Med Surge Exam 1 Respiratory

Base excess deficit

+/- 2 mEq/L

COPD (Chronic Obstructive Pulmonary Disease)

- A preventable & treatable disease with significant extra pulmonary effects that may contribute to the severity in individual patients: airflow limitation that is not completely reversible during forced exhalation - May include bronchitis and emphysema but this is confusing because many patients have overlapping symptoms of these 2 diseases

Pneumonia

- Acute infection and inflammatory process of the lung parenchyma that results in edema and exudate that fills the alveoli - Occurs when defense mechanisms become incompetent or are overwhelmed by virulence or quantity of infectious agents - Three ways organisms reach lungs: - Aspiration from nasopharynx or oropharynx - Inhalation of microbes present in the air - Hematogenous spread from primary infection elsewhere in body

Rheumatic Fever

- Acute inflammatory disease of the heart potentially involving all layers (swollen, tender, painful joints, nodules over joints)

Pneumothorax

- Air in pleural space (S/S depend on size: dyspnea, tachycardia, increased RR, anxious, accessory muscle use, cyanosis, tracheal deviation (if severe), breath sounds diminished/absent, agitation, hypotension, diaphoresis) - Sudden and sharp chest pain

COPD Nursing management

- Assessment - Maintaining Oxygenation - Med Administration - Hydration/Adequate Nutrition (increased calories/protein) - Pulmonary Rehab - Patient Education - Pursed Lip Breathing - Smoking Cessation - Energy Conservation - Medication/ O2 teaching - Vaccine - Psychosocial Support - Advanced Directives

Scarlet Fever

- Bright red (sandpaper-like) rash on body, sore throat, high fever, strawberry tongue

Thoracentesis

- Chest wall/pleural space are perforated - Obtaining specimens, relieving pressure, instill medications

Asthma

- Chronic inflammatory disorder of airways that results in intermittent reversible airflow obstruction of the bronchioles - Occurs either by inflammation or airway hyper-responsiveness.

Atelectasis

- Closure or collapse of alveoli - Dyspnea - Sputum production - Tachycardia - Tachypnea - Decreased oxygen saturation - Decreased breath sounds/crackles - Cyanosis - late signs of hypoxia

COPD complications

- Cor Pulmonale (Right-Sided Heart Failure) - Acute Exacerbations - bacteria/virus - Pneumonia (can cause exacerbation) - Acute Respiratory Failure

Tuberculosis risk factors

- Crowded institutional living conditions - Homelessness - Substance Abuse - Occupation exposure (health care workers) - Immunocompromised (HIV, chemo, diabetes, Chron's) - Immigration from third world country - Advanced age - Recent travel to areas when TB is prominent

Clinical manifestations of pleural effusions

- Dependent on size/compression & underlying condition - Dyspnea especially on exertion - Pleuritic type pain - Dry nonproductive cough

Post-streptococcal glomerulonephritis

- Develop 5-21 days after infection (edema, HTN, hematuria, oliguria, proteinuria)

Reasons for a chest tube

- Drain: fluid, blood, air - Re-establish negative pressure - Facilitate lung expansion - Restore normal pressure - Post-operative chest drainage 3 Chamber system - drainage, water seal, suction

Chest physiotherapy

- Goals - remove bronchial secretions, improve ventilation, and increase efficiency of respiratory muscles. - Uses specific positions for gravity to assist in the removal of secretions. - Vibration loosens thick secretions - Breathing exercises and breathing retraining improve ventilation and control of breathing and decrease the work of breathing.

Risk factors for pleural effusion

- Heart failure - TB - Pneumonia - Pulmonary infections (viral) - Nephrotic syndrome - Connective tissue disorders - Pulmonary embolism - Neoplastic tumors - Trauma

Positive expiratory pressure

- Helps to remove airway secretions - Exhales through device - While exhaling, a ball inside the device moves, causing a vibration that results in loosening secretions

Cytomegalovirus (CMV) pneumonia

- Herpes virus - Asymptomatic and mild to severe disease - Life-threatening in immunosuppressed - Treat with antiviral medications and high- dose immunoglobulin

Exudate

- High concentration of WBCs and plasma proteins - Response to inflammation, infection or malignancy - Inflammatory process increases capillary permeability

Metabolism Alkalosis

- High pH and bicarbonate - Manifestations: symptoms related to decreased calcium/hypokalemia, respiratory depression (CO2 retains), tachycardia - Hypokalemia can cause this - Monitor I&O

Respiratory alkalosis

- High pH and low PaCO2 - Manifestations - lightheadedness, inability to concentrate, numbness/tingling (hypocalcemia)

Pulmonary tuberculosis

- Infectious disease that primarily affects the lung parenchyma - May also involve other body systems - Caused by Mycobacterium Tuberculosis - Acid fast aerobic rod - Slow growing with a waxy outer capsule that increases resistance - Spread by airborne transmission (coughing, sneezing, speaking)

Pharyngitis

- Inflammation of the pharyngeal walls - Acute and chronic

Pleurodesis

- Instillation of sclerosing substance via chest tube or thoracoscopic - Bleomycin or talc

Tuberculosis manifestations

- Low grade fever - Night sweats/chills - Fatigue - Anorexia - Weight loss - Cough initially dry, later productive of purulent and/or blood tinged sputum (lasting longer than 3 weeks) - Chest pain - Weakness

Metabolic acidosis

- Low pH and bicarbonate - Manifestations: headache, confusion, drowsiness, increased respiratory rate (hyperventilation decreases CO2 level), decreased BP/cardiac output, shock - Hyperkalemia (shifts out of cells) - Hypokalemia (shifts back into cells when corrected) - Hypocalcemia - occurs if this is chronic - must be corrected before treating - This inhibits calcium reabsorption in kidneys, which increases calcium loss in urine

Respiratory Acidosis

- Low pH and high PaCO2 - Inadequate excretion of CO2 - Manifestations - increased pulse/respiratory rate/BP, confusion, decreased LOC

Peak flow monitoring

- Measure highest airflow during forced expiration - Portable Measure - Best of 3 Attempts - Compare to Baseline - Self-Management - Green Zone 80% or above - Yellow Zone 60-80% - Red Zone Below 60%

Aspiration pneumonia

- Occurs as either CAP or MCAP - Results from abnormal entry of secretions into lower airway - Major risk factors: - Decreased level of consciousness - Difficulty swallowing - Nasogastric intubation

Community-Acquired Pneumonia (CAP)

- Occurs in patients who have not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms. - Can be treated at home or hospitalized dependent on patient condition. - Empiric antibiotic therapy started asap

Pneumocystis jiroveci pneumonia (PCP)

- Onset slow and subtle - Diffuse bilateral infiltrates to massive consolidation - Can be life-threatening - Spread to other organs - Treat with trimethoprim/sulfamethoxazole (Bactrim, Septra) IV or orally

Peritonsillar Abscess

- Pain, swelling, high fevers, chills, difficulty swallowing, muffled voice

Clinical manifestations of pharyngitis

- Red pharyngeal membrane, tonsils - Pain, "scratchy throat" - Edema - With or without Exudate - Malaise - Sore throat - (Fever, cervical lymph node enlargement, possible palatine petechiae, tonsillar exudates and absence of cough can be suggestive of bacterial pharyngitis) - Rash

Ineffective breathing pattern

- Related to alveolar hypoventilation, anxiety, chest wall alterations, and hyperventilation

Ineffective airways clearance

- Related to expiratory airflow obstruction, ineffective cough, decreased airway humidity, and tenacious secretions

Methylxanthines (Theophylline)

- Relax smooth muscles of the bronchi - Used when other treatments are ineffective - Close monitoring of serum medication levels due to narrow therapeutic range.

Beta 2 - adrenergic agonists

- Relieve bronchospasm - Inhibit Histamine release - Increase ciliary motility

Pneumonia risk factors

- Respiratory depression - Excess mucus - Bronchial obstruction - Increased Age - Smoking - Immobility - Presence of airway devices - Immunosuppression - Transmission from healthcare providers

Cor Pulmonale

- S/S: dyspnea, distended neck veins, peripheral edema, weight gain, lung sounds - "normal" or crackles - Treatment: managing the COPD, long-term 02 therapy, diuretics

Risk factors for reduced ventilation or obstruction

- Secretions - Altered breathing patterns - Reduced lung volumes - Postoperatively (anesthesia/analgesics, pain, positioning abdominal distention) - Impaired cough reflex

Status Asthmaticus

- Severe/persistent asthma that does not respond to conventional therapy - Inflammation of bronchial mucosa/constriction of the smooth muscle, thick secretions - Respiratory acidosis- poor ventilation - Monitor closely - assess airway/patient's response (O2, bronchodilators, steroids) - Life threatening

COPD risk factors

- Smoking # 1 - Passive smoking - Air pollution - Infections - Occupational exposure (coal,cotton,grain) - Genetic abnormalities(deficiency of alpha1antitrypsin (an enzyme inhibitor that counteracts destruction of lung tissue by certain enzymes) - Advanced Age

Treatment and management of atelectasis

- Supplemental O2 - IPPB treatments (intermittent positive pressure breathing) - keep alveoli open - Aerosol nebulizer treatment - Antibiotic therapy - Bronchoscopy - To remove airway obstruction

Pleurectomy (pleural stripping)

- Surgical stripping of parietal pleura away from visceral pleura - Produces intense inflammatory response and adhesions

Treatments of pleural effusions

- Thoracentesis - Chest tube - Pleurectomy - Pleurodesis - Pleuroperitoneal shunt - Hemlich valve - Pleur-X catheter

Health care associated pneumonia

- Was hospitalized for 2 days or longer within 90 days of infection -OR- Resided in long-term care facility -OR- Received recent IV antibiotic therapy, chemotherapy, or wound care within past 30 days -OR - - Attended a hospital or hemodialysis clinic

Transudate

- Watery fluid migrates from intact blood vessels - Capillary pressure high (CHF) - Plasma proteins low (liver or kidney disorders)

Medications for asthma

- β-2 Agonists Short-acting (Albuterol) Long-acting (Salmeterol) - Corticosteroids Inhaled Oral or IV - Anticholinergic - Leukotriene Inhibitors Montelukast (Singulair®) - Theophylline Toxicities Cardiac, Neuro, GI Level (5-15 mg/L) Interactions

Chronic Respiratory Acidosis

-PaCO2 chronically increased - Body can compensate - Respiratory center becomes insensitive to CO2 as respiratory stimulant - Hypoxemia is the primary drive for respiration - Oxygen is only administered with extreme caution

HCO3-

22-26 mEq/L

PCO2

35-45 mmHg

ABG pH

7.35-7.45

PO2

>80 mmHg

SaO2%

>94%

A. The client's immune system cannot mount a response to the skin test.

A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following? A. The client's immune system cannot mount a response to the skin test. B. The client has only mild TB, which is not enough to cause a reaction. C. The solution used for the skin test was probably outdated. D. The skin test was improperly performed.

D. Diminished breath sounds

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? A. Slow, deep respirations B. Normal oral temperature C. Dry, unproductive cough D. Diminished breath sounds

C. instruct the client to breathe into a paper bag.

A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: A. insert a nasogastric tube (NG) as ordered. B. administer acetaminophen (Tylenol) as ordered. C. instruct the client to breathe into a paper bag. D. administer antibiotics as ordered.

D. Ensure nothing by mouth (NPO) until the gag reflex returns

A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, what is the most important nursing intervention? A. Assess for signs of hemoptysis B. Have the client rest in the supine position C. Check the client's level of consciousness frequently D. Ensure nothing by mouth (NPO) until the gag reflex returns

D. Promote carbon dioxide elimination

A nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose. The nurse responds: A. Promote oxygen intake B. Strengthen the diaphragm C. Strengthen the intercostal muscles D. Promote carbon dioxide elimination

D. Beta2 agonist

A nurse is caring for a client 2 hr after admission. The client has an Sa02 of 91% exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? A. Antibiotic B. Beta-blocker C. Antiviral D. Beta2 agonist

B. A hyperinflated chest noted on the CXR

A nurse is caring for a client with an acute exacerbation of COPD. Which of the following would the nurse expect to note on assessment of this client? A. Hypocapnia B. A hyperinflated chest noted on the CXR C. Increased oxygen saturation with exercise D. Widened diaphragm noted on CXR

C. "I can have an increase in my HR while taking this medication."

A nurse is providing discharge teaching to a client who has COPD and has a new prescription for albuterol (Proventil). Which of the following statements made by the client indicates an understanding of the teaching? A. "This medication can increase my blood sugar levels." B. "This medication can decrease my immune response." C. "I can have an increase in my HR while taking this medication." D. "I can have mouth sores while taking this medication."

C. Respiratory alkalosis, uncompensated

A nurse reviews the arterial blood gases and noted a pH of 7.50, a PC02 of 30 mm Hg, and a HC03 of 25 mEq/L. These values indicate? A. Metabolic acidosis, uncompensated B. Respiratory acidosis, uncompensated C. Respiratory alkalosis, uncompensated D. Metabolic acidosis, partially compensated

C. "I get a sharp, stabbing pain when I take a deep breath."

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? A. "Lately I can only breathe well if I sit up." B. "During the night I sometimes get the chills." C. "I get a sharp, stabbing pain when I take a deep breath." D. "I'm coughing up larger amounts of thicker mucus for the last several days."

C. I get a sharp, stabbing pain when I take a deep breath."

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? A. "Lately I can only breathe well if I sit up." B. "During the night I sometimes get the chills." C. I get a sharp, stabbing pain when I take a deep breath." D. I'm coughing up larger amounts of thicker mucus for the last several days."

COPD diagnostic studies and findings

Arterial blood gases - pO2's--- low (normal 80-100) - pCO2's--- high (normal 35-45mmHg) - Hemoglobin & Hematocrit: chronically hypoxic person produces more RBC's (polycythemia>>> increased hematocrit>>>increased viscous workload, increased thrombus formation)

Inhaled anticholinergics

Block the parasympathetic nervous system, resulting in increased bronchodilation and decreased pulmonary secretions. Affect the muscles around the bronchi

Hemothroax

Blood in the pleural space

Emphysema

Destruction of the walls of the alveoli

D. Position the patient upright with the elbows resting on the over-the-bed table

During an acute exacerbation of mild COPD, the patient is severely short of breath, and the nurse identifies a nursing diagnosis of ineffective breathing pattern related to alveolar hypoventilation and anxiety. What is the best nursing action? A. Prepare and administer routine bronchodilator medications B. Peform chest physiotherapy to promote removal of secretions C. Administer oxygen at 5L/min until the shortness of breath is relieved D. Position the patient upright with the elbows resting on the over-the-bed table

Pleural Effusion

Fluid in the pleural space

Chronic bronchitis

Inflammatory disease of the airways

Clinical manifestations of pneumonia

Most common - Cough - Fever, shaking chills - Dyspnea, tachypnea - Pleuritic chest pains - Green, yellow, or rust-colored sputum - Change in mentation for older or debilitated patients Nonspecific manifestations - Physical examination findings - Rhonchi and crackles - Bronchial breath sounds - Egophony - ↑ Fremitus - Dullness to percussion if pleural effusion present

D. Tuberculosis

Nursing students are reviewing the various infectious diseases that require transmission-based precautions. The students demonstrate understanding of the information when they identify which infectious disease as requiring airborne precautions? A. Scabies B. Impetigo C. Rubella D. Tuberculosis

Hospital associated pneumonia

Occurring 48 hours or longer after admission and not incubating at time of hospitalization

Ventilator associated pneumonia

Occurring more than 48 hours after endotracheal intubation

Opportunistic Pneumonia

Patients at risk: - Severe protein-calorie malnutrition - Immune deficiencies - Chemotherapy/radiation recipients - Long-term corticosteroid therapy - Caused by microorganisms that do not normally cause disease

Impaired gas exchange

Related to alveolar hypoventilation

D. An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office

The nurse at the beginning of the evening shift receives a report at 1900 on the following patients. Which patient would the nurse assess first? A. An 85 year old with COPD with wheezing and an O2 saturation of 89% on 2 L of oxygen B. A 62 year old with emphysema who has 300 mL of intravenous fluid remaining C. A 74 year old with chronic bronchitis who has BP 128/58, HR 104, and R 26 D. An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office

D. The lungs are not able to blow off carbon dioxide.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the rise in pH? A. The lungs are unable to breathe in sufficient oxygen. B. The lungs are unable to exchange oxygen and carbon dioxide. C. The lungs have ineffective cilia from years of smoking. D. The lungs are not able to blow off carbon dioxide.

A. Encourage turning, coughing, and deep breathing exercises B. Perform frequent breath sounds assessment Not E because it is not a nursing action - nurse can request but not obtain/order

The nurse is caring for a client who is postoperative day 2 from an open cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions will be appropriate for this client? Select all that apply A. Encourage turning, coughing, and deep breathing exercises B. Perform frequent breath sounds assessment C. Decrease by mouth fluid intake D. Offer a high-potassium diet E. Obtain a chest x-ray

D. Localized decreased breath sounds

The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would expect which finding? A. Barrel shaped chest B. Paradoxical respirations C. Hyper-resonance on percussion D. Localized decreased breath sounds

D. Localized decreased breath sounds

The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would expect which finding? A. Barrel shaped chest B. Paradoxical respirations C. Hyperresonance on percussion D. Localized decreased breath sounds

A. Initially, clear the nose and throat. C. Take a few deep breaths before coughing. D. Use diaphragmatic contractions to aid in the expulsion of sputum.

The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? (Select all that apply.) A. Initially, clear the nose and throat. B. Spit surface mucus and saliva into a sterile specimen container. C. Take a few deep breaths before coughing. D. Use diaphragmatic contractions to aid in the expulsion of sputum. E. Rinse with mouthwash prior to providing the specimen.

Metabolic alkalosis

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Pneumonia

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly patients? A. Pleurisy B. Pneumonia C. Hypoxemia D. Pulmonary Edema

A) "I use my corticosteroid when I am short of breath"

Which statement by the patient with asthma warrants FURTHER teaching? A) "I use my corticosteroid when I am short of breath" B) "I get a flu shot every year" C) "I use my inhaler before I visit my sister who has cats" D) "I walk 30 minutes per day and sometimes use my bronchodilator inhaler before walking to prevent shortness of breath"

B. Slight erythema of the pharynx and tonsils

Which throat manifestations are the key features for a client with acute viral pharyngitis? A. Petechiae on soft palate Bacterial B. Slight erythema of the pharynx and tonsils C. Severe hyperemia of the pharyngeal mucosa D. Erythema of the tonsils with yellow exudates Sometimes can have exudate without bacterial