Med Surg II Exam 1 - Diagnostic Procedures and Respiratory Conditions

in a sterile manner suctioned through ET tube

How is a sputum sample collected from a patient on a ventilator?

bronchoscopy

the visual examination of the bronchi using a bronchoscope

ensure patient is NPO at least 6-8 hours before procedure

administer sedation and monitor vitals

monitor patient after the procedure

What is the nurse's role during a bronchoscopy?

thoracentesis

removal of fluid (ex. hemothorax or pleural effusion) from the PLEURAL SPACE

help position the patient to sitting on side of bed draped over the bedside table

instruct patient to sit still and not cough or move

What is the nurse's role during a thoracentesis?

bedside pulmonary function test

evaluates pulmonary functioning through lung volumes, mechanics of breathing, and diffusion

ventilation perfusion (VQ) scan

nuclear test scan that evaluates both airflow (ventilation) and blood flow (perfusion) in the lungs for evidence of a blood clot in the lungs

used is patient is suspected to have a PE but is allergic to contrast

When are VQ scans most commonly used?

0.8-1.0

What is a normal VQ scan?

ventilation issue

What does a low VQ ratio indicate?

perfusion issue

What does a high VQ issue indicate?

acute respiratory failure

lungs are not able to maintain gas exchange - could be oxygen and/or CO2

HYPOXEMIA (PaO2 less than 60)

What is the hallmark sign of acute respiratory failure?

hypercapnia (PaCO2 greater than 50)

What is another sign of acute respiratory failure that may be present but does not have to be present?

MODS (multiple organ dysfunction syndrome) due to lack of oxygen to vital organs

What is the major complication of acute respiratory failure?

RAT, confusion, chest pain, tachypnea, hyperventilation, dyspnea

What are signs of hypoxemia?

earliest signs of hypoxemia (restlessness, anxiety/agitation, tachycardia)

What is RAT?

headache, drowsiness, flushed skin

What are some signs of hypercapnia?

treat underlying cause, maintain adequate airway, administer O2, mechanically ventilate and sedate, bronchodilator, rest respiratory muscles, good-lung position

What are some interventions for acute respiratory failure?

acute onset, decreased P/F ratio, "white out" on CXR

What are the three defining criteria for ARDS?

PaO2 / FiO2 (decimal)

How do you calculate P/F ratio?

What P/F ratio is indicative of ARDS?

What P/F ratio is indicative of severe ARDS?

aspiration, near drowning, pulmonary contusion, pneumonia, inhalation burns

What are direct causes of ARDS?

sepsis, embolism, shock, DIC, burns

What are indirect causes of ARDS?

exudative, proliferative, fibrotic

What are the 3 phases of ARDS?

occurs within 24-48 hours of insult

damage to the alveolar-capillary membrane occurs

What happens during the exudative phase of ARDS?

further alveolar-capillary damage

V/Q mismatch worsens

lungs become stiff and noncompliant

What happens during the proliferative phase of ARDS?

diffuse fibrosis and scarring

compliance very poor

refractory hypoxemia due to severe V/Q mismatch and intrapulmonary shunting

What happens during the fibrotic phase of ARDS?

mechanically ventilate, lung-protective settings, nitric oxide, ECMO (severe), hydration, bronchodilators, paralytics, sedatives, prone positioning, corticosteroids

How is ARDS managed?

hyperoxygenation (very high FiO2 and PEEP - to keep alveoli open)

What needs to be done when an ARDS patient is ventilated?

to prevent barotrauma due to decreased compliance

Why do ARDS patients need lung-protective ventilation settings?

low tidal volume

What is a lung-protective ventilation settings used on an ARDS patient?

causes vasodilation which will help get more hgb to the pulmonary area

How does nitric oxide help with ARDS?

decrease oxygen requirements

Why do paralytics help with ARDS?

improves the perfusion to the less damaged areas of the lungs

How does proning help with ARDS?

early phases of ARDS

When is proning the most effective if a patient has ARDS?

16 hours at a time

How long should a patient be proned for?

P/F ratio

How do you know if proning is effective?

EARLY, if P/F < 150, 12-18 hour sessions

When should you prone a patient?

keep HOB >30, ensure balloon is inflated, brush teeth and CHG swab q12h, oral care q2h, subglottic suctioning

What are some ways to prevent VAP?

pulmonary embolism

a clot (blood or other matter) that occurs in the body and travels through the venous circulation to the pulmonary circulation and partially or completely occludes a pulmonary artery

50% or more of teh pulmonary bed is occluded

What is considered a massive PE?

Virchow's triad

details three factors for why blood clots in veins (damage to vessels, venous stasis, hypercoagulability)

bedrest/immobility, pregnancy, decreased cardiac output, infection, dehydration, birth control medications, recent trauma, Type A blood, atrial fibrillation, surgery (specifically orthopedic), smoking, history of DVT

What are some predisposing factors for developing a PE?

dyspnea, pleuritic chest pain, cough with pink and frothy sputum, tachypnea, crackles, anxiety

What are some signs and symptoms of PE?

CTPA (computed tomography pulmonary angiography)

What is the current standard of care for diagnosing a PE?

V/Q scan

What is used to diagnose a PE if a patient has an allergy to contrast?

D-dimer test

test to tell you if you have a blood clotting condition, such as deep vein thrombosis (DVT), pulmonary embolism (PE), or disseminated intravascular coagulation (DIC)

only tells you there is a clot, not where the clot is

oxygenation, thrombolytics (dissolve clot), anticoagulants, vena cava filter placement, embolectomy

How do you treat a PE?

heparin drip, warfarin, rivaroxaban, apixaban, dabigatran

What are some examples of anticoagulants used to prevent further clotting in a patient with a PE?

1.5-2.5 x control

What is the therapeutic range for aPTT?

0.3-0.7

What is the therapeutic range for heparin assay?

early ambulation, elevate legs, SCDs, anticoagulants, ROM, hydration

What are some ways to prevent PEs?

status asthmaticus

a severe asthma attack that does not respond to conventional treatment with bronchodilators

bronchial constriction, inflammation, excessive mucous

What are the three characteristics of an asthma attack?

extreme dyspnea, wheezing, cough, tachycardia, tachypnea, increased accessory muscle use

What are some signs and symptoms of an asthma attack?

difficulty speaking, decreased LOC, diminished or absent lung sounds, sudden disappearance of wheezing, inability to lie supine

What are signs that a person who is having an asthma attack is worsening?

PEFR (peak expiratory flow rate)

What are some assessments that a patient is worsening during an asthma attack?

>/= 8mm

What size tube should be used when intubating a patient in status asthmaticus?

bronchodilators

What medications should you use first for a patient in status asthmaticus?

increase sympathetic nervous system (increase fight or flight response) - promotes bronchodilation

How do short-acting beta 2 agonists work?

albuterol and levalbuterol

What are examples of short-acting beta 2 agonists?

decrease parasympathetic nervous system (decreases rest and digest response) - inhibits bronchoconstriction

How do short-acting anticholinergics work?

ipratropium

What is an example of short-acting anticholinergics?

corticosteroids

What is another medication besides bronchodilators used to treat status asthmaticus?

anti-inflammatory effects decrease edema, decrease mucous production

How do corticosteroids help with status asthmaticus?

intercostal nerve blocks (pain control), bronchial hygiene to prevent pneumonia (deep breathing, coughing, ambulating)

How are fractured ribs treated?

if patient is unstable

When is surgery required for patients with fractured ribs or sternum?

flail chest

fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment

paradoxical chest movements

What is the defining sign of flail chest

surgical stabilization, intubation and PEEP, neuromuscular blocking agent, adequate sedation, pain control

How is flail chest treated?

hemothorax

an accumulation of blood in the thorax and is often accompanied by a pneumothorax

>400mL of blood accumulation

When does a hemothorax typically become symptomatic?

diminished or absent breath sounds on the affected side

What are symptoms of a hemothorax?

thoracentesis, chest tube

How is a hemothorax treated?

between 5th and 6th intercostal spaces (blood is in the bottom of the pleural cavity)

Where is a thoracentesis performed for a patient with a hemothorax?

pneumothorax

air in the pleural cavity

closed, open, tension

What are the three types of pneumothorax?

closed pneumothorax

air can enter the pleural cavity from internal airways, no opening in chest wall

open pneumothorax

An open or penetrating chest wall wound through which air passes during inspiration and expiration, creating a sucking sound; also referred to as a sucking chest wound.

tension pneumothorax

a type of pneumothorax in which air that enters the chest cavity is prevented from escaping

causes collapse of both the lungs and heart

dyspnea, restlessness, asymmetrical chest movement, cyanosis, diminished breath sounds on affected side, chest pain, tracheal shift toward unaffected side, mediastinal shift

What are some signs and symptoms of a pneumothorax?

needle aspiration, thoracentesis, chest tube

What are some treatments of a pneumothorax?

2nd intercostal space on anterior chest (air is in top of pleural space)

Where is a needle aspiration done at in a patient with a pneumothorax?

cover with a 3-sided dressing

How should you emergently manage a sucking chest wound?

drainage, suction, water seal

What are the three chambers of a chest tube?

tidaling

the rise and fall of fluid within a closed-chest drainage system with inhalation and exhalation

normal

submerge into a container of sterile water

What do you do if a chest tube comes apart from the collection device?

sterile water, 2 pairs of large hemostats

What supplies do you need to keep at the bedside if a patient has a chest tube?

albuterol, levalbuterol, metaproterenol

What ae examples of short-acting beta 2 adrenergic agonists?

salmeterol (preventative med)

What is an example of a long-acting beta 2 adrenergic agonist?

nervousness, irritability, tachycardia, cardiac dysrhythmias

What are some examples of side effects from beta 2 adrenergic agonsits?

decreases inflammatory process that is a part of asthma and also stops further bronchoconstriction and mucous secretion

How do leukotriene antagonists work?

montelukast

What is an example of a leukotriene antagonist?

beclomethasone, triamcinolone, dexamethasone sodium sulfate

What are examples of inhaled glucocorticoids?

prednisone, methylprednisone

What are some examples of systemic glucocorticoids?

hyperglycemia, infection, delayed healing, weight gain, electrolyte disturbances, osteoporosis, mood swings, thrush

What are some side effects of glucocorticoids?