MEDICAL SURGICAL NURSING EXAM Q&A
STUDY GUIDE WITH VERIFIED ANSWERS
◉ Pathophysiology of PE. Answer: Most commonly, PE is due to a
blood clot or thrombus. However, there are other types of emboli: air,
fat, amniotic fluid, and septic (from bacterial invasion of the
thrombus). When a thrombus completely or partially obstructs a
pulmonary artery or its branches, the alveolar dead space is increased.
The area, although continuing to be ventilated, receives little or no
blood flow. Therefore, gas exchange is impaired or absent in this area.
In addition, various substances are released from the clot and
surrounding area that cause regional blood vessels and bronchioles to
constrict. This results in an increase in pulmonary vascular
resistance—a reaction that compounds the V./Q. imbalance.
◉ Clinical Manifestations of PE. Answer: Dyspnea is the most
frequent symptom; the duration and intensity of the dyspnea depend
on the extent of embolization.
Chest pain is common and is usually sudden and pleuritic in origin. It
may be substernal and may mimic angina pectoris or a myocardial
infarction.
Other symptoms include anxiety, fever, tachycardia, apprehension,
cough, diaphoresis, hemoptysis, and syncope. The most frequent sign
is tachypnea (very rapid respiratory rate).
Obstruction of the pulmonary artery results in pronounced dyspnea,
sudden substernal pain, rapid and weak pulse, shock, syncope, and
sudden death.
,◉ Emergency Management of PE. Answer: Emergency management
consists of the following actions:
Nasal oxygen is given immediately to relieve hypoxemia, respiratory
distress, and central cyanosis; severe hypoxemia may necessitate
emergent endotracheal intubation and mechanical ventilatory support.
IV infusion lines are inserted to establish routes for medications or
fluids that will be needed.
For hypotension that does not resolve with IV fluids, prompt initiation
of vasopressor therapy is recommended, with agents that may include
dobutamine, dopamine, or norepinephrine.
Hemodynamic measurements and evaluation for hypoxemia (pulse
oximetry or arterial blood gas) are performed. If available, MDCTA
will be performed.
The ECG is monitored continuously for dysrhythmias and right
ventricular failure, which may occur suddenly.
Blood is drawn for serum electrolytes, complete blood count, and
coagulation studies.
If the patient has suffered massive embolism and is hypotensive, an
indwelling urinary catheter is inserted to monitor urinary output.
Small doses of IV morphine or sedatives are given to relieve patient
anxiety, alleviate chest discomfort, improve tolerance of the
endotracheal tube, and ease adaptation to the mechanical ventilator, if
necessary
◉ General Management/Treatment PE. Answer: After emergency
measures have been initiated and the patient is stabilized, the
treatment goal is to dissolve (lyse) the existing emboli and prevent
new ones from forming.
,Treatment may include a variety of modalities: general measures to
improve respiratory and vascular status, anticoagulation therapy,
thrombolytic therapy, and surgical intervention.
Measures are initiated to improve respiratory and vascular status.
Oxygen therapy is given to correct the hypoxemia, relieve the
pulmonary vascular vasoconstriction, and reduce the PH.
The use of anti-embolism stockings or intermittent pneumatic leg
compression devices reduces venous stasis. These measures compress
the superficial veins and increase the velocity of blood in the deep
veins by redirecting the blood through the deep veins.
Elevating the leg (above the level of the heart) also increases venous
flow. However, increasing flow may cause a volume challenge to a
hemodynamically unstable patient.
◉ Prevention of PE. Answer: The nurse encourages ambulation and
active and passive leg exercises to prevent venous stasis in patients
prescribed bed rest. The nurse instructs the patient to move the legs in
a "pumping" exercise so that the leg muscles can help increase venous
flow. The nurse also advises the patient not to sit or lie in bed for
prolonged periods, not to cross the legs, and not to wear constrictive
clothing. Legs should not be dangled or feet placed in a dependent
position while the patient sits on the edge of the bed; instead, feet
should rest on the floor or on a chair.
◉ What medications classes are given to patients on mechanical
ventilation?. Answer: Sedatives
Benzos
, Neuromuscluar Blocking Agents (paralytic agents)
◉ Sedatives/Benzos Given to Patients on Mechanical Ventilation.
Answer: Sedatives that may be used are lorazepam (Ativan),
midazolam (Versed), dexmedetomidine (Precedex), propofol
(Diprivan), and short-acting barbiturates.
Propofol (Diprivan) and Diazapam (Valium) are used to sedate/relax
patients on mechanical ventilation
◉ Neuromuscular Blocking Agents Given to Patients on Mechanical
Ventilation. Answer: Modern neuromuscular blocking agents, or
muscle relaxants, are divided into two classes, the nondepolarizing
and depolarizing muscle relaxants. Vecuronium, a nondepolarizing
aminosteroid compound, is the prototype. Neuromuscular blocking
agents facilitate easy tracheal intubation and mechanical ventilation
by relaxing the vocal cords, jaw, and associated respiratory muscles.
Vecuronium or other nondepolarizing neuromuscular blocking agents
are administered in critical care situations to enhance the therapeutic
effects of mechanical ventilation.
If the PEEP level cannot be maintained despite the use of sedatives,
neuromuscular blocking agents (paralytic agents) may be given to
paralyze the patient. Examples of these agents include pancuronium
(Pavulon), vecuronium (Norcuron), atracurium (Tracrium), and
rocuronium (Zemuron). The resulting paralysis allows the patient to
be ventilated more easily
◉ Nursing Care of Patients on Mechanical Ventilation. Answer: If the
patient is intubated and receiving mechanical ventilation with PEEP,
several considerations must be addressed. PEEP, which causes
increased end-expiratory pressure, is an unnatural pattern of breathing
and feels strange to the patient. The patients may be anxious and
"fight" the ventilator. Nursing assessment is important to identify
STUDY GUIDE WITH VERIFIED ANSWERS
◉ Pathophysiology of PE. Answer: Most commonly, PE is due to a
blood clot or thrombus. However, there are other types of emboli: air,
fat, amniotic fluid, and septic (from bacterial invasion of the
thrombus). When a thrombus completely or partially obstructs a
pulmonary artery or its branches, the alveolar dead space is increased.
The area, although continuing to be ventilated, receives little or no
blood flow. Therefore, gas exchange is impaired or absent in this area.
In addition, various substances are released from the clot and
surrounding area that cause regional blood vessels and bronchioles to
constrict. This results in an increase in pulmonary vascular
resistance—a reaction that compounds the V./Q. imbalance.
◉ Clinical Manifestations of PE. Answer: Dyspnea is the most
frequent symptom; the duration and intensity of the dyspnea depend
on the extent of embolization.
Chest pain is common and is usually sudden and pleuritic in origin. It
may be substernal and may mimic angina pectoris or a myocardial
infarction.
Other symptoms include anxiety, fever, tachycardia, apprehension,
cough, diaphoresis, hemoptysis, and syncope. The most frequent sign
is tachypnea (very rapid respiratory rate).
Obstruction of the pulmonary artery results in pronounced dyspnea,
sudden substernal pain, rapid and weak pulse, shock, syncope, and
sudden death.
,◉ Emergency Management of PE. Answer: Emergency management
consists of the following actions:
Nasal oxygen is given immediately to relieve hypoxemia, respiratory
distress, and central cyanosis; severe hypoxemia may necessitate
emergent endotracheal intubation and mechanical ventilatory support.
IV infusion lines are inserted to establish routes for medications or
fluids that will be needed.
For hypotension that does not resolve with IV fluids, prompt initiation
of vasopressor therapy is recommended, with agents that may include
dobutamine, dopamine, or norepinephrine.
Hemodynamic measurements and evaluation for hypoxemia (pulse
oximetry or arterial blood gas) are performed. If available, MDCTA
will be performed.
The ECG is monitored continuously for dysrhythmias and right
ventricular failure, which may occur suddenly.
Blood is drawn for serum electrolytes, complete blood count, and
coagulation studies.
If the patient has suffered massive embolism and is hypotensive, an
indwelling urinary catheter is inserted to monitor urinary output.
Small doses of IV morphine or sedatives are given to relieve patient
anxiety, alleviate chest discomfort, improve tolerance of the
endotracheal tube, and ease adaptation to the mechanical ventilator, if
necessary
◉ General Management/Treatment PE. Answer: After emergency
measures have been initiated and the patient is stabilized, the
treatment goal is to dissolve (lyse) the existing emboli and prevent
new ones from forming.
,Treatment may include a variety of modalities: general measures to
improve respiratory and vascular status, anticoagulation therapy,
thrombolytic therapy, and surgical intervention.
Measures are initiated to improve respiratory and vascular status.
Oxygen therapy is given to correct the hypoxemia, relieve the
pulmonary vascular vasoconstriction, and reduce the PH.
The use of anti-embolism stockings or intermittent pneumatic leg
compression devices reduces venous stasis. These measures compress
the superficial veins and increase the velocity of blood in the deep
veins by redirecting the blood through the deep veins.
Elevating the leg (above the level of the heart) also increases venous
flow. However, increasing flow may cause a volume challenge to a
hemodynamically unstable patient.
◉ Prevention of PE. Answer: The nurse encourages ambulation and
active and passive leg exercises to prevent venous stasis in patients
prescribed bed rest. The nurse instructs the patient to move the legs in
a "pumping" exercise so that the leg muscles can help increase venous
flow. The nurse also advises the patient not to sit or lie in bed for
prolonged periods, not to cross the legs, and not to wear constrictive
clothing. Legs should not be dangled or feet placed in a dependent
position while the patient sits on the edge of the bed; instead, feet
should rest on the floor or on a chair.
◉ What medications classes are given to patients on mechanical
ventilation?. Answer: Sedatives
Benzos
, Neuromuscluar Blocking Agents (paralytic agents)
◉ Sedatives/Benzos Given to Patients on Mechanical Ventilation.
Answer: Sedatives that may be used are lorazepam (Ativan),
midazolam (Versed), dexmedetomidine (Precedex), propofol
(Diprivan), and short-acting barbiturates.
Propofol (Diprivan) and Diazapam (Valium) are used to sedate/relax
patients on mechanical ventilation
◉ Neuromuscular Blocking Agents Given to Patients on Mechanical
Ventilation. Answer: Modern neuromuscular blocking agents, or
muscle relaxants, are divided into two classes, the nondepolarizing
and depolarizing muscle relaxants. Vecuronium, a nondepolarizing
aminosteroid compound, is the prototype. Neuromuscular blocking
agents facilitate easy tracheal intubation and mechanical ventilation
by relaxing the vocal cords, jaw, and associated respiratory muscles.
Vecuronium or other nondepolarizing neuromuscular blocking agents
are administered in critical care situations to enhance the therapeutic
effects of mechanical ventilation.
If the PEEP level cannot be maintained despite the use of sedatives,
neuromuscular blocking agents (paralytic agents) may be given to
paralyze the patient. Examples of these agents include pancuronium
(Pavulon), vecuronium (Norcuron), atracurium (Tracrium), and
rocuronium (Zemuron). The resulting paralysis allows the patient to
be ventilated more easily
◉ Nursing Care of Patients on Mechanical Ventilation. Answer: If the
patient is intubated and receiving mechanical ventilation with PEEP,
several considerations must be addressed. PEEP, which causes
increased end-expiratory pressure, is an unnatural pattern of breathing
and feels strange to the patient. The patients may be anxious and
"fight" the ventilator. Nursing assessment is important to identify
