Respiratory HESI PREP
HESI HINT pneumonia
irritability, restlessness EARLY SIGNS of hypoxia brain isn't getting enough O2
Which diagnostic testing is most useful in evaluating the effectiveness of treatment for asthma? CXR Pulmonary function tests Serum eosinophil counts immunoglobulin E levels
pulmonary function tests it measures airflow cxr is used to check for complications of asthma like infection eosinophil counts can be used to determine if asthma was caused by allergies IgE is to determine if client had allergic asthma
Which finding for a client who has just returned to the nursing unit after bronchoscopy and lung biopsy would be most important to report to the health care provider? client arousable, but lethargic cough productive of bloody mucus HR 126 bpm client report of dry and sore throat
HR 126 bpm Tachycardia may indicate hemorrhage, a possible complication of bronchoscopy and lung biopsy, and should be immediately reported to the health care provider. The nurse will expect prescriptions for frequent vital signs, a complete blood count, and perhaps a return to the operating room. Because sedation is used for bronchoscopy, lethargy is expected for few hours after the procedure. Bloody mucous is expected due to trauma to the trachea and tissue injury from the biopsy. A dry and sore throat is common after bronchoscopy because of trauma to the pharynx.
HESI HINT COPD
Watch for NCLEX-RN questions that deal with O2 delivery. In adults, O2 must bubble through some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification.
Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. Mold Cold air Pet dander air pollution cigarette smoke
all Clients with asthma should be instructed to avoid asthma attack triggers such as mold, cold air, pet dander, air pollution, and cigarette smoke.
HESI HINT for Pneumonia
increased temperature also increases metabolism = increasing oxygen demand fever can cause dehydration because of excessive fluid loss due to sweating/diaphoresis bronchial breath sounds are heard over areas of density or consolidation -- sound waves are easily transmitted over consolidated tissue
When caring for a client who has had a bronchoscopy in the ambulatory surgery unit, which action would the nurse take first? offer ice chips to decrease throat pain avoid turning the head from side to side keep the client in semi fowler position suggest medicated lozenges for sore throat
keep the client in semi fowlers With the head elevated, rather than horizontal or dependent, fluid will NOT COLLECT in the interstitial spaces around the trachea. Because the client's gag reflex may not be intact, ice chips or fluid would not be offered. There is no restriction on turning the head after bronchoscopy. Medicated lozenges would not be suggested because they may numb the throat, further decreasing the gag reflex.
Respiratory Isolation Technique
• Mask is required for anyone entering room. • Private room is required with negative air pressure. • Client must wear mask if leaving room.
After a client has had bronchoscopy, which finding indicates that the client's gag reflex has returned? alert and oriented able to swallow saliva speaks without difficulty denies sore throat
able to swallow saliva The ability to swallow indicates that the gag reflex is intact. Clients may be alert and still have a diminished gag reflex, especially if a topical anesthetic was used to numb the throat. Clients may be able to speak and still have a decreased gag reflex. Because bronchoscopy does cause trauma to the structures in the pharynx, a client who denies a sore throat may have ongoing numbness of the throat and a decreased gag reflex
Clients at high risk for pneumonia
-altered LOC - brain injury - depressed /absent gag and cough reflexes - susceptible to aspirating oropharyngeal secretions, including alcoholics and anesthetized pt - drug OD - stroke victim - immunocompromised
Hydration r/t Pneumonia
thins out mucus trapped in bronchioles and alveoli, facilitating expectoration it's essential for client experiencing fever is important because 300-400 ml lost daily by lungs through evaporation
Ventilator Setting Maintenance
• Verify that alarms are on. • Maintain settings and check often to ensure that they are specifically set as prescribed by health care provider. • Verify functioning of ventilator at least every 4 hours.
Nursing Plans/Interventions --COPD
• teach client to sit upright and bend slightly forward to promote breathing • in bedL tripod position (sit w arms resting on overbed table) • in chair: teach client to lean forward w elbows resting on knees • teach diaphragmatic and pursed lip breathing -- teach prolonged expiratory phase to prevent bronchiolar collapse and prevent air trapping • administer O2 @ 1-2 per nasal cannula • pace activities to conserve energy • maintain adequate dietary intake small frequent meals increase calories and protein, but do not overfeed favorite foods dietary supplements • for ppl continuing to smoke tobacco, vitamin C may be necessary • Mg and Ca because of their role in muscle contraction and relaxation may be important for people w COPD • routine monitoring of Mg and P levels is important bc of their role r/t bone mineral density • provide adequate fluid intake unless contraindicated • fluids should be taken BETWEEN meals rather than with them to prevent excess stomach distention and decrease pressure on diaphragm • instruct client in relaxation techniques, teach prevention of secondary infections, med regimen, health promoting activities, smoking cessation
HESI Hint for Lung Cancer
Assessment: hacking cough early, turning productive as disease progresses; hoarseness, dyspnea, hemoptysis; pain in chest area, diminished breath sounds occasional wheezing, abnormal CT, positive sputum for cytology and for pleural fluid interventions: semi fowler position, pursed lip breathing to improve gas exchange, relax techniques, O2 administration, decrease pain sometimes when tumors are so large that there's large spaces left in the body, they want liquid to move into those spaces so the remaining chest organs dont move---- this is why they wouldn't put a chest tube into these pts CHEST TUBES: if a chest tube becomes disconnected, do not clamp; immediately PLACE THE END OF TUBE IN STERILE SALINE or clean water until new drainage system can be connected--- why??? pneumothorax if chest tube is dislodged from client, the nurse should cover with a dry sterile dressing taped on 3 sides; if an air leak is notes, tape the dressing on three sides ONLY; this allows air to escape and prevents the formation of pneumothorax; notify HCP tidaling in the fluid will occur if there is no external suction-- good indicator that system is intact they should move upward w each inspiration and downward w each expiration -- if it stops check for kinked tubing or occlusions Or change in client position when a chest tube is connected to suction, continuous bubbling is an indication of an air leak between the drain and the client Chemo: administer anti emetics before administration of chemo; targeted therapy is used for non small cell cancer and late stage lung cancer and the drugs are not used alone as therapy for lung cancer radiation: skin care; tell pt to NOT wash off lines drawn by radiologist, wear soft cotton garments only; avoid use of powders and creams on radiation site unless specified by radiologist
HESI HINT pulmonary TB
TST or Mantoux test: a positive test 10mm or greater in diameter 48-72 hours after skin test anyone who received a BCG vaccine will have a positive skin test and be evaluated w an initial chest radiograph precautions: air precautions Assessment: usually asymptomatic; s/s include fever w night sweats; anorexia/weight loss, malaise/fatigue, cough, hemoptysis, dyspnea, pleuritic chest pain w inspiration, cavitation or calcification shown on chest radiograph, positive sputum culture, recurring URIs client teaching: cough into tissues and dispose of immediately into biohazard waste bags, take all meds as prescribed for MINIMUM of 9-12 months; wash hands report symptoms of deteroroating conditions esp hemorrhage interventions: sputum cultures, client can return to work after 3 negative cultures; place client in respiratory isolation while hospitalized, anti TB meds, refrr to local health department for testing and prophylactic treatment, promote adequate nutrition
Bronchodilators and Corticosteroids
adrenergic and sympathomimetics (epinephrine, isoproterenol HCL, albuterol, isoetharine, terbutaline, salmeterol, metaproterenol) are indicated bronchodilators (adverse Ron: anxiety, tachycardia, N/V, urinary retention) implications for ^^: check HR, monitor for urinary retention, especially in men over 40; use bronchodilator inhaler before steroid inhaler; may cause sleep disturbance methylxanthine is an indicated bronchodilator (adverse Rxn: GI distress, sleeplessness, dysrhythmias, hyperactivity, tachycardia) implications: administer WITH food, avoid caffeine, check HR, monitor therapeutic range, crosses placenta corticosteroids (prednisone PO, beclomethasone dipropionate inhaled, fluticasone) (adverse rxn: dysrhythmias w long term use) anticholinergics cause dry mouth and blurred vision and cough; do not exceed 12 doses in 24 hrs
Which rationale would the nurse use when teaching a client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing? decrease air trapping prevent bronchial dilation strengthen intercostal muscles reduce diaphragmatic excursion
decrease air trapping Pursed-lip breathing prolongs the expiratory phase and increases airway positive pressure, leading to more complete expiration and reduced air trapping. Bronchi and bronchioles stay open longer and are expanded during pursed-lip breathing. Pursed-lip breathing does not strengthen the intercostal muscles or reduce diaphragmatic excursion.
A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? encourage client to take slow deep breaths admin 5 L/min O2 per nasal cannula place client in side lying position and perform chest physiotherapy using clapping and vibration raise the head of the bed to a high fowler position and admin 2 L/min of O2 per nasal cannula assist the client in assuming a position of comfort and perform postural drainage
raise the head of the bed to a high fowler position and admin 2 L/min of O2 per nasal cannula Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy (postural drainage) may be done later after the client's condition improves. Delaying intervention is likely to worsen the respiratory distress.
HESI HINT: cancer of larynx
tracheostomy care involves cleaning the inner cannula, suctioning, and applying clean dressings w cancer of larynx the tongue and mouth often appear white, grey, dark brown or black and may appear patchy assessment: MRI, direct laryngoscopy, assess for hoarseness of longer than 2 weeks and color changes in mouth/tongue, dysphagia, dyspnea, cough, hemoptysis, weight loss, neck pain radiating to ear, enlarged cervical lymph nodes, halitosis, radiographs of head neck and chest, CT of neck promote respiratory functioning: assess RR and characteristics q 1-2 hrs; keep bed in semi fowler position at all times; keep laryngeal airway humidified at all times; lung sounds q 2-4 hrs; natural humidifying pathway in body is gone for pt who had laryngectomy; if air is not humidified before entering the lungs, the SECRETIONS TEND TO THICKEN AND GET CRUSTY greatest immediate post op risks are bleeding or occlusion with a laryngectomy tube for the first 24 hours ALWAYS have suction equipment available at the bedside for new and chronic trach clients teach glottal stop technique (take deep breath, occlude trach tube momentarily, cough, simultaneously remove the finger from the tube
Which action by a client with asthma indicates that the client teaching about use of a peak flow meter has been effective? calls HCP when peak flows are in green zone does deep breathing and relaxation exercises when peak flow is in the red zone uses a quick relief inhaled med when peak flow is in the yellow zone stops taking the daily inhaled corticosteroid when peak flow is in yellow
uses a quick relief inhaled med when peak flow is in the yellow Peak flows in the yellow zone are between 50% and 80% of personal best and indicate a need to use a quick relief inhaler such as albuterol to improve breathing. There is no need to call a provider when peak flows are in the green zone, which is 80% to 100% of the personal best. Peak flows in the red zone indicate that peak flows are less than 50% of personal best. The client should use a quick relief inhaled medication, then call the health care provider or go to the hospital when peak flows are this low. The client would continue the usual long-term control medications such as inhaled corticosteroids when peak flows are in the yellow zone while adding a quick relief inhaler such as albuterol to improve peak flow.
Tracheostomy Care
• Aseptic technique (remove inner cannula only from stoma) • Clean nondisposable inner cannula with H2O2; rinse with sterile saline in accordance with hospital policy • 4 × 4 gauze dressing is butterfly folded after inner cannula is inserted.
Proper Use of Inhaler w spacers
• Have client exhale completely. • Grip mouthpiece (in mouth) only if client has a spacer; otherwise, keep the mouth open to bring in volume of air with misted medication. While inhaling slowly, push down firmly on the inhaler to release the medication. • Use bronchodilator inhaler before steroid inhaler. • Wait at least 1 minute between puffs (inhaled doses). • After steroid inhaler use, client must perform oral care to prevent fungal infections.
OXYGEN Administration
• Nasal cannula: low O2 flow for low O2 concentrations (good for COPD) • Simple face mask: low flow, but effectively delivers high O2 concentrations; cannot deliver <40% O2 • Nonrebreather mask: low flow, but delivers high O2 concentrations (60%-90%) • Partial rebreather mask: low-flow O2 reservoir bag attached; can deliver high O2concentrations • Venturi mask: high-flow system; can deliver exact O2 concentration • C-PAP and Bi-PAP
TRACHEAL SUCTIONING
• Suction when adventitious breath sounds are heard, when secretions are present at endotracheal tube, and when gurgling sounds are noted. • Use aseptic/sterile technique throughout procedure. • Wear mask and goggles. • Advance catheter until resistance is felt. • Apply suction only when withdrawing catheter (gently rotate catheter when withdrawing). • Never suction for more than 10 to 15 seconds, and pass the catheter only three or fewer times. • Oxygenate with 100% O2 for 1 to 2 minutes before and after suctioning to prevent hypoxia.
nursing plan/intervention for pneumonia
• assess sputum (color, volume, consistency, odor, clarity) • assist client to cough productively - (deep breathing/incentive spirometer every 2 hours, humidity to loosen secretions--can be oxygenated--, suction airway if needed, chest physiotherapy) • 3L fluid/day unless contraindicated • assess lung sounds before and after coughing • assess rate, depth, pattern of respirations regularly • monitor ABGs (pO2 > 80, PCO2 < 45) • monitor O2 sat w pulse ox • assess skin color, mental status, restlessness, irritability • administer humidified O2 as prescribed • monitor temp regularly • adequate rest periods throughout the day -- uninterrupted sleep • antibiotics • teach high risk pt and fam about risk factors and prevention - adults develop protection within 2-3 weeks after vaccines
Nursing Assessment for COPD
• changes in breathing pattern (increase rate, decrease depth) • overinflation of lungs can cause rib cage to remain • partially expanded (barrel chest) • generalized cyanosis of lips, mucous membranes, face, nail beds • cough -- dry or productive • higher CO2 than avg • low O2 • coarse crackles in lungs that disappear after •coughing/wheezing • dyspnea, orthopnea • poor nutrition, weight loss • activity intolerance • anxiety
HESI hint for COPD
• compensation occurs over time in people w chronic lung disease • ABGs are altered • as COPD worsens, hypoxemia occurs and hypercapnia increases (CO2 in blood) -- which causes chronic respiratory acidosis (increased PCO2) and then that results in kidneys retaining HCO3 as compensation • not all COPD pt are CO2 retainers because CO2 diffuses more easily across lung membranes than O2 • in more advanced emphysema, hypercarbia is a problem due to alveoli being affected in bronchitis, the airways are affected • baseline data for pt must be taken
HESI hint for COPD
• mechanically soft diets that don't require much chewing and digestion- why? because eating consumes energy needed for breathing • prevent secondary infections, avoid crowds, contact. w persons who have infectious diseases and respiratory irritants • teach client to report any change in characteristics of sputum • encourage client to hydrate well (3L/day) and decrease caffeiene due to diuretic effect • obtain immunizations • • • • WHEN ASKED TO PRIORITIZE ACTIONs = ABCs • look and listen -- if client breath sounds clear but they're cyanotic and lethargic obvi they aren't getting adequate oxygenation
HESI hint for COPD
• overinflation of the lungs causes the rib cage to remain partially expanded, giving the characteristic appearance of a barrel chest • person works harder to breathe, but the amount of O2 taken in Is not adequate to oxygenate the tissues • insufficient oxygenation occurs w chronic bronchitis and leads to generalized cyanosis and often R sided HF aka for pulmonale • cells of the body depend on O2 to carry out their functions • inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill • a chronic sign is clubbing of the fingernails and late sign is clubbing of the fingers • the key to respiratory status is assessment of breath sounds as well as visualization of the cilent
HESI hint for COPD
• productive cough and comfort = high fowler or semi fowler position • lessens pressure on diaphragm by abdominal organs can cause gastric distention problems bc it elevates diaphragm and inhibits full lung expansion
Nursing Assessment for Pneumonia
• tachypnea (shallow breaths, accessory muscles) • abrupt onset of fever (maybe w shaking/chills) • productive cough • pleuritic pain • rapid bounding pulse • pain and dullness to percussion over affected area • crackles • tactile fremitis and bronchial breath sounds • elevated WBC • ABGs show hypoxemia • low SaO2 • pleural effusion in chest radiograph older adults: confusion, lethargy/malaise, anorexia, rapid RR, tachycardia
