NUR265 TEST BLUEPRINT UNIT #2 | COMPLETE
SOLUTION |GRADED A+ | 100% CORRECT.
TOPIC NUMBER TOPIC NUMBER
OF ITEMS OF ITEMS
Pharmacology Math 1 Acromegaly 1
Chest Tube 2 HHS/DKA 8
Pneumothorax 2 Mechanical Ventilation 4
ARF/ARDS 5 Myxedema 1
Interdisciplinary Team 1 Hyper/hypothyroidism 8
Hypo/hyperparathyroidism 1 Graves Disease 1
Diabetes Insipidus 5 Pheochromocytoma 2
SAIDH 2 Adrenal Insufficiency 1
Cushing’s 2 Addison’s 1
Prioritization 2
« Fourteen of these test items are, directly or indirectly, related to the topics above
involving prioritization. Pay attention to prioritization buzz words like the
following: First, immediate, immediately, priority, most important, initially, or
next. Read slowly and take your time, no extra points if you finish first!
+ Keep in mind when using the blueprint to study, the “Plan of Care” always refers
to the Nursing Process and you must address the patient’s assessment, planning,
implementation, and evaluation of nursing care.
1. Review your lab values, from unit #1 of general blood chemistry panel, coagulation
studies, complete blood count, and serum osmolarity. Note the influencing factors of
medication regimes for various laboratory results and potential interventions in relation to
the disease processes studied in Unit #2.
2. Develop the plan of care for a patient with a chest tube, pneumothorax, and thoracotomy.
Pay attention specifically to the preparation and set-up, care, and precautions of a Pleur-
evac drainage system.
CHEST TUBE (chart 30-12 page 592): a drain placed in the pleural space, allows lung re-
expansion. Also prevents air and fluid from returning to the chest. Drainage system consists of
one or more chest tubes or drains, a collection container placed below the chest level, and a
water seal to keep air from entering the chest. Drainage system may be stationary, disposable,
self-contained system; or a smaller, portable, disposable, self-contained system that requires no
connection to a vacuum source.
,Tip of the tube used to drain air is placed near the front lung apex. The tube that drains liquid is
placed on the side near the base of the lung. After lung surgery, two tubes, anterior and posterior,
are used. The wounds are covered with airtight dressings.
Stationary chest tube drainage systems use a water-seal mechanism that acts as a one-way valve
to prevent air or liquid from moving back into the chest cavity. The Pleur-evac system is a
common devise using a one-piece disposable plastic unit with three chambers. The three
chambers are connected to one another. The tube(s) from the patient are connected to the first
chamber in the series of three. This is the drainage collection container. The second chamber is
the water seal to prevent air from moving back up the tubing system and into the chest. The third
chamber, when suction is applied, is the suction regulator. Chamber one collects the fluid
draining from the patient and does not have fluid in it at first. This fluid is measured hourl
during the first 24 hours.
Chamber two is the water seal that prevents air from
reentering the patient’s pleural space. As the trapped air leaves the pleural space, it will pass
through chamber one before entering chamber two, which should always contain at least 2cm of
water to prevent air from returning to the patient. As trapped air from the patient’s pleural space
passes through the water seal, which serves as a one-way valve, the water will bubble. Once all
the air has been evacuated from the pleural space, bubbling of the water seal stops.
QSEN NURSING SAFETY PRIORITY: Action Alert
For a water-seal chest tube drainage system, 2cm of water is the minimum needed in the water
seal to prevent air from flowing backward into the chest. Check the water level every shift and
add sterile water to this chamber to the level marked on the indicator (specified by the
manufacturer of the drainage system).
The
water in the narrow column of the water-seal chamber normally rises 2-4 inches during
inhalation and falls during exhalation, a process called tidaling. An absence of fluctuation may
mean that the lung has fully re-expanded or that there is an obstruction in the chest tube.
Chamber three is the suction control of the system. There are different types of suction, most
commonly wet or dry. With wet suction, the fluid level in chamber three is prescribed by the
PHCP (usually 20cm water). The chamber is connected to wall suction, which is turned up until
there is gentle bubbling in the chamber. With dry suction, the PHCP prescribes the suction level
to be dialed in on the device.
QSEN NURSING SAFETY PRIORITY: Action Alert
Manipulation of the chest tube should be kept to a minimum. Do not vigorously “strip” the chest
tube because this can create up to -400cm of water negative pressure and damage lung tissue.
Assess the respiratory status and document the amount and type of drainage hourly on the
collection chamber. Notify the surgeon if more than 70mL/hr of drainage occurs. After the first
24 hours, assess drainage at least every 8 hours.
, PNEUMOTHORAX: air in the pleural space causing a loss of negative pressure in chest cavity, a
rise in chest pressure and a reduction in vital capacity, which can lead to a lung collapse. It’s
often caused by blunt chest trauma.
Assessment findings include [ reduced or absent breath sounds of the affected side in
auscultation, hyperresonance on percussion, prominence of the involved side of the chest, which
moves ioorli with resiirations,
Interventions [ for a stable patient with a small pneumothorax who has mild sxs and no
continuing air leak, no treatment may be needed. For more severe pneumothorax, chest tube
therapy is essential.
THORACOTOMY: a surgical procedure to gain access into the pleural space of the chest and is
needed when there is initial blood loss of 1000mL from the chest of persistent bleeding at the
rate of 150 to 200mL/hr over 3-4 hours. Monitor vital signs, blood loss, and I&O. Assess the
patient’s response to the chest tubes and infuse IV fluids and blood as prescribed. The blood lost
through chest drainage can be infused back into the patient after processing if needed.
3. Describe the plan of care, medical interventions, assessment findings, and those at
highest risk for a PE, and hemo/pneumothorax
PULMONARY EMBOLISM: a collection of particulate matter (solids, liquids or air) that enters
the venous circulation and lodges in the pulmonary vessels. Large emboli obstruct pulmonary
blood flow, leading to reduced gas exchange, reduced oxygenation, pulmonary tissue hypoxia,
decreased perfusion and potential death. Any substance can cause an embolism, but a blood clot
is the most common.
Major risks factors for VTE leading to PE are:
* Prolonged immobility
= Central venous catheters
* Surgery
e Obesity
e Advancing age
» Conditions that increase blood clotting
* History of thromboembolism
Smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate),
and trauma increase the risk for VTE and PE.
Assessment (chart 32-2 page 618) [J signs and sxs range from vague, nonspecific discomfort to
hemodynamic collapse and death.
Assess patient for dyspnea and pleuritic chest pain (sharp,
stabbing-type pain on inspiration). Abnormal heart sounds, like an S3 or S4 may occur. ECG
changes are nonspecific and transient. T-wave and ST-segment changes may occur as can left-
SOLUTION |GRADED A+ | 100% CORRECT.
TOPIC NUMBER TOPIC NUMBER
OF ITEMS OF ITEMS
Pharmacology Math 1 Acromegaly 1
Chest Tube 2 HHS/DKA 8
Pneumothorax 2 Mechanical Ventilation 4
ARF/ARDS 5 Myxedema 1
Interdisciplinary Team 1 Hyper/hypothyroidism 8
Hypo/hyperparathyroidism 1 Graves Disease 1
Diabetes Insipidus 5 Pheochromocytoma 2
SAIDH 2 Adrenal Insufficiency 1
Cushing’s 2 Addison’s 1
Prioritization 2
« Fourteen of these test items are, directly or indirectly, related to the topics above
involving prioritization. Pay attention to prioritization buzz words like the
following: First, immediate, immediately, priority, most important, initially, or
next. Read slowly and take your time, no extra points if you finish first!
+ Keep in mind when using the blueprint to study, the “Plan of Care” always refers
to the Nursing Process and you must address the patient’s assessment, planning,
implementation, and evaluation of nursing care.
1. Review your lab values, from unit #1 of general blood chemistry panel, coagulation
studies, complete blood count, and serum osmolarity. Note the influencing factors of
medication regimes for various laboratory results and potential interventions in relation to
the disease processes studied in Unit #2.
2. Develop the plan of care for a patient with a chest tube, pneumothorax, and thoracotomy.
Pay attention specifically to the preparation and set-up, care, and precautions of a Pleur-
evac drainage system.
CHEST TUBE (chart 30-12 page 592): a drain placed in the pleural space, allows lung re-
expansion. Also prevents air and fluid from returning to the chest. Drainage system consists of
one or more chest tubes or drains, a collection container placed below the chest level, and a
water seal to keep air from entering the chest. Drainage system may be stationary, disposable,
self-contained system; or a smaller, portable, disposable, self-contained system that requires no
connection to a vacuum source.
,Tip of the tube used to drain air is placed near the front lung apex. The tube that drains liquid is
placed on the side near the base of the lung. After lung surgery, two tubes, anterior and posterior,
are used. The wounds are covered with airtight dressings.
Stationary chest tube drainage systems use a water-seal mechanism that acts as a one-way valve
to prevent air or liquid from moving back into the chest cavity. The Pleur-evac system is a
common devise using a one-piece disposable plastic unit with three chambers. The three
chambers are connected to one another. The tube(s) from the patient are connected to the first
chamber in the series of three. This is the drainage collection container. The second chamber is
the water seal to prevent air from moving back up the tubing system and into the chest. The third
chamber, when suction is applied, is the suction regulator. Chamber one collects the fluid
draining from the patient and does not have fluid in it at first. This fluid is measured hourl
during the first 24 hours.
Chamber two is the water seal that prevents air from
reentering the patient’s pleural space. As the trapped air leaves the pleural space, it will pass
through chamber one before entering chamber two, which should always contain at least 2cm of
water to prevent air from returning to the patient. As trapped air from the patient’s pleural space
passes through the water seal, which serves as a one-way valve, the water will bubble. Once all
the air has been evacuated from the pleural space, bubbling of the water seal stops.
QSEN NURSING SAFETY PRIORITY: Action Alert
For a water-seal chest tube drainage system, 2cm of water is the minimum needed in the water
seal to prevent air from flowing backward into the chest. Check the water level every shift and
add sterile water to this chamber to the level marked on the indicator (specified by the
manufacturer of the drainage system).
The
water in the narrow column of the water-seal chamber normally rises 2-4 inches during
inhalation and falls during exhalation, a process called tidaling. An absence of fluctuation may
mean that the lung has fully re-expanded or that there is an obstruction in the chest tube.
Chamber three is the suction control of the system. There are different types of suction, most
commonly wet or dry. With wet suction, the fluid level in chamber three is prescribed by the
PHCP (usually 20cm water). The chamber is connected to wall suction, which is turned up until
there is gentle bubbling in the chamber. With dry suction, the PHCP prescribes the suction level
to be dialed in on the device.
QSEN NURSING SAFETY PRIORITY: Action Alert
Manipulation of the chest tube should be kept to a minimum. Do not vigorously “strip” the chest
tube because this can create up to -400cm of water negative pressure and damage lung tissue.
Assess the respiratory status and document the amount and type of drainage hourly on the
collection chamber. Notify the surgeon if more than 70mL/hr of drainage occurs. After the first
24 hours, assess drainage at least every 8 hours.
, PNEUMOTHORAX: air in the pleural space causing a loss of negative pressure in chest cavity, a
rise in chest pressure and a reduction in vital capacity, which can lead to a lung collapse. It’s
often caused by blunt chest trauma.
Assessment findings include [ reduced or absent breath sounds of the affected side in
auscultation, hyperresonance on percussion, prominence of the involved side of the chest, which
moves ioorli with resiirations,
Interventions [ for a stable patient with a small pneumothorax who has mild sxs and no
continuing air leak, no treatment may be needed. For more severe pneumothorax, chest tube
therapy is essential.
THORACOTOMY: a surgical procedure to gain access into the pleural space of the chest and is
needed when there is initial blood loss of 1000mL from the chest of persistent bleeding at the
rate of 150 to 200mL/hr over 3-4 hours. Monitor vital signs, blood loss, and I&O. Assess the
patient’s response to the chest tubes and infuse IV fluids and blood as prescribed. The blood lost
through chest drainage can be infused back into the patient after processing if needed.
3. Describe the plan of care, medical interventions, assessment findings, and those at
highest risk for a PE, and hemo/pneumothorax
PULMONARY EMBOLISM: a collection of particulate matter (solids, liquids or air) that enters
the venous circulation and lodges in the pulmonary vessels. Large emboli obstruct pulmonary
blood flow, leading to reduced gas exchange, reduced oxygenation, pulmonary tissue hypoxia,
decreased perfusion and potential death. Any substance can cause an embolism, but a blood clot
is the most common.
Major risks factors for VTE leading to PE are:
* Prolonged immobility
= Central venous catheters
* Surgery
e Obesity
e Advancing age
» Conditions that increase blood clotting
* History of thromboembolism
Smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate),
and trauma increase the risk for VTE and PE.
Assessment (chart 32-2 page 618) [J signs and sxs range from vague, nonspecific discomfort to
hemodynamic collapse and death.
Assess patient for dyspnea and pleuritic chest pain (sharp,
stabbing-type pain on inspiration). Abnormal heart sounds, like an S3 or S4 may occur. ECG
changes are nonspecific and transient. T-wave and ST-segment changes may occur as can left-
