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
École, étude et sujet
Galen College Of Nursing
NUR 265
Tous les documents sur ce sujet (210)
1
vérifier
Par: heatherrain_2000 • 2 année de cela
Par: verifiedtutors • 2 année de cela
Thank you for the review and all the best in your studies. You can email me for more resourceful papers at david.jamin19@gmail.com
Vendeur
S'abonner
verifiedtutors
Avis reçus
Aperçu du contenu
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)
Les avantages d'acheter des résumés chez Stuvia:
Qualité garantie par les avis des clients
Les clients de Stuvia ont évalués plus de 700 000 résumés. C'est comme ça que vous savez que vous achetez les meilleurs documents.
L’achat facile et rapide
Vous pouvez payer rapidement avec iDeal, carte de crédit ou Stuvia-crédit pour les résumés. Il n'y a pas d'adhésion nécessaire.
Focus sur l’essentiel
Vos camarades écrivent eux-mêmes les notes d’étude, c’est pourquoi les documents sont toujours fiables et à jour. Cela garantit que vous arrivez rapidement au coeur du matériel.
Foire aux questions
Qu'est-ce que j'obtiens en achetant ce document ?
Vous obtenez un PDF, disponible immédiatement après votre achat. Le document acheté est accessible à tout moment, n'importe où et indéfiniment via votre profil.
Garantie de remboursement : comment ça marche ?
Notre garantie de satisfaction garantit que vous trouverez toujours un document d'étude qui vous convient. Vous remplissez un formulaire et notre équipe du service client s'occupe du reste.
Auprès de qui est-ce que j'achète ce résumé ?
Stuvia est une place de marché. Alors, vous n'achetez donc pas ce document chez nous, mais auprès du vendeur verifiedtutors. Stuvia facilite les paiements au vendeur.
Est-ce que j'aurai un abonnement?
Non, vous n'achetez ce résumé que pour €13,68. Vous n'êtes lié à rien après votre achat.
