MedSurge Respiratory

Med Surge Respiratory Fever can cause _________ because of excessive fluid loss due to diaphoresis. Increased temperature also increases _________ and the demands for 02. Dehydration, metabolism Clients at high risk for pneumonia 1.) Altered level of consciousness 2.) depressed or absent gag and cough reflex 3.) Susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals 4.) Brain injury 5.) drug overdose 6.) stroke victims 7.) Immunocompromised _____________ are heard over areas of density or consolidation. _______ are easily transmitted over consolidated tissue Bronchial breath sounds, sound waves Hydration purpose in pneumonia 1.) thins out the mucus trapped in the bronchioles and alveoli, facilitating expectoration 2.) Essential for client experiencing fever 3.) Is important because 300-400 ml of fluid is lost daily by the lungs through evaporation. Early signs of cerebral hypoxia? Irritability and restlessness. Brain is not receiving enough 02. Pneumonia preventives in older adults, immunosuppressed and debilitated persons, comatose and immobile persons, and patients with functional or anatomic asplenia? Older Adults: Flu shots, immunizations, avoiding pollutants; no smoking Immunosuppressed and debilitated persons: Flu shots, immunizations, infection avoidance, sensible nutrition, adequate intake, balance of rest and activity Comatose and immobile persons: Elevation of head of bed to feed and for 1 hour after feeding; frequently turning. Patients with functional or anatomic asplenia: flu and pneumonia immunizations. Exposure to ____________ is the primary cause of COPD in the united states Tobacco smoke What ABG changes in COPD? As copd worsens, the amount of 02 in the blood decreases (hypoxemia) and the amount of CO2 in the blood increases (hypercapnia) causing chronic respiratory acidosis, which results in metabolic alkalosis as compensation. Why don't all clients with COPD retain CO2. CO2 diffuses more easily across lung membranes than 02. Difference between emphysema and bronchitis In advanced emphysema, due to alveoli being affected, hypercarbia is a problem, rather than in bronchitis, where the airways are affected. Patient Postion for clients with COPD Productive cough and comfort can be facilitated by semi-fowler or high-fowler position, which lessens pressure on the diaphragm by abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits full lung expansion. Normal ABG Values Blood Gas Adult Child Blood Gas 7.35-7.45 same PC02 35-45 same Po2 80-100 same HCO3- 21-28 same Pink Puffer sign of? barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe. The person works harder to breathe, but he amount of 02 taken in is adequate to oxygenate the tissues. Blue bloater sign of? Insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right sided heart failure Signs of inadequate arterial oxygenation Cyanosis and slow capillary refill (<3 seconds). A chronic signs is clubbing of the fingernails, and a late signs is clubbing of the fingers. Health promotion tips for respiratory compromised patients 1.) offer mechanically soft diets which don't require as much chewing and digestion 2.) avoid crowds, contact with people who have infectious diseases and smoke to prevent secondary infections. 3.) Teach client to report any change in characteristics of sputum 4.) Encourage client to hydrate well and decrease caffeine due to diuretic effect 5.) obtain immunizations when needed Priority nursing actions, use ABC rule. 1.) Airway 2.) Breathing 3.) Circulation In CPR, follow CAB guideliens If breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not occurring . ... Keys to respiratory status include? assessment of breath sounds and visualization of the client Breath sounds should be described and not named....ex: crackles, wheezes or high pitched whistling sounds rather than rales, rhonchi, which may not mean the same thing to each clinical professional. What level of 02 delivery must be humidified if delivered directly to the trachea? >4 L/min of 02. If given at 1-4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification. Tongue appearance with cancer of the larynx? white, gray, dark brown, or black and may appear patchy. Tracheostomy care involves cleaning the inner cannula, suctioning, and applying clean dressing ... What to monitor for clients who had a laryngectomy? The natural humidifying pathway is gone for these clients and if the air is not humidified before entering the lungs, secretions tend to thicken and become crusty. Greatest postoperative risk for client who had a laryngectomy? Observe for signs of bleeding or occlusion. A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Technique to prevent choking in laryngectomy clients? Clients cannot cough as they could due to the glottis being gone. Take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube. Criteria for postive TB skin test? An induration of 10 mm or greater in diameter 48 to 72 hours after the skin test Analysis for clients who received the BCG vaccine for TB test? Chest x-rays are required Drug therapy teaching points for TB? Drug therapy is usually 6 months or longer and is essential that the client take the medications as prescribed for the entire time. Rifampin pt. teaching 1.) Reduces the effectiveness of oral contraceptives; client should use other birth control methods during treatment; 2.) gives body fluids orange tinge; 3.) Stains soft contact lenses Isoniazid pt. teaching Increases phenytoin (dilantin) levels Ethambutol pt. teaching Have a vision check before starting therapy and monthly thereafter; may have to take for 1-2 years Rationale for combination TB drug therapy Resistance of bacteria develops more slowly if several anti-TB drugs given, instead of just one at a time Large tumor nursing intervention in the lungs Do not administer chest tubes when large tumors are removed. Large spaces are left and filling the mediastinal cavity with fluid helps prevent the shift of the remaining cheese organs to fill the empty space. Chest tube intervention if disconnected? Place the end of the tube in a container of sterile saline or water until a new drainage system can be connected Chest tube intervention if removed from the client? Cover with a dry sterile dressing, if air leak is noted, tape the dressing on three sides only; this allows air to escape and prevents the formation of tension pneumothorax. Chest tube fluctuations Fluctuations in the fluid will occur in there is no external suction, indicating the system is intact. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions or change in the clients position.