NUR 265 Exam 2 Study Guide &
Exams Questions and Answers
Lungs Physiology
• 2 Pleural, 1 attached to outside of lungs and 1 attached to inside of ribs.
● Space between the 2 pleural is negative to atmosphere
● When inhale becomes more positive and atmosphere more negative. Exhaling is pa...
nur 265 exam 2 study guide amp exams questions and answers
lungs physiology • 2 pleural
1 attached to outside of lungs and 1 attached to inside of ribs ● space between the 2 pleural is negative to
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Galen College Of Nursing
NUR 265
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NUR 265 Exam 2 Study Guide &
Exams Questions and Answers
Lungs Physiology
2 Pleural, 1 attached to outside of lungs and 1 attached to inside of ribs.
● Space between the 2 pleural is negative to atmosphere
● When inhale becomes more positive and atmosphere more negative. Exhaling is
passive
● Most of lower lobes are posterior, must listen to lungs posteriorly
● Breath sounds
o Bronchial: High pitched & loud, normal in tracheal & larynx
o Broncho-vesicular: Moderate pitched & amplitude, normal over major
bronchi
o Vesicular: Low pitched & soft, like wind through trees, normal in lower lung
fields where smaller bronchioles & alveoli are.
Pulmonary Emboli (P 603)
● Occlusion of portion of pulmonary artery by a blood clot – from venous circulation –
lower extremities or heart.
● Causes ventilation-perfusion mismatch (V/Q) – Ventilated alveoli no longer
perfused due to clotted artery.
● Risk Factors
o Venous stasis (w/prolonged immobility); Central venous catheters;
Surgery (NPO, dehydrated, immobilized pts); Obesity; Advanced age;
Hypercoagulability (Platelets >400K and not enough fluids; sticky blood);
Hx of thromboembolism.
o Greatest r/f in the young is the combo of smoking and hormone based
contraceptives.
● Nursing Assessment Findings
o Respiratory Classic Manifestations (Hypoxia drives all s/s)
▪ Dyspnea (sudden onset); Chest pain (sharp & stabbing);
Apprehension, restlessness; Feeling of impending doom;
Cough; Hemoptysis (blood in sputum).
o Respiratory Signs
▪ Pleural friction rub (scratching sounds from pleura rubbing
together & pain on deep inspiration); Tachypnea; Crackles (or
normal); S3 or S4; Diaphoresis; Low grade fever; Petechiae over
chest and axillae; Decreased arterial oxygen saturation (SaO2)
o Many pts w/ a PE do not have “classic” sx (i.e. hypoxia), but instead have
vague sx resembling the flu (n/v & general malaise)
o Cardiac Manifestations
▪ Decreased tissue perfusion: tachycardia, JVD, Syncope
(loss of consciousness), Cyanosis, & Hypotension.
o In patients with r/f for PE, JVD (RSHF), syncope (decreased blood flow to
brain), cyanosis (severe hypoxia) and hypotension together, need rapid
response team called. have help on way b4 o2 applied
o When pt has sudden onset of dyspnea, chest pain, and/or hypotension,
immediately notify Rapid Response Team. Reassure pt. and elevate HOB.
Prepare for O2 therapy and ABG analysis
, o Saddle Emboli – Embolism at split of pulmonary artery that blocks both
branches to the lungs
● Medical Dx
o Chest X-ray – May show PE if large but will help r/o other things
o CT scan – Most often used to dx PE
o TEE (Transesophageal Echocardiography) – See if there are clots in the atria
o Ventilation Perfusion scan (V/Q)
▪ Considered if pt is allergic to contrast dye done w/CT scan
▪ Radioactive substance to see if air is getting into the alveoli; injected
into blood to look at clot and can also detect pneumothorax. Done 2x
o ABGs
▪ Respiratory Alkalosis FIRST from hyperventilation
▪ THEN Respiratory Acidosis from shunting
● Shunting of blood from the right side of the heart to the left side
w/o picking up O2 from lungs
– causes PaCO2 level to rise resulting in respiratory acidosis.
▪ LATER Metabolic Acidosis & lactic acid buildup from tissue hypoxia
▪ Even if ABGs & Pulse Ox shows hypoxemia it is not enough to dx PE
alone as PE is not the only cause of hypoxemia.
● Medical Management
o GIVE O2, IV FLUIDS, INOTROPES (DOBUTAMINE/MILRINONE)
▪ Oxygen therapy to maintain O2 sat at 95% or patient baseline
▪ Hypotension - Tx w/ IV fluids (isotonic) & Inotropes
(Dobutamine/Milrinone, make heart contract more forcefully);
vasopressors (norepi, epi, dopamine) when hypotension persists after
fluids.
o Anticoagulation w/ Heparin drip – Goal is PTT 1.5-2.5 x normal (60-70 sec) =
90-175 sec
▪ Minimize growth of existing clots and prevent new ones
▪ Antidote Protamine Sulfate
▪ Do not use w/salicylates (Aspirin)
o Convert to Warfarin when stable – On 3rd day of Heparin use, overlap – INR
target 2-3 (0.9-1.2 normal)
▪ Antidote – Vit K – phytonadione (Mephyton)
▪ Teach pts to avoid foods high in K (leafy dark green vegis,
herbs, spring onions, Brussel sprouts, broccoli, cabbage,
asparagus, potatoes, & winter squash).
o Enoxaparin or dalteparin
o Fibrinolytic (tPA) to tx massive PE or hemodynamic instability
▪ Antidotes – clotting factors, FFP, & aminocaproic acid (Amicar)
▪ Dissolve the clot itself
o Embolectomy – surgical removal of the embolus – When tPA can’t be used or
for massive PE w/shock
o Inferior Vena Cava Filter – to prevent DVTs from moving to the lungs
**Bleeding precautions with all blood thinners
o Prevent injury to pt on anticoagulation therapy
▪ Use lift sheet; firm pressure on needle stick for 10 minutes; Apply ice
to trauma areas; Avoid trauma to rectal tissues; no razor (electric
only); soft-bristled toothbrush; NO floss; Not blow nose forcefully;
shoes with firm soles; Assess IV sites q4 hrs for bleeding, measure
abd girth q8 hrs – internal bleeding
, ● Nursing Management
o Monitor for hypoxemia & respiratory compromise every 1-2 hrs.
▪ VS, lung sounds, cardiac & respiratory status, & urine output (bc
hypotensive can cause AKI)
o Elevate HOB to high fowlers if BP tolerates.
o Obtain venous access and monitor heparin drip/LMWH/Coumadin
o Pain and anxiety management w/morphine (vasodilator) – O2 1st then other
things b4 morphine.
▪ Communication is critical in allaying anxiety. Acknowledge
the anxiety & pt perception of a life- threatening situation. Stay
with them, speak calmly, and clearly, providing assurances.
o Bleeding precautions, oral care – especially if mouth breather.
● Prevention Measures
o Measures that prevent venous stasis and VTE
o Passive and active ROM for postop & immobilized pts
o Post-op ambulation ASAP
o SCDs or Plexipulse compression – for prevention, not for active DVT
o Pt repositioning q2 hrs
o Low dose anticoagulant & antiplatelet meds
o Smoking cessation (especially females on hormone based contraceptives) bc
increases risk for DVTs
o Traveling – drink plenty of H2O, change positions, avoid crossing legs, get up
and move every 1hr for 5 min.
● NANDA Diagnoses
o Impaired Gas Exchange; Acute Pain, Anxiety; Risk for Bleeding (when on
treatment)
Pleural Effusion (P 504-505)
● Collection of fluid (too much) in the pleural space – clear transudative, or exudative
(outside the lungs)
o Cleat transudative – similar to fluid normally present in pleura space
o Exudative – Excess protein, blood, or evidence of inflammation or infection
(white, green, cloudy is bad)
● Can cause pleurisy sx
o Pleural friction rub, scratching sounds caused by inflamed pleura rubbing
together, pain on deep inspiration.
● Caused by – HF (mediastinal fluid leaks into pleural space); Liver or renal failure;
Infections; chest trauma (inflammation response; smack lungs on ribs in MVA);
Lymphatic destruction by lung tumor; PNA
● Assessment Findings
o Dyspnea (lungs can’t expand)
o Decreased or absent lung sounds (sounds do not transmit through fluids well)
▪ NO CRACKLES BC OCCURS OUTSIDE THE LUNGS
o Dull flat sound on percussion (percuss between ribs)
o Decreased tactile fremitus (vibration of chest wall produced when pt speaks)
– hands around pt ribs
o Chest pain w/respirations if pleurisy develops
● Medical Management
o Thoracentesis – Needle aspiration of pleural space to remove fluid for sx relief
& dx of causative factor.
▪ Want fluid to be clear, if cloudy or another color, send culture for cell
counts.
, o Recurrent effusions may need chest tube w/closed drainage until source tx
o Severe cases caused by lung tumors may need pleural stripping or
pleurodesis to cause pleura to adhere together to prevent further
effusions.
▪ Causes the 2 pleura to SCAR together to decrease inflammation, pain,
decreases dyspnea & pleuritis
▪ Palliative for terminal pts only for pain relief.
o Heart monitor needed
Acute Respiratory Failure (P 610-612)
● Sudden deterioration of gas exchange function of the lungs
● Ventilatory failure, oxygenation (gas exchange) failure, or combo of both, classified
by abnormal ABGs (pa)
● Failure of the pulmonary system to carry out its own major functions
o Delivery of adequate amount of O2 to the arterial blood (paO2 <60
hypoxemia)
o Removal of corresponding amount of CO2 from blood (paCO2 >45
hypercapnia AND pH <7.35 acidemia)
● NO MATTER THE PROBLEM, PT IS ALWAYS HYPOXEMIC (low arterial blood O2
levels)
● Pathophysiology
o Ventilatory Failure
▪ Blood flow (perfusion) is normal but AIR MOVEMENT
(VENTILATION) IS INADEQUATE
▪ To little O2 reaches alveoli and CO2 is retained.
▪ Physical problems of lungs or chest wall, brain defect, poor respiratory
muscle function – diaphragm
▪ PaCO2 >45 AND pH <7.35 (acidemia)
▪ Pneumothorax – open or tension, ARDS, pulmonary edema (fluid in
lungs)
o Oxygenation (gas exchange) failure
▪ Air movement and oxygen intake is normal but LUNG BLOOD FLOW
(PERFUSION) IS DECREASED
▪ APPLYING 100% O2 DOESN’T CORRECT THE PROBLEM
▪ Massive PE
o Combined Ventilatory & Oxygenation Failure
▪ Involves hypoventilation – poor respiratory movements
▪ BOTH ventilation & perfusion are inadequate – leads to more
profound hypoxemia than either alone.
▪ Usually underlying chronic disease – COPD, Asthma, Cystic Fibrosis,
Lung disease
● Assessment Findings
o Dyspnea (hallmark of respiratory failure) – DOE or when lying down (in slow
progression)
o Orthopnea – breathe easier in upright position, can’t sleep flat
o Change in lung sounds – depends on cause: CHF vs PE
o Skin/nail bed color changes (hypoxemia)
o Hypoxemia S/S – Pallor, Cyanosis, Increased HR, Restlessness, Confusion
▪ O2 therapy is appropriate for any pt w/acute hypoxemia
▪ If O2 therapy doesn’t maintain acceptable PaO2 levels (>60)
(normal 80-100) then mechanical ventilation may be needed.
o Decreased O2 sats. on pulse ox – need ABG for most accurate assessment
▪ Pulse ox measures O2 bound to Hgb (increased RBCs = increased O2
sats)
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