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Exam 2 study guide notes
Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)
Temple University
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EXAM 2 : Pulmonary Pulmonary Embolism (5-6 questions) Assessment- get a blood test, CTA, V/Q, angiogram, MRI, etc. Signs & symptoms: variable, dyspnea most common, tachypnea, cough, chest pain, hemoptysis (coughing up blood), crackles, wheezing, fever, tachycardia, syncope, change in LOC Diagnostic studies: Electrocardiogram (R/O AMI, assess for RV strain), ABGs, Chest x-ray, troponin levels, D-dimer-elevated/positive with clot degradation, ventilation-perfusion (V/Q) scan- used if pt cannon have contrast (perfusion-images pulmonary circulation, ventilation-distribution of gas in lung), Pulmonary Angiography- most sensitive but invasive, Echocardiogram CTA of the chest- most frequently used dx test Indication: symptoms that suggest blood clots in lungs- chest pain, rapid breathing SOB, or chest injury/trauma and before surgery of chest/lung Special considerations- IV contrast media is used, allergy history is important- shellfish allergy Nursing interventions: sit up (semi-fowlers) if they cant breath, check PTT, INR PT and CBC- baseline studies, give O2 nasal cannula or high flow nasal cannula, IV access, Fluids, diuretics and analgesics Patient education- Regarding long term anticoagulation therapy- diets must be regular, PT, INR on regular basis till getting to regular dose. Risk for bleeding, measures to prevent DVT- ambulation- compression socks. Importance of follow up exams Anticoagulation Heparin-low molecular weight heparin (LHWH) IV push, 2 nurses check, unfractionated IV heparin- platelets counts drop with heparin, so pt is at risk for thrombocytopenia, CHECK PTT for hep. Antidote: protamine sulfate Warfarin- CHECK PT INR for warf. Goal for PT INR- 2-2. Antidote- vitamin K Valvular heart disease (5- 6 questions) Signs and symptoms of mitral stenosis and regurgitation Mitral Valve Stenosis- scarring of valve leaflets and chordae tendineae, decrease blood flow from LA to LV, risk for afib Caused by rheumatic heart disease Increased LA pressure and volume, increase pressure in pulmonary vasculature, risk for afib bc stretching out atrium S/S: exertional dyspnea, loud S1, murmur, fatigue, palpitations,hoarseness, hemoptysis, chest pain, seizures/stroke Mitral Valve Regurgitation- incomplete valve closure,backward of flow of blood Can be acute or chronic Acute: pulmonary edema and crackles Chronic: left atrial enlargement, ventricular hypertrophy → decrease in CO Damaged caused by: MI, chronic rheumatic heart disease, mitral valve prolapse, ischemic papillary muscle, endocarditis S/S chronic- asymptomatic for years then weakness, fatigue, palpitations, progressive dyspnea, peripheral edema, S3 murmur S/S acute- thready peripheral pulses and cool clammy extremities Signs and symptoms of aortic stenosis and regurgitation Aortic Valve Stenosis
Congenital stenosis usually discovered in childhood adolescence or young adults Can also be degenerative or caused by rheumatic fever Bicuspid Aortic Valve Stenosis- s/s- “SAD” syncope- dizzy/fainting, angina- chest pain, dyspnea- SOB/difficulty breathing Associated with HTN Other S/S- systolic murmur, prominent S Use NTg “cautiously”- can reduce preload and blood pressure so can worsen chest pain Aortic Valve regurgitation Backward flow from ascending aorta into LV Acute- IE, trauma, or aortic dissection (aorta is ripping) - life threatening emergency Chronic AR- rheumatic heart disease, congenital bicuspid aortic valve, syphilis, chronic rheumatic conditions Decreased myocardial contractility Pulmonary hypertension and RV failure S/S acute- severe dyspnea, chest pain ,hypotension, cardiogenic shock, life threatening emergency*** S/S chronic- asymptomatic for years, DOE, PND, angina, “water hammer” pulse if severe- soft or absent S1 S3 S Tricuspid Valve Stenosis- happens on right side, narrowing between the RA and RV don't see that often- IV drug users / endocarditis Occurs in pt with rheumatic fever, and IVDA Right atrial enlargement and increases systemic venous pressure S/S- peripheral edema, ascites, hepatomegaly, murmur- R HF s/s- right sided heart failure s/s Tricuspid Valve Regurgitation- don't see in ppt Related to IVDA and s/sx or right sided heart failure Open surgical valvuloplasty Repair of the valve by suturing the torn leaflets, chordae tendineae, or papillary muscles. Primarily used to treat mitral or tricuspid regurgitation. Minimally invasive valvuloplasty surgery Mini sternotomy or parasternal approach Includes robotic and thoracoscopic surgical systems Results compare with those of the open procedure. Shorter lengths of stay, fewer blood transfusions, less pain, and lower risk of sternal infection and postoperative atrial fibrillation have been reported. For patients with mitral or tricuspid regurgitation, further valve repair or reconstruction using annuloplasty is an option. Annuloplasty involves reconstruction of the annulus, with or without the aid of prosthetic rings. Nursing care of patient after valve repair/replacement Valve repair- ring Monitoring patient for unstable hemodynamic values, bleeding, arrhythmias, surgical site infections and complications from mechanical ventilation Surgical procedure of choice, lower mortality, may not restore toilet valve function PTBV- percutaneous transluminal balloon valvuloplasty- balloon to open the stenosis- done in all besides aortic stenosis Valve replacement → Mechanical vs Tissue valves Mechanical (artificial)- last longer, risk of thromboembolism, requires long term anticoagulation Valve are man made and NOT from tissue- requires lifetime of warfarin
pH pCaO2 pO 2 HCO3 O2 sat (%) Interpretation 7 36 85 25 97 7 39 61 31 91 Metabolic Alkalosis 7 58 135 28 99 Respiratory Acidosis pH pCO2 pO2 HCO3 O2 sat (%) Interpretation 7 35 112 22 98 Tidal Volume (mL) FIO (%) Respiratory Rate PEEP Mode Possible Intervention 520 40 18 5 AC pH pCO2 pO2 HCO3 O2 sat Interpretation 7 32 118 22 98 Respiratory Alkalosis Tidal Volume FIO2 Respiratory Rate PEEP Mode Possible Intervention 600 40 16 5 AC Mechanical Ventilation Process by which fraction inspired oxygen (FIO2) at >21% is moved into and out of lungs by mechanical ventilation Basic ventilator settings Tidal Volume (Vt) 6-10 mL/ kg (500mL normal) Fraction of Inspired Oxygen FiO2 set between 21 and 100% Positive End Expiratory Pressure PEEP - usually 5 cm H Positive Pressure support Usual setting 6-18 cm H Pressure Controlled/ Inverse Ratio Ventilation (PC- IRV) Normal I/E is 1: With IRV, I/E ratio begins at 1:1 and may progress to 4: Ventilator alarms High pressure limit Causes- secretions, coughing, gagging, pt fighting ventilator, water in tubing, kinked or compressed tubing, increased resistance, decreased compliance PNEUMONIC—> Two PB sandwiches make you sick... two P’s→ pneumothorax, pulmonary edema, two B’s→ bronchospasm and biting Need suction Low pressure limit Total or partial ventilator disconnect, loss of airway, ET tube / trach cuff leak LOW PRESSURE= LEAK Reconnect / re-intubate if out Ventilator inoperative or low battery Nursing interventions - maintain airway patency, assess oxygenation saturation, monitor VS, suction pt only as needed (each pt is different-so you listen to lungs to determine if suction is needed), monitor ABGs, decrease risk for VAP, make sure alarms are on to prevent alarm fatigue, Complications of suctioning: hypoxemia, bronchospasm, increased ICP, dysrhythmias, high or low BP, mucosal damage, bleeding, pain and infection
Nursing care of a patient on a ventilator Oral hygiene every 2-4 hours to prevent pneumonia Chlorhexidine oral rinse Oropharyngeal suction Reposition and retape ET tube every 24 hours- prevents pressure injuries Give protonix to avoid stomach ulcers Prevention of ventilator-associated pneumonia Happened within 48 hours of beginning intubated Prevention: HOB elevation, NO routine changes of ventilator circuit tubing, continuous subglottic suctioning, strict hand hygiene, drain water from tubing Weaning- process of decreasing ventilation support, resuming spontaneous ventilation ( phases) Phase 1: Pre-weaning (wiener) or Assessment Phase Assess muscle strength, negative inspiratory force Assess edurances- spontaneous VT, vital capacity, minute ventilation and rapid shallow breathing Auscultate lungs Assess chest x-ray Nonrespiratory Factors- assessment of neuro status, hemodynamic, fluid and electrolyte/ acid base balance, nutrition and hemoglobin Drugs should be titrated to achieve comfort but not excessive drowsiness Phase 2: Weaning Process: recommended spontaneous breathing trial (SBT) Should be done at least 30 min but not>120, may be done with CPAP, lower levels of PSV, or “T” piece Extubate if tolerates SBT, return to ventilation if pt fails SBT Important to rest inbetween weaning trials Obtain baselines assessment, VS resp parameters Monitor for signs of intolerance- tachypnea, dyspnea, tachycardia, dysrhythmias, sustained desaturation (<91%) HTN, hypotension, agitation, anxiety, diaphoresis, sustained VT <5 m/kg changes in mentation Phase 3: Weaning Outcome- extubation or re-extubated because they failed SBT EXTUBATION- hyperoxygenate, SUCTION, deflate cuff, and remove tube at peak of deep inspiration, encourage pt to deep breath and COUGH!! Supplemental O2 (nasal cannula, mask, high flow), careful monitoring postextubation. Respiratory Failure Hypoxemic versus hypercapnic respiratory failure Hypoxemia- oxygenation failure PaO2 (low) drops below 60 mmHg 1st step TX: O2 THERAPY Casuses: COPD, pneumonia, asthma, atelectasis pain, pulmonary embolism, Anatomic shunt or intrapulmonary capillary, severe COPD, recurrent PR, pulmonary fibrosis, ARDS, interstitial lung disease, CNS disease, neuromuscular disease Hypercapnic- ventilatory failure- imbalance between ventilatory supply (gas flow in and out of the lungs) PaCO2 increases above 45 mmHg and pH drops below 7. Respiratory acidosis, retain CO TX goal- keep PacO2 within normal limits Causes: asthma, COPD, cystic fibrosis, drug overdose, brainstem infarct, spinal cord injury, flail chest, kyphoscoliosis, severe obesity, fractures, muscular dystrophy, guillain barre syndrome, MS, muscle weakness
Endocarditis Ineffective Endocarditis (IE) Infection of the inner layer of heart, including valves Antibiotic therapy 6-8 weeks - pt goes home w PIC line Causes Can be bacterial, viral, or fungal Streptococcus viridans Staphylococcus aureus If patient has an artificial valve, they are more likely to have an infection Risk factors IV drug abuse Prosthetic valves Renal dialysis (central lines, AV fistulas, etc.) Central lines leave patients more prone to staph infections. Be cautious! Patho Vegetation occurs- a build-up of a whole bunch of junk and adheres to the valve or the endocardium Part of the vegetation can break off and enter circulation → EMBOLISM S/Sx Usually nonspecific- low-grade fever, chills, weakness, malaise- basically flu-like symptoms Subacute form shows more s/sx of a normal infection instead of a heart issue (ex: joint and muscle pain, back pain, abdominal discomfort, weight loss, headache) Vascular s/sx Splinter hemorrhages in nail beds, petechiae, Osler’s nodes, Janewau’s lesions, Roth’s spots Murmur in most patients Manifestations secondary to embolism: kidney- decreased urine output, brain- stroke like symptoms Diagnostic Studies Lab tests (blood cultures, CBC with differential) Echo, chest x-ray, EKG Cardicac catheterization depending on the results of the test. You can evaluate the valves are coronary arteries if there is vegetation Treatment Antibiotic therapy – usually start it prophylactically 6-8 weeks Patients will go home with a PICC line → PATIENT TEACHING! Collaborative Care IV antibiotics, repeat blood cultures, no new heart valve prior to surgery, valve replacement if needed ETT Management Indications Upper airway obstruction (ex: tumor), apnea, pt with his risk of aspiration (ex: stroke patients), ineffective clearance of secretions, respiratory distress * Procedure Need consent and patient teaching Ambu bag, suction equipment, IV access Admin sedative and paralytic agents if indicated for pt Sniffing position, preoxygenation patient using Ambu bag with 100% O2, Limit each attempt to less than 30 secs Check if properly placed (end-tidal CO2 detector, x-ray) Record position of tube, obtain ABGs
Management Maintain correct tube placement (auscultate bilateral breath sounds because being ventilated can cause pneumos is PEEP is up too high) If patient self extubates, manually bag patient immediately Maintain proper cuff inflation (don’t want it to be too inflated bc it can cause tissue necrosis. Cuff pressure would be 20-25 on manometer) Monitor oxygenation Monitor ventilation (PaCO2, use of accessory muscles → meaning patients needs more sedation) Maintain tube patency (do not routinely suction. Suction when the high-pressure alarm goes off or nursing assessment indicates the need for suctioning Hyperoxygenate patient before suctioning. Limit suctioning in patients with neuro issues because it can increase intracranial pressure Do not flush with saline if the patient has thick secretions- increased risk of infection/pneumonia ORAL CARE Prevent unplanned extubation with sedation WILL ADD MORE- JUST HAVENT BEEN OVER IT IN CLASS YET Mechanical Ventilation Quiz
- The nurse can assess correct endotracheal tube (ETT) cuff pressure by: a. A manometer reading of 22 mm Hg
- Interventions to prevent aspiration in a mechanically ventilated patient with an endotracheal tube (ETT) include: a. Elevate the head of the bed 30-45 degrees
- Synchronized intermittent mechanical ventilation (SIMV) provides: a. a set respiratory rate and tidal volume; and senses the patient's spontaneous breath. In between mandatory set breaths, the patient can breathe at their own rate and tidal volume.
- The nurse is caring for a mechanically ventilated patient on the following setting: assist control rate 18, tidal volume 500 ml, and FIO2 35%. The patient’s respiratory rate is 36. The nurse recognizes that this assessment finding can result in the following abnormal ABG: a. pH 7, PaCO2 30, HCO3 24 mEq/l
- Which of the following is an appropriate tidal volume range (per textbook) for a patient weighing 60 kg and is mechanically ventilated for Acute Respiratory Failure? a. 400 mL
- A mechanically ventilated patient is receiving PEEP +8. The nurse should assess for this complication associated with PEEP: a. pneumothorax
- Measures to prevent ventilator-acquired pneumonia (VAP) include: a. Maintain head of bed at 30 – 45 degrees
- Which assessment finding indicates that the patient may not be tolerating ventilator weaning? a. Pulse oximetry 88%
- Prior to administering an infusion of a neuromuscular blocking agent to a ventilator dependent patient, the nurse should administer which prescribed medication? a. propofol (Diprivan)
- A client with respiratory failure is intubated and placed on continuous mechanical ventilation. Which equipment is most important to keep at the bedside? a. Manual resuscitation bag Tracheostomy Care Quiz
Exam 2 study guide notes
Course: Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)
University: Temple University
- Discover more from:Generalist Nursing Practice IV: Tertiary Care Across the LifespanNURS 4889Temple University30 Documents
- More from:Generalist Nursing Practice IV: Tertiary Care Across the LifespanNURS 4889Temple University30 Documents