HESI STUDY GUIDE RESPIRATORY

HESI STUDY GUIDE RESPIRATORY Penumonia – Inflammation of the lower respiratory tact o Types:  Bacterial (gram positive / negative)  Viral  Fungal (rare)  Chemical o Reach lungs by:  Aspiration  Inhalation  Hematogenous Spread o High Risk Groups  Altered Level of Consciousness  Depressed/absent gag and cough reflexes  Susceptible to aspirating - Oropharyngeal secretions • Alcoholic, anesthetized individuals  Drug Overdose  Stroke Victims  Immunocompromised o Nursing Assessment  Tachypnea – shallow, often accessory muscles  Sudden onset of fever/shaking/chills  Productive Cough with pleuritic (lung) pain  Rapid/bounding pulse  Breath sounds - crackles o OLDER ADULTS: confusion, lethargy/malaise, anorexia, tachypnea, tachycardia o Interventions:  Assess sputum – COCA  Turn and deep breath q2hrs  Humidify room/oxygen  Chest physiotherapy  3L/day of fluids (liquefies secretions)  Monitor ABG’s • PO2 80, PCO2 45  Encourage at risk groups to get annual pneumonia and flu shots