NUR116 Exam II

→ spray as a topical anesthetic to numb the oropharynx is used cautiously, if at all. This agent may induce a condition called methemoglobinemia, which is the conversion of normal hemoglobin to methemoglobin. Methemoglobin is an altered iron state that does not carry oxygen, resulting in tissue hypoxia.

→ Can be cause by benzocaine, a topical anesthetic to numb the oropharynx.

→ normal blood level of methemoglobin is less than 1%.

→ Cyanosis occurs with methemoglobin levels between 10% and20%.

→ Anxiety, tachycardia, and lethargy develop at levels between 20% and 50%.

→ Death can occur when levels reach 50%to 70%. 

→ Methemoglobinemia should be suspected if a patient becomes cyanotic after receiving a topical anesthetic, if he or she does not respond to supplemental oxygen, and if blood is a characteristic chocolate-brown in color.

→ Notify the Rapid ResponseTeam. It can be reversed with supplemental oxygen and IV administration of 1% methylene blue (1 to 2 mg/kg).

→ a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side.

→ Monitor vital signs, and auscultate breath sounds for absent or reduced sounds on the affected side.

→ Check the puncture site and dressing for leakage or bleeding.

→ Assess for complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, infection, and tension pneumothorax.

→ Urge the patient to breathe deeply to promote expansion of the lung

→ Document the procedure, including the patients' response; the volume and character of the fluid removed; any specimens sent to the laboratory; the location of the puncture site; and respiratory assessment findings before, during, and after the procedure

→ Pain on the affected side that is worse at the end of inhalation and the end of exhalation

→ Rapid heart rate

→ Rapid, shallow respirations

→ A feeling of air hunger

→ Prominence of the affected side that does not move in and out with respiratory effort

→ Trachea slanted more to the unaffected side instead of being in the center of the neck

→ Instruct the patient to come to the emergency department imediately if these manifestations occur.

→ Monitor the patients vital signs and breath sounds at least every 4 hours for 24 hours

→ Assess for signs of respiratory distress (e.g., dyspnea, pallor, diaphoresis, tachypnea).

→ Pneumothorax is a serious complication of needle biopsy and open lung biopsy. Report reduced or absent breath sounds immediately.

→ Monitor for hemoptysis (which may be scant and transient) or, in rare cases, for frank bleeding from vascular or lung trauma.

The expectoration (coughing up) of blood or of blood-stained sputum from the bronchi, larynx, trachea, or lungs.

• → Females: 4.2-5.4 million/mm³
• → Males: 4.7-6.1 million/mm³

→ Elevated levels (polycythemia) may be due to the excessive production of erythropoietin, which occurs in response to a hypoxic stimulus, as in COPD, and from living at a high altitude.

→ Decreased levels indicate possible anemia, hemorrhage, or hemolysis.

• → Females: 12-16 g/dL
• → Males: 14-18 g/dL

→ Elevated levels (polycythemia) may be due to the excessive production of erythropoietin, which occurs in response to a hypoxic stimulus, as in COPD, and from living at a high altitude.

→ Decreased levels indicate possible anemia, hemorrhage, or hemolysis.

• → Females: 37%-47%
• → Males: 42%-52%

→ Elevated levels (polycythemia) may be due to the excessive production of erythropoietin, which occurs in response to a hypoxic stimulus, as in COPD, and from living at a high altitude.

→ Decreased levels indicate possible anemia, hemorrhage, or hemolysis.

→ Total: 5,000-10,000/mm³

→ Elevations indicate possible acute infections or inflammations, pneumonia, meningitis, tonsillitis, or emphysema.

→ Decreased levels may indicate an overwhelming infection, an autoimmune disorder, or immunosuppressant therapy.

→ 80-100 mm Hg

→ Older adults: values may be lower

→ Elevations indicate possible excessive oxygen administration.

→ Decreased levels indicate possible COPD, asthma, chronic bronchitis, cancer of the bronchi and lungs, cystic fibrosis, respiratory distress syndrome, anemias, atelectasis, or any other cause of hypoxia.

→ 35-45 mm Hg

→ Elevations indicate possible COPD, asthma, pneumonia, anesthesia effects, or use of opioids (respiratory acidosis).

→ Decreased levels indicate hyperventilation / respiratory alkalosis.

Up to 60 yr: 7.35-7.45

60-90 yr: 7.31-7.42

>90 yr: 7.26-7.43

→ 21-28 mEq/L

→ Elevations indicate possible respiratory acidosis as compensation for a primary metabolic alkalosis.

→ Decreased levels indicate possible respiratory alkalosis as compensation for a primary metabolic acidosis.

95%-100%

Decreased levels indicate possible impaired ability of hemoglobin to release oxygen to tissues.

• → Codeine
• → Cocaine
• → Antihistamines
• → Hyperbaric oxygen
• → Some inherited diseases cause the cilia to move poorly or not function at all.  Cystic fibrosis is an example of a disease that causes several problems including poor ciliary movement

• → tobacco smoke
• → viral infections
• → fungus
• → bacterial infection
• → allergies
• → ashthma
• → Dry airInhalation of air or steam above 40 degrees centigrade
• → Cold air or liquids
• → Sulphur dioxide
• → ozone
• → smog

• → cough
• → dyspnea (from brochospasm)

→ Class I: No significant restrictions in normal activity. Employable. Dyspnea occurs only on more-than-normal or strenuous exertion.

→ 4: No breathlessness, normal.

→ Class II: Independent in essential ADLs but restricted in some other activities.Dyspneic on climbing stairs or on walking on an incline but not on level walking. Employable only for sedentary job or under special circumstances.

→ 3: Satisfactory, mild breathlessness. Complete performance is possible without pause or assistance but not entirely normal.

→ Class III: Dyspnea commonly occurs during usual activities, such as showering or dressing, but the patient can manage without assistance from others. Not dyspneic at rest; can walk for more than a city block at own pace but cannot keep up with others of own age. May stop to catch breath partway up a flight of stairs. Is probably not employable in any occupation.

→ 2: Fair, moderate breathlessness. Must stop during activity. Complete performance is possible without assistance, but performance may be too debilitating or time consuming.

→ Class IV: Dyspnea produces dependence on help in some essential ADLs such as dressing and bathing. Not usually dyspneic at rest. Dyspneic on minimal exertion; must pause on climbing one flight, walking more than 100 yards, or dressing. Often restricted to home if lives alone. Has minimal or no activities outside of home.

→ 1: Poor, marked breathlessness. Incomplete performance; assistance is necessary.

→ Class V: Entirely restricted to home and often limited to bed or chair. Dyspneic at rest. Dependent on help for most needs.

→ 0: Performance not indicated or recommended; too difficult.

95% - 100%

May be lower in older Pts or 3-5% lower in African Americans.

Results lower than 91% (and ceratinly 86%) are emergent.

Below 85% body tissues have a difficult time becoming oxygenated.

→ Maintain IV access

→ Continuously monitor the patients pulse, blood pressure, respiratory rate, and oxygen saturation

→ Apply supplemental oxygen.

→ Monitor the patient until the effects of the sedation have resolved and a gag reflex has returned

→ Continue to monitor the patients vital signs, including oxygen saturation

→ Assess breath sounds every 15 minutes for the first 2 hours.

→ Assess for potential complications. These may include bleeding, infection, or hypoxemia (possibly related to a pneumothorax or methemoglobinemia).

→ Low-Flow: inexpensive, but the disadvantage is that the amount of oxygen delivered  vaires and depends on the Pt's breathing pattern.

• → Cannula
• → Simple Facemask
• → Partial Rebreather
• → Non-Rebreather

→ High-Flow: Deliver an accurate oxyhen level that meets the Pt's oxygen need when properly fitted.

• → Venturi Mask
• → Aerosol mask, Face Tent, Tracheostomy Collar
• → T-Piece

• → Cannula
• → 24%-40% FiO₂ at 1-6 L/min

• → Simple Facemask
• → 40%-60% FiO₂ at 5-8 L/min (5 is MIN to flush CO₂ from mask)

• → Partial Rebreather
• → 60%-75% FiO₂ at 6-11 L/min (L rate must maintain bag 2/3 full)

• → Non-Rebreather
• → 80-95% FiO2 at L rate to maintain bag 2/3 full.
• → Make sure valves and rubber flaps are patent & functional

• → Venturi Mask
• → 24%-50% FiO2 at Mfg rec, usu 4-10 L/min

• → Aerosol mask, Face Tent, Tracheostomy Collar
• → 24%-100% FiO2 at 10 L/min MINimum
• → Empty condensation from tubing

•  → T-Piece
• → 24%-100% FiO2 at 10 L/min MINimum
• → Empty condensation from tubing
• → Keep exhalation port open & uncovered

• → Sources
• → Compressed
• → Large H, mobile E, and smaller D & C
• → Liquid
• → More expensive than compressed
• → Same volume lasts longer
• → Evaporates if not used continuously
• → Concentrator
• → Removes nitrogen, water vapor, and hydrocarbons from room air.
• → Least expensive
• → Noisy and large

• → Delivery devices
• → Humidity sources - rarely needed, but helpful above 4 L/min

→ Safety

→ In any of the three home oxygen systems, an oxygen-conserving reservoir-type nasal cannula can be used to reduce oxygen flow needs by about 50%.

• → Focus care on ensuring a patent airway
• → Confirm the presence of bilateral breath sounds
• → Conduct a thorough respiratory assessment at least every 2 hours.
• → Tube dislodgement and accidental decannulation can occur when the tube system is not secure.
• → Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult.
• → Ensure that a tracheostomy tube of the same type (including obturator) and size (or one size smaller) is at the bedside at all times, along with a tracheostomy insertion tray.
• → Pneumothorax (air in the chest cavity)
• → Subsutaneous emphysema - palpate for air under skin around tracheostomy. If puffy and crackling sensation, notify physician immediately.
• → Infection → Sterile technique: Assess stoma at least once per shift for purulent drainage, redness, pain or swelling.
• → Tracheomalacia: constant pressure exerted by the cuff causes trachial dialation and errosion of the cartilage
• → Tracheal stenosis: narrowed tracheal lumen is due to scar formation from irritation of tracheal mucosa by the cuff.
• → Tracheoesophageal fistula (TEF):excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created between the trachea and the anterior esophagus. The patient at highest risk also has a nasogastric tube present.
• → Trachea-innominate artery fistula: a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure causes necrosis and erosion of the innominate artery. This is a medical emergency.

→ For Pts who cannot cough adequately, assess need for suctioning:

→ Auscultation of audible or noisy secretions, crackles or wheezes

→ Pt restless, inc pulse, or resp rates

→ Mucous present in artificial airway

→ Pt requests it

→ Inc in peak airway pressure on ventilator

1. Assess the need for suctioning (routine unnecessary suctioning causes mucosal damage, bleeding, and bronchospasm).

2. Wash hands. Don protective eyewear Maintain Standard Precautions.

3. Explain to the patient that sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief.

4. Check the suction source. Occlude the suction source, and adjust the pressure dial to between 80 and 120 mm Hg to prevent hypoxemia and trauma to the mucosa.

5. Set up a sterile field.

6. Preoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes (at least three hyperinflations) to prevent hypoxemia. Keep hyperinflations synchronized with inhalation.

7. Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion.

8. Withdraw the catheter 0.4 to 0.8 inch (1 to 2 cm), and begin to apply suction. Use intermittent suction and a twirling motion of the catheter during withdrawal. Never suction longer than 10 to 15 seconds.

9. Hyperoxygenate for 1 to 5 minutes or until the patient's baseline heart rate and oxygen saturation are within normal limits.

10. Repeat as needed for up to three total suction passes.

11. Suction mouth as needed, and provide mouth care.

12. Wash hands.

13. Describe secretions, and document patient's responses.

Suctioning can cause hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, bronchospasm, and cardiac dysrhythmias.

Hypoxia can be caused by these factors in the patient with a tracheostomy:

• • Ineffective oxygenation before, during, and after suctioning
• • Use of a catheter that is too large for the artificial airway
• • Prolonged suctioning time
• • Excessive suction pressure
• • Too frequent suctioning

150,000 - 400,000 per μL (microlitre or mm³)

This is the Antihemophilic factor who's deficiency is hereditary for Hemophilia A (classic) 80% of the cases.

While a deficiency of Factor IX causes Hemophilia B (Christmas disease), the remaining 20% of the hemophiliac cases.

11-12.5 sec

Increased → Possible deficiency of clotting factors V and VII

Decreased may indicate Vitamin K excess.

• → Destroys old or imperfect RBCs
• → Breaks down the hemoglobin released from these destroyed cells
• → Stores platelets
• → Filters antigens

A patient who has had a splenectomy has reduced immune functions. Thus, after a splenectomy, patients are less able to rid themselves of disease-causing organisms and are at greater risk for infection and sepsis.

→ Site for production of prothrombin and most of the blood clotting factors

→ Proper liver function and bile production are important in forming vitamin K in the intestinal tract. (Vitamin K is needed to produce blood clotting factors VII, IX, and X and prothrombin.)

→ Large quantities of whole blood and blood cells can be stored in the liver

→ Converts bilirubin (one end product of hemoglobin breakdown) to bile and stores extra iron within the protein ferritin.

PT (prothrombin time - used less often): warfaring Tx is considered appropriate when PT is prolonged by 1.5 to 2 times Pts normal PT value.

Normal INR (ratio of Pts PT time to a standard PT time) is 0.7 to 1.8

A better measure for warfarin titration is to dose to achieve INR of 2.0 to 3.0

Normal aPTT (activated partial thromboplastin time) is 30-40 seconds

Measures the deficiencies in all clotting factors except VII and XIII. (II, IX and X are Vitamin K -dependent)

Target PTT for heparin TX is a PTT value 1.5 - 2.0 times a normal PTT or 45-80 seconds.

Cancer with uncontrolled production of immature WBCs in the bone marrow.

Cancerous cells in AML or Acute Myelocitic Leukemia, have their origin in the Myeloid (all blood cells except NK, T- and B-lymphocytes)

1. Assess laboratory values.

2. Verify the medical prescription.

3. Assess the patient's vital signs, urine output, skin color, and history of transfusion reactions.

4. Obtain venous access. Use a central catheter or at least a 20-gauge needle if possible.

5. Obtain blood products from a blood bank. Transfuse immediately - RBCs to be complete within 4 hours from refrigeration.

6. With another registered nurse, verify the patient by name and number, check blood compatibility, and note expiration time.

7. Administer the blood product using the appropriate filtered tubing.

8. If the blood product needs to be diluted, use only normal saline solution.

9. Remain with the patient during the first 15 to 30 minutes of the infusion.

10. Infuse the blood product at the prescribed rate.

11. Monitor vital signs @ 5, 10, 15, 45

12. When the transfusion is completed, discontinue infusion and dispose of the bag and tubing properly.

13. Document.

• Sickle cell disease
• Autosomal recessive inheritance of two defective gene alleles for hemoglobin synthesis

• Glucose-6-phosphate dehydrogenase(G6PD) deficiency anemia
• X-linked recessive deficiency of the enzyme G6PD
• Autoimmune hemolytic anemia
• Abnormal immune function in which a person's immune reactive cells fail to recognize hisher own red blood cells as self cells

• Iron deficiency anemia
• Inadequate iron intake caused by
• • Iron-deficient diet
• • Chronic alcoholism
• • Malabsorption syndromes
• • Partial gastrectomy
• Rapid metabolic (anabolic) activity caused by
• • Pregnancy
• • Adolescence
• • Infection

• Vitamin B12 deficiency anemia
• Dietary deficiency
• Failure to absorb vitamin B12 from intestinal tract as a result of
• • Partial gastrectomy
• • Pernicious anemia
• Folic acid deficiency anemia
• Dietary deficiency
• Malabsorption syndromes
• Drugs
• • Oral contraceptives
• • Anticonvulsants
• • Methotrexate

• Aplastic anemia
• Exposure to myelotoxic agents
• • Radiation
• • Benzene
• • Chloramphenicol
• • Alkylating agents
• • Antimetabolites
• • Sulfonamides
• • Insecticides
• Viral infection (unproven)
• • Epstein-Barr virus
• • Hepatitis B
• • Cytomegalovirus

→ At least 40% and often more of RBCs contain an abnormal beta chain, known as Hemoglobin S.

→ When exposed to low O₂ content, these beta chains contract, changing the shape of the cell to that of a sickle.

→ This causes these RBCs to stick and clump together, occluding the vessel and leading to further tissue hyposia.

→ Extensive periodic sickling (weekly to yearly) is called a crisis.

→ Eventually these crisis infarct more areas of organs such a spleen, liver, heart, kidney, brain, bones & retina leading to organ failure.

→ In sickle cell disease, the Pt has 2 HbS gene alleles, one from each parent, resulting in 80-100% of RBCs containing HbS.

→ In sickle cell trait, the Pt has 1 HbS gene allele and only half the RBCs will be defective so the person with trait will have only mild manifestations.

→ Pain is most common problem.

→ Drug therapy for a crisis often starts with at least 48 hours of IV analgesics

→ Risk for bacterial sepsis because of reduced spleen function. Twice-daily prophylactic oral penicillin reduces # of pneumonia and other streptococcal infections.

→ Keep Pt hydrated - dehydration increases sickling.

→ O2 given during crisis because lack of it is the main cause of sickling.

→ Transfusion with RBCs can increase the HbA levels and dilute the HbS levels.

• • Chills
• • Distended Neck Veins (Circ overload)
• • Dyspnea
• • Fever
• • Tachycardia
• • Tachypnea
• • Hypotension
• • Hypertension