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1

respiratory assessment

  • dyspnea

  • cough

  • sputum production

  • chest pain

  • hemoptysis

  • adventitious breath sounds

  • signs of hypoxia

  • signs of respiratory distress

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PFT

assess lung function and extent of dysfunction

measures lung volumes and capacities, diffusion capacity, gas exchange, flow rates, airway

  • if patient is a smoker, do not smoke 6-8 hrs before test

  • if patient uses inhalers, withhold 4-6 hrs before test

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ABG

measures pH, PaO2, PaCO2, HCO3

status of oxygenation and acid-base balance of the blood

  • can be obtained by arterial puncture or thru arterial line

pH: 7.35-7.45

PaO2: 80-100

PaCO2: 35-45

HCO3: 22-26

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acidosis

pH levels less than 7.35

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alkalosis

pH levels greater than 7.45

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allen’s test

used to assess collateral blood flow to the hands

  • usually used in prep for a procedure that has potential to disrupt blood flow in either the radial or ulnar artery

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how to perform allen’s test?

  • compress the ulnar and radial arteries simultaneously while instructing the client to form a fist

  • instruct the client to relax his hand while assessing the palm and fingers for blanching

  • release pressure on the ulnar artery while observing the hand for flushing caused by capillary refilling

hand should turn pink within 5-15 seconds, indicating patency of the ulnar artery and an ability to use the radial artery to obtain arterial blood gases.

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pulse ox

noninvasive method of continuously monitoring o2 sat

normal: >95%

<90% = tissues are not receiving enough o2

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pulse ox considerations

inaccurate readings from:

  • anemia

  • abnormal hgb

  • high carbon monoxide levels

  • use of dyes

  • dark skin

  • nail polish

  • sulinght, fluorescent, xenon lights

  • patient movement

  • bp and o2 on same arm

  • cold fingers

  • calasis

  • swelling

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culture and sputum studies

used to deterine bact. inf.

  • collect in the morning before anything to eat or drink

  • no mouthwash

  • deep breathing to stimulate cough

  • send specimen 30min-1hr after collecting

    • can alter results if later b/c bact. grows

  • results should take w/i 48-72 hrs, preliminary reports w/i 24 hrs

all cultures should be obtained prior to initiation of antibiotic therapy

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imaging studies types

  • CXR

  • computerized tomography (CT)

  • magnetic resonance imaging (MRI)

  • pulmonary angiography

  • lung scan

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CXR nursing responsibilities

  • usually obtained after full inspiration bc lungs are best visualized when they are well aerated

  • patient need to take deep breath and hold

  • contraindicated in preg. women

interventions

  • does not require fasting, pain

  • positioned in a standing, sitting, or recumbent position in order to obtain view of chest

  • wear gown, remove metal objects from chest

  • may be given a lead shield to minimize radiation exposure to thyroid, ovaries, testicles

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CT pre & post procedure nursing responsibilities

  • patient lays supine and still for a short time

  • typically 30 mins

  • typically do not experience claustrophobia but can be given anti-anxiety meds pre-procedure

  • if contact dye is used, patient will need to stay NPO for 4hrs before exam

  • assess allergies to iodine or shellfish

post

  • encourage fluids to flush out dye

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MRI pre & post procedure nursing responsibilities

  • remove all metal items

    • hearing aids, hair clips, meds with metallic foil components (nicotine patches)

  • assess for. implanted metal devices like aneurysm clips, cardiac pacemaker, defibrillator

  • patient lie flat and still for 30-90mins

  • patient notified they will hear loud humming or thumping noise

    • earplugs offered

  • clarify if procedure will use dye or patient needs to be NPO

  • typically do not experience claustrophobia but can be given anti-anxiety meds pre-procedure

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pulmonary angiography pre & post procedure nursing responsibilities

used to investigate congenital abnormalities of pulmonary vascular tree, high suspicion for PE

pre

  • verify consent has been obtained

  • assess for allergies to iodine and shellfish

  • assess anticoag. status and renal function

  • patient not eaten for 6-8 hrs

  • administer pre-procedure meds: anti-anxiety, secretion-reducing agents, antihistamines

  • may experience warm flushing sensation or chest pain during injection of dye

post

  • monitor vital signs, LOC, O2 sat, vascular access site for bleeding or hematoma

  • perform freq. assessment of neurovascular status

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lung scan pre & post procedure nursing responsibilities

types: V/Q scan, gallium scan, position emission tomography (PET)

pre

  • educate patient on procedure

  • IV assess needed

  • enema is sometimes prescribed prior to gallium scan to dec uptake in the GI tract

  • CXR before v/Q

  • V/Q and gallium req. small amt od radioisotopes so radiation safety measures not indicated

  • may eat or drink before V/Q and gallium

  • avoid caffeine, alcohol, tobacco for 24 hrs and NPO 4 hrs before for PET scan

  • empty bladder ( foley cath maybe)

post

  • encourage fluids to eliminate radioisotopes thru urine

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endoscopy procedures

  • bronchoscopy (lung cancer)

  • laryngoscopy (laryngeal cancer)

  • thoracentesis

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endoscopy: bronchoscopy

direct inspection and examination of larynx, trachea, and bronchi thru either a flexible fiberoptic or a rigid bronchoscope

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bronchoscopy & laryngoscopy pre-procedure nursing responsibilities

  • verify consent

  • NPO for 4-8 hrs before to reduce risk for asp. when cough reflex is blocked

  • RN explains procedure to patient to reduce fear, anxiety

  • administer pre-procedure meds: usually atropine or sedative or opioid

  • remove dentures and other oral prostheses

  • under local anesthesia or mod. sedation

  • rigid bronchoscopy general anesthesia may be used

  • topical anesthetic like lidocaine sprayed on pharynx or dropped on the epiglottis and vocal cords and into trachea to suppress cough reflex

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bronchoscopy & laryngoscopy post-procedure nursing responsibilities

  • NPO until cough reflex is back

  • once cough reflex back, ice chips and then fluids

  • older patient: assess conf and lethargy

  • monitor RR

  • observe for

    • hypoxia

    • hypotension

    • tachycardia

    • dysrhythmias

    • hemoptysis

    • dyspnea

  • small smt of blood tinged sputum and fever expected w/i 24 hrs

  • patient not discharged from recovery area until cough reflex and RR back

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endoscopy: thoracentesis

surgical perforation of the chest wall and pleural space with a large-bore needle

used for

  • obtain specimens for diagnostic evaluation

  • instill medication into the pleural space

  • remove fluid (effusion) or air from the pleural space for therapeutic relief of pleural pressure

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thoracentesis pre-procedure nursing responsibilities

  • informed consent form signed by patient

  • gather all needed supplies

  • obtain pre-procedure x‑ray to locate pleural effusion and to determine needle insertion site

  • position sitting upright with arms and shoulders raised and supported on pillows and/or on an overbed table and with feet and legs well-supported

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thoracentesis post-procedure nursing responsibilities

  • apply a dressing over the puncture site

  • assess the dressing for bleeding or drainage

  • monitor vital signs and respiratory status hourly for the first several hours after

  • auscultate lungs for reduced breath sounds on side of thoracentesis

  • encourage the client to deep breathe to assist with lung expansion

  • obtain a postprocedure chest x-ray (check resolution)

complication

  • mediastinal shift

  • bleeding

  • infection

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biopsy

similar to bronchoscopy

  • monitoring for complications

    • SOB

    • bleeding

    • infection

  • instruct at report pain, purulent drainage, SOB, bleeding, redness

  • mostly for cancers

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respiratory care modalities: nursing management

  • positioning

  • deep breathing exercises

  • rest and activity pacing

  • incentive spirometry

  • hydration

  • chest physiotherapy

  • oxygen therapy

  • suctioning

  • artificial airway management

  • chest tubes

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chest physiotherapy

  • chest percussion

    • 3-4x before meals and bedtime

    • bronchodilator 30mins-1hr

    • remain in each position 10-15 mins

  • vibration

  • postural drainage

    • assess breath sounds before and after

    • assess pain

    • assess sputum

    • oral care

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O2 therapy care

  • RN can initiate, notify MD

  • assess resp status

  • pulse ox, ABGs

  • semi-fowlers

  • promote good oral hygiene

  • assess skin integrity

  • provide o2 at lowest flow

    • may give higher depending on patient situation

  • humidify and titrate o2

  • turn, cough, deep breathe

  • discontinue O2 gradually

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O2 therapy indications

hypoxemia

  • inadeq. level of O2 in the blood

hypoxia

  • dec in tissue O2

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O2 therapy safety considerations

  • combustion

    • no vaseline

    • no smoking

  • oxygen toxicity

    • high concentrations of O2 for long duration (24-48 hrs)

  • oxygen-induced hypoventilation

    • can develop in patients with COPD and chronic hypoxemia

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O2 delivery devices

  • nasal cannula

  • simple mask

  • face tent

  • non-rebreather mask

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nasal cannula

low flow O2 delivery

  • FiO2: 24-44%

  • 1-6 L/min

  • easy, safe

  • patient can talk, eat

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simple mask

low flow O2 delivery

  • FiO2: 40-60%

  • 5-6 L/min

  • easy to apply

  • may be a problem if patient has claustrophobia

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face tent

high flow O2 delivery

  • FiO2: 24-100%

  • 10-15 L/min

  • provide humidification

  • useful for facial trauma, burns

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non-rebreather mask

high flow O2 delivery

  • FiO2: 80-95%

  • 10-15 L/min

  • delivers highest O2 concentration possible

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suctioning

  • high-fowlers or semi-fowlers

  • different catheters

  • sterile procedure

  • suction pressure: 120-150 mmHg

  • apply suction during withdrawal

  • apply suction intermittently, not longer than 10-15 secs

  • no more than 2 passes; limit to 5 mins

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endotracheal intubation

  • tube inserted thru nose or mouth into trachea

  • allows for emergent airway management

  • providing airway for patients who cannot maintain an adeq. airway on their own

  • short-term

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tracheostomy

  • surgical procedure which an opening is made into the trachea

  • indwelling tube inserted into trachea : tracheostomy tube

  • temp or permanent

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laryngeal cancer risk factors

  • tobacco (other carcinogens also)

  • alcohol

  • genetic age

  • vitamin deficiency

  • weak immune system

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laryngeal cancer assessment

  • hoarseness

  • cough

  • sore throat

  • pain and burning esp. with hot liquids and citrus juices

  • lump in the neck

  • dysphagia

  • dyspnea

  • ulceration

  • foul breath

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laryngeal cancer diag.

  • laryngoscopy

  • fine needle asp. biopsy

  • CT/MRI

  • PET scan

  • barium swallow

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laryngeal cancer management

  • surgery

  • radiation

  • chemotherapy

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indirect v. direct laryngoscopy

indirect: does not need to be NPO before procedure

direct: NPO before and general anesthesia

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laryngeal & lung cancer tumor staging and grading

T umor: inc in size

N lymph nodes: inc involvement in regional lymph node

M etastasis: no distant metastasis =M0; distant metastasis = M1

  • TNM staging system

    • tumor size (T1, T2, T3)

    • lymph nodes (N1, N2, N3)

    • metastasis (M0, M1, M2)

  • grading

    • stage 1: localized

    • stage 2-3: N1, N2

    • stage 4: M1-M3

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laryngeal cancer surgical management

  • partial laryngectomy

    • used for early stages of cancer

    • portion of larynx is removed with 1 vocal cord and tumor

    • airway intact so no dysphagia

    • voice: hoarse

  • total laryngectomy

    • complete removal of larynx

    • more advanced cancer, when tumor extends to vocal cords

  • vocal cord stripping

    • removal of mucosa of the edge of vocal cord

  • cordectomy

    • excision of vocal cord

  • laser surgery

    • treatment and recovery shorter

    • fewer side effects

    • method of choice usually

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laryngeal cancer post-laryngectomy care

  • airway

    • laryngectomy tube

  • speech

    • artifical larynx

  • nutrition

    • enteral/parenteral

  • body image

  • safety

    • asp., inf. hemorrhage

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radiation therapy types

  • external: teletherapy

  • internal: brachytherapy

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side effects of teletherapy

  • skin reaction

  • fatigue

  • xerostomia (dry mouth)

  • loss of taste

  • acute mucositis

  • ulceration of mucous membranes

  • pain

  • dysphagia

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radiation nursing care

  • oral care

  • skin care

  • provide rest

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chemotherapy systemic effects (manifestations)

  • hair loss

  • pain

  • mouth sores

  • trouble breathing

  • weakened immune system

  • N&V

  • constipation, diarrhea

  • bruising, bleeding

  • rashes

  • neuropathy (arms &legs)

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chemotherapy management

  • promote comfort

  • ensure nutrition

  • promote rest

  • prevent infection

  • prevent injury

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lung cancer (bronchogenic carcinoma)

leading cancer killer in US

  • most common cause is inhaled carcinogens, like cigarette smoke, radon gas, occupational/environmental agents

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lung cancer risk factors

  • tobacco smoke

  • environmental exposure

  • genetics

  • dietary habits

  • previous scars in the lungs (TB, fibrosis)

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lung cancer manifestations

  • cough or change in chronic cough

  • dyspnea

  • hemoptysis

  • chest or shoulder pain

  • recurring fever

  • repeated upper respiratory infections

  • pleural effusion

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lung cancer assessment & diag.

  • CXR, CT of chest and brain, US, MRI

  • scans: bone, abdominal, PET, liver US

  • sputum cytology

  • bronchoscopy

  • biopsy

if surgery

  • PFTs

  • ABGs

  • V/Q scans

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lung cancer medical management

surgery

  • pneumonectomy

    • removal of lung

    • lay on affected side

  • lobectomy

    • removal of a lobe

  • segmentectomy

    • removal of a segment

  • wedge resection

    • removal of a small, pie shaped area of the segment (lung tissue)

chemotherapy

radiation

  • external RT: teletherapy

  • internal RT: brachytherapy

    • principle of DST: distance, shield, time

palliative therapy

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chest surgery: chest tube assessment

semi/high fowler’s

  • drainage

    • report if >70mL/hr

  • fluctuation (tidaling/oscillation)

    • if no tidaling, means lung expanded or obstructed

    • tidaling is expected w/ water seal

  • bubbling

    • water seal allows air to leave and prevent from entering

  • crepitus

  • assess vital signs, breath sounds, SaO2, color, and respiratory effort every 4 hr

  • encourage coughing and deep breathing every 2 hr

  • document amt, color hourly for 1st 24 hr then q8hr

    • date, time, level

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chest surgery: chest tube safety precautions

  • keep the drainage system below the client’s chest level, including during ambulation

  • monitor chest tube placement and function

    • check the water seal level every 2 hr, and add fluid as needed. The fluid level should fluctuate with respiratory effort.

  • tape all connections to ensure system is airtight and prevent chest tube from disconnecting

  • expect bubbling in water seal on forced expiration/coughing = chest tube working

  • avoid clamping tube unless system needs to be replaced or air leak located

  • notify provider if O2 <90, eyelets visible in tube, darainage is above presc. amt or stop w/i 24 hrs

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chest surgery: chest tube emergency management

air leaks

  • monitor water seal for cont. bubbling

  • locate source of leak

    • tighten connection, replace drainage system

  • notify provider of air leak

accidental disconnection, system breakage, or removal

  • instruct patient to exhale as much as possible and cough to remove as much air from pleural space

  • if chest drainage compromised, immerse chest tube in sterile water

  • if chest tube accidentally removed, dress with dry, sterile gauze

tension pneumothorax

  • causes: sucking chest wounds, prolonged clamping of tube, kinks or obstruction in tubing, mech. vent. w/ high levels of pos. end expiratory pressure (PEEP)

  • findings: tracheal deviation, absent breath sounds on one side, distended neck veins, resp. distress, asymmetry of chest, cyanosis

  • notify provider or rapid response immediately

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chest surgery: chest tube removal

  • provide pain meds 30 mins before

  • assist provider with sutures and removal

  • instruct patient to take a deep breath, exhale, and bear down or take a deep breath and hold it when removing

  • apply airtight sterile petroleum jelly gauze dressing. secure with heavyweight stretch tape

  • obtain CXR

  • monitor excessive would drainage, infection, recurrent pneumothorax

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pleural effusion

collection of fluid in the pleural space, usually secondary to other disease process (like cancer)

  • usually caused by underlying disease, not usually primary

  • fluid, blood, pus

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pleural effusion causes

  • heart disease

  • TB

  • pneumonia

  • pulmonary infections

  • nephrotic syndrome

  • connective tissue disease

  • PE

  • neoplastic tumors

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pleural effusion assessment

  • s&s of underlying disease

  • dyspnea or orthopnea

  • cough

  • dec. or absent breath sounds

  • dec. fremitus: chest vibrates when talking

  • dull, flat chest percussion

    • vibration is stronger if there’s a tumor

    • vibration is dec. if it’s fluid

  • dec. chest wall expansion

  • tracheal deviation to unaffected side

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pleural effusion diag.

  • physical assessment

  • CXR

  • chest CT

  • thoracentesis

  • pleural fluid analysis

  • pleural biopsy

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pleural effusion management

  • treat underlying cause

  • chest pain management

  • thoracentesis

    • removal of fluid from pleural space

  • pleurodesis

    • instillation of meds into pleural space after draining

  • surgical pleurectomy

    • removal of pleural layers that have reoccuring pleural effusion

  • pleuroperitoneal shunt

    • device that contains a pump chamber that manually transfers fluid from pleural cavity to peritoneal cavity

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pulmonary embolus (PE)

obstruction of the pulmonary artery or its branches by a thrombus that originates in the venous system or in the right side of the heart

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PE types

  • blood clots (most common)

  • air

  • fat (frac. of long bones)

  • amniotic fluid

  • septic (infection)

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PE risk factors

  • DVT

  • trauma (frac. of long bones)

  • surgery

  • pregnancy

  • a-fib

  • HF

  • hyper-coagulability (more dehydrated = risk for)

  • prolonged immobility

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PE manifestations

  • dyspnea, ari hunger: syncope

  • chest pain: sudden pleuritic on inspiration, pressure in chest

  • anxiety, feelings of impeding doom

  • chest wall tenderness

  • VS: tachycardia, tachypnea, dec. O2 sat, fever, hypotension

  • adventitious breath sounds

  • new heart murmurs

  • diaphoresis

  • pleural effusion

  • hemoptysis

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PE assessment & diag.

  • pulmonary angiography

    • contrast dye and x-ray

  • ventilation-perfusion (V/Q) scan

  • CXR, ECG, pulse ox, ABGs

  • D-dimer assay

    • if elevated = clotting going on somewhere

    • identify early clotting

  • spiral chest CT

    • best way to find clot and diag. PE

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PE emergency management

emergency management

  • O2 (ex. NC)

  • IV lines

  • dobutamine or dopamine (low bp & hr)

  • cardiac glycosides

  • morphine (for chest pain but pt at risk for resp. depression)

  • sedatives

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PE pharmalogic management

pharmalogic management

  • anticoagulation therapy

    • heparin

      • prevents clots: subQ, IV (faster anticoag.)

    • warfarin (coumadin)

      • if patient has DVT clot and on subQ, will change to IV b/c works faster for anticoag. but willnot dissolve current DVT , only prevent future DVTs

    • enoxaparin (lovenox)

    • rivaroxaban (xarelto)

  • thrombolytic therapy (dissolves clots but risk for bleeding)

    • urokinase, strepokinase, alteplase

    • TPA: tissue plasminogen activator

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PE nursing management

prevention

  • elevated legs

  • move legs (circle toes)

  • compression stockings

  • SCDs

  • ambulate

assessment

manage chest pain

managing O2 therapy

monitor anticoag. and thrombolytic therapy

  • heparin: PTT (60-70), aPTT (20-39)

  • warfarin: INR (1), PT (9-12.5)

  • therapeutic value should be double to show that therapy is effective

    • normal value x 1.5-2.5 (double)

monitor for complications

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tuberculosis (TB)

  • caused by mycobacterium tuberculosis

  • transmitted via airborne route

  • may affect organs other than lungs

  • risk of transmission dec. after 2-3 wks of anti TB therapy

  • early detection and treatment is vital

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TB risk factors

  • immunocompromised

  • contact with an untreated person

  • lower socioeconomic status

  • crowded environments

  • adv. age

  • health care occupation

  • immigration

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TB patho

bacteria transmitted thru the airways to the alveoli

phases

  • initial exposure: granuloma, ghon tubercle, dormant

  • infection: 2-10 wks after exposure

  • active disease: compromised immune system

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TB manifestations

  • persistent cough longer than 3 wks

  • night sweats

  • low grade fever

  • weight loss/anorexia

  • purulent, blood tinged sputum

  • hemoptysis

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TB assessment & diag.

  • physical assessment and hx

  • skin test: two step PPD/Mantoux test (10mm or >)

  • blood test: EBP: quantiferon-TB gold plus

  • sputum culture

  • CXR

  • acid-fast bacilli smear and culture

    • 3 early morning sputum samples

    • wear PPE

    • neg. airflow room

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TB: mantoux test

  • induration of greater than 10 = pos.

  • induration of greater than 5 for an immunocompromised patient = pos.

  • patient w/o symp. may recieve preventive therapy

  • cross reaction w/ BCG vaccine (bacillus calmette-guerin)

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anti-TB meds

R ifampin (rifadin)

I soniazid (INH or nydrazid)

P yrazinamide

E thanbutol hydrochloride (myambutol)

S treptomycen

  • 6-12 months

    • initial intensive regimen: 8 wks

      • RIPE meds

    • cont. regimen: 4-7 months

      • RI meds

      • considered noninfectious after 2-3 wks of cont. med treatment

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TB nursing management

  • prevention infection transmission

  • promote airway clearance

  • promote activity and nutrition

  • improve immunity

  • administer O2 as prescribed

  • adhere to treatment regimen

    • take full med regimen

  • follow up care

  • contact social services as necessary

  • community clinic as necessary

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