NR 325Adult health 2 Hesi study Guide

Respiratory system Pathophysiology Nursing Assessment Analysis Plans Hints Pneumonia: Inflammation of lower respiratory tract Caused by infectious agents 1. Aspiration 2. Inhalation 3. Hematogenous spread Organisms reach the lungs in 3 methods: 1. Bacterial (gram pos and neg) 2. Viral 3. Fungal 4. Chemical Pneumonia is classified according to causitive agent Pneumonia may be community acquired or nosomcomial 1. Debilitated by lung secretions 2. Cigarette smokers 3. Immoblie 4. Imunosuppressed Expereincing a depressed gag reflex 5. 6. Sedated Experiencing neuromusclar disorders 7. High risk groups include Tachypnea: shallow respirations with use of accessory muscles. A. Abrupt onset of fever with shaking and chills (not reliable in O/A) B. C. Productive cough with pleuritic pain D. Rapid bounding pulse 1. Confusion 2. Lethargy 3. Anorexia 4. Rapid respiratory rate E. In older adults sx include: Pain and dullness to percussion over the affected lung area F. G. Bronchial breaht sounds/crackles Chest radiography indication of inflitrates with consolidation or pleural effusions H. I. Elevated white blood cell coung J. ABG of hypoxemia On pulse oximetry a drop in O2 satruation ( 90 and ideally 95) K. A. Impaired gas exchange related to… B. Ineffective airway celarance related to… C.Activity intolerance related to… D. Risk for deficient fluid volume related to…. E. Ineffective breathing pattern related to… Assess suptum for volume, color, consistency and clarity. A. deep breathing care every 2 hours (many use incentive spiometer) 1. Using humidity to loosen sevretions (may be oxylgenerated) 2. 3. Suctioning airway if necessary B. Assist client to cough productively by: Assess lung sounds before and after coughing C. Assess rate, depth, and pattern of respirations regularly (normal adult rate 16 to 20 breaths/min) D. Monitor Abg's (pO2 80mm2; Pco2 45mm hg) E. Monitor O2 saturation with pulse oximetry (ideally 95%) F. G. Assess skin color Assess mental status, restlessness, and irritability H. I. Administer o2 as prescribed J. Monitor temperature regularly Provide adequate rest periods, including uniterrupted sleep. K. Encourage at risk groups to annual pneumonia and influenza (flu) immuniziations. L. High risk for pneumonia Any person who has an altered level of consciousness, has depressed or absent gag and cough reflexes or is susceptible to aspirating orophayngeal secretions, including alcoholics, anesthesized, those with a brain injury and those in a state of drug overdose and stroke victims are at high risk When feeding-- raise the head of the bed and position the client on his or her side and not on the back. Bronchial brath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissues. Hydration Enables liquefication of mucous trapped in the bronchioles and alveoli, facilitating expectoration Is essential for client experiencing fever Is important because 300 to 400 mL of fluid is lost daily by the lugns through evaporation. Irritably and restlessnes are early signs of cerebral hypoxia; the cleint's brain is not recieiing enough of O2. Pneumonia Preventaives Older adults: flue shots; pneumonia, immunizations; avoiding soucres of infection and indoor pollutants (dust, smoke and aerosols); no smoking. Immunosuppressed and debilitated persons: infection avoidance, sensible nutition, adequate intake, balanced rest and activy. Comatose and immoblie persons: elevetion of head of bed to fed and for 2 hours after/ frequently turning Pathophysiology Nursing assessment Analysis Plans Hints Chronic airflow limitation Description: chonic lung disease includes chonic bronchitis; pulmonary emphysema and asthma. Emphysema and chonic boronchitis termed as chonic obstructive pulmonary disease (COPD) are characterized bronchospasm and dyspnea. The damage to the lung is not reversity and increases in the severity. Asthma, Unlike COPD, is an intermittent disease with reversible airflow obstruction. Changes in breathing pattern (eg. An increase with rate iand depth) Use of accessory breathing (barrel chest) Gernalized cyanosis of the lips, mucous memrbanes, face, nail beds ("blue bloaters) Cough (dry or productive) Higher Co2 than average Low O2 as determined by pulse oximetary Decreased breath sound Coarse crackles in lung fields that tend disappear after coughing, wheezing Dyspnea, orthopena Poor ntuition Activity intolerance 1. Anger 2. Fear of being alone 3. Far of not being able to catch breath Anxiety concerneing breathing manicested by: Ineffective airway clearance related to Ineffective breathing pattern related to Impaired gas exchage related to Activity related to In bed teach client to sit with arms resting on overbed table (tripod position0 1. In chair teach client to lean forward with elbows resting on knees (tripod position) 2. Teach client to sit upright and bend slightly forward to promote breathing Teach diaphragmatic and pursed lip rbeathing. Teach prolonged expiratory phase to clear trappped air Administer O2 at 1 - 2 L per nasal canula. Pase activities to conserve energy 1. Select small, frequent mealse 2. Inscreased calories and protein Maintain adequate dietary intake 3. Favorite 4. Dietary supplements Select foods that derive their calories from high fat rather than high carbohydrate level because Co2 that is a natrual end product of carbohydrate metablism and can elevate PaCo2 levels For people contiinuing to smoke tobacco, adiditional vatamin C may be necessary. Magnesium and clacium, because of their role in muscle contraction and relaxation, may be important for people with COPD. Routine monitoring of magnesium and phosphorus levels is important because of their role related to bone mineral density (osteoprorisis). Provide an adequate fluid intake (minimum 3 L day) Fluids should be taken between meals (rathern them) to prevent excess stomach distention and to decrease pressure on the diaphragm Instruct the client in relaxation techniques (teach when not in distress) Teach prevention of seconday infections Teach about medication regimen Smoking cessation is imparative Encourage health promoting activities. Exposrue to tobacco smoke is the primary cause of COPD in the United States. Compensation occurs over time in clients over time in clients with chonic lung disease, and ABG's are altered. As COPD worsens the amount of O2 in the blood decreases (hypoxemia) and the amount of carbon dioxide (Co2) in the blood increases (hypercarbia), causing chonic repisratory acidosis (increased arterial carbon dioxide (paCo2), which results in metabolic a (increased arterial bicarbonate) as compensation. Not all clients with COPD are Co2 retainers, even when hypoxemia is present, because Co2 diffuses more easliy across lung memebranes than O2. In advanced emphysema, due to the alveoli bereing affected hypercarbia is is a problem rather than borchitis where the airway are affected. It is imparitive that basline data be obtained for the client. Productive cough and comfort can be facilited by semi fower or high power position, which lessens pressure on the diaphragm by abdominal organs. Gastric distention become a proity in these cliente because it elevates the idaphragm and inhibits full lung expansion. NORMAl ABG values Adult pH 7.35 - 7.45 Pco2 35 - 45 mmHG Po2 80 to 100 mmhg Hco3- 21 to 28 mEq/L Child pH 7.36 - 7.44 Same as adult Same as adult Same as adult Pink puffer: barrel chest is indicative of emphysema and is caused by the use of accessory muscles to breathe. The person works harder to breathe, but the amount of O2 taken is adequate to oxygenate the tissues. Blue bloater-- insufficient oxygenation occurs with chonic bronchitis and leads to generalized cyanosis and often right sided heart failrue (cor pulmonale) Cells of the body depend on O2 to carry out their functions. Inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill ( 3 seconds). A chonic sign is clubbing of the fingers. Caution must be used in administering O2 (not greater than 2L of O20 to a COPD client. The stimulus to breathe is hypoxia (hypoxic drive), not the usualy hypercapnia, which is the stimulus to ADULT HEALTH II - III HESI Monday, March 18, 2013 4:55 PM Study guides and Miscellaneous crap Page 1 the usualy hypercapnia, which is the stimulus to breathe for healthy persons. Therefore, if too mcuh O2 is given they may stop breathing. Helath promotion-- Eatin consumes energy needed for breathing. Offer mechanically soft diets, which do not require as much chewing and digestion. Assist with feeding if needed. Prevent seconday infections: avoid corowds, contact with persons who have infectious diseases, and respriatory irritants (tobacco smoke) Teach the client to report any change in characteristics of sputum. Encourage client to hydrate well (3L/day) and decreases caffiene due to diuretic effect. Obtain immunizationw when needed (flu and pneumonia) When asked to pioritize nursing actions use the ABC rule: Airway Breathing Circulation Look and listen! If breath sounds are celar but the client is cyanotic and lethargic, adequate oxygenation is not occurring. The key to respriatory status is assessment of breath sounds as well asl visualization of the client. Brath sound are better described, not named; e.g., sounds should be descrinbed as crackles, wheezes or high pitched whisteling sounds rather than rales, rhonchi, ect. Which may not mean the same thing to each clinical professional. Whatch out for NCLEX questions that deal with O2a delivery. In adults, O2 it must bubblet hrough some water solution so it can be humidified if given at 4L/min or delivered directly to the trachea. If given at 1 - 4/min or mask or nasal prongs the oropharynx and nasal pharynx provided adequate humidification. Pathophysiology Nursing assessment Analysis Plans Hints Tuberculosis: A. Transmission is airborne After initial exposrue, the bacteria encapsulate, they form a ghon lesion B. Bacteria remain dormant until later time, when clinical sympoms appear C. Communicable lung disease caused by an infection by mycobacterium tuberculosis A. Is often asymptomatic 1. Fever with night sweats 2. Anorexia, weight loss 3. Malaise, fatigue 4. Cough, hemoptysis Dsypnea, pleuritic chest pain with inspiration 5. Cavitation or calicfication as evidenced on chest radiograph 6. 7. Positive sputum B. Symptoms include A. Knowledge deficiency (spefify) related to… B. Risk for infection related to… Imbalanced nutition less than body requirements related to…. C. A. Provide cleint teaching Take all priescribed medication daily for 9 to 12 months 1. Wash hands using proper handwashing technique 2. Report symptoms of deteriorating condition, especially hemorrhage 3. B. Cough into tissues and dispose of immediately into special Collect sputum cultures as needed; caliet many return to work after three negatives cultrues. C. Place client in respriatory isolation while hospitalized D. Administer anti-TB medications as prescribed E. Refer client and high risk persons to local or state health department for testing and phrophylactic treatment F. Tuberculosis (TB) skin test A positive TB skin test is exhibited by an inducation 10 mm orgreater in a diameter 48 hours after the skin test. Anyone who has received bacillus Calmette- Guerin (BCG) vaccine will have a positive skin test and must evaluated with chest radiograph. Teaching is very important with the client with TB. Drug therapy is usually long term (9 months or longer). It is essnetial that the cleint take the medicatiosn as prescibed for the entire time. Skipping doses or prematurlely terminating the drug therapy can result in a public health hazard Teaching points: Rifampin reduces effectiveness of