Med Surg Exam 4 ML PDF

MED SURG. EXAM 4 RESPIRATORY & FLUID/ELECTROLYTE IMBALANCE CHAPTER 6 (20 questions) ❖ Fluid Balance: Intracellular fluid- Fluid inside the cells Extracellular fluid- Fluid outside the cells o Interstitial fluid- Is the water that surrounds the body's cells and incl...

MED SURG. EXAM 4 RESPIRATORY & FLUID/ELECTROLYTE IMBALANCE CHAPTER 6 (20 questions) ❖ Fluid Balance: Intracellular fluid- Fluid inside the cells Extracellular fluid- Fluid outside the cells o Interstitial fluid- Is the water that surrounds the body's cells and includes lymph. o Intravascular fluid- Blood plasma, is the fluid within the arteries, veins, and capillaries. o Trans-cellular fluid- Those in specific compartments of the body. Such as cerebrospinal fluid, digestive juices, and synovial fluid in joints. ❖ Movement of fluids & Electrolytes: Active transport- ATP is where we get energy from. Passive transport- NO ENERGY o Diffusion: the movement of a substance from an area of higher concentration to an area of lower concentration. o Filtration: is the movement of both water and smaller molecules through a semipermeable membrane from an area of high pressure to an area of lower pressure. o Osmosis: is the movement of water from an area of lower substance concentration across a semipermeable membrane to an area of higher concentration  ❖ Tonicity/Osmolarity: Isotonic: Same osmolarity as blood o Normal Saline 0.9% Hypertonic: Higher osmolarity than blood o Water leaves the cells and enters the blood stream Hypotonic: Lower osmolarity than blood o Water solution leaves the blood and other areas and enters the cell *Osmolarity- refers to the concentration of the substances in body fluids. The normal osmolarity of blood is between 270 and 300 milliosmoles per liter. ❖ Fluid Imbalances: ❖ Dehydration: o The most common form of dehydration results from loss of fluid from the body, resulting in decreased blood volume. Hypovolemia: o It occurs when the patient is hemorrhaging or when fluids from other parts of the body are lost. Causes of Hypovolemia: o Severe Vomiting & Diarrhea o Excessive wound drainage o Profusely sweating o NPO Status (Long term) o GI Suction Diagnostic Tests: o Elevated BUN o Elevated Hematocrit o Skin turgor o Cap refill. Interventions for Hypvolemia: o Replace fluids and resolve cause of dehydration o Isotonic fluids (0.9% NS) o Encourage fluid intake o Daily weights o Monitor I’s & O’s *Hypovolemia can also occur when fluid from the intravascular space moves into the interstitial fluid space. This process is called THIRD SPACING (common in burns, liver cirrhosis, extensive trauma) *If dehydration is not treated then the lack of sufficient blood volume causes organ function to decrease and eventually fail. *REMEMBER.. Healthy adults should urinate 30ml per hour S/S Of Hypovolemia: S/S Of Hypervolemia: Thirst Hypertension Rapid weak pulse BOUNDING pulse Rapid shallow respirations Increased, labored respirations Hypotension Distended Neck Veins Dry mucous membranes Pitting edema Poor skin turgor Polyuria Increased temp. Ascites (excess peritoneal fluid) Decreased urine output Dyspnea Weight loss Crackles in lungs Fluid Overload/Fluid Excess: o Sometimes called over-hydration, it is a condition in which a patient has too much fluid in the body. o Healthy adult kidneys can compensate for mild to moderate hypervolemia. o Typically, the kidneys increase urinary output to get the extra fluid off, however sometimes there are conditions where the kidneys cannot keep up with excess fluid. Causes of Hypervolemia/Fluid overload: o Poorly controlled IV therapy o Excessive ingestion of fluid o Can occur secondary to excessive sodium intake. o Adrenal gland dysfunction o Corticosteroid use Diagnostic Tests: o Decreased BUN  o Decreased Hematocrit Interventions for Hypervolemia: o Diuretics o Sitting patient up in Semi-Fowler position o Oxygen therapy o Monitor oxygen o Strict I’s & O’s o Daily weights o Fluid restriction o Low sodium diets *Conditions that can result in inadequate excretion of fluid include kidney failure heart failure, and the syndrome of inappropriate ADH *Hypervolemia typically results in heart failure, due to the heart not being able to pump correctly causing pulmonary edema. *If a potassium sparing diuretic is prescribed, educate your patient to eat foods high in potassium ❖ Electrolyte Balance: 2 types of electrolytes Cations: Carry a positive electrical charge Anions: Carry a negative electrical charge Sodium Imbalances: o Normal sodium level is 135-145 o Sodium is a major Cation in the blood & helps maintain serum osmolarity o Sodium is important for cell function Hyponatremia: o Occurs when the sodium level is less than 135 o In an actual decrease, the patient has inadequate intake of sodium or excessive sodium loss from the body o In a relative decrease the sodium is not lost from the body, instead it may leave the intravascular space and move into the interstitial tissues.  o Occurs with heat strokes and heat exhaustion o Occurs if a patient is NPO for too long Prevention for Hyponatremia: o Additional sodium is administered IV route o If it is a super active patient replace both sodium and water o Monitor the elderly closely o Stop diuretics o Antidiarrheal meds *Mental status changes occur due to the low sodium and decrease in osmolarity causes more “water pressure”. This causes water to collect in and around the brain, it causes ICP. S/S Hyponatremia: S/S Hypernatremia: Fluid Imbalance Tremors Headache, Seizures, Muscle weakness Thirst Altered mental status Altered mental status (AMS) Elevated temp. Seizures Tachycardia Unusual contractions of muscles N/V Skeletal muscle weakness (later sign) Diarrhea Respiratory failure Hypernatremia: o Occurs when the sodium level is above 145 o Patient has received too much sodium or is unable to excrete sodium (kidney failure) o In a relative increase, the amount of sodium does not change, but the amount of fluid in the intravascular space decreases. o Lack of H20 o Corticosteroids Diagnostic tests: o Serum osmolarity lab test o BUN lab test  o Urine specific gravity o Hematocrit Interventions for Hypernatremia: o Treat fluid imbalance first o Fluid replacement WITHOUT sodium o Diuretics o Daily weights o Strict I’s & O’s Potassium Imbalances: o Most common electrolyte o Normal lab value: 3.5-5.3 o Potassium is especially important for CARDIAC MUSCLES Causes of Hypokalemia: o Potassium level drops below 3.5 o Inadequate intake of potassium o Excessive loss of potassium through the kidneys o Most often occurs as a result of medications such as: ▪ Potassium-wasting diuretics (Lasix, hydrochlorothiazide) ▪ Digitalis preparations (Digoxin) ▪ Corticosteroids (prednisone) Diagnostic Tests: o Potassium lab draw o EKG (may show cardiac arrythmias o Metabolic alkalosis (pH greater than 7.45) Interventions for Hypokalemia: o Replace potassium in the body o Mild to moderate hypokalemia oral supplementation are given o Severe hypokalemia IV potassium is administered  o Educate patients on the side effects of potassium *Potassium should be administered AFTER the patient has voided *If potassium is administered in too high concentrations, it can cause cardiac arrest *DO NOT ADMINISTER POTASSIUM IV PUSH!!! (or someone Finna die) S/S of Hypokalemia: S/S of Hyperkalemia: Hypotension (postural) Muscle twitches & cramps Tachycardia Diarrhea Cardiac arrhythmias Hypotension Weak, thready, irregular pulse Cardiac Arrhythmias Altered mental status Weak pulse Lethargy Increased respirations Decreased GI motility Muscle weakness Muscle cramps & twitching Vital sign changes Vital sign changes Lethargy Diminished skeletal muscle activity Altered mental status resulting in ineffective respirations Increased GI motility Causes of Hyperkalemia: o Potassium level over 5 o Overuse of potassium-based salt substitutes or excessive intake of oral IV potassium can cause increased levels of potassium o Potassium sparing diuretics (spironolactone) o Kidney failure patients are at risk due to the kidneys cannot excrete potassium o Metabolic acidosis imbalance commonly seen in patients with uncontrolled diabetes mellitus. o Acidosis Diagnostic Tests: o Potassium lab draw  o EKG o PH lab draw Interventions for Hyperkalemia: o Limitations to potassium in diets o Potassium wasting diuretics o For Patients with kidney problems, cation exchange resin, such as sodium polystyrene sulfonate may be administered orally or rectally. o Glucose and insulin Calcium Imbalances: o Mineral stored in bones and teeth o Normal value is 9-11 Causes Hypocalcemia: o Most patients develop hypocalcemia slowly as a result of chronic disease or poor intake. o Postmenopausal women are MOST at risk o Osteoporosis can occur due to decreased amount of calcium o Insufficient intake of vitamin D prevents calcium absorption as well. o Patients with hyperphosphatemia often experience hypocalcemia o Thyroid or neck surgery o Alkalosis o Lactulose intolerance Interventions for Hypocalcemia: o Calcium is replaced o Calcium supplements should be administered 1-2 hours after meals to increase intestinal absorption. o IV calcium gluconate o IV calcium chloride o High calcium diet o Monitor done density o Monitor postmenopausal women o Cardiac monitoring o Monitor thyroid hormone levels  o PLACE PATIENT ON SIEZURE PERCAUTIONS o MONNITOR FOR RESP. FAILURE Diagnostic Tests: o Trousseau sign & Chvostek signs are used to help diagnose o EKG S/S Hypocalcemia: S/S of Hypercalcemia: Hypotension Tachycardia Bradycardia Hypertension Palpitations Increased DVT risk Brittle bones (women are at highest risk for Increased Muscle weakness osteoporosis) Diarrhea Altered mental status Muscle cramping (Charlie horse) Urinary calculi (stones) Laryngospasm Decreased deep tendon reflexes Seizures Arrhythmias Resp. Failure Resp. Failure Hypercalcemia: o Calcium level is above 11 Causes of Hypercalcemia: o Excessive amount of calcium or vitamin D o Kidney failure o Hyperparathyroidism o Dehydration o Cancers o Overuse or prolonged use of thiazide diuretics. (hydrochlorothiazide) Interventions for Hypercalcemia:  o Continuous cardiac monitoring o Decrease calcium intake o Replace thiazide diuretics with loop diuretics (furosemide) o IV fluids to help promote diuresis o If severe hypercalcemia patient may need dialysis o Increase phosphate Magnesium Imbalances: o Magnesium and calcium work together for the proper functioning of excitable cells. o Normal levels 1.5-2.5 Causes of Hypomagnesemia: o Low intake of magnesium o Loop diuretics o Thiazide diuretics o A major cause is ALCOHOLISM Interventions for Hypomagnesemia: o Increase intake of magnesium o Increase intake of potassium and calcium o Include leafy greens, vegetables, and whole grains into diet o Cardiac monitoring o Monitor for arrhythmias S/S of Hypomagnesemia: S/S of Hypermagnesemia: Hypertension Increased muscle weakness Tachycardia Decreased deep tendon reflexes Decreased GI motility Arrhythmias Muscle twitching/cramping Drowsiness & Lethargy Increased respirations Bradycardia Anorexia Resp. Failure N/V Heart failure Arrhythmias Hypotension Positive Trousseau & Chvostek signs Decreased renal excretion  Hypermagnesemia: o Magnesium level is above 2.5 Causes of hypermagnesemia: o Increased intake coupled with Decreased renal excretion by kidney failure Interventions for Hypermagnesemia: o Monitor for Resp. Failure o Decrease magnesium intake o Increase phosphate o Diuretics (Lasix) & Dialysis o Calcium gluconate is administered to block the increase of magnesium levels that can damage the heart *Signs & Symptoms are usually not apparent until the magnesium level is greater than 4. Acid-Base Balance: o An acid is a substance that release a hydrogen o A common acid in the body is hydrochloric acid o A base is a substance that binds hydrogen o A common base in the body is bicarbonate (HCO3) Alkali is another word for "base”. Sources of Acids & Bases: o Acids are formed as end products of glucose, fat, and protein metabolism. o These are called fixed acids because they do not change once they are formed. o Carbonic acid is a weak acid that can be formed when the carbon dioxide resulting from cellular metabolism combines with water o. The pH of a solution can vary from 0 to 14, with 7 being neutral, 0 to 6.99 being acid, and 7.01 to 14 being base, or alkaline. Control of Acid-Base Balance: o 3 major mechanisms are used:  - Cellular buffers: Are first to attempt to return the pH to its normal range. (EX: Hemoglobin, Bicarbonate, phosphate) - The lungs: Blow off additional CO2 through rapid breathing - Kidneys: Are the slowest to respond to changes in serum pH taking as long as 24-48 hours to assist with compensation. Kidneys also reabsorb additional bicarbonate. PH 7.35 -------------------- 7.45 CO2 35 ------------ 45 HC03 20 -------------- 26 Respiratory Acidosis: Metabolic Acidosis: Decreased pH Decreased pH Increased CO2 Decreased HCO3 Causes of Resp. Acidosis: Causes of Metabolic Acidosis: Hypoventilation DKA Anesthesia Severe Diarrhea Drug overdose Renal failure COPD, Pneumonia Shock Head injuries Intestinal suctioning Clinical Manifestations for Resp. Clinical Manifestations for Metabolic Acidosis: Acidosis: Headache headache Changes in LOC Hypotension Hypoventilation Hyperkalemia Dyspnea Warm, flushed skin Hyperkalemia Changes in LOC Treatment for Resp. Acidosis: Treatment for Metabolic Acidosis: Bronchodilators Sodium bicarbonate Non-invasive positive pressure ventilation Treat underlying cause Oxygen Smoking Cessation Narcotics, hypnotics, & tranquillizers Respiratory Alkalosis: Metabolic Alkalosis: Increased pH Increased pH Decreased CO2 Increased HCO3 Causes of Respiratory Alkalosis: Causes of Metabolic Alkalosis: Hyperventilation (Anxiety, Fear) Overdose of Antacids or Baking Soda Mechanical Ventilation Diuretics Overactive Thyroid Vomiting Gastric suctioning (NGT suctioning) Clinical Manifestations for Resp. Clinical Manifestations for Metabolic Alkalosis: Alkalosis: Decreased LOC Changes in LOC Deep, Rapid breathing N/V Tachycardia Diarrhea Hypokalemia Hypokalemia Hypotension Tremors Treatment for Resp. Alkalosis: Treatment for Metabolic Alkalosis: Breathe into a paper bag Administer NS Treat underlying cause Supplemental potassium  Body’s Compensatory Mechanisms: o Respiratory Acidosis- Kidneys reabsorb more HCO3 & excrete Carbonic Acid o Metabolic Acidosis- Deep rapid breathing (Kussmaul respirations) to rid the body of CO2. o Respiratory Alkalosis- Kidneys decrease the rate of HCO3 reabsorption o Metabolic Alkalosis- Slow, shallow respirations to increase CO2 retention Practice problems for ABGs: pH: 7.86 =Alkalosis pH: 7.17 = Acidosis pH: 7.53 = Alkalosis CO2: 43 = Normal CO2: 34 = Acidosis CO2: 21 = Acidosis HC03: 33 = Alkalosis HC03: 21 = Normal HCO3: 21 = Normal pH: 7.35 = Normal CO2: 47 = Acidosis HCO3: 38 = Alkalosis CHAPTER 31 (15 questions) ❖ Acute Bronchitis: Inflammation of the bronchial tree. When the mucous membranes lining the bronchial tree become irritated and inflamed, excessive mucus is produced. o The result is congested airways o Acute bronchitis is usually an isolated episode caused by a virus  o If bronchitis occurs more than 3 months out of the year for two consecutive years, chronic bronchitis is diagnosed. ❖ Bronchiectasis: The dilation of the bronchial airways. The dilated areas become flabby and scarred. Secretions pool in these areas and are difficult to cough up which causes an environment where bacteria can flourish, and infection is common. o Usually occurs secondary to another chronic respiratory disorder, such as cystic fibrosis, asthma, TB, bronchitis, or exposure to a toxin. S/S: o Recurrent lower respiratory infections. o Sputum is copious and purulent o Extreme airway inflammation may cause sputum to be bloody. o Wheezes & crackles may be auscultated o Cubbing of the fingers may develop with chronic disease Diagnostic tests: o Chest X-ray o Sputum cultures o CT scan o Bronchoscopy Interventions: o Antibiotics may be used intermittently o Infection prevention o Flu & Pneumonia vaccines should be implemented if patient consents o Bronchodilators o Mucolytics o Expectorants o Bronchitol a form of mannitol, is an inhaled mucolytic that promotes mucus clearance. o Anti-inflammatory agents such as corticosteroids or leukotriene inhibitors reduce airway inflammation. o Oxygen is used if hypoxemia is present o Surgery may be considered to remove the diseased area ❖ Pneumonia(s): An acute inflammation and slash or infection of the lungs that occurs when an infectious agent enters and multiplies in the lungs of a susceptible person. o The most common cause of Community acquired bacterial pneumonias is Streptococcus pneumoniae, also called pneumococcal pneumonia. o Pneumonia can be seen on a Chest X-Ray Viral Pneumonia: Influenza viruses are the most common cause of viral pneumonia. o The presence of viral Pneumonia increases the patient's susceptibility to secondary bacterial pneumonia. o Generally, patients with viral pneumonia are less ill than those with bacterial pneumonia. Aspiration Pneumonia: Some pneumonias are caused by aspiration of foreign substances. This most often occurs in patients with decreased levels of consciousness or an impaired cough or gag reflex. o These conditions can occur with alcohol ingestion, Stroke, General anesthesia seizures, Gastrointestinal reflux disease. Ventilator associated Pneumonia: VA P is a type of aspiration pneumonia that develops in patients who are intubated and mechanically ventilated. o The endotracheal tube keeps the glottis open, so secretions can be easily aspirated into the lungs. Chemical Pneumonia: Inhalation of toxic chemicals can cause inflammation and tissue damage. Which can lead to chemical pneumonia. o This increases the risk for subsequent bacterial infection. Prevention for Pneumonia(s): o Both flu and pneumonia vaccinations are essential to preventing pneumonia.  o As the nurse Encourage patients to preform regular coughing, Deep breathing and position changes. Especially for the ones on bed rest or after surgery. o Also educate patients about the importance of hand hygiene, and infection control o VAP can be reduced with frequent mouth care using CHG. S/S of Pneumonia: o Fever o Shaking o Chills o Chest pain o Dyspnea o Fatigue o Productive cough o Crackles Purulent & wheezes o Older patients may experience new onset confusion or lethargy *Elderly patients are extremely at risk, especially at age 65 and over Complications with Pneumonia: o Other underlying chronic diseases o Pleurisy & Pleural Effusion are two of the MOST common complications (generally resolved within 1-2 weeks) o Atelectasis (collapsed alveoli) Interventions for Pneumonia(s): o Broad-Spectrum antibiotics are administered AFTER cultures are sent off to the lab. o Expectorants o Bronchodilators o Analgesics  o Meter dosed inhalers may be prescribed o Supplemental Oxygen may be used if needed ❖ Tuberculosis (TB): Infectious disease caused by the bacterium mycobacterium tuberculosis. o TB primarily affects the lungs, but the kidneys, liver, brain and bones may be affected also. o Mycobacterium is an acid-fast bacillus. Meaning when it is stained in the Lab and then washed with an acid, the stain remains or stays fast. o TB can live in dark places in dried sputum for months but killed in a few hours of direct sunlight. o It is spread by inhalation of the TB bacilli from respiratory droplets o TB infection without disease is called LATENT TB, during this time the body develops immunity, which keeps the infection under control Risk factors: o Crowded or poorly ventilated living conditions o Elderly population at risk o TB is also prevalent among the urban poor and minority groups S/S of TB: o Chronic productive cough o Blood-tinged sputum o Drenching night sweats o Chest pain o Poor appetite o Weight loss o Low grade fever *If effective treatment is NOT initiated, a downhill course occurs, with primary fibrosis, hemoptysis, and progressive weight loss *Spread of TB bacilli throughout the body can result in pleuritis, pericarditis, peritonitis, meningitis, bone & joint infections, or GI infections may occur.  Diagnostic tests: o PPD skin test – Test is considered positive if a skin raises after 48-72 hours, a positive test results indicates that a person has been exposed to TB, it does not mean the person is infected with TB. o QFT-TB & T-SPOT are blood tests that detect the cell- mediated immune response to TB bacteria in Blood. Prevention for TB: o Clean well-ventilated living areas o If a patient is hospitalized for TB, place them on RESPIRATORY ISOLATION, with negative pressure isolation as well. (staff should wear high efficiency filtration masks) o TB vaccinations o Antibiotic therapy (Isoniazid, Rifampin, Ethambutol, Pyrazinamide) o Medication must be taken for 6-9 months or up to 2 years for MDR-TB, because of the length of therapy and the incidence of side effects. adherence to therapy is often a problem. *Patients must be isolated until their symptoms no longer contains TB bacteria ❖ Pleurisy (Pleuritis): A small amount of serous fluid that prevents friction as the pleurae slides over each other during inhalation and exhalation. o If the membranes become inflamed for any reason, they do not slide easily. o This causes the characteristic sharp pain. On inspiration. The irritation causes an increase in the formation of pleural fluid. This in turn reduces friction and decreases pain o This usually is related to other underlying respiratory disorders S/S: o Sharp pain in the chest on inspiration o Breathing may be shallow and rapid (because deep breathing increases pain) o Fever  o Chills o Elevated WBC count o Pleural friction rub is heard on auscultation *As pleural membranes become more inflamed, serous fluid production increases, which may result in pleural effusion. Diagnostic tests: o Auscultation of a pleural friction rub o Chest X-Ray o CT o Ultrasound o CBC Interventions: o NSAIDS o Opioids o The doctor may perform a nerve block by injecting anesthetic near the intercostal nerves to block transmission. ❖ Plural Effusion: When excess fluid collects in the pleural space o A normal amount of pleural fluid around each lung is 1-15ml. More than 25ml is considered abnormal. S/S: o SOB o Cough o Tachypnea o Dull sound is heard when the affected area is percussed o Lung sounds are decreased or absent over the effusion o Friction rub may be auscultated Interventions: o Bedrest o Severe symptoms may result in a thoracentesis.  o Pleurodesis o Chest X-Ray o CT ❖ Empyema: Collection of pus in the pleural space. This is a pleural effusion that has become infected o Usually a complication of pneumonia o Nursing care is the same as the care for a patient with a pleural effusion o Chest tube or surgery may be necessary to drain the area ❖ Pulmonary fibrosis: A group of disorders that cause scarring and fibrosis of lung tissue. Causes: o Could be hereditary o This could occur is exposed to certain viral illnesses o Wood and metal dust exposure o Medications o Radiation therapy o Smoking S/S of PF: o Progressive SOB o Inspiratory crackles o Chronic cough o Flu like symptoms o Fatigue o Clubbing of fingers Diagnostic Tests: o Chest X-Ray o CT scan o Spirometry  o ABGs o Bronchoscopy o Lung biopsy Interventions: o Antifibrotic drugs (reduce disease progression and preserve lung function) o Encourage patient to quit smoking if they smoke o Oxygen if needed o Flu and pneumococcal vaccines o Younger patients may be considered for a lung transplant ❖ Atelectasis: Collapse of the alveoli o Most commonly occurs in Post-surgical patients who do not cough and deep breathe effectively o Can be caused by anything that causes hypoventilation o Nursing focus is prevention o Patients should be educated on the importance of coughing and deep breathing or the use of an incentive spirometer whenever at risk for hypoventilation is present. o Position changes and ambulation are also helpful ❖ COPD: Airways are narrowed or blocked by inflammation and mucus, and there is loss of elasticity in the alveoli. Both conditions make it difficult for air to be removed from the alveoli, leading to trapping of air. o A patient with unremitting asthma is treated as having COPD. Chronic bronchitis: o symptoms occurring for at least 3 months of the year for two consecutive years Patients may have multiple exacerbations, each lasting 2 weeks or more. Emphysema:  o Emphysema affects the respiratory bronchioles and alveoli distal to the terminal bronchioles causing destruction of the alveolar walls and loss of elastic recoil. S /S of COPD: o chronic cough with or with sputum production o Progressive dyspnea o Barrel shaped chest. o Crackles and wheezing are often noted on auscultation. o Progressive SOB (most common for emphysema) o Decrease mobility. o Polycythemia due to hypoxemia (causes ruddy skin color) Complications: o Some patients with emphysema develop a large air within the lung tissue (bullae) or adjacent to the pleurae (blebs). These are like blisters that can rupture and cause the lung to collapse. Interventions: o Reduce symptoms and reduce risk of exacerbations. o Encourage patient to quit smoking Medications: o Adrenergic o Anticholinergics o MDI’s o NMT’s o Corticosteroid inhalers *Antitussive agents should be avoided in COPD patients because they need to cough up secretions ❖ Asthma: chronic inflammation of the airways and hyper responsiveness of the bronchi, smooth muscles (bronchospasm) o Asthma is typically inherited o There is no prevention S/S of asthma: o Wheezing o Chest tightness  o Dyspnea o Coughing o Tachypnea *Status asthmaticus occurs if bronchospasm is not controlled and symptoms are prolonged. ❖ Cystic Fibrosis: CF is a disorder of the exocrine glands that affects primarily the lungs, tract, and sweat glands. Abnormal sodium and chloride transport across cell membranes, causing thick, tenacious secretions, is responsible for many of the characteristic symptoms. o In the past, cystic fibrosis (CF) was thought to be just a childhood disease because most affected children did not survive past puberty. o Thick, sticky respiratory secretions are difficult to remove and cause airway obstruction, resulting in air trapping and frequent respiratory infections. o Patients with CF secrete sweat that is high in sodium and chloride because these electrolytes are not reabsorbed as they pass through the sweat ducts o CF is a genetic disorder, BOTH parents must be a carrier S/S of CF: o Symptoms usually first appear in infancy o Chronic sinusitis to production of thick sputum o Finger clubbing o Bouts of infection become more frequent with eventual loss of lung function o Respiratory failure o Frequent foul-smelling stools o Poor appetite o Bowel obstruction o Cirrhosis o Cholecystitis o Cholelithiasis *Chronic disease causes delayed sexual maturation in both male and female and infertility is common. Interventions: o No cure for CF  o Controlling infection o Relieving symptoms o Removal of thick sputum is promoted with hydration o Inhaled beta antagonist bronchodilators o Lung transplant o Pulmonary rehabilitation o High doses of Ibuprofen may slow lung deterioration ❖ Pulmonary Embolism: Foreign object that travels through the blood stream, such as a blood clot, air, or fat. o To help prevent PE it is important to encourage the patient to regularly ambulate if able. S/S: o Suden onset dyspnea for no apparent reason o Tachycardia o Tachypnea o Cough o Chest pain o Auscultation may reveal crackles or friction rub o High BP Diagnostic tests: o D-dimmer o Spiral CT scan o Pulmonary angiogram o Chest X-Ray Interventions: o Thrombolytic agents (Alteplase) must be administered within 4-6hrs of the clot's occurrence.  o Anticoagulants (heparin) o Cardiac Cath (to remove clot) o Surgical embolectomy o Long term anticoagulants o If clots keep recurring a filter will be placed into the inferior vena cava, the jugular or femoral vein to filter out clots from traveling to the heart or lungs ❖ Pneumothorax: Air trapped in the chest o If the pneumothorax occurs without an associated injury, it is called a spontaneous pneumothorax. o A traumatic pneumothorax results from a penetrating chest injury o If either the visceral pleura or the chest wall and parietal pleura are perforated, air will enter the pleural space, negative pressure will be lost, and the lung on the affected side will collapse Spontaneous Pneumothorax: o If no injury is present, the pneumothorax is considered spontaneous. This occurs mostly in tall, thin individuals and in smokers Traumatic pneumothorax: o Penetrating trauma to the chest wall and parietal pleura allows air to enter the pleural space Open pneumothorax: o If air can enter and escape through the opening in the pleural space Closed pneumothorax: o If air collects in the space and is unable to escape Tension pneumothorax: o In a closed pneumothorax, air, and therefore, tension, builds up in the pleural space and is unable to escape. S/S:  o Sudden dyspnea o Chest pain o Tachypnea o Restlessness o Anxiety o Asymmetrical chest expansion on inhalation *Crepitus may occur when air leaks into subcutaneous tissues due to a pneumothorax or a leaking chest tube site. Diagnostic Tests: o Chest X-Ray o Ultrasound o CT scan Interventions: o Chest tube o Surgical repair o Small pneumothorax may absorb with no treatment ❖ Fail Chest: Part of the chest collapses with the negative pressure of inhalation and bulges with exhalation. This is called paradoxical respirations o Treat this condition with supplemental oxygen, analgesics, intubation or mechanical ventilation. S/S: o Chest movement that is opposite to that usually seen with respiration Priority nursing care: o Impaired gas exchange o Ineffective breathing pattern o Acute pain o Respiratory distress ❖ ARDS: Acute Resp. Distress Syndrome Causes: o Occurs because of acute lung injury o Most common cause is widespread sepsis o Pneumonia o Shock o Narcotic overdose o Aspiration S/S of ARDS: o Dyspnea o Tachypnea (causes respiratory alkalosis due to hyperventilation, then develops into acidosis as patient tires out) o Cyanosis o Fine inspiration crackles o Confusion and lethargy Complications: o Heart failure o Pneumothorax o DIC Interventions: o Cared for in ICU or PCU unit o Oxygen therapy (adjusted based off ABG results) o ABGs o Diuretics o IV fluids o Antibiotics o Intubation & mechanical ventilation Practice Questions:  Define what an electrolyte is. What precautions/interventions should the nurse take with a patient that is Hypercalcemic? Abrupt onset of fever, chills, myalgia, sore throat, general malaise, and headache are symptoms of what disease process? What technique is used to keep airways open during exhalation, which promotes carbon dioxide excretion? What complications can occur if a patient has untreated strep throat? What is the movement of a substance from an area of higher concentration to an area of lower concentration? What is the raised area called that a nurse is observing for after a TB test? This area should be either visible or not visible after 48-72 hours after the test. How long should a patient lay flat post pulmonary angiogram? What is the MOST notable complication for the nurse to monitor with a patient that has an altered potassium level? What type of precautions would you place for a patient with the Flu?  What disease process would the nurse suspect with chronic inflammation of the Airways and hyper responsiveness of the bronchial smooth muscles (bronchospasms) Patients experiencing an exacerbation report wheezing chest tightness. Dyspnea coughing. In difficulty moving air in and out of the lungs? What is the best determinant of a patient's fluid volume status? Discharge education for a patient with asthma should include what? Increased level of specific gravity of urine indicates what? Patients with acute or severe hypocalcemia are given what medication? When educating a patient on their recent diagnosis of TB, how long will the nurse state the patient could be on medications to treat the TB? What are the Signs and Symptoms of Hypokalemia? What is related to chronic inflammation, and people with allergies are prone to developing them. They are also associated with cystic fibrosis. Some patients also have asthma and are allergic to aspirin. What symptom could indicate bleeding post tonsillectomy? Patients with hyperphosphatemia Often experience what other electrolyte imbalance? What is a pleural effusion?  Where is the “voice box” located? How long should a patient with hoarseness in their voice wait before seeking health care provider guidance? How long should a nurse place pressure on a patient's nares Who is experiencing Epistaxis (nasal bleeding)? If a patient has a chest tube and tidaling stops and lung sounds are equal on both sides, this indicates what? What type of diuretic is furosemide? What indicates the presence of crepitus? A nurse notes vigorous bubbling in the water seal Chamber of the chest tube system. What should the nurse do? Elderly patients are at an increased risk for dehydration because They have decreased what? What is the priority after a bronchoscopy is performed? How many seconds can the nurse safely suction with each pass of the catheter during Endotracheal suctioning?  Narcotics, Hypnotics, and tranquilizers Are administered cautiously in patients who are experiencing What type of electrolyte imbalance? Severe diarrhea could cause what Electrolyte imbalance? What oxygen saturation level would require a need for oxygen orders? MORE PRACTICE ABGs PH: 7.47 CO2: 33 HCO3: 14= Respiratory Alkalosis PH: 7.21 CO2: 28 HCO3:12= Metabolic Acidosis PH: 7.37 CO2:53 HCO3: 33= Respiratory Acidosis pH: 7.21, CO2: 20, HCO3: 15= Metabolic Acidosis pH: 7.56, CO2: 38, HCO3: 31= Metabolic Alkalosis pH: 7.43, CO2: 54, HCO3: 34= Respiratory Acidosis pH: 7.28, CO2: 36, HCO3: 16= Metabolic Acidosis pH: 7.26, CO2: 51, HCO3: 33= Respiratory Acidosis pH: 7.81, CO2: 28, HCO3: 18= Respiratory Alkalosis pH: 7.68, CO2: 39, HCO3: 31= Metabolic Alkalosis 1. pH: 7.14, CO2: 40, HCO3: 12= 2. pH: 7.85, CO2: 55, HCO3: 29= 3. pH: 7.34, CO2: 50, HCO3: 23= 4. pH: 7.22, CO2: 48, HCO3: 25= 5. pH: 7.34, CO2: 21, HCO3: 19= 6. pH: 7.14, CO2: 46, HCO3: 35= 7. pH: 7.68, CO2: 42, HCO3: 32= 8. pH: 7.25, CO2: 22, HCO3: 12= 9. pH: 7.44, CO2: 53, HCO3: 31= 10. pH: 7.28, CO2: 36, HCO3: 18= R= RESPIRATORY= CO2 high & pH low= Respiratory Acidosis O: OPPOSITE =CO2 low & pH high= Respiratory Alkalosis M: METABOLIC= HC03 low & pH low= Metabolic Acidosis E: EQUAL= HCO3 high & pH high= Metabolic Alkalosis HIGH pH & LOW co2= Resp. Alkalosis LOW pH & HIGH co2= Resp. Acidosis HIGH pH & HIGH HCO3= Metabolic Alkalosis LOW pH & LOW HCO3= Metabolic Acidosis NORMAL pH, LOW co2, LOW HCO3= Metabolic Acid NORMAL pH, HIGH co2, HIGH HCO3= Metabolic Alkalosis