Respiratory for Med-Surg Exam 2

chronic 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

* **R**ifampin (Rifadin)
* **I**soniazid (INH or Nyrazid)
*  (peripheral neuropathy, give Pyridoxine (B6 vitamin) to prevent)
* **P**yrazinamide 
* (avoid with gout because uric acid increase, hyperuricemia)
* **E**thambutol 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