NR324 Adult Health I Exam 1 Review.

NR324 Adult Health I Exam 1 Review. What is the primary purpose of the Respiratory System? -Gas exchange *Transfer of oxygen (O2) and carbon dioxide (CO2) between the atmosphere and blood Surfactant Lipoprotein that reduces surface tension to help prevent collapsed alveoli (atelectasis) Pulmonary circulation involving the arteries Deoxygenated blood from right ventricle Pulmonary circulation involving the capillaries Exchange gases at alveoli Pulmonary circulation involving the veins Returns oxygenated blood to left atrium Bronchial circulation involving the arteries Oxygen is delivered tot he bronchi and lung tissues Bronchial circulation involving the azygos veins Deoxygenated blood is delivered to the superior vena cava Partial pressure of oxygen in arterial blood (PaO2); normal 80 to 100 mm Hg Oxygen dissolved in the plasma Arterial oxygen saturation (SaO2); normal greater than 95% Oxygen bound to hemoglobin Lungs return to original size after expansion Elastic recoil What nursing interventions should be done prior to a client going in for a Thoracentesis? -Rights -Allergies -Verify consent -Check if the patient understands their procedure What are the nursing interventions during a Thoracentesis should the nurse consider? -Positioning client -Continuous monitoring Abnormal accumulation of fluid in alveoli and interstitial spaces Pulmonary Edema What are the nursing considerations for removal of chest tubes? -When lungs re-expanded and drainage minimal -Premedicate prior to removal -Valsalva maneuver during removal -Apply occlusive dressing -Chest x-ray -Monitor for respiratory distress Bubbling in water-seal chamber -Brisk at first, eventually disappears as the lung expands -Intermittent with exhalation, coughing, or sneezing Tidaling in water-seal chamber -Fluctuation of water with pressure changes during respiration -Disappears as lung re-expands *If stops suddenly, check for occlusion Suction control chamber Wet suction -Amount of water in the chamber (20 cm) controls suction -Excess suction from source vented -Usual suction order = −20 cm H2O -Adjust suction until gentle bubbling in third chamber Dry suction—no water (less noise) -Dial regulator to pressure; visual alert What are the immediate nursing interventions/treatments for a client experiencing a pulmonary embolism? -Bed rest in semi-fowler's position -Assess cardiopulmonary status -Administer: oxygen, IV fluids and medications -Monitor: coagulation and complications Mean pulmonary artery pressures *Normal 12-16 mm Hg *Greater than 25 mm Hg at rest *Greater than 30 mm Hg with exercises What occurs when utilizing a nebulizer? The machine converts drug solutions into a fine mist for inhalation via a face mask or mouthpiece (easy to use) What are factors nurses should consider when teaching a patient regarding inhaler/nebulizer therapy? -Age, dexterity, psychological state, affordability, convenience, administration time, and preference -Financial resource: Importance of adhering to Fluid Volume Deficit § Abnormal loss of body fluids: Diarrhea, vomiting, hemorrhage, polyuria § Inadequate fluid intake § A shift from plasma to interstitial fluid Fluid Volume Excess § Excess intake of fluids § Abnormal retention of fluids (heart failure, renal failure) § A shift of fluid from interstitial fluid into plasma fluid Normal Na+ range 135-145 mEq/L Hypernatremia (High serum sodium) may occur with inadequate water intake, excess water loss, or, rarely, sodium gain Signs & Symptoms of hypernatremia • extreme thirst • agitation • confusion • seizures, coma • fluid retention • decreased urine output • dry flushed skin • muscle twitches & contractions Causes of hypernatremia • inadequate water intake • increased water loss, i.e., fever, excessive sweating, diarrhea, Diabetes Insipidus • excess sodium intake, i.e., IV fluids • decreased sodium excretion (renal) Management of hypernatremia • Restrict sodium & fluid intake as ordered Treatment of hypernatremia • If due to water loss, admin IV fluids asordered • If due to decreased sodium excretion, admin diuretics that promote sodium loss Hyponatremia - (low serum sodium) may result from a loss of sodium-containing fluids, water excess in relation to the amount of sodium (dilutional hyponatremia), or a combination of both - The main cation of extracellular fluid (ECF); the kidneys regulate sodium essential in regulating water of both intracellular fluid (ICF) and extracellular fluid (ECF) - Necessary for nerve function, muscle contraction, and regulating acid-base balance - The most common electrolyte disorder Causes of hyponatremia • Inadequate sodium intake • dilution of serum sodium, i.e., excessive hypotonic fluids, kidney disease, SIADH, heart failure • increased sodium excretion, excessive sweating, diuretics, vomiting, diarrhea, wound drainage Signs & Symptoms of hyponatremia • headache, confusion • seizures, coma • nausea, cramping and diarrhea • muscle weakness • decreased urinary output Management of hyponatremia § • if fluid deficit (hypovolemia), adminsodium chloride IV• if fluid overload (hypervolemia), admindiuretics as prescribed• instruct patient to increase oral sodiumintake • if pt is taking lithium, monitor levels -hyponatremia can cause lithium toxicity • Increasing sodium levels too quicklycan cause permanent brain damage. § The main cation of extracellular fluid (ECF); the kidneys regulate sodium § Essential in regulating water of both intracellular fluid (ICF) and extracellular fluid (ECF) § Necessary for nerve function, muscle contraction, and regulating acid-base balance § Hyponatremia is the most common electrolyte disorder Normal range of K+ 3.5-5 mEq/L Hyperkalemia (high serum potassium) may result from impaired renal excretion, a shift of potassium from ICF to ECF, a massive intake of potassium, or a combination of these factors. The most common cause of hyperkalemia is renal failure.