NUR 265 Exam 2 Study Guide 2023 With Complete 100%Correct Solutions. NUR 265 Exam 2 Study Guide
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
oBronchial: High pitched & loud, normal in tracheal & larynx
oBronchovesicular: Moderate pitched & amplitude, normal over major bronchi
oVesicular: 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
oVenous 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.
oGreatest r/f in the young is the combo of smoking and hormone based contraceptives. Nursing Assessment Findings
oRespiratory 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).
oRespiratory 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)
oMany pts w/ a PE do not have “classic” sx (i.e. hypoxia), but instead have vague sx resembling the flu (n/v & general malaise)
oCardiac Manifestations
Decreased tissue perfusion: tachycardia, JVD, Syncope (loss of consciousness), Cyanosis, & Hypotension. oIn 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
oWhen 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
oSaddle Emboli – Embolism at split of pulmonary artery that blocks both branches to the lungs
Medical Dx
oChest X-ray – May show PE if large but will help r/o other things
oCT scan – Most often used to dx PE
oTEE (Transesophageal Echocardiography) – See if there are clots in the atria
oVentilation 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
oABGs
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 oGIVE 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.
oAnticoagulation 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)
oConvert 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).
oEnoxaparin or dalteparin
oFibrinolytic (tPA) to tx massive PE or hemodynamic instability
Antidotes – clotting factors, FFP, & aminocaproic acid (Amicar)
Dissolve the clot itself oEmbolectomy – surgical removal of the embolus – When tPA can’t be used or for massive PE w/shock
oInferior Vena Cava Filter – to prevent DVTs from moving to the lungs **Bleeding precautions with all blood thinners
oPrevent 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
oMonitor for hypoxemia & respiratory compromise every 1-2 hrs.
VS, lung sounds, cardiac & respiratory status, & urine output (bc hypotensive can cause AKI)
oElevate HOB to high fowlers if BP tolerates.
oObtain venous access and monitor heparin drip/LMWH/Coumadin
oPain 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.
oBleeding precautions, oral care – especially if mouth breather.
Prevention Measures
oMeasures that prevent venous stasis and VTE oPassive and active ROM for postop & immobilized pts
oPost-op ambulation ASAP
oSCDs or Plexipulse compression – for prevention, not for active DVT
oPt repositioning q2 hrs
oLow dose anticoagulant & antiplatelet meds
oSmoking cessation (especially females on hormone based contraceptives) bc increases risk for DVTs
oTraveling – drink plenty of H2O, change positions, avoid crossing legs, get up and move every 1hr for 5 min.
NANDA Diagnoses
oImpaired 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)
oCleat transudative – similar to fluid normally present in pleura space
oExudative – Excess protein, blood, or evidence of inflammation or infection (white, green, cloudy is bad)
Can cause pleurisy sx
oPleural friction rub, scratching sounds caused by inflamed pleura rubbing together, pain on deep inspiration.
