Studied by 1 personchronic cough and hemoptysis is usually due to
tuberculosis or lung cancer
is mucoid sputum is usually due to a bacterial or viral respiratory infection?
viral
chest pain that hurts worse during inspiration is due to a _____ issue
respiratory
Resonance
air sound
dull breath sound due to
fluid or over solid mass/organ
stridor is due to
upper airway obstruction
wheezing is due to
lower airway obstruction
signs of hypoxia
pale
low O2 sat
tachycardia
signs of respiratory distress
drowsy
nasal flaring
chest retractions
accessory muscle use
stridor
what do PFTs test?
lung function an extent of dysfunction
normal pH
7.35-7.45
normal PaCO2
35-45
normal PO2
80-100
normal HCO3
22-26
after ABG, what do you need to do for 15 min?
apply pressure
Allen’s Test
occlude ulnar and radial artery, release and see how quickly blood comes back, 15-20+ seconds is slow, test for peripheral circulation
most accurate cancer diagnosis
biopsy
sputum slides are ____ specimens, so send off to lab within 30-60 min
sterile
when should you collect sputum?
before meals (no mouthwash before)
Thoracentesis
Side lying with head 35-45 degrees or tripod on UNAFFECTED side
Monitor vitals (fluid loss=tachycardia)
Assess drainage
how often should you do postural drainage?
3-4x a day, before meals and at bedtime
Nasal cannula
FiO2: 24-44%
1-6L/min
Easy, safe
Client can talk, eat
Simple mask
FiO2: 40-60%
5-6L/min
Easy to apply
May cause issues if claustrophobic
Face tent
FiO2: 24-100%
10-15L/min
Provide humidification
Useful for facial trauma, burns
Non-rebreather mask
FiO2: 80-95%
10-15L/min
Highest O2 concentration possible
Suctioning
High fowlers or semi fowlers
Different catheters
Sterile procedure
Suction pressure: 120-150 mmHg
Apply suction during withdrawal
Apply suction intermittently, no longer than 10-15 seconds
No more than 2 passes, limit to 5 min
suction should be intermittent, don’t suction for more than _____ seconds
10-15
endotracheal intubation is for ___ term, sedated patients
short
tracheostomy is for ___ term, awake patients
long
vitamin B deficiency leads to an increased risk for
cancer
laryngeal cancer symptoms
Cough, sore throat
Pain/ burning especially with hot liquid and juices (citrus)
Lump in neck
Dysphagia, dyspnea
Ulceration, foul breath
Odynophagia: painful swallowing
diagnosis of laryngeal cancer
Laryngoscopy (Direct or Indirect)
Fine needle aspiration (FNA) biopsy
CT/MRI
Positron Emission Tomography (PST) scan
Barium swallow
TNM Staging System
Tumor size (T1, T2, T3)
Lymph nodes (N1, N2, N3)
Metastasis (M0, M1, M2)
Stage 1: localized
Stage 2-3: N1-N2 (nodes)
Stage 4: M1-M3
surgery for laryngeal cancer
(sense of smell and taste are affected)
Partial laryngectomy (may still have a voice)
Total laryngectomy
Vocal cord stripping
Cordectomy
Laser surgery
Post Laryngectomy care:
Airway
Laryngectomy tube
Speech
Artificial larynx
Nutrition
enteral / parenteral
Body image
Safety
Aspiration, infection, hemorrhage
Don't submerge yourself!
Is radiation systemic or localized?
localized
side effects of teletherapy (external radiation)
Skin reaction
Fatigue
Xerostomia
Loss of taste
Mucositis
Nursing care for patients undergoing radiation
Oral care
Skin care
Provide rest
systemic effects of chemotherapy
Pain
Hair loss
Dyspnea
Weak immunity
Bruising/bleeding
Hair loss
Mouth sores
nausea/ vomiting
constipation/ diarrhea
neuropathy
Leading cancer killer in the US
lung cancer
lung cancer risk factors
Tobacco smoke
Environmental exposure
Genetics
Dietary habits
Previous scars in the lungs
TB, Fibrosis
Lung Cancer Symptoms
Cough or change in chronic cough
Dyspnea
Hemoptysis
Chest or shoulder pain
Recurring fever
Repeated upper respiratory infections
Pleural effusion
with a pneumonectomy, would you place a chest tube
no (there is no lung to put it in)
with internal radiation (brachytherapy), they are radioactive so don’t spend more than __ min with the patient
30
Pre-Chest tube insertion steps
Get chest tube box (has everything practitioner will need)
Set up wall suction
Set up chest tube drainage water seal container
Use sterile technique
Attach wall suction to drain container
At least -80mmHg
Keep chest drain below level of chest at all times!!
Remove any dependent loops from tubing
Assess quantity and quality of fluid in chamber
Mark the date and time with sharpie
Assess dressing and inspect skin for signs and symptoms of infection, and palpate skin for subcutaneous emphysema
what mmHg should you set the chest tube suction at?
at least -80
tidaling
up and down movement of patient pressure float ball
the float will move __ when the patient inhales
up
float will move ____ when the patient exhales due to positive pressure
down
if there is no tidaling, it is likely due to
Air leak
Tumbling occlusion
Lung fully expanded
PEEP: dampens oscillation
bubbling indicates there is an
air leak
how to locate air leak
briefly clamp the chest tube at the dressing
Bubbling stops: air leak at insertion site or in the lung itself
If bubbling continues: clamp tube close to the first tubing connection, if it stops then you know it is within this connection
NEVER CLAMP THE TUBE FOR MORE THAN 10 SECONDS= RISK OF TENSION PNEUMOTHORAX
how to collect sample from chest tube
clean for 15 seconds, apply sterile syringe to collection duct and get sample
what to do if chest tube is dislodged at insertion site
apply sterile occlusive dressing, TAPE ON 3 SIDES to prevent increased lung tension
what to do if chest tube is dislodged below insertion site
place end of tubing in 1-2 inches sterile water to reestablish a water seal
pleural effusion
Collection of fluid in the pleural space, usually secondary to other disease processes
Fremitus
vibration of chest, fluid causes decreased fremitus
pleural effusion signs and symptoms
Dyspnea or orthopnea
Cough
Decreased breath sounds, fremitus
Fremitus: vibration of chest, fluid causes decreased fremitus
Dull, flat chest percussion
Decreased chest wall expansion
Tracheal deviation to unaffected side
treatment of choice for pleural effusion
thoracentesis
pleurodesis
administration of medication into pleural space
surgical pleurectomy
removal of pleural layers for recurrent pleural effusions
Pleuroperitoneal shunt
drains from pleural space into peritoneal cavity
Pulmonary Embolus types
Blood clot
Air
Fat
Amniotic Fluid
Septic
Pulmonary embolism risk factors
Most often coming from clot
DVT, trauma (fracture of long bones) (bone fracture=fat embolism), surgery, pregnancy
A-Fib, heart failure
Hypercoagulability (thicker blood), prolonged immobility
pulmonary embolism s/s
Dyspnea, air hunger, syncope
Chest pain (sudden), pleuritic, on inspiration, pressure in chest
Anxiety, feelings of impending doom
Chest wall tenderness
VS: tachycardia, tachypnea, decreased O2 sat, fever, hypotension
Adventitious breath sounds
New heart murmurs
Right side of heart would have harder time if they have pulmonary embolism, may have right sided heart failure
Diaphoresis
Pleural Effusion
Hemoptysis
Sign of PE
this test shows you have a clot SOMEWHERE in your body, not specific
D-Dimer Assay
pulmonary embolism diagnosis
Pulmonary angiography (shows which parts are occluded)
Ventilation-Perfusion (V/Q scan)
CXR, ECG, ABG
D-Dimer Assay (not diagnostic but lab that shows you have a clot SOMEWHERE)
Spiral chest CT (one of the best)
Emergency management of pulmonary embolism
O2
IV lines
dobutamine or dopamine (vasopressors/vasoconstrictors)
cardiac glycosides (increase cardiac contraction)
morphine (can cause respiratory depression)
sedatives
anticoagulation therapy ___ clots
prevents
Anticoagulation therapy for pulmonary embolism
Heparin (only for IV: won't dissolve clot but will prevent further clotting)
Warfarin (coumadin) (only for IV: won't dissolve clot but will prevent further clotting)
Enoxaparin (Lovenox); Rivaroxaban (Xarelto)
Thrombolytic therapy ____ clots
dissolves
Thrombolytic therapy for pulmonary embolism
Urokinase
Streptokinase
Alteplase (tPA) (increases risk for bleeding)
monitoring anticoagulant therapy
should be DOUBLED to show anticoagulation achieved
Heparin: PTT (60-70s), aPTT (20-39s)
Warfarin: INR (1); PT (9-12.5s)
tuberculosis risks
Immunocompromised
Contact with untreated person
Lower socioeconomic status
Advanced age
outside US/immigration
crowded places
healthcare occupation
initial exposure phase of tuberculosis
Granuloma (small area of inflammation), Ghon Tubercle (initial lesion), Dormant
infection phase of tuberculosis
2-10 weeks after exposure
active disease phase of tuberculosis
compromised immune system
tuberculosis s/s
Persistent cough lasting longer than 3 weeks
Night sweats
Low grade fever
Fatigue/lethargy
Weight loss/ anorexia
Purulent, blood-tinged sputum; hemoptysis
risk of transmission decreases after ____ weeks of anti-TB therapy
2-3
TB diagnosis
Physical assessment and history
Two step PPD/Mantoux test (10mm +)
EBP: Quantiferon Gold Plus
CXR
Acid-Fast Bacilli Smear and Culture
Two step PPD/Mantoux test
Induration of greater than 10: positive
Induration of greater than 5 for immunocompromised: positive
Clients without symptoms receive preventative therapy
Cross reaction with BCG vaccine (Bacillus Calmette-Guerin)
EBP Quantiferon Gold Plus
one time test, don’t have to go back
after a positive TB test, what do you need to confirm it is in fact tuberculosis?
sputum culture
Acid-Fast Bacilli Smear and Culture
tests for TB
3 morning sputum samples
wear PPE
negative airflow room
Anti-TB Medications
Rifampin (Rifadin)
Isoniazid (INH or Nyrazid)
(peripheral neuropathy, give Pyridoxine (B6 vitamin) to prevent)
Pyrazinamide
(avoid with gout because uric acid increase, hyperuricemia)
Ethambutol hydrochloride (Myambutol)
(can cause optic neuritis)
how long does TB treatment last
6-12 months
initial intensive regimen of TB treatment lasts
8 weeks
continuation regimen of anti-TB treatment lasts
4-7 months
to be considered negative, TB patient needs to have __ negative sputum cultures
3
Caring for TB patient
Prevent infection transmission
Promote airway clearance
Promote activity and nutrition
Improve immunity
Administer O2 as prescribed
Adhere to treatment
Follow-up care
Contact social services as necessary
Community clinic as necessary
a nurse is caring for a client with a tracheostomy. Which of the following findings indicates that the nurse should suction the secretions?
client is unable to speak
clients airway was last suctioned 2h ago
client coughs and expectorates a large mucus plug
nurse auscultates course crackles in lung fields
nurse auscultates course crackles in lung fields
a nurse in the ED is assessing a client for a closed pneumothorax and significant bruising on the left chest following a motor vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax?
absence of breath sounds
expiratory wheezing
inspiratory stridor
rhonchi
absence of breath sounds
A nurse is preparing to assist a provider to withdraw arterial blood from a client’s radial artery for measurement of ABG. Which of the following actions should the nurse plan to take?
hyperventilate the client with 100% oxygen prior to obtaining the specimen
apply ice to the site after obtaining the specimen
perform an Allen’s test prior to obtaining the specimen
release pressure applied to the puncture site 1 min after needle is withdrawn
Perform an Allen’s test to ensure adequate circulation from the ulnar artery in case the radial artery is injured from the blood draw
a nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states “I am afraid it will hurt to cough after the surgery”. Which of the following statements by the nurse is appropriate
“after the surgeon removes the lung there will be no need to cough”
“i’ll make sure you get a cough suppressant to keep you from straining the incision when you cough”
“Don’t worry. You will have a pump that delivers pain meds as you need it, so you will have very little pain”
“I will show you how to splint your incision when coughing”
“I will show you how to splint your incision when coughing”
A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care?
clamp the chest tube if there is continuous bubbling in the water seal chamber
keep the chest tube drainage system at the level of the right atrium
tape all connections between the chest tube and drainage system
empty the collection chamber and record the amount drainage every 8 hours
tape all connections between the chest tube and drainage system
a nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication?
hallucinations
pruritus
hand and foot syndrome
tinnitus
tinnitus
a nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client?
lying flat on the affected side
prone with the arms raised over the head
supine with the head of the bed elevated
sitting while leaning forward over the bedside table
sitting while leaning forward over the bedside table
a nurse on a med-surg unit is caring for a client who is postoperative following a hip replacement surgery. the client reports feeling apprehensive and restless. which of the following should the nurse recognize as an indication of pulmonary embolism
sudden onset of dyspnea
tracheal deviation
bradycardia
difficulty swallowing
sudden onset of dyspnea
a nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. which of the following pieces of information should the nurse include?
if the test is positive, it means you have an active case of tuberculosis
if the test is positive, you should have another skin test in 3 weeks
you must return to the clinic in 2-3 days
a nurse will use a small lancet to scratch the skin of your forearm before applying the TB test substance
you must return to the clinic in 2-3 days
a nurse is providing teaching a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
i can keep my dentures in during the procedure
i am allowed only clear liquids prior to the procedure
a tissue sample might be obtained during the procedure
a signed consent form is not required for this procedure
a tissue sample might be obtained during the procedure
Note
Flashcard