NUR 265 EXAM 2 RESPIRATORY

PULMONARY EMBOLISM - blood clot that gets caught in the lungs PE R/F - DVT immobility estrogen therapy increased age large bone fracture obesity PE TX - heparin coumadin (starting day 2) tPA to dissolve massive clot PE SX - sudden onset dyspnea decreased O2 cyanosis tachycardia respiratory alkalosis sense of impending doom apprehension s3 or s4 sounds petechiae over chest pleural friction rub PE PREVENTION - range of motion exercise ambulate post op ASAP SCD hose compression stockings increase physical activity fluids prevent pressure in lower extremities (avoid crossing legs, restrictive clothing, placing pillows beneath knees) reposition Q2H smoking cessation anticoagulation and antiplatelet therapy avoid massaging legs FLAIL CHEST - two or more fractured ribs or ribs that have separated from the cartilage FLAIL CHEST SX - paradoxical chest movement SOB dyspnea cyanosis tachycardia hypotension anxiety increased work of breathing FLAIL CHEST TX - humidified oxygen pain management turn, cough, deep breathing mechanical ventilation (severe) monitor ABG and O2 closely monitor for shock and fluid/electrolyte imbalance PULMONARY EFFUSION - fluid in the pleural cavity PULMONARY EFFUSION TX - thoracentesis (monitor for pneumothorax and recurrent fluid accumulation) send fluid to lab for analysis provide symptomatic relief for causative factors PNEUMOTHORAX - collapsed lung, air in the pleural cavity HEMOTHORAX - blood in the pleural cavity TENSION PNEUMOTHORAX - a type of pneumothorax in which air that enters the chest cavity is prevented from escaping (r/f cardiac arrest) PNEUMOTHORAX TX - chest tube pain control HEMOTHORAX TX - chest tube pain control TENSION PNEUMOTHORAX TX - thoracostomy chest tube pain control PNEUMOTHORAX SX - reduced or absent breath sounds on the affected side hyperresonance on percussion tracheal deviation (severe) prominence of the involved side of the chest which moves poorly with respirations HEMOTHORAX SX - dullness on percussion TENSION PNEUMOTHORAX SX - extreme respiratory distress cyanosis JVD hemodynamic instability CHEST TUBE - promotes reexpansion of lung chamber 1: drainage collection (document output hourly) chamber 2: water seal (should have at least 2 cm of water) chamber 3: suction (should have 20 cm of water, tidaling with inspiration and expiration) keep below level of chest avoid stripping tubes keep sterile gauze at bedside monitor for air leaks, displacement (eyelets should not be visible) if output > 70mL/hr = call physician once bubbling ceases = lung has fully reexpanded PULMONARY CONTUSION - lung bruise most common injury after MVA can lead to ARDS PULMONARY CONTUSION SX - may be asymptomatic at first but go on to develop respiratory failure decreased breath sounds bruising over injury dry cough tachypnea tachycardia dullness to percussion hazy opacity in the lobes may develop over several days (C-XR)