Med Surg 1 Exam 2

Upper airway

nose, sinuses, pharynx, larynx

Lower airway

trachea, bronchi, lobar, segmental, and subsegmental bronchi, bronchioles, alveolar ducts, alveoli

Gas exchange

oxygen transport to cell sand carbon dioxide transport away from cells through ventilation and diffusion

perfusion

arterial blood flow through tissues, and blood pumped by the heart

Diffusion

inside the RBC, oxygen reacts chemically with hemoglobin and is transported by both free and hemoglobin facilitated diffusion. Oxygen diffuses through the cell membrane and is transported in blood plasma by free diffusion. Oxygen moves by diffusion from an area of higher concentration inside the lungs to an area of lower concentration in the blood

Respiration

act of inhaling, exhaling air to transport oxygen to alveoli

Ventilation

actual exchange of oxygen and carbon dioxide

Crackles

high pitched popping sounds, heard on inspiration. Caused by fluid associated with or resulting from inflammation or exudates within the lung field

Wheezing

high pitched whistling sound. cannot be cleared by cough

Stridor

high pitched sound within the trachea and larynx that suggest narrowing of tracheal passages

Rhonchi

coarse, low-pitched sounds that continue throughout inspiration. May indicate blockage of large airway passages. Can be cleared with cough

Pleural Friction Rub

associated with pleural inflammation and occurs when inflamed pleural surfaces slide across on another. Low-pitched crackling sound is typically present during inspiration and expiration

Health Promotion and Maintenance Asthma COPD

minimize exposure to inhalation irritants, smoking cessation

Laboratory Assessment for Asthma and COPD

RBC, ABG, chest x-ray, CT, pulse oximetry, capnometry and capnography, exercise testing, bronchoscopy, thoracentesis, lung biopsy

Nasal Cannula characteritics

1-6 L, O2 concentration of 24-44%, often used for chronic lung disease or long-term therapy

Facemask Characteristics

O2 concentration of 40-60%, minimum of 5L/min

Partial rebreather characteristics

O2 concentration of 60-75%, 6-11 L/min, patient rebreathes 1/3 exhaled tidal volume

Nonrebreather characteristics

delivers highest o2 concentration, O2 concentration can be greater than 90%, used for unstable clients that may require intubation

Venturi mask

adaptor located between bottom of mask and O2 sources, pulls in a proportional amount of room air for each liter flow of oxygen

Noninvasive Positive Pressure Ventilation (NPPV)

uses positive air pressure to keep alveoli open, improve gas exchange

CPAP

same air pressure on inhale and exhale, delivers air pressure at single set level that stays consistent during sleep

BIPAP

different air pressure levels for inhale and exhale, allows for lower pressure during exhalation, used for more complex breathing problems

Asthma Pathophysiology

chronic disease that occurs intermittently, inflammation and airway tissue sensitivity, occurs in response to presence of specific allergens, general irritants, microorganisms, aspirin, and NSAIDs

Risk factors for asthma

genetics, GERD, allergens, exercise, food, respiratory infections

Aspirin and NSAIDs considerations asthma

block COX 1 receptors which release inflammation cells (leukotrines)

Asthma symptoms

wheezing, dyspnea, coughing, chest tightness, increased mucous production, hypoxemia, tachycardia, barrel chest, choppy words

Labs Asthma

ABGs, pulmonary function tests, peak expiratory rate flow, forced vital capacity

How is asthma diagnosed

diagnosed by a pulmonary function test, peak flow meter decides treatment

methylxanthines considerations

CNS stimulants that are chemically related to caffiene. Produce bronchodilation through relaxation of bronchial smooth muscles. EX theophylline

Corticosteroids considerations

anti-inflammatory effect helps to prevent and treat acute episodes of asthma. Used to reduce the frequency and severity of asthma attacks, allows reduced usage of other medications. EX- salmeterol/fluticasone, IV push methylprednisolone

Anticholinergics considerations

potent bronchodilators that block muscarinic receptors of the PNS. Blocking these receptors promote smooth muscle relaxation and bronchodilation. Ex Ipratropium

Short acting beta agonists considerations

bronchodilators for asthma and other pulmonary disease. 1st line treatment of acute bronchoconstriction. EX albuterol

Long acting beta agonists considerations

used in combination with inhaled corticosteroids for prophylaxis of mild to moderate persistent asthma and COPD

Leukotriene modifiers considerations

interfere with the inflammatory process in the airways by suppressing the effects of leukotrienes, a group of inflammatory mediators. EX monteleukast

Status Asthmaticus Considerations

severe, life threatening acute episode of airway obstruction, intensifies once it begins and often does not respond to common therapy, prepare for emergency intubation

Status Asthmaticus Treatment

IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen

Pursed lip breathing

exhaling through a narrow opening in the lips prolonging the expiratory phase. This promotes more alveolar emptying while maintaining open alveoli

Bronchitis

inflammation of the mucous membranes of the bronchial tubes

Tripod position

the act of sitting and leaning forward

Barrel chest

increased anteroposterior chest and diameter caused by air trapping and hyperinflation

Air trapping

decreased airflow with exhalation. Caused by narrowing airway passages

COPD pathophysiology

chronic obstruction of lung airflow that interferes with normal breathing, not fully reversible, chronic bronchitis and emphysema, cigarette smoking is the greatest risk factor

Chronic bronchitis pathophysiology

continuous inflammation and low-grade infection of the bronchi, excessive secretion of mucus and certain pathologic changes in the bronchial structures, often occurs as a result of prolonged exposure to bronchial irritants

Emphysema pathyophysiology

air spaces enlarge as a result of destruction of alveolar walls, caused by the effect of proteolytic enzymes released from leukocytes in response to alveolar inflammation, the surface area where case exchange takes place is reduced, effective respiration is impaired

Complications of COPD

hypoxemia, acidosis, respiratory infection, cardiac failure, dysrhythmias, respiratory failure

Laboratory assessment for COPD

WBC, ABG, sputum cultures, electrolyte levels, Hemoglobin and Hematocrit

Physical assessment of COPD

general appearance, positioning, rapid shallow respirations, tachypneic, wheezing, diminished breath sounds, barrel chest, digital clubbing, hypoxemia and hypoxia, cyanosis or pallor

Polycythemia

high hemoglobin

Normal O2 sat for COPD

88-92%, 95% and above indicates toxicity

SABA and LABA side effects

tremors, hyperglycemia, headache, tachycardia

Corticosteroids side effects

hyperglycemia, increased WBC, depression, thrush, osteoporosis, peptic ulcer

Anticholinergics side effects

tremors, headache, tachycardia

Pneumonia

excess fluid in the lungs, inflammatory process that causes a decrease in gas exchange, can be lobar in nature

Pneumonia Etiology

caused by bacteria, viruses, mycoplasmas, fungi, and rickettsiae. Also caused by noninfectious causes

Community acquired pneumonia (CAP)

contracted outside of a healthcare setting, common bacterial agents; strept. pneumonia, hemophilus influenzae, common viral agents; influenza and RSV

Hospital acquired pneumonia (HAP)

onset/diagnosis of pneumonia greater than 48hrs after admission

Healthcare acquired pneumonia (HCAP)

onset occurs less than 48 hours after admission with a patient with these risk factors; in hospital for more than 48 hrs in the past 90 days, living in a nursing home, received IV therapy, wound care, antibiotics, chemotherapy in the past 30 days

Ventilatory acquired pneumonia (VAP)

onset/diagnosis of pneumonia within 48-72 hrs after endotracheal intubation

Health Promotion and Maintenance Pneumonia

vaccination, avoid crowds during flu season, cough, turn, move, deep breathe, clean respiratory equipment, avoid pollutants, stop smoking, get rest and sleep, eat healthy diet, 3L of water daily

Laboratory Assessment Pneumonia

gram stain, culture and sensitivity of sputum, CBC, blood cultures, ABGs, serum electrolytes, BUN, and creatinine, lactate level

Pneumonia Pathophysiology

increased respiratory rate/dyspnea, hypoxemia, cough, purulent, blood tinged, or rust colored sputum, fever, pleuritic chest discomfort

Pneumonia Treatment

macrolides, doxycycline, fluroquinolone, beta-lactam PCN, cephalosporins, carbapenems, monobactams

Comorbid illnesses pneumonia

COPD, asthma, chronic heart disease, chronic liver disease, chronic alcohol use disorder, diabetes mellitus, smoking, HIV

Macrolides

prevent protein synthesis within bacterial cells, bacteriostatic

Adverse effects- nausea, vomiting, diarrhea, hepatotoxicity, flatulence, jaundice, anorexia (typically with erythromycin)

Azithromycin and clarithromycin- fewer GI effects, longer duration of action, better efficacy, better tissue penetration

Doxycycline

bind to Ca, Mg, and Al, ions to form insoluble complexes, diary products, antacids, and iron salts reduce oral absorption, should not be used in children younger than 8 or in pregnant or lactating women because it can cause yellowing of permenant teeth.

Adverse effects- discoloration of permanent teeth and tooth enamel in fetuses and children or nursing infant if taken by the mother, may retard skeletal development if taken during pregnancy, superinfection, diarrhea and pseudomembranous colitis, avoid dairy products and tanning beds due to photosensitivity

Penicillins

enter the bacteria via the cell wall and bond to the penicillin binding protein, normal cell wall synthesis is disrupted

Adverse effects- urticaria, prutitus, angioedema

Interacts with- NSAIDs, oral contraceptives, warfarin

Pulmonary Tuberculosis

highly communicable disease caused by mycobacterium tuberculosis, transmitted via aerosolization

Secondary Tuberculosis

reactivation of TB in a previously infected person

TB etiology

close contact with an infected person is how it can be transmitted, characterized by granulomas in the lungs, nodular accumulations of inflammatory cells that are walled off with clear boundaries and have a center that has a cheesy or caseated consistency. Tubercule bacilli spread to other body organs via blood and lymphatic system and may become dormant or walled off by calcified or fibrous tissue

Mycobacterium Infections

very slow growing organism, more difficult to treat than most other bacterial infections, first infectious episode is a primary TB infection, reinfection is a chronic form of the disease, dormancy- may test positive for exposure but are not necessarily infectious because of this dormancy process

Risk factors for Tb

children, malnutrition, diabetes, elderly, immunocompromised, HIV, homeless, alcohol, IV drug use, working in healthcare

Assessment TB

past exposure and vaccine

Physical assessment- progressive fatigue, low grade fever, lethargy, nausea, anorexia, weight loss, irregular menses, cough with mucopurulent sputum, contact with blood streaks, dull aching chest pain

Psychosocial assessment

Diagnostic assessment- chest x-ray, sputum culture, NAAT, TST, IGRA< PPD, nucleic acid amplification

Symptoms of active TB disease

cough lasting 3 or more weeks, coughing up blood or sputum, chest pain, weakness or fatigue, no appetite, fever and or chills, night sweats

TB diagnosis

step 1- tuberculin skin test

step 2- if skin results are positive, chest x-ray

step 3- if the chest x-ray shows signs of TB, then sputum or stomach secretion cultures

TB related injections

Bacille Calmette-Guerin (BCG)- a vaccine injection derived from an inactivated strain of mycobacterium bovis, not used in the US, reduces active TB by 60-80%, prevents more severe cases, can cause false positives on PPD

TB Analysis

potential for airway obstruction, potential for development or drug-resistant disease and spread of infection, fatigue, weight loss

Antitubercular Drugs

INH, Ethambutol, Pyrazinamide, Rifampin

TB drug therapy considerations

reduces cough and reduces the infectiousness of TB, successful treatment can last for as long as 12 months, perform drug susceptibility test on the first mycobacterium spp to prevent the development of MDR-TB

Isoniazid

Drug of choice for TB, resistant strands of mycobacterium emerging, metabolized in the liver through acetylation-watch for slow acetylators, kills actively growing bacteria outside the cell and inhibits the growth of dormant bacteria inside macrophages and caseating organisms. Contraindicated with liver disease, Vitamin B6 is given with this to prevent neural damage

Considerations- avoid antacids, take drug on empty stomach, avoid alcohol, tell patients to report darkening of urine, jaundice, and increased bruising or bleeding

Adverse effects- peripheral neuropathy, hepatotoxicity

Rifampin

Adverse effects- turns all bodily fluids a red-orange color

oral use only, kills slower growing organisms

Considerations- instruct women to use another method of contraception during sex other than oral contraceptives, avoid alcohol, report signs of liver toxicity, ask about other medications because this medication can interact with other drugs

Ethambutol

diffuses into the mycobacteria and suppresses RNA synthesis, inhibiting protein synthesis

Contraindications- optic neuritis, pediatric patients younger than 13

Adverse effects- retrobulbar neuritis, blindness

Considerations- report changes in vision, avoid alcohol, ask about gout because gout can worsen on this med, instruct patients to drink at least 8 ox of water when taking this drug and increase fluid intake

Pyrazinamide

bacteriostatic or bactericidal, inhibits lipid and nucleic acid synthesis in mycobacteria

contraindications- severe hepatic disease, acute gout

Adverse effects- hepatoxicity, hyperuricemia, polyphagia

Considerations- gout can worsen, drink 8 oz of water and increase fluid intake with this drug, wear protective clothing to avoid sun damage, avoid alcohol, report signs of hepatotoxicity

Transient Ischemic Attack (TIA)

warning sign, temporary neurologic dysfunction, brief interruption in cerebral blood flow, often caused by carotid stenosis or a temporary clot

ABCD assessment tool stroke

age greater than or equal to 60, BP greater than or equal to 140/90, clinical TIA features unilateral, duration of symptoms

Stroke pathyophysiology

interruption of perfusion to any part of the brain, medical emergency

Acute ischemic stroke

obstruction within a blood vessel supplying blood to the brain can be thrombolic or embolic

Thrombus

a stationary blood clot

embolus

a mobile or floating blood clot which is often a fragment of a thrombus

Hemorrhagic stroke

when a weakened blood vessel ruptures

Types of stroke

acute ischemic, hemorrhagic, intracerebral hemorrhage, subarachnoid hemorrhage, aneurysm, arteriovenous malformation

Hallmark sign of subarachnoid hemorrhage

horrible headache

Etiology Stroke

genetic- first degree relative with history of HTN, atherosclerotic disease, and aneurysm

Leading causes- smoking, obesity, HTN, diabetes mellitus, elevated cholesterol

Assessment Stroke

ensure patient is transported to a stroke center, physical assessment, neurologic examination, psychosocial assessment- emotional liability

Signs and symptoms of stroke

sudden confusion or trouble speaking or understanding others, sudden numbness or weakness of the face, arm or leg, sudden trouble seeing in one or both eyes, sudden dizziness, trouble walking, loss of balance and coordination, sudden severe headache with no known cause

What is the most common stroke type

middle cerebral artery stroke

contralateral

opposite side

hemiparesis

one sided weakness

hemiplegia

one sided paralysis

dysphagia

trouble swallowing

contralateral sensory perception deficit

numbness, tingling, unusual sensations