Medsurg Exam 1

Nasal Cannula

Flow rates of 1-6 L/min; Provide humidification for flow rates of >4/Lmin

Simple Face Mask

Flow rate of 5-8L/min to ensure flushing of CO2 from mask; Use caution with clients who have a high risk of aspiration or airway obstruction

True or False: Flow rates of less than 5L/min with a Simple Face Mask can result in rebreathing of CO2

True

Partial Rebreather Mask

Flow rates of 6-11L/min; Mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to 1/3 of exhaled air together with room air

Non Rebreather Mask

Flow Rates of 10-15L/min to keep the reservoir bag 2/3 full during inspiration and expiration; Delivers the highest O2 concentration possible

Venturi Mask

Flow rates of 4-10L/min via different sizes of adapters which allow specific amounts of air to mix with oxygen; Delivers the most precise oxygen concentration

A patient has a chronic lung disease, which oxygen delivery device is best suited for them?

Venturi Mask

Oxygen Toxicity

Can result from high concentrations of oxygen, long durations of oxygen therapy, and the client’s degree of lung disease

Manifestations of Oxygen Toxicity

Nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, hypoventilation

Rhinitis

An inflammation of the nasal mucosa and often the mucosa in the sinuses that can be caused by infection or allergens

Viral Rhinits

The common cold is caused by viruses spread from person to person in droplets from sneezing and coughing or by direct contact

Allergic Rhinitis

The presence of an allergen causes histamine release and other mediators from WBCs in the nasal mucosa

Manifestations of Rhinitis

Excessive nasal drainage and congestion, purulent nasal discharge, sneezing and pruritis of the nose, itchy watery eyes, sore throat, low grade fever

Nursing care for a patient with Rhinitis

Encourage rest, increased fluid intake, use of home humidifier. Promote proper disposal of tissues and cough etiquette. Hand Hygiene !!

Pharmacological Treatments for Rhinitis

Antihistamines, Leukotriene inhibitors, Mast Cell stabilizers, Decongestants, Expectorants, Intranasal glucocorticoid spray, antibiotics if bacterial

Sinusitis

An inflammation of the mucous membranes of one or more of the sinuses, usually the maxillary or frontal sinus

What viruses are the cause of sinusitis?

Streptococcus Pneumoniae and Haemophilus Influenzae

Clinical Manifestations of Sinusitis

Nasal congestion, headache, facial pressure or pain, cough, bloody or purulent nasal drainage, tenderness to palpation, low grade fever (viral), high grade fever (bacterial)

Nursing care of sinusitis

Encourage use of steam humidcation and irrigation. Discourage air travel, swimming, and diving. Encourage cessation of tobacco use

Pharmacological Treatments for Sinusitis

Nasal Decongestions, Broad spectrum antibiotics, NSAIDs

True or False: Rebound nasal congestion can occur if a nasal decongestant is used longer than 3-4 days?

True

Mucocele

Cyst formation in the paranasal sinus

What can occur from sinusitis if pathogens enter the bloodstream from the sinus cavity?

Meningitis and encephalitis

Seasonal Influenza

Occurs as an epidemic, usually in the fall and winter months

Pandemic Influenza

REfers to a viral infection among animals or birds that has mutated and is becoming highly infectious to humans

Manifestations of Influenza

Severe headache, muscle aches, chills, fatigue, weakness, severe diarrhea and cough, fever, hypoxia

Pharmacological Treatments for Influenza

Antivirals, Influenza Vaccines

Acute Bronchitis

Acute inflammation of the bronchi and bronchioles, characterized by increased mucus produciton and airway irritation

Manifestations of Acute Bronchitis

Persistent cough, productive or nonproductive sputum, ronchi, dyspnea, chest discomfort, fatigue, low grade fever, sore throat

What microorganism causes Pertussis?

Bordetella pertusis

Pertussis

Severe coughing fits that may end with a “whooping” sound during inspiration

Manifestations of Pertussis

Paroxysmal coughing episodes, violent cough, thick mucus production, vomitting, facial flushing, exhaustion

Diagnostic Tests for Pertussis

Nasopharyngeal swab, culture, CBC with leukocytosis and lymphocytosis, pulse ox

Which antibiotics are first line for pertussis?

Macrolides- Azithromycin, Clarithromycin, Erythromycin

Nursing Care of Pertussis

Oxygen therapy, droplet precaution, increase hydration, small frequent meals, suctioning PRN, rest periods

Pneumonia

An inflammatory process in the lungs that produces excess fluid triggered by infectious organisms

What are the 3 ways pneumonia can reach the lungs?

Aspiration, inhalation, hematogenous spread

Community aquired pnemonia

Acute lung infection that occurs in patients who have not been hospitalized or lived in a long term care facility within 14 days of symptom onset

Hospital Aquired Pnemonia

More likely to be resistant, 48 hours or longer after admission to the hospital

Aspiration Pneumonia

The abnormal entry of material from the mouth or stomach into the trachea and lungs

Ventilator Associated Pneumonia

48 hours after endotracheal intubation

Risk factors of pneumonia

Age, prolonged immobility, enteral feedings, immunosuppressive conditions, malnutrition, smoking, tracheal intubation

Manifestations of Pneumonia

Green, yellow, or rust colored sputum, crackles, pleuric chest pain

Pharmacological Treatments for Pneumonia

Antibiotics, Bronchodilators, anti-inflmmatories

Blunt Trauma

Chest is struck by an object, the impact can cause shearing and compression of other structures

Penetrating Trauma

A foreign object impales or passes through the body tissues, creating an open wound

Manifestations of a fractured rib

Pain at site of injury, patient splints the area, patient takes shallow breaths to try to decrease comfort

What can develop from a fractured rib?

Atelectasis and pneumonia

True or False: A nurse should strap the chest with tape or a thoratic binder if a patient has a fractured rib?

False

Flail Chest

Results from the fracture of 3 or more ribs consecutively or in 2 or more places which causes an unstable segment

How does flail chest affect air flow?

Caves in on inhalation and balloons out on exhalation

Expected findings of Flail chest?

Tachycardia, paradoxical chest wall movment, unequal expansion, hypotension, dyspnea, cyanosis, anxiety, chest pain

Nursing care of flail chest?

Administer humidifed oxygen, monitor vital signs, encourage deep breathing and proper positioning, administer pain meds

Pneumothorax

The presence of air or gas in the pleural space that causes lung collapse

Open Pneumothorax

Air entering through an opening in the chest wall

Closed Pneumothorax

No external Wound

Spontaneous Pneumothorax

Occurs with rupture of small blebs on the surface of the lung and can occur where there has been no trauma

Iatrogenic Pneumothorax

Can occur due to a laceration or puncture of the lung during medical procedures

Tension Pneumothorax

Occurs when air enters the pleural space during inspiration through a one way valve and is not able to exit upon expiration

Expected findings of pneumothorax

Anxiety, pleuritic pain, tachypnea, tachycardia, hypoxia, reduced or diminished breath sounds

Hemothorax

An accumulation of blood in the pleural space from injury to the chest wall , diaphragm, lung, blood vessels, or mediastinum

How does an occlusive dressing work on inspiration?

As negative pressure is created in the chest, the dressing pulls against the wound, preventing air from entering the pleural space

How does an occlusive dressing work on expiration?

As the pressure rises in the pleural space, the dressing is pushed out and air escapes through the wound and from under the dressing

Chest tubes

Drain the pleural space and allow for lung expansion

What is a large (36F-40F) Chest tube used for?

To grain blood

What is a medium (24F-36F) Chest Tube used for?

To drain fluid

What is a small (12F-24F) Chest Tube used for?

To drain air

Chest Tubes: The Collection Chamber

Recieves fluid and air from the pleural space, the draiend fluid stays in this chamber and expels air to the water seal chambber

Chest Tubes: The Water-seal Chamber

Contains about 2cm of water which acts as a 1 way valve, incoming air from the colleciton chamber bubbles up through the water, this water prevents backflow of air into the paitnet

What could tidaling cessation in a chest tube chamber indicate?

Chest tube is occluded, assess the chest tube immediately

Chest Tubes: Water Suction

A column of water controls the amount of suction from the wall regulator, the chamber is filled with a specific amount of water, if the chest tube is tipped or knocked over, problems can arise

Chest Tubes: Dry Suction

Does not contain water, the amount of suction is determined by dialing on the chest tube drainage device to the ordered amount, a visual alert shows you if the suction is working

Chest Tubes: Heimlich Valve

Used to remove air from the pleural space; prevents air from going back into the patient

True or False: Chest tube drainage of greater 200mL in an hour should be reported?

True

Subutaneous emphysema from chest tubes

Air leaks into the tissues surrounding the chest tube insertion site

What is the immediate priority if a chest tube suddenly becomes disconnected?

Reestablish the water seal system

Pulmonary Edema

A complication of various heart and lung disease and usually occurs from increased pulmonary vascular pressure secondary to severe cardiac dysfunction

Risk factors of pulmonary edema

Acute MI, fluid volume overload, HTN, valvular hear disease, left sided heart failure

Expected findings of Pulmonary Edema

Anxiety, inability to sleep, peristent cough, tachypnea, cyanosis, hypoxiema, crackles

How should a nurse position a client with pulmonary edema?

High fowler’s position with feet and legs dependent or sitting on the side of the bed

Pharmacological Treatments for pulmonary edema?

Rapid acting diuretics, morphine, vasodilators, inotropic agents, antihypertensives

A nursing student is explaining how a Venturi mask works. Which statement indicates correct understanding?

“The mask uses adjustable ports to deliver a precise concentration of oxygen.”

A client receiving supplemental oxygen becomes increasingly restless and reports a headache. The nurse notes that the client's oxygen saturation has decreased from 94% to 88%. Which action should the nurse take first?

Assess the client's respiratory status and verify that the oxygen delivery system is functioning properly.

The nurse receives report on four clients. Which client should the nurse assess first?

A client with pneumonia who has become restless and has an SpO₂ of 87%

The nurse is assessing a client with suspected pneumonia. Which findings is NOT consistent with pneumonia?

Hyperresonance over the affected lung

A client diagnosed with pneumonia asks the nurse, “What exactly is happening in my lungs?” Which response by the nurse is most appropriate?

“The infection causes inflammation and fluid to collect in the alveoli, interfering with normal gas exchange.”

A client reports nasal congestion and headache for several days. Which additional finding most strongly supports the nurse's suspicion of sinusitis rather than rhinitis?

Facial pain that worsens when bending the head forward

The nurse is caring for a client with a chest tube following a pneumothorax. Which assessment finding requires the nurse's priority intervention?

The chest tube drainage increases to 220 mL during the past hour

A client recently diagnosed with pertussis asks, “How did I get this infection?” Which response by the nurse is most appropriate?

“Pertussis is generally transmitted by inhaling respiratory droplets from an infected person.”

The nurse is caring for a client who requires a high concentration of supplemental oxygen. Which oxygen delivery device should the nurse anticipate using?

Nonrebreather mask

A client diagnosed with acute bronchitis asks why an antibiotic was not prescribed. Which response by the nurse is most appropriate?

"Most cases of acute bronchitis are caused by viral respiratory infections and improve with supportive care."

Anemia

A deficiency in the number of erythrocytes, the quantity or quality of hemoglobin, or volume of packed red blood cells

Causes of anemia

Blood loss, menorrhagia, GI bleed, rapid metabolic activity, increased hemolysis, inadequate diet, bone marrow suppression, age

Normochromic

Normal amount of HgB per cell

Hypochromic

Decreased HgB per cell

TIBC

Indicates measurement of all proteins that bind with iron and transports it for storage

Transferrin

The largest amount of iron-binding proteins

Ferritin

Total iron stores in the body

s/s of Moderate Anemia

Increase in cardiopulmonary symptoms