Test III Info Theory PDF

Oxygenation - COPD & Asthma COPD - Chronic obstructive pulmonary disease Slowly progressive resp. disease of airflow obstruction ○ Emphysema, chronic bronchitis ○ Preventable and treatable but not fully reversible ○ Involving the airways, pulmonary parenchyma, o...

Oxygenation - COPD & Asthma COPD - Chronic obstructive pulmonary disease Slowly progressive resp. disease of airflow obstruction ○ Emphysema, chronic bronchitis ○ Preventable and treatable but not fully reversible ○ Involving the airways, pulmonary parenchyma, or both Pathophysiology of COPD: Airflow limitation is progressive, associated with abnormal inflammatory response to noxious particles or gases. Chronic inflammation damages tissue Scar tissue in airways causes narrowing Scar tissue in parenchyma decreases elastic recoil (compliance) Scar tissue in pulmonary vasculature causes thickened vessel lining and hypertrophy of smooth muscle (pulmonary hypertension) COPD risk factors: Exposure to tobacco smoke Passive smoking Occupational exposure Pollution Genetic abnormalities Clinical manifestations of COPD 3 primary symptoms: ○ Chronic cough ○ Sputum production ○ Dyspnea Weight loss due to dyspnea “Barrel chest” Assessment and diagnosis of COPD: Health history Pulmonary function tests Spirometry Arterial blood gas  Chest x-ray Complications of COPD: Resp. insufficiency and failure Pneumonia Chronic atelectasis Pneumothorax Cor pulmonale Medical management: Promote smoking cessation Reduce risk factors Manage exacerbations Provide supplemental oxygen therapy Pneumonia vaccine Flu vaccine Pulmonary rehab Nursing management: Airway clearance (!!!) Breathing pattern ○ Diaphragmatic ○ Purse lipped Activity tolerance Monitor for complications ○ VS ○ X-ray ○ Lung sounds Chronic bronchitis: Cough and sputum production for at least 3 months in each of 2 consecutive years Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucous may plug airways Alveoli may be damaged, fibrosed, and alveolar macrophage function decreases Pt is more susceptible to resp. infection Emphysema: Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli Decreased alveolar surface area increases “dead space,” impaired oxygen diffusion Hypoxemia results Increased pulmonary artery pressure may cause right-side heart failure Symptoms of hypoxia: RAT - restlessness, anxiety, tachycardia/tachypnea BED - bradycardia, extreme restlessness, dyspnea (Peds) FINES - feeding difficulty, inspiratory stridor, nares flare, expiratory grunting, sternal retractions Exemplar: Asthma Chronic inflammatory disease of the airways that causes hyperresponsiveness, mucosal edema, and mucus production Inflammation leads to cough, chest tightness, wheezing and dyspnea Asthma is largely reversible; spontaneously or with treatment. Allergy is the strongest predisposing factor Risks for development of asthma attack: Allergens resp. Tract infections Exercise Drugs and chemicals Hormonal changes and emotional upsets Airborne pollutants GI reflux Clinical manifestations: Cough, dyspnea, wheezing Exacerbations: ○ Cough ○ Wheezing ○ Chest tightness  ○ Dyspnea ○ Diaphoresis ○ Tachycardia ○ Hypoxemia ○ Central cyanosis Diagnosis: History Physical Lab findings Pulmonary function tests Predictors of severity: Impairment: ○ Night time awakening ○ Need for short-acting bronchodilators to relieve symptoms ○ work/school days missed ○ Ability to engage in normal activities Future adverse events: ○ Number of exacerbations ○ # of ER visits per year ○ # of risk factors ○ Medication compliance Treatment: Quick relief meds ○ Beta 2 adrenergic agonist ○ Anticholinergics Long-acting meds: ○ Corticosteroids ○ Leukotriene modifiers ○ Long-acting beta 2 adrenergic agonists Pneumonia Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses Impacts ventilation and perfusion Class: based on causative organism, timing of exposure, extenuating circumstances Risk factors - Mucous production/bronchial obstruction - fluids, bronchodilators, coughing Immunosuppression - wear mask Smoking - immobility/depressed cough/dysphagia/aspiration - activity as tol, spirometer, suctioning, elevate HOB Antibiotic therapy - take full dose and regimen, ETOH - Sedation - Older adult - Unclean equipment - Organism transmission HCP - Clinical manifestations Various depending on type Streptococcal: sudden onset of chills, fever, pleuritic chest pain, tachypnea, resp. distress Viral, mycoplasma, or legionella: relative bradycardia Other: respiratory tract infection, headache, low-grade fever, pleuritic pain, myalgia, rash, pharyngitis Orthopnea, crackles, purulent sputum Assessment and diagnosis: History Physical exam Chest x-ray Blood culture Sputum examination bronchoscopy Medical management Antibiotics - primary bacterial infection or secondary to viral infection Supportive treatment - fluid, oxygen, antipyretics, antitussives, decongestants, antihistamines Nursing assessment: Vital signs Secretions: amount, color, odor Cough: frequency and severity  Tachypnea, SOB Inspect and auscultate chest Changes in mental status, fatigue, edema, dehydration, concomitant heart failure, especially in older pts Diagnosis: Infective airway clearance Fatigue and activity intolerance Risk for FVD Imbalance nutrition Knowledge deficit Collaborative problems Continuing symptoms after initiation of therapy Sepsis and septic shock resp. Failure Atelectasis Pleural effusion Delirium Planning: Improved airway patency Increased activity Maintenance of proper fluid volume Maintain adequate nutrition Understanding treatment protocol and preventative measures Absence of complications Prevention: Pneumococcal vax  ○ Reduces pneumonia incidence and deaths in older population ○ Recommended for all adults 65+ and 19+ with conditions that weaken the immune system Interventions: Oxygen with humidification ○ Face mask / nasal cannula Coughing techniques Chest physiotherapy Position changes Incentive spirometry Nutrition Hydration Rest Activity as tol Pt teaching Self-care Expected outcomes: Demonstrates improved airway patency Rests and conserves energy and then slowly increases activity Adequate hydration and nutrition Verbalizes knowledge about management strategies Complies with management strategies Exhibits no complications Aspiration: Inhalation of material into lungs S/S: tachycardia, dyspnea, central cyanosis, hyper/hypotension, potential death Nursing interventions ○ HOB elevated ○ Avoid gag reflex ○ Check for placement before tube feedings ○ Thickened fluids for swallowing problems CO2 + H2O = H2CO3 (carbonic) acid Carbonic acid levels are controlled by resp center in medulla oblongata Resp center provides partial compensation for imbalance Exhausts quickly How do lungs compensate during acidosis? When pH is low: ○ H+ ions increased ○ Acidosis occurs ○ Resp center is stimulated ○ Rate and depth of respirations increase ○ Lungs blow of carbon dioxide ○ Less carbonic acid in body ○ pH returns to normal How do lungs compensate during alkalosis? When pH is high: ○ H+ ions decreased ○ Alkalosis occurs ○ Resp center is depressed ○ Rate and depth of resps decrease ○ Lungs retain carbon dioxide ○ More carbonic acid in body ○ pH returns to normal Renal system: Excretes acidic or alkaline urine Takes 24-48 hours to start working Will fully compensate if kidneys are working properly How do kidneys compensate during acidosis? When pH is low: ○ H+ ions are increased  ○ Acidosis occura ○ Kidneys excrete H+ ions (acid) and retain HCO3 (base) ○ Less H2CO3 (carbonic acid) in body more HCO3 ○ pH returns to normal How do kidneys compensate during alkalosis? When pH is high: ○ H+ ions are decreased ○ Alkalosis occurs ○ Kidneys retain H+ ions (acid) and excrete HCO3 (base) ○ More H2CO3 (carbonic acid) in body, less HCO3 ○ pH returns to normal Acid-base effect on electrolytes: K+ and H+ move freely between ICF/ECF Acidosis can result in hyperkalemia Acidosis ○ High H+ in ECF ○ H+ shift into ICF ○ K+ shift into ECF ○ High H+ excreted by renal tubules and high K+ reabsorbed in exchange Compensation: Occurs in 3 stages: ○ Uncompensated Body is in imbalance, no comp has occurred ○ Partially compensated Body is trying to adjust but is not complete ○ Fully compensated Restoration of pH is in progress and success is noted by changes in ABGs - underlying cause may still be uncorrected ABGs - Ph: 7.35 - 7.45 paO2 - 80 - 100 mmHg PaCO2 - 35 - 45 mmHg HCO3 - 22 - 26 mEq/L  O2Sat - 95 - 100 % Classes of imbalances: Resp imbalances ○ Resp acidosis - increase in carbonic acid ○ Resp alkalosis - decrease in carbonic acid Metabolic imbalances ○ Metabolic acidosis - decrease in bicarbonate ○ Metabolic alkalosis - increase in bicarbonate Hypoventilation caused by: Drugs ○ Anesthesia ○ Barbiturates ○ Narcotics Head trauma Cardiac arrest Respiratory disease or trauma Improperly regulated ventilator Neuromuscular disorders that prevent resp muscles from working ○ Guillain-Barre syndrome ○ ALS S/S: Dyspnea Hypoxia Headache Tremors Decreased LOC and mental confusion Drowsiness that may progress to coma Labs:  pH less than 7.35 PaCO2 greater than 45 HCO3 within normal limits Hyperkalemia Compensatory mechanisms: Buffer system Kidneys: ○ Excrete H+ ○ Retain HCO3 ○ Kidneys must be healthy to compensate Resp alkalosis: Excessive amounts of CO2 exhaled: pH is high Pathophysiology: hyperventilation Causes: High temp Anxiety disorders Improperly regulated ventilator S/S: Rapid deep breathing Anxiety, panic Numbness, tingling Convulsions Confusion Labs: pH greater than 7.45 PaCO2 less than 35mm Hg HCO3 WNL Metabolic acidosis:  Pathophysiology ○ Increased production of metabolic acids ○ Decreased excretion of metabolic acids ○ Increased loss of HCO3 ○ Increased chloride levels Causes ○ Acute lactic acidosis: Cardiac arrest Starvation ○ Salicylate poisoning ○ Diabetic ketoacidosis ○ Renal failure ○ Loss of bicarbonate from: Chronic diarrhea Intestinal fistula Pancreatic or biliary drainage S/S: Depression of CNS ○ Drowsiness ○ Weakness ○ Decreased LOC ○ Coma Hyperkalemia Nausea/vomiting Labs: pH less than 7.35 PaCO2 within normal limits HCO3 less than 22mEq/L hyperkalemia Metabolic alkalosis: Excessively high levels of base or decrease in metabolic acids Causes: ○ Ingestion of high doses of alkaline medications ○ Excessive output of gastric content: Vomiting Gastric suction S/S:  ○ Stimulation of CNS Hyperirritibility Confusion Lightheadedness Numbness Tingling Labs: ○ pH greater than 7.45 ○ PaCO2 within normal limits ○ HCO3 greater than 26 Compensation ○ Respiratory Hypoventilation to conserve CO2 ○ Renal: Retain H+ Excrete HCO3 Assessment of GI system 1# Health history: Information about abd pain, dyspepsia, gas, nausea, vomiting, etc is obtained Pain: ○ Character, duration, frequency, location, distribution of abd pain, and timing of pain are all important. Details of assessment: Dyspepsia: most common symptom of pt with GI dysfunction Intestinal gas: bloating, distention, feeling full of gas, with excessive flatulence can be signs of foot intolerance or gallbladder disease N/V Changes in bowel habits or stool character: may signal colonic dysfunction or disease Past health, family, and social history: oral and dental, lesions in mouth, discomfort with certain food, alc and tobacco usage, dentures. Physical assessment of GI system: Oral cavity:  Lips Gums Tongue Abd assessment: Inspection Auscultation Percussion Palpitation Rectal inspection Nursing interventions for GI tests: Inform provider of medical conditions or ab values that may affect procedure Assess for adequate hydration before during and after procedure Provide health info to pts and significant others Provide postprocedural care info Help pt cope with discomfort and anx GERD: Common disorder in which backflow of gastric or duodenal contents into the esophagus causing injury to the esophagus. Increased incidence with age. Risk factors include tobacco, coffee, alcohol, gastric infection Assessment and symptoms: Regurgitation Indigestion Odynophagia Ulcers in pharynx Dental erosion Laryngeal damage Diagnostic study:  Barium swallow - consuming a radiopaque liquid followed by fluoroscopic exam. ○ Allows visibility of structures and movement Nursing interventions: Pre-op: NPO or clear liquid/low residue diet NPO after midnight No smoking or gum-chewing Bowel cleansing prep Meds held day of Post-op Increase fluids after assessing gag reflex Laxative Management of GERD: Low-fat diet Avoid caffeine, tobacco, beer, alcohol, mint, carbonated beverages Avoid eating or drinking 2 hours before bed Elevate HOB by at least 30 degrees Endoscopy: Visualization of structures through a lighted scope Endoscopy nursing interventions: Pre op ○ NPO for 8 hours Intra-procedure ○ Local anesthetic or spray to throat ○ IV sedation ○ Atropine to dry secretions ○ Left lateral position Post-procedure ○ LOC ○ VS, O2 sat ○ Pain  ○ Assess s/s perforation Pain, bleeding, difficulty swallowing ○ Return of gag reflex Exemplar: Obesity Associated with 6 to 20-year decrease in life expectancy Cancer risk increases with BMI Likelihood of DBII increased 10-fold Asthma or HTN by fourfold Twice as likely to have Alzheimer's Chronic inflammation changes Assessment Height and weight to determine BMI ○ Overweight = BMI 25 - 29.9 ○ Obese = over 30 ○ severe/extreme obesity = Over 40 BMI calculation: Weight in lbs/height in inches x 703 Waist circumference greater than >35 in women and greater than 40 in men = greater risk for obesity Hip to waist ratio = “apple” vs “pear” shape Lab studies = cholesterol, triglycerides, fasting BG, HA1c, liver function Nutritional assessment Dietary intake ○ 24-hour recall ○ Food diary ○ Food frequent records ○ Full diet history Medical and socioeconomic data ○ Medical ○ Social ○ Economic Anthropometric data ○ Accurate height and weight ○ BMI ○ Waist circumference Clinical observations for nutritional assessment Signs of good nutritional status: ○ Alert ○ Energetic ○ Shiny, lustrous hair ○ Pink, moist lips ○ No cavities ○ Smooth, uniform-colored skin ○ Firm nails ○ well-developed/toned muscles ○ Physiological stability ○ Normal VS Signs of poor nutritional status ○ Listless ○ Easily fatigued ○ Dry, brittle hair ○ Dark skin under eyes ○ Missing teeth ○ Pale skin ○ Spoon-shaped nails ○ Difficulty walking ○ Depression ○ Swollen abdomen Nutrition lab values: RBC: M = 4.2 - 5.4. F = 3.6 - 5.0 ○ # of RBCs in blood. High equals dehydration, chronic hypoxia, increased production. Low equals blood loss, destruction, decreased production, FVE HGB: 12.4-17.4g/dL (M) 11.7-16g/dL (F) ○ O2 carrying capacity of RBCs ○ High = dehydration, increased RBC production ○ Low = anemia, blood loss, FVE, destruction ○ Hct = 42-52% (M) 36-48% (F) % of RBC in blood ○ High = dehydration, increased RBC production ○ Low = anemia, blood loss Prealbumin = 19 – 38 mg/dL ○ Measures protein produced in liver ○ low = Protein depletion/malnutrition Serum albumin = 3.5 – 5.2 g/dL  ○ Most abundant protein; helps maintain osmotic pressure in vascular and extravascular spaces ○ Low = malnutrition (prolonged protein depletion) malabsorption Total protein = 6.0-8.0 g/dL ○ Measures serum albumin and globulin ○ low = dehydration; vomiting/diarrhea ○ low = malabsorption/malnutrition; prolonged ○ Bedrest Fasting glucose = 60-100 mg/dL ○ Measure plasma glucose level after a 12- to 14-hour fast ○ low = malabsorption syndrome BUN = 6-20 mg/dL ○ Byproduct of protein metabolism ○ high = Decreased renal function ○ low = Low protein intake Creatinine = 0.6-1.2 mg/dL (M) 0.4-1.0 mg/dL (F) ○ Byproduct of metabolism ○ High = dehydration, muscle damage, decreased kidney function ○ Low = decreased protein intake, decreased muscle mass Obesity management interventions Lifestyle modifications Pharmacologic Nonsurgical Surgery Lifestyle modification Aimed at weight loss and maintenance Setting weight loss goals Improving diet habits Increasing physical activity Addressing barriers to change Self-monitoring and strategizing ongoing lifestyle changes aimed at a healthy weight Healthy sleep habits Medications for obesity Antiobesity medication meant to supplement not supplant diet modification and exercise Indications ○ BMI >30 ○ BMI >27 with related concomitant morbidity Action: ○ Inhibit GI absorption of fats ○ Altering central brain receptors to enhance safety or reduce cravings Nursing management Approach pts with obesity with the same respectful, courteous, and empathetic behavior as extended to pts without obesity Understand effects of obesity ○ Mechanics of ventilation and circulation ○ Pharmacokinetics and pharmacodynamics ○ Skin integrity ○ Body mechanics and mobility Effects of obesity: Mechanics of ventilation and circulation ○ Maintain in low fowlers to maximize chest expansion ○ Continuous pulse oximetry ○ Supplemental oxygen ○ Frequent respiratory assessments ○ CPAP/BiPAP Central and peripheral circulatory compromise ○ Use appropriately sized BP cuff ○ Monitor for DVT ○ Correct medication dose ○ Pressure injuries Pharmacokinetics and pharmacodynamics ○ Understand that some drugs have enhanced effects while others have diminished effects in pts with obesity ○ Altered liver function impacts some drug metabolism ○ Be cognizant that weight-based calculations of drug dosages for pts with obesity may need to be altered Skin integrity and body mechanics ○ Assess for pressure ulcers Outcome planning and implementation Goal: maintain or restore optimal nutritional status Nutritional education Monitor status Stimulate appetite Assist with eating Enteral feeding: Meet nutritional requirements when oral intake is not possible but the GI tract is functional Advantages: ○ Safe and cost-effective ○ Preserve GI integrity  ○ Preserve normal metabolism Tube feeding administration methods Tubes ○ Nasogastric or nasoenteral tubes ○ Gastrotomy or jejunostomy tubes for long term feeding Methods ○ Intermittent bolus feedings ○ Intermittent gravity drip ○ Continuous infusion ○ Cyclic feeding Verifying placement of tube: Verify placement BEFORE instilling food, fluids, or medications Methods: ○ Xray ○ Inject air and auscultate over stomach ○ Gastric pH ○ Assess aspirate ○ CO2 monitoring ○ Measuring tube length Caring for a pt receiving and enteral feeding: Tube placement Pts ability to tolerate formula and amount Clinical response Signs of dehydration Elevated BG level, decreased urinary output, sudden weight gain, and periorbital or dependent edema Infection control practices Check gastric residual I&O, weekly weights, dietician consult Problems and potential complications: N/V Gas, bloating, cramping Dumping syndrome Aspiration pneumonia Tube displacement Tube obstruction Nasopharyngeal irritation Hyperglycemia Dehydration and azotemia Planning care for pt receiving enteral feeding  Major goals: ○ Nutritional balance ○ Normal bowel elimination pattern ○ Reduced risk for aspiration ○ Adequate hydration ○ Individual coping ○ Knowledge and skill in self-care ○ Prevention of complications Maintaining nutrition balance and tube function Administer feeding at prescribed rate and method according to pt tolerance Measure gastric residual volumes before intermittent feedings and every 4 - 8 hours during continuous feedings. Hold for residual > 500 ml Admin water before and after each med and feeding, before and after checking residual, every 4 - 6 hours, and whenever the tube feeding is discontinued or interrupted Do not mix meds and feedings Use a 30-mL or larger syringe Maintain delivery system as required. Do not hang more than 4 hours of feeding in open system. Maintaining normal bowel elimination: Selection of TF formula; consider fiber, osmolality, and fluid content Prevent contamination; maintain closed system; do not hang longer than 4 hours in open system Maintain proper nutritional intake Assess reason for diarrhea and obtain treatment as needed Administer slowly to prevent dumping syndrome Avoid cold TF Nursing care: responding Attaining optimal level of nutrition Preventing infection Maintaining skin integrity Adjusting to changes in body image Preventing complications Flush tube 30 mL water Flush between each medication Potential complications: Diarrhea NV Gas, bloating, cramping Dumping syndrome Aspiration pneumonia  Tube displacement Tube obstruction Nasopharyngeal irritation Hyperglycemia Dehydration and azotemia Parenteral therapy Intake is insufficient to maintain anabolic state Ability to ingest food orally or by tube is impaired Underlying medical condition precludes oral or TF Pt is uninterested in ingesting adequate nutrients Preoperative and postoperative needs are prolonged Assessment/noticing: Assistant in identifying pts who need PN ○ Decreased oral intake over 1 week ○ Weight loss 10% or more of usual ○ Muscle wasting, decreased tissue healing ○ Persistent NV ○ Hydration status ○ Electrolytes ○ Caloric intake Diagnoses: Imbalanced nutrition Risk for infection Risk for imbalanced fluid volume Risk for activity intolerance Complications Pneumothorax Clotted or displaced catheter Sepsis Hyperglycemia Rebound hypoglycemia Fluid overload Planning Attaining optimal nutrition Absence of infection Adequate fluid volume Optimal level of activity Knowledge of self-care Absence of complications Maintaining optimal nutrition Daily weight at same time daily Accurate I&O Caloric count Trace elements included in solution Maintaining fluid balance: Infusion pump. Flow should not be changed rapidly, if fluid runs out, hang 10% dextrose solution Monitor indicators of fluid balance and electrolyte levels I&O Weights Monitor BG levels PT education: Goals and purpose Components of PN Demonstrate use of equipment Demonstrate dressing change Potential complications and actions Elimination The removal of waste from the body via: ○ Skin ○ Lungs ○ Kidneys ○ Intestines Occurs via: ○ Perspiration ○ Expiration ○ Urination ○ Defecation Elimination: normal vs abnormal Normal: toxins are excreted from body via urine, stool, sweat, or drainage Abnormal: normal methods of excretion are altered because of malformations, failure of organs/systems, injuries, medication side effects, or sensory deficits Assessment: I&Os Bowel elimination  Urination Use of diapers, bedside commode, etc Pt hx of elimination malfunction such as cystitis, diverticulitis, colitis, abd surgeries Presence of flank pain, abd pain, hematuria, etc Urinary incontinence risk factors: Constipation Caucasian or Hispanic Obesity Smoking Chronic cough Pregnancy and childbirth Nerve injury to lower back History of pelvic surgery Menopause Enlarged prostate Prevention of urinary incontinence Frequent and full emptying of bladder Prevent constipation High fiber diet Adequate weight to prevent obesity Drink plenty of fluids (no holding of fluids) Kegel exercises Diagnostic tests/procedures Urinalysis Renal panel (BUN, creatinine, GFR) Urine C&S Bladder scanning for urine retention KUB ultrasound to rule out obstruction MRI, CAT scan, U/S to rule out adhesions from previous bladder surgeries or mass Self-catheterization for those with reflex incontinence Biopsy Cystoscope Nursing implications Urinary catheter insertion (caution for CAUTI) Establish bladder training schedule Maintain urinary catheter/leg bag/condom catheter Document strict I&Os Pt education Suprapubic catheter care Education pt on correct self-catheterization  ○ Consider need for home health - communicate with case manager Benign prostatic hyperplasia (BPH) Enlargement of prostate Usually seen in men >40 years old By age 60, 50% of males will have BPH Can cause complete blockage of urethra, leading to urinary retention Risks for BPH: >estrogen,