NURS 334, gas exchange, exam 2

nursing assessment for pneumonia

-hx

-lung cancer

-copd

-DM

-debilitating disease

-malnutrition

-use of antibiotics, corticosteroids, chemotherapy, immunosuppressants

-recent abdominal or thoracic surgery

-smoking, alcoholism, respiratory infections

-prolonged bed rest

-dyspnea

-nasal congestion

-pain with breathing

-sore throat

-muscle aches

-fever

-restlessness or lethargy

-splinting affected area

-tachypnea

-asymmetric chest movements

-use of accessory muscles

-crackles

-green or yellow sputum

-tachycardia

-changes in mental status

-leukocytosis

-abnormal ABG's

-pleural effusion

-pneumothorax on x-ray

collaborative care for pneumonia

-antibiotic therapy

-oxygen for hypoxemia

-analgesics for chest pain

-antipyretics

-influenza drugs

-influenza vaccine

-3L fluids per day

-1500 cal per day

-pneumococcal vaccine (indicated for those at risk, chronic illness [heart and lung disease, DM], recovering from severe illness, 65 or older, in a LTC facility)

nursing diagnosis for pneumonia

Ineffective breathing pattern

Ineffective airway clearance

Acute pain

Imbalanced nutrition: Less than body requirements

Activity intolerance

nursing planning for pnuemonia

Goals: pt will have

-clear breath sounds

-normal breathing patterns

-no signs of hypoxia

-normal chest xray

-no complications related to pneumonia

nursing implementation for pneumonia

Teach nutrition, hygiene, rest, regular exercise to maintain natural resistance

Prompt treatment of URIs

Encourage those at risk to obtain influenza and pneumococcal vaccinations

Reposition patient q2h

Assist patients at risk for aspiration with eating, drinking, and taking meds

Assist immobile patients with turning and deep breathing

Strict asepsis

Emphasize need to take course of medication(s)

Teach drug-drug interactions

nursing evaluation and pneumonia

-no dyspnea

-O2>95%

-no adventitious breath sounds

-clears sputum from airway

-reports pain controlled

-verbalizes causal factors

-adequate fluid and caloric intake

-preforms ADL's

questions to consider and PE

-does the pt have a hx of leg pain (specifically the calf)

-has the pt had a clot before?

-has the pt had a recent surgery?

-has the pt done a lot of sitting such as traveling recently which puts pressure on the back of the legs?

-does the pt smoke?

-does the pt have a sedentary lifestyle?

-has the pt been on an anticoagulant?

complications of a PE

1. pulmonary infarction

**alveolar necrosis and hemorrhage, abscess, pleural effusion

2. pulmonary hypertension

**results from hypoxemia associated with massive or recurrent emboli, right ventricular hypertrophy

chest xray and PE

any pleural effusion or atelectasis? any other causes for symptoms?

electrocardiograms and pe

changes in ST segment and T wave

troponin levels and PE

blood test that determines the protein (troponin) level released in blood when heart muscle is damaged

B-type natriuretic peptide (BNP) and PE

hormone secreted by ventricles in heart in response to pressure changes in the heart. would see an increase if there is a clot

D-dimer in PE

blood test measuring cross-linked fibrin

-elevated with clot degradation

- false negatives with small PE

spiral (helical) CT scan and PE

most frequently used test to diagnose PE.

requires IV contrast media

ventilation-perfusion scan

a scan that tests whether a problem in the lungs is caused by airflow (ventilation) or blood flow (perfusion)

**used if the patient cannot have contrast.

pulmonary angiography

x-ray imaging of the blood vessels of the lungs after the injection of contrast material

prevention of PE

exercises to avoid venous stasis

early ambulation

anticoagulant therapy

Sequential compression devices (SCDs)

goals of treatment for PE

supportive, prevent further thrombi, prevent further embolization to pulmonary system, provide cardiopulmonary support, mortality risk decreases with early intervention

supportive care variable and PE

-oxygen first, and then mechanical ventilation

-->pulmonary toilet (good pulmonary hygiene)

**turn, cough, deep breathe. early ambulation. incentive spirometry

**fluids, diuretics, analgesics

surgical therapy for PE

Pulmonary embolectomy for massive PE

Inferior vena cava (IVC) filter (Prevents migration of clots in pulmonary system) will be placed above the clot to prevent migration.

nursing management for PE

-semi-fowlers position

-IV access

-oxygen therapy

-frequent assessments (respiratory, cardiovascular)

-emotional support and reassurance

-education r/t anticoagulation

-monitor lab results

patient teaching and PE

May need anticoagulants for a period of time.

measures to prevent DVT

importance of follow-up exams

nursing evaluation and PE

expected outcomes:

-adequate tissue perfusion and respiratory function

-adequate cardiac output

-increased level of comfort

-no recurrence of PE

causes of fat embolism

(increased risk with increased length of bone fracture)

blunt trauma

parenteral lipid infusion

acute pancreatitis

diabetes

burns

cardiopulmonary bypass

s/s of fat embolism

· Restlessness

· Hypoxemia

· Mental status changes

· Tachycardia and hypotension

· Dyspnea and tachypnea

· Petechial rash over the upper chest and neck

treatment of fat embolism

supportive

place in high-fowlers position

oxygen--nonrebreather mask

monitor VS and respiratory status

IV fluids

ABG's

transfer to CC unit

significance of asthma

Affects about 17.5 million Americans

Women are 76% more likely to have asthma than men.

Older adults may be undiagnosed.

Risk factors for asthma

-related to patient (genetic factors)

-related to environment

-male gender is a risk factor in children

-obesity is also a risk factor

-genetics-inherited component is complex

-immune response-hygiene hypothesis

triggers for asthma

allergens

exercise

cold air

air pollutants

occupational factors

respiratory infections

nose and sinus problems

-drugs and food additives

peak flow monitoring and asthma

-measures a variety of values (total volume capacity, forced expiratory volume, residual in lungs)

-measures lung capacity

-asthma action plan often uses PFM as a baseline of healthy lung conditions

pulmonary function tests

-measures a variety of values (total volume capacity, forced expiratory volume, residual in lungs)

-can receive results in numbers or graph

-can be completed in hospital pt room, RT department, in clinics, at certain places of work

-dont tell a diagnosis but rather can help assess the condition of the lungs.

eosinophils and asthma

would expect to see an elevated level

Niox Mino and asthma

hand-help point of care device

-measures fractional exhaled nitric oxide (FENO)--> NO is usually increased in breath of patients with asthma

teaching, self-management and asthma

starts at the time of diagnosis and is to be integrated through care

**any healthcare setting

tailored to the needs of the patient, culturally sensitive, needs to be realistic

desired therapeutic outcomes and asthma

Control or eliminate symptoms

Attain normal lung function

Restore normal activities

Reduce or eliminate exacerbations and side effects of medications

intermittent and persistent asthma

Avoid triggers of acute attacks

Pre-medicate before exercising

Short-term (rescue or reliever) medication

Long-term or controller medication

Bronchial thermoplasty in asthma therapy

Cauterize conducting airways --> removes epithelial cells and smooth muscle cells --> epithelial cells grow back but not smooth muscle

anti-inflammatory drugs in asthma

-corticosteroids

-leukotriene modifiers

-monoclonal antibody to IgE (eosinophils)

Three types of bronchodilators in asthma

-B2-adrenergic agonists

-Methylxanthines

-anticholinergics

correct medication administration and asthma

inhalation of drugs is preferable to avoid systemic effects

**MDI's (metered-dose inhaler), DPI's (dry-powder inhaler), and nebulizers are devices used to inhale medications

patient teaching/drug therapy and asthma

using an MDI with a spacer is easier and improves inhalation of the drug

**DPI (dry powder inhaler) requires less manual dexterity and coordination

nonprescription combination drugs and asthma

epinephrine can also increase heart rate and blood pressure

ephedrine stimulates CNS and CV system

pt shouldnt use cough, cold, and flu OTC medications without consulting with HCP.

nursing assessment and asthma

-health history (especially precipitating factors and medication)

-ABGs

-lung function tests

-asthma control test

physical exam:

-use of accessory muscles

-diaphoresis

-cyanosis

-lung sounds

nursing diagnosis and asthma

-ineffective airway clearance

-anxiety

-deficient knowledge

nursing planning and asthma

overall goals:

-maintain greater than 80% of personal best PEFR

-have minimal symptoms

-maintain acceptable activity levels

-few or no adverse effects

-no recurrent exacerbations of asthma or decreased incidence of asthma attacks

-adequate knowledge to participate in and carry out management

nursing health promotion and asthma

teach patient to identify and avoid known triggers

prompt diagnosis and treatment of upper respiratory infection and sinusitis may prevent exacerbation (intake of 2-3 L/day, avoid cold air, avoid aspirin, NSAIDs, and non-selective B-blockers)

acute intervention and asthma

-monitor respiratory and cv systems

-lung sounds

-HR, BP, RR

-decrease pt sense of panic (stay with patient, encourage slow breathing, position comfortably)

ambulatory and home care and asthma

-must learn about medications and develop self-management strategies

-patient and HCP must monitor responsiveness to medication

-patient must understand importance of continuing medication when symptoms arent present

important patient teaching and asthma

-seek medical attention for bronchospasm or when severe side effects occur

-maintain good nutrition

-exercise within limits of tolerence

-measure peak flow at least once per day

-asthmatic individuals frequently dont perceive changes in their breathing

nursing implementations and asthma

peak flow should be monitored daily and a written plan should be followed according to results of daily PEFR

Green zone peak flow (asthma)

- 80-100% personal best/baseline

- remain on meds

Yellow zone peak flow (asthma)

- 50-79% of personal best/baseline

- indicates caution

- something is triggering asthma

- quick relief meds

Red zone peak flow (asthma)

50% or less of personal best

Indicates serious problem

Definitive action must be taken with health care provider

cystic fibrosis (CF)

hereditary disorder of the exocrine glands characterized by excess mucus production in the respiratory tract, pancreatic deficiency, and other symptoms

**pancreatic enzymes are to be taken with every meal, snack, etc

**airway clearance test to help determine therapies, vibrating vest, drug therapy

anemia

A condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume.

Function of RBCs (erythrocytes)

transport oxygen from lungs to systemic tissues

and

carry carbon dioxide from the tissues to the lungs

normal level of hgb

male--> 14-18 g/dL

female-->12-16 g/dL

normal level of hct

male- 38-48%

female-35-45%

nursing assessment and anemia

Subjective Data

Important health information:

· Past health history

· Medications

· Surgery or other treatments

· Dietary history

Functional health patterns:

Objective Data

· General

· Integumentary

· Respiratory

· Cardiovascular

· Gastrointestinal

· Neurologic

· Diagnostic findings

nursing diagnosis and anemia

Fatigue

Imbalanced nutrition

Ineffective health management:

-->assume normal ADL's

-->maintain adequate nutrition

-->develop no complications related to anemia

anemia

gerontologic considerations and anemia

common in older adults: chronic disease, nutritional deficiencies

iron deficiency anemia

anemia resulting when there is not enough iron to build hemoglobin for red blood cells.

**heme accounts for 2/3 of the body's iron

etiology of iron deficiency anemia

-inadequate dietary intake (5-10% of ingested iron is absorbed)

-malabsorption (iron absorption occurs in the duodenum. disease or surgery that alters, destroys, or removes the absorption surface of this area of the intestine can cause anemia)

-blood loss (2 mL whole blood contains 1 mg iron. this is a major cause of iron deficiency in adults. chronic blood loss most common through GI and GU systems)

-hemolysis (pregnancy contributes to this condition)

pallor and anemia

most common CM of anemia

glossitis and anemia

inflammation of the tongue

cheilitis and anemia

inflammation of the lips

diagnostic studies and anemia

-lab findings (hgb, hct, MCV, MCH, MCHC, reticulocytes, TIBC, bilirubin, platelets

-stool guaiac test (to R/O a GI bleed)

-endoscopy

-colonoscopy

-bone marrow biospy (they arent producing enough RBC/decreased erythropoietin)

-nutrition

-chronic disease

collaborative care and anemia

goal is to treat the underlying disease--> causing reduced intake or absorption of iron

efforts are aimed at replacing iron:

-nutritional therapy

-oral or occasional parenteral iron supplements

-transfusion of packed RBC's

-absorption problem

at risk groups and anemia

-premenopausal women

-pregnant women

-persons from low socioeconomic backgrounds

-older adults

-individuals experiencing blood loss

-surgical patient

-chronic illness

nursing and collaborative management and anemia

-diet teaching

-what to do if supplemental iron upsets your stomach

-discuss diagnostic studies

-emphasize compliance

-iron therapy for 2 to 3 months after hgb levels return to normal