medsurg exam 1 mcphs
AP diameter barrel chest: - ANS-> or = to 1:1
Non-barrel chest AP diameter: - ANS-1:2 assessing patient with chest tubes: - ANS-Difficulty
breathing
Effective breathing (pulse ox, RR, HR)
Auscultate lung sounds
Check the trachea for alignment. Crepitus
s/s of infection
Pain
Chamber for bubbling & tidaling
Exhalation, forceful cough, position changes
Water Level
Drainage- amount, color, & characteristics
blood and blood components - ANS-packed red blood cells
platelets
fresh frozen plasma
albumin
several specific clotting factors
calcium regulation: - ANS-parathyroid hormone, calcitonin
calcium responsibilities: - ANS-bone/teeth formation, muscle/nerve function, clotting
chest tube bedside supplies: - ANS-petrolatum impregnated gauze, extra split gauze, sterile
water, padded clamp
chest tube nursing interventions: - ANS-Deep breathing, cough, max inhalation
Spirometry incentives Turning & repositioning
Pain management
When to notify provider?
Abnormality in the trachea Sudden onset/increase dyspnea
O2 sat <90
Drainage >70mL/hr
The chest tube breaks. Drainage stops or changes color
*Nursing consideration- patients generally having thoracotomies are due to cancer-
may need emotional support
COPD assessment findings: - ANS-chronic bronchitis
emphysema
Increased work of breathing
Accessory breathing
Tripod positioning
Fatigued
"hypoxia"
Orthopnea
, Rapid, shallow breaths-*40-50 rpm
Increased SOB with exertion
Abnormal lungs *wheezing
Digital clubbing
Polycythemia
Barrel Chest
COPD diagnostic tests: - ANS-sputum samples, chest X-ray, pulmonary function test (PFT),
completele blood count (CBC), arterial blood gas (ABG)
COPD nursing interventions: - ANS-Maintenance of ABC's
Oxygen:
SpO2 <88% on RA or <2 LPM/PaO2 <55 mmHg
Monitor for changes in respiratory status
heightened patient monitoring while in the hospital Breathing techniques
Diaphragmatic or abdominal breathing
Pursed-lip breathing
Cough/Deep breathing
Place patient in upright position
Suctioning à only when necessary
Hydration
Reduce anxiety
COPD risk factors: - ANS-cigarette smoking, genetics alpha 1-antitrypsin deficiency,
occupational/enviornmental exposures, asbestos exposure
COPD treatment non-surgical medications: - ANS-Bronchodilators
Steroids
Expectorants
Anxiolytics
Antibiotics
Vibratory Positive Expiratory Pressure Device
Weight management
COPD treatment surgical: - ANS-Lung transplant
Lung reduction surgery
Most common procedure is VATS
COPD: - ANS-loss of lung elasticity and hyperinflation of the lungs, destruction of alveoli
dietary sources of magnesium: - ANS-meats, whole grains, dark chocolate, dry beans and
peas, nuts, seafood, green leafy vegetables
dietary supplements of calcium: - ANS-diary products, sardines & salmon, green leafy
vegetables, legumes, nuts, whole grains
fluid overload assessment findings: - ANS-edema, pitting edema
high HR, high RR, high BP
weight gain
crackles in lungs
skin is pale, cool to touch
mental status changes
distended neck & hand veins: engorged veins
AP diameter barrel chest: - ANS-> or = to 1:1
Non-barrel chest AP diameter: - ANS-1:2 assessing patient with chest tubes: - ANS-Difficulty
breathing
Effective breathing (pulse ox, RR, HR)
Auscultate lung sounds
Check the trachea for alignment. Crepitus
s/s of infection
Pain
Chamber for bubbling & tidaling
Exhalation, forceful cough, position changes
Water Level
Drainage- amount, color, & characteristics
blood and blood components - ANS-packed red blood cells
platelets
fresh frozen plasma
albumin
several specific clotting factors
calcium regulation: - ANS-parathyroid hormone, calcitonin
calcium responsibilities: - ANS-bone/teeth formation, muscle/nerve function, clotting
chest tube bedside supplies: - ANS-petrolatum impregnated gauze, extra split gauze, sterile
water, padded clamp
chest tube nursing interventions: - ANS-Deep breathing, cough, max inhalation
Spirometry incentives Turning & repositioning
Pain management
When to notify provider?
Abnormality in the trachea Sudden onset/increase dyspnea
O2 sat <90
Drainage >70mL/hr
The chest tube breaks. Drainage stops or changes color
*Nursing consideration- patients generally having thoracotomies are due to cancer-
may need emotional support
COPD assessment findings: - ANS-chronic bronchitis
emphysema
Increased work of breathing
Accessory breathing
Tripod positioning
Fatigued
"hypoxia"
Orthopnea
, Rapid, shallow breaths-*40-50 rpm
Increased SOB with exertion
Abnormal lungs *wheezing
Digital clubbing
Polycythemia
Barrel Chest
COPD diagnostic tests: - ANS-sputum samples, chest X-ray, pulmonary function test (PFT),
completele blood count (CBC), arterial blood gas (ABG)
COPD nursing interventions: - ANS-Maintenance of ABC's
Oxygen:
SpO2 <88% on RA or <2 LPM/PaO2 <55 mmHg
Monitor for changes in respiratory status
heightened patient monitoring while in the hospital Breathing techniques
Diaphragmatic or abdominal breathing
Pursed-lip breathing
Cough/Deep breathing
Place patient in upright position
Suctioning à only when necessary
Hydration
Reduce anxiety
COPD risk factors: - ANS-cigarette smoking, genetics alpha 1-antitrypsin deficiency,
occupational/enviornmental exposures, asbestos exposure
COPD treatment non-surgical medications: - ANS-Bronchodilators
Steroids
Expectorants
Anxiolytics
Antibiotics
Vibratory Positive Expiratory Pressure Device
Weight management
COPD treatment surgical: - ANS-Lung transplant
Lung reduction surgery
Most common procedure is VATS
COPD: - ANS-loss of lung elasticity and hyperinflation of the lungs, destruction of alveoli
dietary sources of magnesium: - ANS-meats, whole grains, dark chocolate, dry beans and
peas, nuts, seafood, green leafy vegetables
dietary supplements of calcium: - ANS-diary products, sardines & salmon, green leafy
vegetables, legumes, nuts, whole grains
fluid overload assessment findings: - ANS-edema, pitting edema
high HR, high RR, high BP
weight gain
crackles in lungs
skin is pale, cool to touch
mental status changes
distended neck & hand veins: engorged veins
