Test 3 - Lower Respiratory

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mthompson17
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265047
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Test 3 - Lower Respiratory
Updated:
2014-03-16 12:04:53
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lower respiratory nursing
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nursing
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Test 3 Lower Respiratory Problems - Walker
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  1. What are most lung abscesses caused by?
    aspiration of GI materials
  2. What factors increase risk for lung abscess?

    5 examples?
    Risk factors are similar to pneumonia:  anything that decreases RR/depth, mobility, or LOC - can also be caused by bad oral hygiene

    • 1. alcoholism
    • 2. seizures
    • 3. neuromuscular diseases
    • 4. drug OD
    • 5. general anesthesia
  3. 7 S/S of lung abscess?
    • 1. cough with purulent, dark brown, foul smelling/tasting sputum
    • 2. hemoptysis
    • 3. fever/chills
    • 4. pleuritic pain
    • 5. dyspnea
    • 6. weight loss
    • 7. prostration
  4. 3 PA findings with lung abscess?
    • 1. dullness to percussion
    • 2. decreased breath sounds
    • 3. crackles when abscess drains/bursts
  5. What type of exam is important in a pt with lung abscess?
    oral exam
  6. 6 complications of lung abscess?
    • 1. chronic pulmonary abscess
    • 2. bronchopleural fistula
    • 3. bronchectasis
    • 4. empyema - pus in pleural space
    • 5. brain abscess
  7. Dx studies for lung abscess?
    • CXR - show lesion with fluid
    • CT
    • sputum cultures
    • pleural fluid & blood cultures may be done
  8. When does lung abscess require drainage?
    if it cannot drain via the bronchus
  9. 3 Tx for lung abscess?
    • 1. ABX for 2-4 mo
    • 2. postural drainage & chest physiotherapy
    • 3. dental care
  10. Nursing interventions for pt with lung abscess?
    • 1. airway & breathing/maintain O2 sat
    • 2. oral care
    • 3. pain control
    • 4. Teaching:  oral care, ABX, TCDB q2h, incentive spirometer
  11. Pneumoconiosis?
    "dust in the lungs" - caused by inhalation & retention of dust particles
  12. Patho of pneumoconiosis?
    dust particles cause inflammatory response -> phagocytes -> fibrosis
  13. 3 types of particles that can cause pneumoconiosis?
    • 1. silicosis
    • 2. asbestosis
    • 3. berylliosis
  14. Patho of chemical pneumonitis?
    toxic fumes -> pulmonary edema -> obstruction of bronchioles r/t inflammatory response & fibrosis
  15. CXR results with chemical pneumonitis?
    will usually be normal
  16. PNEUMOCONIOSIS:

    How long before s/s occur?

    2 early s/s?

    2 late s/s?
    may not occur for 10-15 years

    early:  dyspnea & cough

    late:  chest pain & productive cough
  17. Tx of pneumoconiosis?
    best Tx is decrease/stop exposure:  wear a mask

    Tx coexisting problems:  asthma, pneumonia, chronic bronchitis, emphysema
  18. Complications of pneumoconiosis?
    • 1. pneumonia
    • 2. chronic bronchitis
    • 3. emphysema
    • 4. lung CA
    • 5. cor pulmonale (late complication)
  19. Patho of lung cancer?
    inflammation causes hypersecretion of mucus & cell destruction/cell replacement with stratified squamous cells
  20. 3 risk factors for lung cancer?
    • 1. age >50
    • 2. smoking
    • 3. exposure to industrial carcinogens especially asbestos (mining, chemical/petroleum manufacturing)
  21. When do s/s of lung cancer usually appear?
    usually 15-19 years after exposure
  22. 3 most common s/s of lung cancer?
    • 1. cough
    • 2. dyspnea
    • 3. chest pain
  23. What should be a red flag that a pt may have lung cancer?
    repeatedly visiting MD with persistent cough & being Dx with bronchitis
  24. 5 common sites of lung cancer metastasis?
    • 1. brain
    • 2. liver
    • 3. bone
    • 4. lymph nodes
    • 5. adrenal glands
  25. Paraneoplastic syndrome?
    s/s caused by cancer but not locally - may be caused by chemicals/hormones released by the cancer or by the body's immune response to the cancer

    may be altered hormones, blood problems, neuro, etc
  26. Why may s/s of lung cancer be missed?
    s/s may be attributed to smoking
  27. Earliest manifestation of lung cancer?
    persistent pneumonitis with fever, chills, & cough
  28. Most common s/s of lung cancer?
    persistent productive cough
  29. S/S that may occur with lung cancer?
    • 1. productive cough
    • 2. chest pain
    • 3. dyspnea
    • 4. hoarseness (laryngeal nerve involvement)
  30. Complications of lung cancer?
    • all are r/t spread of cancer or pressure exerted on nearby structures
    • 1. unilateral paralysis of diaphragm
    • 2. dysphagia
    • 3. superior vena cava obstruction
    • 4. pericardial effusion
    • 5. cardiac tamponade
    • 6. dysrrhythmias
    • 7. compromised airway r/t bronchial obstruction
  31. PET use in Dx cancer?
    measures metabolic activity in tissue:  malignant tissue has increased activity
  32. Prevention of lung cancer?
    • 1. Avoiding inhaled irritants:  mask
    • 2. screening:  CXR, CT, sputum, cytology
    • 3. smoking cessation & education
  33. Tx of choice for lung cancer?
    surgery may be curative
  34. Radiation therapy may relieve what 4 s/s of lung cancer?
    • 1. dyspnea
    • 2. hemoptysis
    • 3. superior vena cava syndrome
    • 4. pain relief
  35. Stereostatic radiotherapy?
    high dose of radiation delivered accurately to tumor
  36. How is chemo given for lung cancer?
    will get combo of 2 or more meds
  37. 10 chemo meds used to Tx lung cancer?
    • 1. etoposide(Vepesid)
    • 2. carboplatin (Paraplatin)
    • 3. cisplatin (Platinol)
    • 4. pacilotaxel (Taxol)
    • 5. vinorelbine (Navelbine)
    • 6. cyclophosphamide (Cytoxan)
    • 7. ifosfamide (Ifex)
    • 8. docetaxel (Taxotere)
    • 9. gemcitabine (Gemzar)
    • 10. pemetrexed (Alimta)
  38. Targeted therapy for cancer?

    2 examples?
    drugs that block growth of molecules that tumor needs to grow

    • erlotinib(Tarceva)
    • bevacizumab (Avastin)
  39. Bronchoscopic laser therapy for lung cancer?
    laser removes obstructing bronchial lesions to relieve respiratory s/s
  40. Photodynamic therapy?
    porfimer (Photofrin) injected IV & selectively concentrates in tumor

    48 h later tumor is exposed to laser light -> creates a toxic form of oxygen -> destroys tumor then necrotic tissue is removed with bronchoscope
  41. Purpose of airway stenting with lung cancer?
    hold airway open & relieve compression
  42. Cryotherapy for lung cancer?
    bronchoscopy with freeze therapy
  43. Nursing interventions for lung cancer pt?
    • 1. anxiety relief & support
    • 2. s/s mgmt:  pain mgmt, resp status
    • 3. monitor neuro etc for metastasis
    • 4. Teach:  s/s to report, safe use of home O2
    • 5. monitor for AE of chemo/radiation:  extravasation, decreased immune, bleeding, NV, skin irritation
  44. Stages of cancer?
    • Stage I:  tumor limited to tissue of origin
    • Stage II:  limited local spread
    • Stage III:  extensive local & regional spread
    • Stage IV:  metastasis
  45. TNM?
    • T - tumor size & growth
    • N- spread to nodes?
    • M - metastasis
  46. AE of IV chemotherapy drugs?
    vesicants/irritants
  47. How are IV chemo drugs administered?
    through central line
  48. AE of chemotherapy drugs & radiation?
    • 1. extravasation
    • 2. stomatitis, mucositis, esophagitis
    • 3. NV
    • 4. anorexia
    • 5. diarrhea & constipation
    • 6. reproductive dysfunction
    • 7. nephrotoxicity, hepatotoxicity, cardiotoxicity
    • 8. increased ICP with radiation edema to CNS
    • 9. peripheral neuropathy
    • 10. cognitive changes - "chemo brain":  similar to first s/s of dementia
    • 11. bone marrow suppression
    • 12. alopecia
    • 13. skin changes & damage
    • 14. hyperuricemia
    • 15. reproductive dysfunction
  49. What patients are radioactive during cancer Tx?
    pt with brachytherapy - implanted radiation
  50. Interventions when caring for pt who is radioactive r/t radiation therapy?
    • 1. organize care to limit time spent with pt & tell pt why
    • 2. use shielding if available
    • 3. must wear film badge during ALL care
  51. Nursing interventions for stomatitis, mucositis, & esophagitis r/t chemo/radiation?
    • 1. assess mouth qd, oral hygiene & teaching
    • 2. nutritional supplements:  ensure
    • 3. may need analgesics before eating, talking, swallowing
    • 4. avoid irritating foods:  eat moist, bland, soft foods
    • 5. artificial saliva for dryness
    • 6. no tobacco/alcohol - irritating
    • 7. topical anesthetics:  lidocaine, etc
  52. What type of diet should pt undergoing chemo/radiation have?
    non-irritating, small, frequent meals of high-protein, high-calorie meals
  53. What labs should be monitored for a pt undergoing chemo/radiation?
    • 1. RBC, HgB, Hct, Fe, WBC, platelets
    • 2. LFT
    • 3. BUN, creatinine
    • 4. electrolytes r/t NV, diarrhea
    • 5. albumin r/t nutrition
    • 6. uric acid levels - increased by cell destruction that occurs with chemo
  54. Interventions for anemia in chemo/radiation pt?
    • 1. monitor H&H
    • 2. admin Fe & erythropoietin
    • 3. encourage foods that increase RBC production:  nuts, meats, green leafy veggies, whole grains
  55. Interventions for leukopenia in chemo/radiation pt?
    • 1. monitor WBC esp. neutrophils
    • 2. teach pt to report fever & s/s of infection
    • 3. teach pt to avoid lg crowds & infectious ppl
    • 4. admin WBC growth factors:  neupogen, neulasta, epogen, procrit, aranesp, neumega
  56. Interventions for thrombocytopenia r/t chemo?
    • 1. observe s/s of bleeding
    • 2. monitor platelets counts
    • 3. teach pt to use electric razor, soft toothbrush, etc
  57. Interventions for radiation skin problems?
    • 1. mild soaps & moisturizers
    • 2. no tight-fitting or irritating clothing
    • 3. avoid direct exposure to sun - cover with clothing & sunscreen
    • 4. avoid all temp extremes
    • 5. no saltwater or chlorinated pools
  58. Causes of pneumothorax?
    blunt or penetrating injury or spontaneous
  59. Pneumothorax?
    air in the pleural space which causes partial or complete collapse of the lung
  60. When should pneumothorax always be suspected?
    after any blunt trauma to the chest wall
  61. 4 types of pneumothorax?
    • 1. closed - no external wound
    • 2. open - air coming in through an external opening
    • 3. hemothorax -
    • 4. tension pneumothorax
  62. Patho of tension pneumothorax?
    laceration of pleura lets air in but not out & collapses lung -> will put pressure on heart, great vessels, & other lung and cause both lungs to collapse

    increased pressure causes decreased venous return & CO
  63. Causes of pneumothorax?
    • 1. broken ribs
    • 2. subclavian artery cath insertion
    • 3. excess pressure when bagging
    • 4. esophageal tearing r/t forceful vomiting
  64. Causes of tension pneumothorax?
    • 1. penetrating injury
    • 2. excess pressure when bagging
    • 3. occluded/clamped chest tube in a pt with pneumothorax
  65. Intervention if clamped/occluded chest tube cause a tension pneumothorax?
    unclamp tube or remove obstruction
  66. S/S of pneumothorax?
    • if small mild tachycardia & dyspnea may be only s/s
    • 1. tachycardia
    • 2. dyspnea
    • 3. shallow, rapid respirations
    • 4. decreased O2sat
    • 5. absent breath sounds over affected area
  67. S/S of tension pneumothorax?
    • all s/s of pneumothorax AND:
    • 1. severe respiratory distress
    • 2. hypotension
    • 3. tracheal deviation
    • 4. chest pain radiating to shoulder
    • 5. JVD
    • 6. cyanosis
  68. S/S of hemothorax?
    same s/s of other pneumothorax AND s/s of blood loss & hypovolemic shock:  cool, clammy skin, confusion, decreased UO, pallor
  69. How may hypovolemia caused by hemothorax be Tx?
    blood from a closed hemothorax may be removed & reinfused for a short period of time
  70. ED management of pneumothorax?
    insert lg-bore needle in chest wall at 4th or 5th intercostal space to release trapped air then insert chest tube & connect to water seal drainage
  71. Tx for pneumothorax where pt is stable & minimal air or fluid is in intrapleural space
    resolves spontaneously usually
  72. Tx of pneumothorax if pt is unstable?
    chest tube placement  - remove air & fluid so lung can re-expand
  73. Where may chest tube be inserted?
    ED, bedside, or OR
  74. Tx for repeated spontaneous pneumothorax?
    • partial pleurectomy
    • stapling
    • pleurodesis - fluid into pleural cavity through chest to prevent pneumothorax
  75. Flail chest?
    2 or more ribs fractured in 2 or more locations
  76. Consideration if pt has flail chest?
    will probably have other internal injuries
  77. Effect of flail chest?
    prevents adequate ventilation & increases work of breathing

    underlying lung may have contusion that will also increase hypoxemia
  78. S/S of flail chest?
    • 1. rapid, shallow respirations
    • 2. tachycardia
    • 3. paradoxical chest movement -one side up higher than the other
  79. How will chest move during respirations with flail chest?
    during I affected portion is sucked in & bulges outward during E
  80. Dx studies used for flail chest?
    ABGs, CXR
  81. Priority & priority intervention with flail chest?
    priority is airway mgmt/ventilation

    priority intervention is intubation ASAP
  82. Tx of flail chest?
    • 1. intubate
    • 2. O2
    • 3. careful IV hydration of cystalloid solution - mgmt of bleeding/shock
    • 4. pain control
    • 5. Tx other injuries/symptoms
  83. Insertion of chest tube at bedside?
    • 1. pt sitting up with arms on bedside table or lying with affected side elevated
    • 2. clean with antiseptic solution
    • 3. inject local anesthetic before incision
  84. Nursing consideration for insertion of chest tube?
    chest tubes are painful - monitor & Tx
  85. Where is chest tube placed to remove air?

    ....to remove fluid/blood?
    air- through 2nd intercostal space

    fluid/blood - through 8th or 9th intercostal space
  86. What is done after chest tube placement?
    tube is sutured to chest wall and covered with a dressing and placement is checked
  87. When should the nurse change the dressing on a chest tube?

    Nursing interventions regarding chest tube dressing?
    NEVER

    can reinforce if bleeding or drainage occurs and inform MD
  88. 3 basic compartments of pleural drainage system?
    collection chamber - receives fluid/air from chest cavity & holds fluid - air moves on to water seal chamber

    water seal chamber - contains 2cm of water & acts as a 1-way valve to keep air from backflowing

    suction control chamber - applies suction
  89. Normal water fluctuations in the water seal chamber?
    • 1. intermittent bubbling during exhalation, coughing, or sneezing
    • 2. tidaling - normal fluctuations in the water that reflect I&E causing changes in pressure
    • 3. will have bubbling when air is being evacuated
  90. How much water should be in the water seal chamber & the suction control chamber?
    water seal - 2cm

    suction control - 20cm
  91. What are heimlich valves used for?
    chest tube used for emergency transport, homecare, or long-term care nursing units
  92. How do heimlich valves work?
    attach to external end of chest tube - opens to increased intrathoracic pressure (I)  & closes to decreased intrathoracic pressure (E)
  93. Advantage of Heimlich valve?
    can hide drainage bag under clothes to allow for ambulation
  94. How should vaccum for suction control chamber on chest tube drainage system be adjusted?
    vacuum turned up until see bubbling
  95. Pigtail catheter?
    less traumatic & not suitable for trauma or drainage of blood

    for pleural effusions
  96. When may chest tube be clamped?
    may be monentarily clamped to change drainage or check for leaks or may be clamped to see if pt is ready for it to be removed
  97. Nursing mgmt of chest tubes & pleural drainage systems?
    • 1. routine monitoring to eval/observe tidaling
    • 2. ascultation of breath sounds/palpation for crepitis (subQ emphysema)
    • 3. keep tubing straight & coiled loosely below chest level
    • 4. secure drainage system to floor at HOB to prevent falling over - not under bed
    • 5. keep occlusive dressing & sterile water/NS at bedside
  98. Monitoring for pt that has an occlusive dressing over chest tube?
    monitor for tesion pneumo b/c may trap air
  99. Nursing action if tension pneumo occurs r/t occlusive dressing over chest tube?
    use vaseline gauze foil pack - lay over area
  100. Lobectomy?
    remove one lobe
  101. Pneumonectomy?
    remove entire lung
  102. segmental resection?
    remove one or more lung segments
  103. Wedge resection?
    remove small, localized lesion that occupies only part of a segment
  104. Nursing action if chest tube is disconnected?
    reestablish water-seal system immediately by placing tube in 2cm sterile water & attach new drainage system ASAP
  105. Test used to monitor tube position & lung reexpansion?
    CXR
  106. Consideration when removing fluid from pleural space r/t amnt of fluid removed?
    rapid removal of 1-1.5L or more of fluid can cause reexpansion pulmonary edema or vasovagal response -> hypotension
  107. Nursing care of chest tube?
    • 1. monitor for infection at site
    • 2. monitor for tidaling & monitor system
    • 3. care & teaching to prevent atelectasis & shoulder stiffness
  108. Removing chest tube?
    • 1. give pain med 15 min before
    • 2. removed by MD or FnP
    • 3. Suture cut & sterile airtight vaseline dressing applied - pt should valsalva/hold breath while tube being removed
    • 4. CXR to eval for pneumothorax &/or reaccumulation of fluid
  109. What may be indicated if bubbling in water seal increases?
    air leak
  110. How is tidaling checked if drainage system is connected to suctioning?
    remove from suctioning
  111. When will a system leak be indicated?
    Interventions?
    if continuous bubbling is occurring

    • determine source of air leak:
    • 1. momentarily clamp b/t insertion site & dainage set - if bubbling stops air leak is above the clamp
    • 2. retape tubing connections
    • 3. notify MD if it continues
  112. Consideration if chest drainage system is not working properly or is being drained by gravity?
    do not lower water-seal column
  113. Monitoring of pt with chest tube?
    • 1. monitor VS, lung sounds, & pain
    • 2. assess for s/s of reaccumulation of air & fluid:  decreased or absent breath sounds
    • 3. assess for significant bleeding (>100ml/h)
    • 4. assess for site infection
    • 5. eval for subQ emphysema at site
    • 6. encourage TCDB, ROM to should of affected side, incentive spirometry qh while awake
    • 7. order is required to clamp more than momentarily
  114. Mgmt of chest drainage with a chest tube?
    • 1. never elevate system to level of pt chest - will cause backflow
    • 2. if chambers are full - call MD - do not empty
    • 3. report change in quantity or characteristics of drainage
    • 4. check position of drainage container
    • 5. if drainage system breaks, place distal tube in 2cm sterile water
    • 46. do not strip chest tubes - dangerously increases intrapleural pressures - may be milked (fold/squeeze then release)
  115. Intervention if drainage system is overturned & water seal is disrupted?
    return it to an upright position & encourage pt to take a few deep breaths followed by forced exhalations & coughing
  116. When should drainage tube be milked?

    How is it done?
    only if drainage & evidence of clots/obstruction

    take 15cm strips of chest tube & squeeze & release starting close to chest & repeating down tube distally
  117. Monitoring wet/dry suction chest drainage systems?
    • 1. keep suction control chamber at correct level by adding sterile water prn (evaporation)
    • 2. keep muffler over suction control chamber to prevent evaporation & noise
    • 3. after filling chamber connect suction tubing to wall suction & turn on until see bubbling (usually 80-120mmHg)
    • 4. If no bubbling is seen in suction control chamber:  no suction is occurring, suction is not high enough, or pleural air leak is so large that suction is not high enough to evacuate it
  118. what should be done if vigorous bubbling occurs in suction chamber?
    turn suction down some - causes water to evaporate faster
  119. Changing chest tube dressing?
    • not routinely changed - call md if soiled
    • If have orders to change it:
    • 1. remove old dressing & avoid removing unsecured chest tube
    • 2. assess site & culture site prn
    • 3. cleanse site with sterile normal saline
    • 4. apply sterile gauze & tape or may use petroleum gauze
    • 5. date dressing & document
  120. Obtaining a sample from the chest tube?
    • 1. form a loop in the tubing in an area to get most recently drained fluid
    • 2. swab sampling site of tubing with antiseptic
    • 3. aspirate from sampling site with syringe, cap syringe, label with pt name, date, time, & source of specimen
    • 4. send to lab
  121. Preop chest surgery?
    • 1. baseline respiratory & CV system data & testing obtained
    • 2. anesthesia consultation
    • 3. PA of lungs including percussion & auscultation
    • 4. encourage smoking cessation prior to surgery
    • 5. preop teaching - deep breathing, spirometer, & splinting incision to facilitate deep breathing
    • 6. teach that will have chest tube
  122. Thoracotomy?
    surgical opening into the thoracic cavity with lg incision - cuts through bone, muscle, & cartilage
  123. Post-thoracotomy consideration?
    1. pain is a major issue - will prevent pt from deep breathing, coughing, & moving shoulder on affected side
  124. How is pain Tx with thoracotomy?
    PCA & intercostal nerve blocks to enable pt to deep breathe, cough, & move affected shoulder
  125. Chest tube considerations if pneumonectomy is performed?
    may not have chest tube

    if have one it will be clamped & only released by the surgeon to adjust voluime of serosangineous fluid that will fill space vacated by the lung - daily CXR will assess volume & space
  126. Advantages of video-assisted thoracic surgery (VATS)?

    Chest tube with VATS?
    less discomfort, faster return to normal, reduced hospital stay, lower postop morbidity, & fewer complications

    just like any other chest surgery
  127. Post-VATS care?
    • 1. assess respiratory function
    • 2. sputum volume & color
    • 3. breath sounds
    • 4. chest tube function & drainage
    • 5. pain
    • 6. temp & s/s of infection
  128. Post-op considerations with a thoracotomy?
    • 1. ventilation assitance
    • 2. infection protection
    • 3. tube care
  129. Nursing interventions for ventilation assistance post-thoracotomy?
    • 1. frequent position changes
    • 2. TCDB
    • 3. auscultate breath sounds - adventitious or decreased/absent sounds
    • 4. pain meds to prevent hypoventilation
    • 5. position to minimize respiratory effort - elevate HOB & provide overbed table to lean on
    • 6. ambulate 3 to 4 times a day
  130. Interventions for infection protection post-thoracotomy?
    • 1. same as for all surgeries
    • 2. increased mobility to increase circulation for healing
    • 3. obtain cultures prn
  131. Tube care post thoracotomy?
    • 1. monitor bubbling in suction chamber & tadaling in water-seal chamber
    • 2. ensure all tubing connections are securely attached & taped
    • 3. keep drainage container below chest level to prevent pneumothorax
    • 4. observe volume, shade, color, & consistency of drainage from lung
    • 5. clean around tube insertion site
    • 6. change dressing around chest tube q28-72h prn
  132. Pt positioning immediately after chest surgery?
    place with operative side down - opposite of pneumonia
  133. Normal chest tube drainage immediately after chest surgery?
    will have bloody drainage up to 200ml/h but should decrease
  134. Pleural effusion?
    fluid in pleural space
  135. Classification of pleural effusions?
    classified as transudative or exudative depending on protein content of fluid
  136. How much fluid is normally in the ipleural space?
    5 to 15mL
  137. 5 processes that can cause pleural effusion?
    • 1. decreased oncotic pressure
    • 2. increased capillary permeability
    • 3. bleeding into the space
    • 4. decreased lymphatic clearance
    • 5. infection
  138. Formation of transudate & exudate?
    transudate occurs primarily in noninflammatory conditions - protein-poor, cell-poor fluid

    exudate occurs r/t increased capillary permeability r/t inflammatory reaction - high in protein & dark in color
  139. 2 causes of transudative pleural effusion?
    • 1. increased hydrostatic pressure in HF
    • 2. decreased oncotic pressure with hypoalbuminemia in liver/renal disease
  140. Causes of exudative pleural effusions?
    • 1. infection
    • 2. malignancies
    • 3. necrosis
    • 4. pancreatitis
    • 5. esophageal perforation & GI problems
    • 6. PE
  141. Empyema?
    collection of purulent fluid in pleural space
  142. 3 causes of empyema?
    • 1. pneumonia
    • 2. TB
    • 3. infection of surgical chest wounds
  143. Complication of empyema?
    fibrothorax - fibrous fusion of the visceral & parietal pleurae -> encased in fibrous peel -> restricts lung
  144. Complication that can occur with pleural effusions & empyema?
    trapped lung - visceral pleura becomes encased in pulmonary restriction
  145. Color of trasudative & exudative fluid in pleural effusion?
    transudative - clear or pale yellow

    exudative - dark yellow or amber
  146. Dx of pleural effusion?
    • 1. CXR indicates fluid >250
    • 2. type determined by sample of pleural fluid obtained through thoracentesis
    • 3. fluid analyzed for RBC, WBC, malignant cells, bacteria, & glucose
  147. S/S of pleural effusion?
    • 1. progressive dyspnea
    • 2. decreased movement of chest wall on affected side
    • 3. pleuritic pain
    • 3. dullness to percussion
    • 4. absent or decreased breath sounds
  148. Tx that will relieve dyspnea in pleural effusion?
    thoracentesis
  149. S/S of empyema?
    • s/s of pleural effusion AND
    • 1. fever
    • 2. night sweats
    • 3. cough
    • 4. weight loss
  150. Thoracentesis nursing care?
    • 1. position pt sitting on edge of bed & leaning over a bedside table
    • 2. VS & pulse ox monitored before & after
    • 3. observe for s/s of respiratory distress
    • 4. follow-up CXR to look for pneumothorax
  151. How much fluid may be removed from a pleural effusion at one time?
    usually only remove 1000-1200 mL at a time
  152. Tx of pleural effusion?
    • 1. Tx underlying cause:  HF
    • 2. chemical pleurodesis - obliterates pleural space to prevent reaccumulation of fluid
  153. Consideration with chemical pleurodesis?
    chest tubes are left in place after until fluid drainage is less than 150mL/day and no air leaks are noted
  154. Tx of empyema?
    • 1. chest tube drainage
    • 2. ABX
    • 3. intrapleural fibinolytic therapy may be done to dissolve fibrous adhesions
  155. Complications of thoracentesis?
    • 1. pneumothorax
    • 2. hypotension, hypoxemia, or pulmonary edema if more than 1200mL rapidly removed
  156. Pleurisy?
    inflammation of the pleura
  157. 5 common causes of pleurisy?
    • 1. pneumonia & bronchitis
    • 2. TB
    • 3. chest trauma
    • 4. pulmonary infarctions
    • 5. neoplasms
  158. S/S of pleurisy?
    • 1. abrupt, sharp pain aggravated by inspiration -> shallow, rapid breathing
    • 2. pleural friction rub may occur
  159. Tx of pleurisy?
    • 1. Tx underlying disease
    • 2. pain relief - NSAIDs/analgesics, lying on or splinting the affected side
    • 3. teach to splint rib cage when coughing
    • 4. intercostal nerve blocks
    • 5. interventions to prevent atelectasis - TCDB, incetive spirometer, etc
  160. What interventions are important for all respiratory disorders?
    preventing atelectasis - have incentive spirometer at bedside, TCDB, mobility, etc
  161. Risk factors/causes of atelectasis?
    • 1. airway obstruction - retained exudates & secretions
    • 2. postop & immobilized pt
  162. Sarcoidosis?
    chronic, multisystem granulomatous disease of unknown cause
  163. What body systems does sarcoidosis affect?
    • 1. primarily lungs
    • 2. skin
    • 3. eyes
    • 4. liver
    • 5. kidney
    • 6. heart
    • 7. lymp
  164. What ethnic group is more likely to have sarcoidosis?
    African Americans
  165. 2 complications of sarcoidosis?
    • 1. cor pulmonale
    • 2. bronchiectasis
  166. S/S of sarcoidosis?
    many pt do not have s/s
  167. Tx of sarcoidosis?
    • aimed at suppression of inflammatory response
    • 1. steroids
    • 2. monitor progression with PFT q3to6 months, CXR, & CT
  168. Pulmonary edema?
    fluid in alveoli & interstitial spaces of lungs
  169. Cause of pulmonary edema?
    • complication of heart & lung diseases:
    • 1. L-sided HF
    • 2. decreased albumin
    • 3. O2 toxicity
    • 4. high altitude or up from diving too quickly
    • 5. over-hydration with IV fluids
    • 6. altered capillary permeability of lungs:  inhaled toxins, inflammation, severe hypoxia, near-drowning, pneumonia
    • 7. lymph system problems
    • 8. opioid OD
    • 9. reexpansion pulmonary edema
  170. Most common cause of pulmonary edema?
    L-sided heart failure
  171. Tx of pulmonary edema?
    • medical emergency
    • 1. possible intubation
    • 2. diuretics
  172. S/S of pulmonary edema?
    • 1. respiratory distress, anxiety, & tachypnea
    • 2. pale, cold, clammy skin - vasoconstriction
    • 3. cyanosis
    • 3. wheezing, crackles, rhonchi
    • 4. BP may be decreased or increased
  173. Pulmonary embolism causes?
    anything that blocks pulmonary arteries:  thrombus, fat, air, tumor tissue
  174. Where do thrombi that cause PE most commonly come from?
    • 1. DVT (most common)
    • 2. R side of heart (Afib)
    • 3. pelvic veins - surgery, childbirth
  175. How can a nurse cause a PE?
    • 1. flushing central lines & getting air in line
    • 2. pulling central lines with pt sitting up
  176. How to pull out a central line?
    • 1. pt should be supine or trendelenberg (best)
    • 2. pt should tk deep breath & valsalva when line is removed
    • 3. if meet resistance - stop - may have clot at the end
  177. What area of the lungs is commonly affected by PE?
    lower lobes
  178. When are DVTs most likely to be dislodged?
    can be dislodged spontaneously but most likely with mechanical force (standing) or change in rate of blood flow (valsalva)
  179. What is the most common cause of fat embolism?
    hip fractures
  180. Risk factors for PE?
    • 1. immobility
    • 2. surgery w/in last 3 months
    • 3. stroke
    • 4. Hx of DVT or PE
    • 5. malignancy
    • 6. obesity in women
    • 7. heavy cigarette smoking
    • 8. HTN
  181. S/S of PE?
    • 1. most common is sudden onset of dyspnea, tachypnea, &/or tachycardia
    • 2. commonly have hypoxemia with a low PaCO2
    • 3. impending doom
    • 4. crackles
    • 5. fever
    • 6. pulmonic heart sound louder
    • 7. mental status change r/t hypoxia
    • 8. pleuritic chest pain
    • 9. hemoptysis
    • 10. pleural friction rub
  182. Dx Studies used with PE?
    • 1. VP lung scan
    • 2. D-dimer
    • 3. if D-dimer is elevated will do ultrasound &/or CT
  183. Normal D-dimer results?
    <250mcg/L
  184. Nursing mgmt of PE?
    • 1. sit pt up and give O2 - may need intubation
    • 2. TCDB q2h & incentive spirometry
    • 3. Tx shock with IV fluids & vasopressors
    • 4. diuretics for heart failure
    • 5. morphine to decrease angina
    • 6. anticoagulants:  heparin, lovenox, etc for Afib
    • 7. surgery prn
    • 8. IVC to prevent more PE
    • 9 fibrinolytics may be given if R-sided dysfunction occurs
    • 10. monitoring ABG, resp status, clotting times, VS, ECG, s/s of bleeding r/t anticoagulants,
  185. What does d-dimer show?

    What will be done if it is elevated?
    risk for DVT

    will do ultrasound, lung scans, CT, etc
  186. PE affect on the heart?
    can cause R ventricular failure
  187. Complications of PE?
    • 1. pulmonary infarction & abscess can develop
    • 2. pulmonary hypertension - r/t hypoxemia or recurrent emboli
    • 3. R sided heart hypertrophy
  188. VQ lung scan?
    2 parts - perfusion & ventilation scanning

    perfusion - radioisotope IV & view pulmonary circulation

    ventilation - inhale radioative gas & view distribution through the lungs - requires cooperation of the pt
  189. CXR of pt with a PE?
    atelectasis & pleural effusion
  190. ECG of pt with a PE?
    ST elevation & T wave changes
  191. What lab may be used to determine the severity of PE?
    BNP
  192. Prevention of PE?
    prevent DVT:  compression devices, early ambulation, anticoagulants,
  193. Cause of pulmonary HTN?
    anything that causes increae in pulmonary vascular resistance to blood flow
  194. Classic s/s of pulonary HTN?

    Other s/s?
    dyspnea on exertion & fatigue

    chest pain, dizziness, & syncope
  195. Drug that may be given for pulmonary HTN/
    viagra
  196. Primary pulmonary HTN?
    deficient vasodilator mediators causes HTN
  197. What causes the s/s of pulmonary HTN?
    inability of CO to increase in response to increased O2 demand
  198. Complication of pulmonary HTN?
    R-sided hypertrophy/Cor pulmonale/HF
  199. Tx of primary pulmonary HTN?
    • all Tx aimed at dilating pulmonary arteries, decreasing R ventricular overload, & reversing remodeling r/t HTN
    • 1. diuretic therapy - for dyspnea & peripheral edema
    • 2. anticoagulation
    • 3. O2 - hypoxia causes vasoconstriction
    • 4. calcium channel blockers - dilate pulmonary arteries
    • 5. prostacyclin analogs, endothelin receptor blockers, phosphodiesterase inhibitors
  200. 3 drugs that are prostacyclin analogs?
    • iloprost/Ventavis,
    • epoprostenol/Flolan,
    • treprostinil/Remodulin
  201. How is epoprostenol administered?
    central line with pump with continuous portable infusion pump - must teach pt how to use
  202. AE of epoprostenol?
    has 6min 1/2 life - if it is accidentally disconnected pt will have clinical deterioration with s/s of Rsided heart failure:  dyspnea, cyanosis, cough, syncope, & weakness

    if pt loses weight dosage needs to be adjusted
  203. How is treprostinil admin?

    AE?
    SubQ or IV

    pain and reactions at site
  204. How is iloprost admin?

    AE?
    inhaled form of prostacyclin given 6to9 times per day via nebulizer

    orthostatic hypotension - should not give if systolic pressure is less than 85
  205. 2 endothelin receptor blockers?

    Action?
    bosentan/Tracleer & ambrisentan/Letairis

    cause vasodilation by blocking endothelin (a vasoconstrictor)
  206. How are endothelin receptor blockers admin?

    AE & monitoring?
    orally

    hepatotoxicity - monitor monthly LFT
  207. Phosphodiesterase inhibitor?

    Action?

    Contraindication?
    sildenafil/Revatio

    prlongs vasodilatory effect of nitric oxide & decreases pulmonary vascular resistance

    contraindicated in pt using nitrates
  208. Anatomic changes that cause increase in pulmonary vascular resistance?
    • 1. loss of capillaries r/t alveolar wall damage:  COPD
    • 2.  siffening of pulmonary vasculature:  fibrosis, connective tissue disorders
    • 3. obstruction of blood flow:  chronic emboli
  209. Hypoxia effect on pulmonary hypertension?
    hypoxia -> vasoconstriction -> blood is shunted away from the poorly ventilated alveoli
  210. Tx of secondary pulmonary HTN?
    Tx underlying cause & Tx used for primary pulmonary HTN
  211. Cor pulmonale?
    enlargement of R ventricle secondary to diseases of the lung, thorax, or pulmonary circulation
  212. Most common cause of cor pulmonale?
    COPD
  213. s/S of cor pulmonale?
    subtle and usually masked by respiratory condition that caused it

    may have dyspnea on exertion, lethary, fatigue
  214. Physical signs of cor pulmonale?
    • 1. R ventricular hypertrophy on ECG
    • 2. increase in intensity of second heart sound
    • 3. polycythemia & increased total blood volume r/t hypoxemia
    • 4. s/s of R-sided failure if it occurs:  peripheral edema, weight gain, distended neck vens, full, bounding puls, enlarged liver
  215. Tx of cor pulmonale?
    • 1. Tx underlying resp condition
    • 2. long-term low-flow O2- decrease hypoxemia -> decreases vasoconstriction-> decreases pulmonary HTN
    • 3. correct F&E & pH imbalances
    • 4. diuretics & low-sodium diet to decrease work-load on heart
    • 5. bronchodilator for obstructive disorders
    • 6. Tx pulmonary HTN
    • 7. may give theophylline - ionotropic effect
    • 8. phlebotomy for Hct >65%
  216. Lung transplantation requirements?
    • Cannot have:
    • 1.malignancy or recent Hx of malignancy (w/in last 2 years)
    • 2. renal or lever insufficiency
    • 3. HIV
    • 4. will have psych screening
  217. Concerns post-op lung transplantation?
    • 1. will have immunosuppressive therapy
    • 2. monitor for infection
  218. Pre-lung transplant consideration?
    pt must carry a pager everywhere & should stay in the area
  219. Early post-op care after lung transplantation?
    • 1. ventilatory support
    • 2. fluid & hemodynamic mgmt
    • 3. immunosuppression
    • 4. detection of early rejection
    • 5. prevention/Tx of infection
    • 6. pulmonary clearance measures:  aerosolized bronchodilators, physiotherapy, TCDB
    • 7. maintainence of fluid balance is vital
  220. Most important post-op lung transplantation infection to watch for?

    S/S?
    • cytomegalovirus (CMV)
    • 1. fever
    • 2. bone marrow suppression
    • 3. hepatitis
    • 4. enteritis
    • 5. pneumonitis
  221. Immunosuppressive therapy given after lung transplantation?
    cyclosporine, tacrolimus, azathioprine, mycophenolate, prednisone
  222. S/S of lung transplant rejection?
    • low-grade fever
    •  fatigue
    • O2desaturation with exercise
  223. Tx of lung transplant rejection?
    high doses of corticosteroids IV X 3 days
  224. S/S of chronic lung transplant rejection?
    bronchiolitis obliterans - obstructive airway disease that causes progressive occlusion:  gradual onset of progressive airflow obstruction with cough, dyspnea, recurrent lower resp tract infection
  225. Asthma?
    chronic inflammation of airways
  226. S/S of asthma?
    • rucurrent episodes of
    • 1. wheezing
    • 2. breathlessness
    • 3. chest tightness
    • 4. cough
  227. Risk factors for asthma?
    • 1. genetic
    • 2. male gender
    • 3. obesity
    • 4. allergies to common allergens
  228. Triggers of asthma attacks?
    • 1. allergens
    • 2. after (not during) vigorous exercise especially with cold, dry air
    • 3. cigarrette or wood smoke, vehicle exhaust
    • 4. irritants
    • 5. respiratory infections
    • 6. allergic rhinitis
    • 7. some medications, dyes, & foods
    • 8. GERD
    • 9. emotional stress & hyperventilation
    • 10. hormones & menses
  229. Occupations that increase risk for asthma attacks?
    agricultural workers, painters, plastics manufacturing, cleaning work
  230. Meds that may trigger asthma attacks?
    • 1. aspirin
    • 2. NSAIDs
    • 3. beta blockers - cause bronchoconstriction
  231. Foods that can trigger asthma attacks?
    • 1. tartrazine - yellow no 5
    • 2. sulfiting agents:  preservative found in fruits, beer, wine, & salad bars
  232. When does GERD primarily affect asthma?
    at night
  233. S/S that may occur with an asthma attack caused by aspirin/NSAIDs?
    • 1. s/s of asthma
    • 2. profound rhinorrhea
    • 23. congestion
    • 4. tearing
    • 5. facial flushing
    • 6. GI s/s
    • 7. angioedema can occur
  234. Patho of asthma?
    • infection causes inflammatory response that leads to
    • 1. vascular congestion
    • 2.edema
    • 3. production of thick, tenacious mucus
    • 4. bronchial muscle spasm
    • 5. thickening of airway walls
    • 6. increased bronchial hyperresponsiveness
  235. Concern after an asthma attack occurs?
    can reoccur 4 to 10 h after attack r/t further inflammatory response
  236. Tx of inflammatory response that occurs in asthma?
    corticosteroids
  237. What is the cause of bronchoconstriction in asthma?
    increased parasympathetic NS stimulation --> increased Ach release --> smooth muscle contraction & mucus secretion --> bronchoconstriction
  238. Remodeling in asthma?
    chronic inflammation --> structural changes & progressive loss of lung function
  239. What happens to respirations & pH during asthma?
    initially will cause hyperventilation --> decreased PaCO2 & PaO2 & respiratory alkalosis

    PaCO2 begins to normalize when pt tires & respirations start to slow --> respiratory acidosis (ominous sign)
  240. Can severity of asthma be judged by wheezing?
    no, wheezing may not be audible r/t marked reduction in airflow
  241. Why may an asthma cough be nonproductive?

    What will occur as the ep8isode resolves?
    thick mucus

    will become productive with stringy mucus
  242. S.S of hypoxemia?
    • 1. restlessness/anxiety
    • 2. inappropriate behavior
    • 3. increased pulse & BP
    • 5. pulsus paradoxus
  243. What is indicated by diminished/absent breath sounds with asthma?
    ominious sign- significant decrease in air movement r/t exhaustion & inability to ventilate
  244. Dx tests used for asthma?
  245. 1. PFT
    • 2. peak expiratory flow rate (PEFR)
    • 3. CXR
    • 4. pulse ox
    • 5. blood level of eosinophils & IgE if indicated
    • 6. sputum cultures
  246. Considerations with PFT?
    pt should withhold taking bronchodilator meds for 6 to 12 h before test
  247. What does an elevated eosinophil & IgE indicate?
    allergy to common allergens (atopy)
  248. Pt who should not have allergy skin testing?
    exzema
  249. What will CXR of asthma show during an attack?
    hyperinflation
  250. How is obstruction measured during an acute asthma attack?
    beside spirometry
  251. Niox Mino?
    device that measures airway inflammation r/t asthma by measuring fractional exhaled nitric oxide (FENO)

    nitric oxide is increased in asthma attack

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