizures: b/c irritability of CNS and peripheral nerves EKG changes

management of hypocalcemia

``` IV Calcium-slow (calcium gluconate to increase absorption of ca) Vitamin D Diet Seizure precautions Cardiac monitoring Calcium supplements Teaching Encourage exercise to strengthen bones ```

manage hypocalcemia

causes: malignancy: 20% of pts with cancer have increases Ca --> tumor cells secrete PTH and that increases Ca hyperparathyroidism immbolization

hypercalcemia

S/S Muscle weakness: lower tone in smooth muscle Incoordination Constipation, anorexia, nausea, vomiting * Hypertension Neurologic effects when Ca >16 (slurred speech, impaired memory, confusion, lethargy) ``` Treat underlying cause (tumor --> chemo) IVF to dilute calcium Furosemide: excrete ca Calcitonin: lower Ca level by increase urinary excetion and helps bones reabsorb Dialysis Increase mobility Encourage fluids Encourage fiber: help constipation Monitor for EKG changes ```

s/s management of hypercalcemia

1.3-2.3mEq/L, excreted by kidneys Neuromuscular function Cardiovascular system -vasodilation: increase in mag and decrease in BP, causes alcohol withdrawal in hypo magnesium

magnesium

``` cause: alcohol withdrawal: NG suction, diarrhea Tube feed DKA: acidosis push mag back into cell and mag levels decrease s/s Muscle weakness Tremors Seizures Apathy Depression Agitation EKG changes- torsades de pointes, pvc’ NM diet, oral pills, IV slow assess swallow r/t muscle weakness, DTR (be hyperactive DTR) and teach ```

hypomagnesaemia

``` cause: renal failure b/c it's excreted in the kidneys and DKA s/s Hypotension Nausea, vomiting, weakness Lethargy dysarthria Loss of deep tendon reflexes Paralysis Respiratory depression, cardiac arrest when severely elevated nm: Discontinue all magnesium administrations Loop diuretics if renal function allows Dialysis ``` Assess vitals: BP Assess cardiac & respiratory status: EKG continuous telemetry Assess deep tendon reflexes: watch for loss Assess neuro status

hypermagnesemia

2.5-4.5 mg/dL Maintenance of acid-base balance Structural support to bones/teeth

phosphorus

``` Causes Anorexia Alcoholism Heat stroke DKA Chronic diarrhea s/s Neurologic: irritability, fatigue, weakness muscle weakness: including respiratory NM: Phosphorous infusions -*Sodium phosphorus or potassium phosphorus ``` ``` Assessment identify patient early Prevent infection: hypo can alter grandular sites Monitor labs Diet ```

hypophosphatemia

``` Causes Renal failure * Chemotherapy s/s: like decreased calcium seizures, lethargy(2 tests) nm: Phosphate binders Loop diuretics Dialysis Low phosphorus diet Recognize s/s of hypocalcemia Monitor urine output ```

hyperphosphatemia

97-107, produced in stomach, inverse relationship with bicarbonate Found in interstitial fluid, gastric juice, sweat, bile, saliva Maintains acid-base balance

chloride

``` Causes GI drainage Severe vomiting, diarrhea Any cause of volume depletion s/s: like hyponatremia, hypokalemia (they're lost with chloride) hypokalemia can cause hypochloremia (watch for cardiac arrhythmias) nm Normal saline Discontinue loop diuretic Diet ``` ``` Monitor I&O: excess water Monitor ABGs: r/t acid base balance Monitor labs Vital signs Diet teaching ```

hypochloremia

``` Causes Related to hypernatremia, bicarb loss, metabolic acidosis Increased intake of chloride Hyperparathyroidism, renal failure s/s Tachypnea Weakness Lethargy Hypertension Usually also has a high sodium level and fluid retention nm Hypotonic IV solutions IV sodium bicarbonate Diuretics Restrict sodium, chloride and fluids ``` Monitor vitals- respiratory r/t fluid, hypertension, neurological r/t sodium abgs, I&O Assess respiratory, neuro and cardiac

hyperchloremia

exam 2 Flashcards

(84 cards)