NSG 252-Exam 3
tx goal of ARDS
(1) adequately oxygenate the lungs and vital organs; (2) recognize and treat underlying medical and surgical disorders; (3) prevent further lung injury and complications, including, but not limited to, venous thromboembolism, aspiration, nosocomial infections; and (4) ultimately decrease mortality.
Kawasaki disease
(inflammation of blood vessels, hence the strawberry tongue) causes coronary artery aneurysms. cause unknown
three stages of Kawasaki disease
- Acute - Subacute - Convalescent
sxs of flail chest
-hypotension, tachypnea, cyanosis, chest pain - Pain and Respiratory distress - Paradoxical chest wall movement - Crepitus - Respiratory Failure
hemorrhagic stroke causes
-intracerebral hemorrhage -subarachnoid hemorrhage -cerebral aneurysm -arteriovenous malformation
left brain damage signs
-paralyzed right side: hemiplegia -impaired speech/language aphasias -impaired right/left discrimination -slow performance, cautious -aware of deficits: depression, anxiety -impaired comprehension related to language, math
Digoxin levels
0.8-2, count # of beats for full minute
The nurse is assessing a client following a thoracentesis and immediately reports which finding to the health care provider? 1. sub q emphysema around the site 2. serous drainage oozing from site 3. increased temp to 100.4F 4. diminished breath sounds on the affected side
1 The focus of this question is the recognition of the most critical potential complication following a thoracentesis. The palpation of expanding subcutaneous emphysema or crepitus, around the thoracentesis insertion site is most likely an indication that a pneumothorax has occurred.
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees 4. Head turned to the side when flat in bed5. Neck and jaw flexed forward when opening the mouth
1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that the head is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the neck or turning the head from side to side.
The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 1. Keep suction equipment at the bedside. 2. Elevate the head of the bed 30 degrees. 3. Keep the client lying in a supine position. 4. Keep the head and neck in good alignment. 5. Administer prescribed respiratory treatments as needed.
1. Keep suction equipment at the bedside. 2. Elevate the head of the bed 30 degrees. 4. Keep the head and neck in good alignment. 5. Administer prescribed respiratory treatments as needed. The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.
The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of which condition? 1. Normal condition 2. Increased pressure 3. Borderline situation 4. Compensating condition
1. Normal condition The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range.
The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition? Select all that apply 1. The client is aphasic. 2. The client has weakness in the face and tongue. 3. The client has weakness on the right side of the body. 4. The client has complete bilateral paralysis of the arms and legs. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.
1. The client is aphasic. 2. The client has weakness in the face and tongue. 3. The client has weakness on the right side of the body. Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in this hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
The nurse is developing a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. 1. Thicken liquids. 2. Assist the client with eating. 3. Assess for the presence of a swallow reflex. 4. Place the food on the affected side of the mouth. 5. Provide ample time for the client to chew and swallow.
1. Thicken liquids. 2. Assist the client with eating. 3. Assess for the presence of a swallow reflex. 5. Provide ample time for the client to chew and swallow. Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.
first thing the nurse does when drainage from chest tube suddenly stops?
1. auscultate lung sounds 2. turn, cough, & deep breathe 3. reposition patient
A child with TOF is experiencing a TET spell. What is the order of priority?
1. knee to chest position 2. 100% oxygen 3. Morphine as prescribed 4. IV fluids 5. Document
interventions for flail chest
1. pain control=priority---opioids 2. pulmonary hygiene (turn, cough, deep breathe, & incentive spirometer)
ARDS pulmonary artery wedge pressure
18mmHg or less
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle
2. Nail bed pressure Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
The nurse cares for the client diagnosed with a serious closed head injury. The client's parent says to the nurse, "will my child be all right? Is my child going to die? I'm so scared". Which is the BEST response for the nurse to give the client's parent? 1. of course your child will be all right. it will take time for your child to get better 2. I'll be available if you have any questions. Here is a booklet on head injuries 3. It must be frightening to see your child hurt 4. It's too soon to know the outcome. Would you like to talk with the HCP?
3
Which ABG values supports suspected ARDS? 1. PaO2 55, PaCO2 47 2. PaO2 62, PaCO2 32 3. PaO2 47, PaCO2 63 4. PaO2 82, PaCO2 22
3
Which of the following is the most common side effect of tPA? 1. increased ICP 2. HTN 3. Bleeding 4. Headache
3
A client injured in a motor vehicle accident is transferred to the intensive care unit with a diagnosis of head trauma. The emergency room nurse reports the client has increased intracranial pressure. Which assessment findings are the most important for the nurse to monitor? Select all that apply. 1. Urine Output 2. Rate of Respirations 3. Cerebral perfusion pressure 4. Systolic Blood Pressure 5. Assess for Rhinorrhea
3, 4, 5 Head trauma can cause increased intracranial pressure (ICP) when cerebrospinal fluid or bleeding from your brain causes increased pressure inside your skull and brain tissue. Signs and symptoms include mental status changes, pupillary changes, headache, increased respiratory rate, seizures, and nausea/vomiting. Nursing interventions include reducing stimuli, elevating head of bed to 30 degrees to reduce arterial pressure while keeping the neck in a neutral position, promoting venous drainage, as well as keeping the client's body temperature in normal range. It is important to also monitor for volume overload. Treatment options include drainage of cerebrospinal fluid or blood, osmotic or loop diuretics, sedation, and anticonvulsants. Sometimes a craniectomy is also indicated.
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder
3. Flaccid paralysis Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1. Insert nasal packing. 2. Document the findings. 3. Contact the health care provider (HCP). 4. Monitor the client's blood pressure and check for signs of increased intracranial pressure.
3. Contact the health care provider (HCP). Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention. Options 1, 2, and 4 are inappropriate nursing actions in this situation.
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.
4. Fluid separates into concentric rings and tests positive for glucose. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self
4. Consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning
4. Exhaling during repositioning. Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence? 1. Strict adherence to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Preventing unnecessary pressure on the lower limbs 4. Limiting bladder catheterization to once every 12 hours
4. Limiting bladder catheterization to once every 12 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
The nurse is performing an assessment on a client with a diagnosis of thrombotic brain attack (stroke). Which assessment question would elicit data specific to this type of stroke? 1. "Have you had any headaches in the past few days?" 2. "Have you recently been having difficulty with seeing at nighttime?" 3. "Have you had any sudden episodes of passing out in the past few days?" 4. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"
4. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesia's on one side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."
4. "We need to remind him to turn his head to scan the lost visual field." Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? 1. Providing sensory cues 2. Giving simple, clear directions 3. Providing a stable environment 4. Encouraging multiple visitors at one time
4. Encouraging multiple visitors at one time Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside.
A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? 1. Side-lying with a pillow under the hip 2. Prone with a pillow under the abdomen 3. Prone in slight Trendelenburg's position 4. Side-lying with the legs pulled up and the head bent down onto the chest
4. Side-lying with the legs pulled up and the head bent down onto the chest A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.
normal ICP
5-15 mmHg
neglect syndrome
A neurological disorder in which a part of the body or a part of the visual field is ignored or suppressed; most commonly associated with damage to posterior parietal areas of the brain.
A nurse must position the patient prone after his diagnosis of ARDS. Which of the following is a benefit of using this position? SATA A. Decreased atelectasis B. Reduced need for endotracheal intubation C. Mobilization of secretions D. Decreased fluid accumulation E. Increased response to corticosteroid therapy
A, C, D
ARDS acronym
A- atelectasis R- refractory hypoxemia D- decreased lung compliance S- surfactant cells are damaged
A nurse is assisting a provider with the removal of a chest tube. Which of the following nursing interventions is the priority once the provider removes the tube from the chest? A. Applying an occlusive dressing B. Assessing lung sounds C. Cleaning the wound with soap and water D. Culturing the insertion site
A.
An infant went through a TOF repair. Which postop findings indicate that the repair is successful?
Absence of cyanosis when feeding Lips are pink when crying RR of 32/min
risk factors of ARDS
Aspiration (gastric secretions, drowning, hydrocarbons) Drug ingestion and overdose Hematologic disorders (disseminated intravascular coagulopathy, massive transfusions, cardiopulmonary bypass) Prolonged inhalation of high concentrations of oxygen, smoke, or corrosive substances Localized infection (bacterial, fungal, viral pneumonia) Metabolic disorders (pancreatitis, uremia) Shock (any cause) Trauma (pulmonary contusion, multiple fractures, head injury) Major surgery Fat or air embolism Sepsis
ARDS diagnostics
BNP levels, Echo, pulmonary artery catheter, CXR=bilateral infiltrates
if giving TPA to patient, what do you monitor before administration?
BP (Hypertension increasing bleeding)
what does a patient present as with coarctation of the aorta?
BP and pulses in UE is higher than in LE weak or absent femoral pulses H/a, dizziness, fainting, epistaxis from HTN
signs of skull fractures
Battles sign raccoon eyes rhinorrhea (clear fluid from nose) otorrhea
A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning
C The answer is C. It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP).
A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first? A. The client with tidaling in the drainage tubing B. The client whose drainage system is standing on the floor C. The client with continuous bubbling in the drainage chamber D. The client with suction pressure set at -20 cmH2O
C. Continuous bubbling signifies an air leak..not good
two chronic causes of resp failure
COPD and neuromuscular diseases
diagnostics for TBI
CT scan, MRI, PET
diagnostics for increased ICP
CT, ICP monitoring
what are we assessing on a patient with ARDS?
CXR, ABGs, O2 levels, airway, mental status
what can cause an increase in vascular resistance and cause an increase in R to L shunting and cyanosis in infants
Crying, defecating, or the stress of feeding
TET spells s/s
Cyanosis Hypoxemia O2 65-85% clubbing polycythemia
The nurse is caring for a client with a chest tube. The nurse will refrain from clamping the chest tube because which of the following could happen? A. barrel chest B. pneumonia C. airway constriction D. tension pneumothorax
D.
tPA (tissue plasminogen activator)
Drug that immediately dissolves clots-given for ischemic stroke-give within 3 hours of sxs
nursing interventions for patient with expressive aphasia
Encourage patient to repeat sounds of the alphabet. Explore the patient's ability to write as an alternative means of communication.
communicating with the patient with aphasia
Face the patient and establish eye contact. Speak in a clear, unhurried manner, and normal tone of voice. Use short phrases, and pause between phrases to allow the patient time to understand what is being said. Limit conversation to practical and concrete matters. Use gestures, pictures, objects, and writing. As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question. Keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.
T/F: clamp the tube if the patient leaves the unit for a test or moves away from the bed
False! never clamp tube for this!
acute stage of kawasaki disease
Fever Irritability Red throat/strawberry tongue Swollen hands and feet Trunk rash Diarrhea Hepatic dysfunction
Mitral Valve Prolapse
Improper closure of the valve between the heart's upper and lower left chambers.
management of PDA
Indomethacin surgical ligation of the open ductus during infancy; subsequent problems minimal after surgical correction
Tension pneumothorax S/S
JVD, diminished/absent lung sounds, tracheal deviation towards the unaffected side, poor BVM compliance, tachy, asymmetrical expansion,
medication used for increased ICP
Mannitol
meds used for increased ICP
Mannitol Sedatives Anticonvulsants like Dilantin & Keppra Antipyretics like Tylenol Anti-ulcer like Protonix
collaboration team for stroke
OT, PT, nutrition, speech, patient's family
Symptoms of Right Hemispheric Stroke
Paralysis or weakness on L side of body L visual field deficit Spatial-perceptual deficits increased distractibility/short attention span impulsive behavior and poor judgment/lack of awareness of deficits
Symptoms of Left Hemisphere Stroke
Paralysis or weakness on R side of body R visual field deficit Aphasia Altered intellectual ability slow, cautious behavior
right brain damage signs
Paralyzed left side: hemiplegia Left-sided neglect Spatial-perceptual deficits Tends to deny or minimize problems Rapid performance, short attention span Impulsive, safety problems Impaired judgment Impaired time concepts
nursing interventions for patient with homonymous hemianopsia
Place objects within intact field of vision. Approach the patient from side of intact field of vision. Instruct/remind the patient to turn head in the direction of visual loss to compensate for loss of visual field. Encourage the use of eyeglasses if available. When educating the patient, do so within patient's intact visual field.
nursing interventions for patient with hemiparesis
Place objects within the patient's reach on the nonaffected side. Instruct the patient to exercise and increase the strength on the unaffected side.
TRoubLe
R to L---bad!
Client is recovering from head trauma with a GCS score of 15 over 2 hours ago, but now GCS is 14. What is the nurses first action?
Report to provider immediately
early signs of impaired oxygenation
Restlessness, Fatigue, Headache, Dyspnea, Air hunger, Tachycardia, Increased BP
parent education for patient with Kawasaki Disease
S/s irritability that lasts 2 months after onset of sxs peeling of hands/feet joint stiffness in AM, after naps, cold temps record temps Admin Aspirin s/s bleeding if taking anticoags avoid MMR and Varicella vaccine to the child for 11 months after IVIG
S/s of ARDS
SOB, cough, fever, fast HR, rapid breathing, chest pain, possible cyanosis
nursing interventions for patient with receptive aphasia
Speak clearly and in an unhurried manner to assist the patient in forming the sounds. Explore the patient's ability to read as an alternative means of communication.
nursing interventions for patient with dysphagia
Test the patient's pharyngeal reflexes before offering food or fluids. Assist the patient with meals. Place food on the unaffected side of the mouth. Allow ample time to eat.
disorders with decreased pulmonary blood flow
Tetralogy of Fallot Tricuspid atresia
expressive aphasia
The inability to produce language ( despite being able to understand language)
homonymous hemianopsia
The loss of the right or left half of the field of vision in both eyes.
CHD that start with the letter T
Trouble!!!
T or F: CSF contains glucose
True
T or F: always assess patient first before assessing the chest tube equipment
True
T/F In tension pneumothorax air enters but cannot leave the chest
True
T/F: In open pneumothorax, air enters the chest during inspiration and exits during expiration
True
Causes of ARDS
VAP, sepsis, near-drowning, smoke inhalation
interventions for RF
VS control pain bed rest admin abx/limit physical activity seizure precautions
Tetralogy of Fallot
VSD overriding aorta obstruction to pulmonary flow R ventricular hypertrophy
antidote for warfarin
Vitamin K
sxs of hemorrhagic stroke
Worst h/a ever N/V dizziness LOC visual changes nuchal rigidity
diagnostics for airway obstruction
Xray, laryngoscopy, or bronchoscopy
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? a. Intubate the client and control breathing with mechanical ventilation b. Increase oxygen administration c. Administer a large dose of furosemide (Lasix) IVP stat d. Schedule the client for pulmonary surgery
a A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.
A mediastinal shift occurs in which type of chest disorder? a. Tension pneumothorax b. Traumatic pneumothorax c. Simple pneumothorax d. Cardiac tamponade
a A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.
The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? a. Unresponsive arterial hypoxemia b. Diminished alveolar dilation c. Tachypnea d. Increased PaO2
a Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.
A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately? a. "Client is becoming agitated and complains of pleuritic pain." b. "Client is drowsy and complains of headache." c. "Client has subcutaneous emphysema around needle insertion site." d. "Client has oxygen saturation of 93%."
a After a thoracentesis, the nurse monitors the client for pneumothorax or recurrence of pleural effusion. Signs and symptoms associated with pneumothorax depend on its size and cause. Pain is usually sudden and may be pleuritic. The client may have only minimal respiratory distress, with slight chest discomfort and tachypnea, and a small simple or uncomplicated pneumothorax. As the pneumothorax enlarges, the client may become anxious and develop dyspnea with increased use of the accessory muscles.
An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care? a. Suction the client's airway secretions. b. Immobilize the ribs with an abdominal binder. c. Prepare the client for surgery. d. Immediately sedate and intubate the client.
a As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.
Transposition of the great vessels
a congenital abnormality where the aorta is attached to the right ventricle and the pulmonary artery to the left ventricle (this is backwards and leads to two separate blood routes)
Surgical repair for PDA is performed to prevent which complication?
a worsening of pulmonary vascular congestion
pleural effusion
abnormal accumulation of fluid in the pleural space
PDA
abnormal persistence of an open lumen in the DA between the aorta and pulm artery after birth; results in increased pulm blood flow & redistribution of flow to other organs
late signs of increased ICP in children
abnormal pupil response decreased motor response Cheyne-stokes abnormal posturing
CHD produces their effects mainly through what?
abnormal shunting of blood, production of cyanosis, and disruption of pulmonary blood flow
early sign of increased ICP
agitation/restlessness/irritability change in LOC decreased mental status sudden vomiting without nausea
sub-q emphysema & clinical findings
air has gotten out of the normal airway and found its way into interstitial space. edema/crackles on palpation (like bubble wrap under skin), mediastinal shift
causes of spontaneous pneumothorax
air-filled bleb, blister
how can the nurse provide instructions to help the client that had a stroke perform ADLs?
allow time to understand each instruction simple gestures (point) & show pictures ask yes or no questions normal voice---not loud voice
complications with hemorrhagic stroke?
altered mental status/confusion (due to vasospasms), seizures (do EEG), hydrocephalus, hyponatremia
convalescent stage of kawasaki disease
appears normal with signs of inflammation
if chest tube is dislodged, what does the nurse do?
apply a sterile dressing
biggest sign and symptom of stroke
arm drift/hemiparesis
complications from VSD
arrhythmias, HF, pulmonary HTN
causes of ischemic stroke
artery thromboses, cardiogenic embolic, cryptogenic
causes of upper airway obstruction
aspiration of foreign bodies, anaphylaxis, viral or bacterial infection, trauma, and inhalation or chemical burns
What is the priority for a client with 3 chambered chest drainage system for hemothorax?
assess client's respiratory status frequently
pneumothorax s/s
asymmetrical chest expansion decreased breath sounds on affected side hyper resonance deviated trachea
sedatives used while patient is on mechanical ventilator with PEEP
ativan, midazolam, precedex, propofol, and short-acting barbiturates
A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures should be initiated in this client? a. Psychological counseling b. Nutritional support c. High-protein oral diet d. Occupational therapy
b Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS.
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? a. Pneumothorax b. Flail chest c. ARDS d. Tension pneumothorax
b During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
A client involved in a motor vehicle crash suffered a blunt injury to the chest wall and was brought to the emergency department. The nurse assesses the client for which clinical manifestation that would indicate the presence of a pneumothorax? a. Diminished breath sounds b. Sucking sound at the site of injury c. Decreased respiratory rated. d. Bloody, productive cough
b Open pneumothorax is one form of traumatic pneumothorax. It occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration. Because the rush of air through the wound in the chest wall produces a sucking sound, such injuries are termed "sucking chest wounds."
management for coarctation of the aorta
balloon angioplasty surgery
example of open TBI
basilar skull fracture
how does carbon monoxide exert its toxic effect?
binding to circulating hemoglobin and thereby reducing oxygen
Hemianopsia
blindness in half the visual field
Hemorrhagic stroke treatment
blood pressure management, ICP monitoring, and management, neurological status, swallow evals, MRI, CT, cerebral angiography, lumbar puncture (to rule out meningitis)
halo sign
blood stain surrounded by a yellowish stain; highly suggestive of a cerebrospinal fluid leak
A child's initial assessment supports the medical dx of coarctation of the aorta
bounding pulses in the arms cool, lower extremities
when does the nurse notify the HCP when looking at the collection chamber?
bright red blood over 100ml/hr + after first hour of placement
Blood coagulation is a complex reaction that involves: a. vasoconstriction, platelet aggregation, and plasminogen action b. vasodilation, platelet aggregation, and activation of the clotting cascade c. vasoconstriction, platelet aggregation, and conversion of prothrombin to thrombin. d. vasodilation, platelet inhibition, and action of the intrinsic and extrinsic clotting cascades
c. vasoconstriction, platelet aggregation and conversion of prothrombin to thrombin
management of the patient with carbon monoxide poisoning
carry the patient to fresh air immediately; open doors/windows loosen all tight clothing initiate CPR prevent chilling; wrap in blankets keep patient quiet as possible do not give ETOH in any form or permit pt to smoke 100% O2 is given
Decorticate posturing
characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex.
obstructive congenital disorders
coarctation of the aorta aortic stenosis pulmonary stenosis
3 parts to chest tube system
collection chamber, water chamber, suction control chamber
example of closed TBI
concussion contusion
The client was admitted for shock has been prescribed norepinephrine. During planning this client's care, which intervention would be a priority for the nurse to incorporate?
continuous BP monitoring
first thing to tell a patient to do when the chest tube is disconnected
cough & exhale immediately (prevents air from rushing into pleural space) then apply occlusive petroleum gauze dressing secured on 3 sides
sign that patient is aspirating when eating
coughing
subacute stage of kawasaki disease
cracking lips & fissures desquamation of skin on tips of fingers/toes joint pain cardiac manifestations thrombocytosis
s/s of hypoxia in babies
cyanosis poor feeding/weight loss clubbing fingers dyspnea/tachypnea polycythemia
How does a patient with transposition of the great vessels present?
cyanotic at birth
The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema? a. Elevated white blood count b. Elevated troponin levels c. Elevated myoglobin levels d. Elevated B-type natriuretic peptide (BNP) levels
d Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema.
ARDS ABG results
decrease PO2, increase dyspnea (Pt's not getting better even with increased FiO2!)
what does a R to L shunt result in?
deoxygenated blood from the R side of the heart mixes with oxygenated blood in the L side of the heart and is ejected into the systemic circulation
diet for stroke prevention
diet low in fat and cholesterol
restrictive lung diseases
diseases that cause decrease in lung volumes
patient education for hemianopsia
dress the weaker side first scan surroundings turn head to affected side approach patient from unaffected side
what does percussion over the lung with hemothorax sound like?
dull
key symptom with hemothorax
dull percussion
management of aortic stenosis
dx confirmed with echo beta blockers and/or antiarrhythmic agents to reduce risk of HF/dysthymias bed rest/limited activity/close monitoring
5 key elements of the VAP bundle
elevate HOB 30-45 degrees daily sedation vacations and assessment of readiness to extubate peptic ulcer disease prophylaxis DVT prophylaxis Daily oral care with chlorhexidine
polycythemia
excess of red blood cells
what is barotrauma?
excessive positive pressure that can cause lung damage and can result in a spontaneous pneumothorax
main presenting symptoms of hemorrhagic stroke
exploding headache, decreased level of consciousness
symptoms of TIA
facial droop, arm weakness, tingling, loss of a function such as strength, speech, or sensation: generally "negative" symptoms, with the exception of tingling. Nonfocal symptoms such as LOC, confusion, lightheadedness, generalized weakness, or incontinence are less often part of TIA and tend not to predict future strokes.
flail chest
fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment
reasons that babies get congenital heart defects
genetics (fam hx, down syndrome) during pregnancy-infection (Rubella) & ETOH/drugs Diabetes
HOLY
high fowler's oral suctioning and O2 listen to lung sounds yell for help (notify HCP)
management for TOF
hospitalization and bed rest after 20th week w/hemodynamic monitoring via pulmonary artery catheter to monitor volume status; O2 therapy
key symptom for pneumothorax
hyperresonance with percussion
major complications after resuscitation from near-drowning?
hypoxia and acidosis
the nonfatal drowning process involves the onset of what?
hypoxia, hypercapnia, bradycardia, and dysrhythmias
nursing interventions for increased ICP
immobilize head CO2 low HOB 30 degrees (semi-fowlers) no flexion & bending of extremities no coughing/sneezing/blowing nose/Valsalva's suctioning (no longer than 10 seconds) neuro checks using GCS
Apraxia
inability to perform particular purposive actions, as a result of brain damage.
receptive aphasia
inability to understand spoken or written words
ARDS complications
increased intrathoracic pressure decreased CO hypotension hyperinflation of lungs pneumothorax sub Q emphysema
Rheumatic fever
inflammatory autoimmune response to streptococcal infection. Most often in children. Can cause carditis (inflammation of heart) and damage heart valves
ARDS patho
inflammatory triggers release of cell mediators, injury to alveolar capillaries, alveoli fill with fluid, then collapse, hypoxemia results
physical assessment findings ARDS
intercostal retractions, crackles
Causes of hemorrhagic stroke
intracerebral hemorrhage, cerebral aneurysm, arteriovenous malformation
What is the best response from the nurse when a client asks about tidaling in the water seal chamber?
it shows your lung has not yet re-expanded
nursing interventions for increased ICP
keep HOB at least 30 degrees keep head in a neutral, midline position do not cough/blow nose administer stool softeners insert urinary catheter minimize suctioning decrease stimulation implement seizure precautions
classic sign of epidural hematoma
loss of consciousness, then alertness, then loss of consciousness again this is a medical emergency!!
late signs of ARDS
low PaO2 despite increasing levels of administered O2, severe dyspnea/WOB, hypercapnia (high PaCO2) and hypoxemia, metabolic acidosis, crackles/rhonchi, CXR white out, cyanosis, pallor
ABGs with patient with ARDS
low PaO2, high CO2 (look for the lowest O2)
assessment of patient with RF
low-grade fever that spikes in the late afternoon increased anti-streptolysin O titer increased ESR increased c-reactive protein levels Aschoff bodies (lesions) nurse should inquire about recent sore throat
treatment for hemorrhagic stroke
management of BP w/anti-hypertensives Surgery Monitor ICP
what do nurses usually do at the beginning and end of shift for pt with chest tube?
mark the drainage at the beginning and end of shift to monitor output of lung fluids
clinical manifestations of patient with carbon monoxide poisoning
may appear intoxicated from cerebral hypoxia headache muscular weakness palpitation dizziness confusion---to progress to coma
priority intervention for pt with ARDS
mechanical ventilation with PEEP
nursing management of patient with ARDS
mechanical ventilation, monitor resp status, ABGs, pulse ox, VS, proning, turning schedule, skin care, ROM exercises
once a chest tube is placed in a patient, what are some nursing duties?
monitor patient's resp status and VS, check the dressing, and maintain patency and integrity of drainage system
interventions for Kawasaki Disease
monitor temp frequently, monitor strict I & O's, weigh child daily, soft foods and fluids, administer aspirin with milk or food, encourage fluid intake, IVIG infusion - monitor vitals, comfort measures, sponge baths with tepid water
management of mitral valve prolapse
most women asymptomatic, occasional palpitations/chest pain requiring beta blockers
coarctation of the aorta
narrowing of the descending portion of the aorta, resulting in a limited flow of blood to the lower part of the body
aortic stenosis
narrowing of the opening of the aortic valve, leading to an obstruction to L ventricular ejection
respiratory distress sxs in babies
nasal flaring, grunting, retractions, labored breathing
tension pneumothorax management
needle decompression, chest tube, ABGs (checking for hypoxia), CXR, O2
spontaneous pneumothorax
no trauma that precipitated it (for example, ventilation settings too high causing pressure)
hemorrhagic stroke diagnostics
non contrast CT, LP, ECG
chest tubes- is gentle/intermittent bubbling normal or not?
normal; constant bubbling is not normal and is indicative of an air leak
main presenting sxs with ischemic attack
numbness or weakness of the face/arm/leg, esp on one side of the body
Client in C spine after a fall...what is the priority assessment by the nurse?
obtain GCS score
Atrial Septal Defect
opening between the atria with L to R shunting due to greater left-sided pressure; arrhythmias present in some women
VSD
opening in ventricular septum, permitting blood flow from L to R ventricles
key symptom with flail chest
paradoxical chest wall movement
disorders with increased pulmonary blood flow
patent ductus arteriosus (PDA), atrial septal defect (ASD), and ventricular septal defect (VSD)
clinical manifestations of airway obstruction
patient cannot breathe, speak, or cough patient may clutch neck choking, apprehensive appearance refusing to lie flat flaring nostrils/increasing anxiety cyanosis/loss of consciousness
person most at risk for getting ARDS
patient with acute pancreatitis
if water seal chamber is damaged or disconnected what does the nurse do
place distal end in sterile saline
if the water seal of a chest tube is damaged, what does the nurse do?
place the distal end into 250ml sterile saline
nursing considerations for thoracentisis
position patient upright to enable pooling of fluid and leaving over to facilitate access. Patient must hold still, nurse will pre-medicate for pain and provide calming presence
flail chest tx
position the good lung down, provide adequate O2 and ventilation, closed chest drainage, frequent resp assessments, pain control
Decerebrate posturing
posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe.
patient has ARDS and is getting worse, what does the nurse do?
prepare for intubation and xfer to ICU
pneumothorax
presence of air in pleural space that causes the lung to collapse
What does surfactant do?
prevents alveoli from collapsing
txs and diagnostics for ARDS
proning, O2 therapy, tube feedings, chest xray
Antidote for heparin overdose
protamine sulfate
sxs of permanent brain damage in pt with carbon monoxide poisoning
psychoses spastic paralysis ataxia visual disturbances deterioration of mental status & behavior
4 risk factors related to CVD maternal mortality
race/ethnicity (black women) age (older than 40) HTN/preeclampsia obesity
management of VSD
rest with limited activity if symptomatic
early signs of ARDS
restlessness, change in LOC, increase RR, dyspnea, resp alkalosis, hypoxemia (PaO2 less than 60), increased WOB/HR/temp, white infiltrates on CXR, increased peak inspiratory pressure on vent
traumatic pneumothorax
result of any blunt or penetrating injury to the chest
most serious complications of rheumatic fever
rheumatic heart disease which affects mitral valve manifests 2-6 weeks after untreated strep A
common reasons for tension pneumothorax
rib fracture (closed trauma), gun shot
A nurse is caring for a client receiving lidocaine IV. which factor is most relevant to the administration of this med?
runs of vtach on a cardiac monitor
child with congenital heart issues presents on assessment as
sensitive for overload (monitor fluid status), BP, HR, nutritional education
flail chest s/s
shallow respirations paradoxical chest wall movement chest pain
indirect injury from ARDS
shock sepsis major surgery drug ingestion hematological d/o metabolic d/o
Dysarthria
slurred speech
direct injury from ARDS
smoke inhalation aspiration prolonged high concentrations of O2 embolism localized infection trauma
simple pneumothorax
spontaneous pneumothorax air enters pleural space through a breach of either the parietal or visceral pleura
Tet spells, what does the child do and why?
squatting (knees to chest) increases systemic vascular resistance, causing reversal of shunt and increases PaO2
interventions for head injuries
stabilize cervical spine assess GCS
essential equipment to have at the bedside of a client with closed chest drainage system
sterile connector, sterile petroleum gauze, padded clamp
what is nonfatal drowning?
survival for at least 24 hours after submersion that caused respiratory arrest
Ischemic stroke treatment
tPA if within 3-4.5 hours and no hemorrhage/risk of it reduce risk: aspirin, clopidogrel, BP control, blood sugar and lipids control, treatment of conditions that inc risk (e.g. a.fib.)
late stages of oxygenation impairment
tachycardia, tachypnea, circumoral cyanosis, diaphoresis, accessory muscle use, inability to speak in full sentences, and altered mental status. Pain usually is not present. Some patients may progress through these phases over several hours, whereas others may progress within seconds.
when a chest tube is being removed, what does the nurse instruct the patient to do?
take a deep breath, hold it, & bear down (Valsalva maneuver)
If chest tube is dislodged, what does the nurse do?
tell pt to cough & exhale immediately to prevent tension pneumothorax apply occlusive (petroleum gauze) dressing secured on 3 sides
Agnosia
the inability to recognize familiar objects.
in the case of potential facial trauma or basal skull fracture, what should not be used and why?
the nasopharyngeal airway because it could enter the brain cavity instead of the pharynx
why is eye care important in the patient who is sedated/paralyzed?
the patient cannot blink, increasing the risk of corneal abrasions
tidaling
the rise and fall of fluid within a closed-chest drainage system with inhalation and exhalation
where should there be continuous bubbling in the chest tube?
the suction chamber
thoracentesis
the surgical puncture of the chest wall with a needle to obtain fluid from the pleural cavity; position in high fowlers
Cushing's triad
three classic signs—bradycardia, systolic hypertension, and bradypnea
key symptom with tension pneumothorax
tracheal deviation
3 types of chest tubes
traditional water-seal (wet suction) chamber dry-suction water seal (dry suction) dry-suction (one-way valve system)
TIA
transient ischemic attack....mini stroke, no dead tissue.
mixed congenital disorders
transposition of the great vessels truncus arteriosis
tension pneumothorax
trapped air and increased pressure in lungs
management of ASD
treatment with atrioventricular nodal blocking agents, sometimes electrocardioversion
medical management ARDS
tx of underlying cause intubation/mech vent with PEEP to keep alveoli open prone position frequent repositioning nutritional support (35-45 kcal/kg/day) reduce anxiety
physical findings of ARDS
use of accessory muscles, decreased breath sounds if the patient cannot adequately ventilate, and other findings related specifically to the underlying disease process and cause of acute respiratory failure.
v/q
ventilation/perfusion
VarieD PictureS Of A RancH
ventricular defect pulmonary stenosis overriding aorta right hypertrophy
in a traditional water-seal chamber, is intermittent bubbling normal?
yes, it is functioning properly
risk factors for stroke
• High blood pressure • Atherosclerosis • Heart disease • Smoking or tobacco use • Atrial fibrillation (Afib) • Diabetes • Overweight or Obesity • Blood disorders • Excessive alcohol • Certain medications
