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Summary NUR 463 Essential HESI STUDY GUIDE
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- University Of Rhode Island
This is a comprehensive and detailed hesi study guide that contains all the key concepts and terms to know for Nur 463. *Essential Study Material!!
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Med Surg EverythingChest Tube and Water or Dry Seal Management
Inserted into pleural space to remove air/fluid, restore intrathoracic
pressure, allowing lung to reexpand
3 compartments/chambers
o Collection chamber (1)
Air/fluid collected from pleural or mediastinal space
Fluid remains, air vented to second compartment
(water-seal chamber)
o Water-Seal chamber (2)
Contains 2 cm water; prevents backflow; one-way valve
Fluctuations in water level “tidaling”
Water moves up with inspiration and down with
expiration
o Suction control chamber (3)
Water suction uses 20 cm water to drain chest
Dry suction: safe and effective vacuum
Patient Safety
o Maintain 2 cm water q shift; add sterile water if needed
o Keep lower than pt chest
o Keep straight and tubing coiled loosely below chest level w/
connections tight/taped
o Monitor fluid drainage; mark time and measurement of fluid level
Notify HCP if >70ml/hr of drainage
o Monitor WOB and pain level
o Assess for tidaling (bubbling in water-seal chamber)
o Replace unit when full
o Crackles around tube are normal
o If system breaks, insert 1 inch of tubing into bottle of
sterile water; do not clamp!
o Removal: pre-medicate for pain, position semi-fowlers,
Valsalva maneuver and hold breath, CXR to reassess
o If chest tube dislodged
Cover area with dry, sterile dressing
If air leak, tape dressing on 3 sides only (allows air to
escape; prevents tension pneumothorax)
Notify HCP ASAP
JP Drain; Hemovac
Prevent fluid at surgical wound site and promote wound healing
Empty q 4-12 hrs unless it is .5-2/3 full before then
Drainage tube patency and negative pressure in reservoir (bulb) must
be maintained to provide adequate drainage
1
,Pneumonia
Inflammation of lung tissues causing consolidation of exudate
Sx: green, yellow, thick sputum, coarse crackles
o Bacterial: confusion, tachycardia, general deterioration,
increased RR/HR
Risk factors
o Age >65 or <2 yo
o Recent surgery (abdominal, thoracic)
o Altered LOC (alcoholism, head injury, seizure, smoking, splenic
dysfunction, anesthesia, drug OD, CVA), depressed or absent
gag/cough reflexes
o Prolonged immobility
o Immunosuppressed pt
Complications
o Sepsis, ARDS, pleural effusion, emphysema, pleurisy, lung
abscess
Prevention/Management
o Pneumococcal vaccine (children <5, adults >65,
immunocompromised, smokers)
o Seasonal flu vaccine yearly
o Meticulous hang hygiene
o Sedation interruptions
o HOB 30-45˚
o Oral care q 2 hrs
o Routine peptic ulcer prophylaxis
o Subglottic suctioning
o Sedation/weaning
o Early mobilization
o Blood and sputum culture
o Isolation
o Encourage fluids and rest
o Antipyretics, pain meds
o Monitor O2 sat and admin O2 (humidified to loosen
secretions)
o CDB
o IS
o Comatose and immobile pt: elevate 30˚ for feeding and for 1 hr
after; turn frequently
Nursing Assessment
o Tachypnea, productive cough, pleuritic pain, fever of
abrupt onset, dyspnea, increased tactile fremitus, mental
status changes, crackles, decreased breath sounds, dullness
on percussion, ABG indicates hypoxemia
2
, Hypoxemia: PaO2 55% and SpO2 is 88%
Can also be caused by hypothermia SaO2 85% and
PaO2 of 50 mmHg
o TURN UP OXYGEN
o Whispered pectoriloquy
Normal: spoken word can’t be heard
(muffled/unclear)
Increased clarity indicates consolidation (tumor,
pna); abnormal
If lungs are filled with more air, breath/voice sounds
are absent or diminished (pneumothorax, severe
emphysema)
o Fever
Increased temp increases metabolism and demand for O2;
can cause dehydration d/t excessive fluid loss d/t
diaphoresis
Hydration is essential; 300-400 ml fluid lost daily by lungs
through evaporation
Peritonsillar Abscess
Complication of acute pharyngitis or acute tonsillitis when bacterial
infection invades one or both tonsils
Tonsil may enlarge and threaten airway patency
Known as hot potato voice
Sx: high fever, leukocytosis, chills
Age Related Changes of for Older Adult
Decreased cough reflex, decreased ciliary action, lungs stiffer,
decreased alveolar surface for gas exchange, loss of lean body mass,
skeletal changes of chest
Increased protein in urine, slightly increased serum glucose levels
o Result of kidney changes or subclinical UTI
USG declines by age 80 from 1.030 1.024
Chronic Airflow Limitation
Asthma (reversible)
COPD (chronic progressive)
o Emphysema
o Chronic bronchitis
o d/t smoking, environmental/occupational exposure, genetic
predisposition)
o Temp is most important assessment; infection most
common factor precipitating respiratory distress; pt
taking long term steroids are predisposed to infection
o Severe polycythemia
3
, Diet: soft diet that doesn’t require much chewing and digestion; assist
with feeding if needed; eating consumes energy needed for breathing
Prevent secondary infections, report changes in characteristic of
sputum, encourage ≥3 L/day of fluids and decreased caffeine d/t
diuretic effect, obtain immunizations when needed
Expect H&H to be elevated
Chronic Bronchitis
Chronic sputum with cough production on daily basis for
minimum of 3 mo/year
Chronic hypoxemia, increased mucus production, exacerbations d/t
infections, increased CO2 retention/acidemia
Insufficient oxygenation leads to generalized cyanosis and often Right
HF
Absence of sputum, edematous, cyanotic, shallow respirations
“blue bloater”
Emphysema
Abnormal enlargement of air spaces distal to terminal alveolar walls
Increased dyspnea/WOB
o Reduced gas exchange, increased air trapping, decreased
capillary network, increased work and O2 consumption
Advanced emphysema hypercarbia is a problem; imperative that
baseline data is obtained for pt
“pink puffer”; normal skin coloring but puffing respirations, fine “rice
crispy” crackles, positive crepitus if you push on chest
Total lung capacity increased because of hyperinflated lungs
ABG normal
Copious amounts of thick, white sputum
COPD
Nursing assessment
o Bronchitis
Right side HF, cyanosis, distended neck veins
Bronchial breath sounds heard over areas of density or
consolidation; sound waves easily transmitted over
consolidated tissue
o Emphysema
Pursed lip breathing, non-cyanotic, thin
Pursed lip: relax shoulders, purse lips, exhale
Distant, quiet breath sounds, wheezes
o Auscultation
Crackles, rhonchi, expiratory wheezes
o Low PaO2, high PaCO2, low pH, high HCO3
Acute complications: repeated/prolonged respiratory infections,
acute respiratory failure, pneumothorax
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