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study guide medsurgII exam 2
- Course
- Med-sure II (NSG223)
- Institution
- Herzing University
MED SURG II EXAM 2 STUDY GUIDE, received an A in the class :) and on exam, very focused and helpful
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Passed with an A. Everything on there. THANK YOU
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EXAM 2 MED SURG IIDisorders Of the Respiratory System
Background
Respiratory Assessment
● “99”, whisper test, breathing to measure if hand’s separate 1 inch
● Lung sounds - apasis to basis
● Anterior lung sounds only if patient can’t breath well enough to sit up or turn
● Tell patient they will tire easily and prepare them for assessment
● Put stethoscope over tissues NOT BONES
● Listen for Lung Sounds (detect adventitious sounds)
○ Crackles (crinkled paper) - high pitched, heard during inspiration, not cleared
by cough
○ Rhonchi (rough) - rumbling, course sounds like a snore, during inspiration or
expiration, may clear with coughing or suctioning
○ Wheeze - musical noise during inspiration or expiration, usually louder during
expiration
Assessment of breathing patterns (picture on slides)
○ 12-20 normal respirations
○ 8/min dont give narcotics
Hypoxemia
● Inadequate O2 for metabolism
● Catching early signs is important (what are signs?)
● Early Signs
○ RAT (restlessness, anxiety, tachycardia / tachypnea)
● Late Signs
○ BED (bradycardia, extreme restlessness, dyspnea (severe))
● In PEDS
○ FINES (feeding difficulty, inspiratory stridor, nares flare, expiratory grunting,
sternal retractions)
● Common - hydrocarbonate+hypercapnia when hypoxia present d/t
hypoventilation and retention of CO2
● Need Oxygen Therapy!!! (LOW O2 IN BLOOD)
○ Teach deep breathing first
○ Normally dont go over 2L/min, know patients BASELINE
○ O2 - 92% and below put on oxygen
Pulmonary Edema
● Abnormal accumulation of fluid in the interstitial spaces and alveoli of the lungs
● Acute event resulting from left ventricular failure (or acute MI or chronic HF)
● Hacking cough, fatigue, weight gain, increased edema, decreased activity tolerance
are early indicators
● Early stage, treated with diuretics and reducing preload by
○ Placing t in upright position with feet & legs dependent
● Treated with oxygen, ventilatory support, IV meds, nursing assessments
&interventions
○ Oxygen - to relieve hypoxemia and dyspnea
○ Diuretics - promote excretion of sodium and water, Furosemide or another
loop diuretic given IV push or as continuous infusion
, ○ Vasodilators - IV nitroglycerin or nitroprusside for symptom relief,
contraindicated in pts who are hypotensive
Respiratory Failure
Acute Respiratory Failure - not disease, condition
● Results from inadequate gas exchange
● Hypoxemia: Decrease in arterial oxygen tension (PaO2) to less than 60 mmHg
○ Decrease in arterial O2 saturations
● Hypercapnia: Increase in arterial carbon dioxide tension (PaCO2) to greater than
50mmHg
○ Increase in arterial O2
● Arterial pH less than 7.35
● Ventilatory failure mechanisms
○ Impaired function of CNS
■ Drug OD, head trauma, infection, hemorrhage, sleep apnea
○ Neuromuscular dysfunction
■ Myasthenia gravis, guillain-barre syndrome, amyotrophic lateral
sclerosis, spinal cord trauma
○ Musculoskeletal dysfunction
■ Chest trauma, kyphoscoliosis, malnutrition
○ Pulmonary dysfunction
■ COPD, asthma, cystic fibrosis
○ Oxygen failure
■ Pneumonia, ARDs, HF, COPD, PE, restrictive lung diseases (diseases
that cause decrease in lung volumes)
1. Hypoxemic Respiratory Failure
● Oxygen failure (lung failure)
● O2 <60 mmHg on 60% oxygen
● Acute - min to hr
● Chronic - several days or longer
● Causes (4)
○ Ventilation-perfusion (V/Q) mismatch
○ Shunt
○ Diffusion limitation
○ Alveolar hypoventilation
2. Hypercapnic Respiratory Failure
● Ventilation failure (pump failure)
● O2 >45 mmHg and pH <7.35
● Acute - min to hr
● Chronic - several days or longer
● Imbalance between ventilatory supply and demand
● airway/aleoli (asthma, emphysema, cystic fibrosis)
● CNS (drug OD, brainstem infarction, spinal cord injury)
● Chest wall and neuromuscular conditions
Patient can have both of these at the same time
Chronic Respiratory Failure
● Deterioration of gas exchange function of the lung that developed insidiously or has
persisted for a long period after an episode of acute resp failure
● Two causes
, ○ COPD
○ Neuromuscular disease
● Develop tolerance to gradually worsening hypoxemia and hypercapnia
● Can also develop acute failure
Diagnostic Studies
● 1st - history and physical assessment
● Most definitive - ABG analysis
● Others: chest x-ray, CBC, sputum/blood cultures, electrolytes, ECG, urinalysis, V/Q
lung scan, pulmonary artery catheter
Prevention
● HX, physical assessment, identify at-risk pts
● Respiratory therapy : oxygen therapy delivery system should be
○ Tolerated by patient
○ Maintain PaO2 at 55-60mmHg or more & SaO2 at 90% ore more
○ Mobilize secretions
■ Hydration, humidification, chest PT, airway suctioning, augmented
cough, positioning
■
Treatment
● Augmented cough - mobilize secretions for obstructed airway, resp therapist does to
break secretions, like the vest that shakes
● Non Invasive PPV (positive pressure ventilation) - + pressure air, helps with
breathing, DO NOT TAKE OFF
● Bronchodilators to reduce airway inflammation
● Corticosteroids to reduce pulmonary congestion
● Diuretics, nitrates if HF present
● IV Antibiotics if treating underlying pulmonary infection
● Benzodiazepines and Narcotics to reduce anxiety, pain, agitation
● Enteral / Parenteral / Supplements - maintain nutrition, need protein
● Medical Supportive therapy - treat underlying cause, maintain adequate cardiac
output and hemoglobin concentration
Geriatric Considerations
● Physiologic aging results in
○ Decreased ventilatory capacity, alveolar dilation, larger air spaces, loss of
surface area, diminished elastic recoil, decreased respiratory muscle strength,
decreased chest wall compliance
● Lifelong smoking, poor nutritional status, less available physiologic reserve
(cardiovascular, respiratory, autonomic nervous system)
Pulmonary Embolism
● PE, refers to the obstruction of the pulmonary artery or one of its branches by a
thrombus (or thrombi) that originates somewhere in the venous system or in the
right side of the heart; common disorder of DVT
● DVT, a related condition, refers to thrombus formation in the deep veins, usually in
the calf or thigh but sometimes the arm, especially in pts with peripherally inserted
central caths
● VTE is a term that includes both DVT and PE
○ PE is the biggest concern of VTE, from clot breaking off
, ● PE can be associated with trauma, surgery (orthopedic, major abdominal, pelvic,
gynecologic), pregnancy, HF, 50+ age, hypercoagulable stages, and prolonged
immobility
● Caused by a blood clot (thrombus) (or air embolism or tissue tumor) that completely
or partially obstructs (blocks) the pulmonary artery and results in impaired gas
exchange
Medical MGT
● Massive PE is a life-threatening emergency, immediate priority to stabilize
cardiovascular system
○ Increases work of right ventricle, can cause right-sided HF w/ cardiogenic
shock
● Treatment
○ #1 priority - give oxygen via nasal cannula to relieve hypoxemia, respiratory
distress, and central cyanosis
■ Severe hypoxemia = emergency endotracheal intubation & mechanical
ventilatory support
○ IV infusion for meds & fluid
○ Vasopressor therapy (dobutamine, dopamine, norepinephrine)
○ Evaluation for hypoxemia (pulse ox, ABGs, MDCTA performed)
○ ECG monitoring for dysrhythmias / right ventricular failure
○ Blood draws (electrolytes, CBC, coagulation studies)
○ Indwelling cath, monitor output in massive PE
○ IV morphine / sedative to relieve anxiety, chest pain, tube placement,
ventilator
● Surgical MGT
○ Surgical embolectomy - indicated for massive PE or hemodynamic instability
or contraindications to thrombolytic (fibrinolytic) therapy
○ Pts who have contraindications to therapeutic anticoagulation or when
recurrent PE occurs, and inferior vena cava (IVC) filter may be inserted
■ Provides screen in the IVC, allowing blood to pass through while large
emboli from pelvis or lower extremities are blocked or fragmented
before reaching the lung
Nursing MGT
● Preventing thrombus formation
○ Encourage ambulation or active / passive leg exercises if bedridden
○ Instruct pt to move the legs in pumping exercise to engage leg muscles
○ Advise pt to not lie or sit for prolonged periods, cross legs, or wear
constrictive clothing
○ Intermittent pneumatic compression (IPC) devices - sleeves placed on legs
that inflate with sequential compression
■ Pt supine, legs shouldn’t dangle, feet resting on floor or chair
○ Don’t leave IV caths in place for prolonged periods
○ All increase venous flow and decrease venous stasis
○ Oxygen therapy to correct hypoxemia, relieve vasoconstriction, reduce pH
● Monitor Signs & Symptoms of PE
○ Extremities evaluated for warmth, redness, inflammation
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