Exam One Study Guide Typed.docx

Care for the surgical patient (19 q’s) 



Informed consent- It is the doctor’s responsibility to explain the procedure to the patient. If the patient has minor questions after the doctor leaves it is ok for the nurse to fill in gaps. If the pt seems too confused or not really sure of the surgery, then the nurse needs to get the DR again. (it is our job to reinstruct, clarify, and get an idea of the pts understanding) The doctor signs, the pt signs, and a witness (who can be the nurse) signs. It is done BEFORE preop meds are given. If the patent is unable to sign, then they can draw two XX’s and it will require two witnesses. If the patient is unable to sign and there is no next of kin, in emergency situations, then two unrelated doctors need to review the case and determine that they would recommend the procedure as well. o Time out or Never event- Before starting the operative procedure, facilities use a time out to verify the correct site, patient, and procedure. The doctor should be there since he is responsible. Also, in selecting the right site you should involve the pt. Preop Assessment- basic assessment plus anything that could cause complications in the surgery. You’ll determine age, weight, and get to know them more to try and figure out what issues may arise/ could arise during the procedure. o Medical History (need to know to be able to determine risks) and current status:  Respiratory- are they at higher risk for pulmonary complications? Smoking (how much and how often- it can lower o2, and cause increased mucous which increases odds of pneumonia and Atelectasis) COPD, allergies. Plus, basics like RR, breath sounds, checking for cyanosis, spiO2, fingertip clubbing, check for labored breathing, dyspnea. (obese clients may suffer from sleep apnea and not even know)  Neuro- determine if A&O b4 surgery. Ability to follow commands. You want to make sure they can understand preop teaching and be able to take care of themselves after discharge.  Musculoskeletal- Also determine pt’s risk for falling by checking muscle strength, steadiness of gait, and sense of independence (goes hand in hand with neuro assessment). Check for things like RA other arthritis that may cause issues r/t immobilization during and after surgery.  Cardiovascular- Cardiac disease, hyper/hypotension, anemia, coagulation disorders dysrhythmias, check peripheral pulses, Heart sounds, HR, BP before surgery to determine baseline. Also check to see what meds the dr will allow if NPO. IE will they allow atenolol? (question about cardiac problems with great importance. Complications from anesthesia occur more often in pts with cardiac problems such as CAD, angina, MI w/in 6 months, HF, hypertension, and dysrhythmias. The risk for MI in greater in those w/ issues, so they may require preop beta blockers)  Renal- any impairments? What is usual urinary pattern? What to make sure pt can clear anesthetic agents, and be able to keep F&E homeostasis.  Endocrine- big one here is diabetes which is a chronic issue that causes delayed wound healing, but also stress effects glucose levels, so appropriate insulin will have to be given. You’ll check fasting blood glucose, and then deliver ½ of what they normally require for the drug.  Others- malnutrition (decreased protein= decreased wound healing or obesity more fatty tissue and hidden malnutrition= delayed healing). Dehydration. Tricyclene antidepressants, anticoagulants, NSAIDs. ALLERGIES!! Herbal supplements such as garlic, echinacea, gingko biloba, ginseng, fish oil, and fever few are a couple that can increase risks for bleeding.  Labs- very important to determine if there is an issue that may delay surgery. Low K could delay surgery because it can be life threating and lead to dysrhythmias. It will have to be fixed b4 surgery. Clotting studies may be ordered depending on the pt and their meds. Creatine and bun to assess kidney functions, etc. o Previous surgical experiences and Psychosocial:  Type of surgery and reaction to anesthesia







Try to determine family HX of anesthesia reaction- malignant hyperthermia (caused by inhaled general anesthesia meds; you’ll see blue skin, dangerously low BP, too much calc is being released with leads to painful muscle contractions, temperature raises, and metabolism goes into overdrive. You will stop anesthesia and administer Dantrolene which blocks calcium)  Unpleasant past surgery experiences. We want to take the anxiety out! We want to make this experience better.  Anxiety and fear affects the pts ability to learn, cope, and cooperate with teaching and operative procedures. Ask open ended questions to determine coping methods. Also, do they have a support system when they leave? o Medications- See previous in notes and also:  Corticosteroids (interfere with anesthesia), anticoagulants, antibiotics (interact with anesthesia), tranquilizers (over sedation), diuretics (affects electrolytes), antidiabetic agents (since NPO will not be given or given at ½ dose), recreational drugs (interactions w/ meds and anesth)  Drugs for cardiac disease, respiratory disease, seizures, and hypertension are often allowed with a sip of water b4 surgery. **check w/ dr or anthes to see which drugs are allowed. Skin Prep- One to two days b4 surgery the dr will ask the pt to shower using an antiseptic soap. B4 surgery the nurse will shave the pt with clippers not a razor to prevent nicks or sterile supplies (razor) right before surgery. They will then clean the pt again before the surgery depending on what area is to be operated on. SCIP- Surgical Care Improvement Project: o o o o o o o o o

o 



Inf 1- Prophylactic antibiotic received w/in 1 hr prior to surgery- you want bactericidal blood Inf 2- Prophylactic antibiotic selection- based on EBP the antibiotic is picked based on risk and type of procedure already. Inf 3- Prophylactic antibiotic discontinued w/in 24 hrs of surgery. It should provide benefit w/out risk. IE doing it too long has little benefit but increased risk of C. diff Inf 4- Cardiac pts w/ controlled BS by 6 am postop- helps stop post op complications (applies to cardiac pts only) Inf 6- Appropriate hair removal- see skin prep Inf 9- Urinary catheter removed POD 1 or POD2 to avoid UTIs. (can be kept w/ medically documented reason) Inf 10- Surgery pts w/ Perioperative Temperature management- prolonged hypothermia leads to coag probs, infections, altered drug metabolism. Temp must be measured w/in 15 mins of stopping anesthesia. Card 2- Beta blocker therapy- Pts with specific conditions receive beta-blockers b4 surgery and continue after. EBP shows it results in significant reduction of coronary events, cardiovascular mortality, and overall mortality. VTE 1- Recommended Venous Thromboembolism Prophylaxis Ordered- purpose is to reduce complications of VTE since surgery is a major risk factor for VTE and PE. Although PVT prophylaxis is effective it is underused. There are recommendations based on risk factor, surgery type, and how long they will be immobilized. VTE 2- Surgery pts who received appropriate VTE before and after surgery- purpose is to reduce complications from postop VTE, particularly among the pts at the highest risk.

Robotic Surgery- It is MIS (minimally invasive surgery) which is used for a lot of things now. It involves a small incision, and endoscope is inserted, and there is little blood loss and a shorter recover time. Robotic surgery takes MIS to a new level and is changing how surgery is done today. The surgeon controls the surgery from a distance using a screen and robotic arms. Mechanical trauma and thermal injury can occur. Preop pt and family education- (The JC require that you provide info about informed consent, dietary restrictions, specific preparation for surgery (i.e. bowel and skin preps), exercises after surgery, and plans for pain management). o Teach the patient and family about exercises and procedures (e.g. checking dressing and obtaining vital signs frequently) to be performed after surgery. Teaching b4 surgery reduces apprehension and fear, increases cooperation, and participation in care after surgery, and decreases respiratory and vascular complications. When fear and anxiety is high you must address that 1st or the pt will not learn as much or be willing to participate in the care. You want to demonstrate and get a return demonstration of the activities. Also, encourage the pt to get up and do the exercises early in the recovery pd and continue every 1-2 hours after surgery for 48 hours.

o

o

o





Breathing- Deep breathing: sit upright, take a gentle breath and let out completely, then take a deep breath and hold for 5 seconds, and exhale. Expansion breathing- take deep breath and feel rib cage move out. Coughing and splinting- unless contraindicated place a pillow over surgical incision and hold firmly in place, take 3 slow and deep breaths to stimulate cough reflex, inhale through the mouth and on the 3rd breath cough to clear secretions. Show them how to use an incentive spirometer. Prevent VTE and DVT- (assessment for vte is sudden swelling in one leg caused by a DVT. The pt may feel a dull ache in the calf area that becomes worse with moving- this can lead to a PE if not corrected). Teach how to use TED hose which you don’t want them to be too small or too large. They should be worn all day and removed 1-3 times per day for 30 minutes and the area under them needs to be inspected. Leg exercises- which are raising leg knee to chest, pointing then reflexing then circumduction feet, and lastly place ball of one foot onto bed and push until you feel the calf flexing. Mobility- soon as possible after surgery get up and moving. Other then preventing DVT VTE it will stimulate GI motility, enhance lung expansion, mobilize secretions, promote venous return, prevent joint rigidity, and relives pressure. Turn at least every 2 hours while confined to bed, and if confined to bed do all the other exercises at least every 2 hrs.

Anesthesia o General- total loss of consciousness, no feeling of pain, no control of muscle movement. Can cause nausea, vomiting, and restlessness most common. More severe are malignant hyperthermia (see above), overdose of anesthetic (usually due to kidney disorder), unrecognized hypoventilation (can monitor end-tidal carbon dioxide monitor to confirm CO levels in pts expired gas), intubation complications (chipped tooth, swollen lip, or neck injury- will have sore throat) o Local or regional- briefly disrupts sensory never impulse transmissions from a specific body area or region. Pt is conscious and gag reflex intact. Complications are r/t pt sensitivity, incorrect delivery, systemic absorption, and overdose. The nurse will monitor for CNS stimulation followed by CNS and cardiac depression with indicates a systemic toxic reaction... o Moderate sedation- AKA conscious sedation- IV delivery of hypnotic, sedative, and opioid drugs to reduce LOC. Allows pt to maintain an airway and respond to verbal commands. (CAN BE GIVEN BY A NURSE) Post OP Assessment-1st thing to assess is Resp function including a patent airway and adequate gas exchange. Monitor pulse ox and if it drops below 95% or whatever their baseline was notify the surgeon or anesthesia provider. If it drops below 10% call rapid response. Then you’ll check VS, color, fluid intake, special equipment, and dressings (drainage, and record output from drains. o SEE POST OP ASSESSMENT SHEET/COMPLICATIONS SEE FOR MORE DETAILS (most common complications are pneumonia, shock, cardiac arrest, respiratory arrest, CLOTTING, VTE, and GI bleeding. o For incision infection report it to the surgeon. It will be red, tender, purulent and odorous drainage

Fluid and Electrolyte (11 q’s) 

Fluid Imbalance – Dehydration: o Signs and symptoms- thirst, decreased skin turgor, dry mucous membranes and dry skin, sunken eyeballs, tachycardia (not enough volume to pump so CO decreased, and you’ll see the compensatory mechanisms of heart pumping faster), weak pulses, postural hypotension, Oliguria, flat neck and hand veins, increases respiratory rate. (with severe cases you will see changes in mental status and level of consciousness, apprehension and restlessness, confusion and coma in most severe cases).  For labs you will see increased hematocrit, increased serum sodium levels, increased serum osmo, increased urine specific gravity, increased glucose, and increased protein levels.

o



Risk factors- hemorrhage, V/D, profuse salivation, fistulas, ileostomy, profuse sweating, burns, severe wounds, long term NPO, diuretics, gi suction, hyperventilation, renal failure, difficulty swallowing, impaired thirst, unconsciousness, fever, impaired motor function, and diabetes insipidus (not enough ADH produced in the brain so you’ll see polydipsia and polyuria. The way you tell it is DI is that all labs will point to dehydration, BUT urines specific gravity will be lower instead of concentrated) o Prevention of dehydration- Have water available at bedside at all times, educate pt especially older to drink often, measure I&o, check labs, assess for hypotension and weak pulses, assess respiratory system and perfusion, check orientation including vision hearing reflexes and muscle strength, daily weights, and skin. If the dehydration is mild increase oral fluids, if it is severe give IV fluids.  Isotonic dehydration- body loses salt and water equally (most common). It decreases circulating blood volume, so perfusion is down which causes tachycardia and increased RR. Infusion of isotonic solutions causes no fluid movement. You will give isotonic solutions which are 0.9 saline, 5% dextrose, 5% dextrose in 0.225 saline, and Ringers lactate.  Hypotonic- electrolyte deficit is greater than the water loss. So ICF is more concentrated which causes the fluid to shift inside the cells. (could give hypertonic? Prob won’t happen as these are dangerous)  Hypertonic- deficit of fluid greater than solutes. Fluid moves from the ICF to the ECF. You’ll see cells that shrivel. You will give Hypotonic solution which is 0.45 saline. o Assessment of the older client- Assess for confusion first. It is more common in older adults and is often the first sign of dehydration. Tenting can work, however, in older adults they lose skin elasticity, so they can often tent and not really be dehydrated. You will want to monitor labs. Assess for clinical signs like thirst, weight loss, sunken eyes, hypotension. Assess capillary refill, and if it is longer than 3 seconds the pt may be dehydrated. Record and monitor ins and outs. o Furosemide- often causes dehydration especially when clients are not drinking water. The signs would be the same as with dehydration. This must be monitored closely since it wastes potassium, can lose sodium. Daily you need to assess weights, labs, and in and outs to determine if the pt is dehydrated among assess for confusion, risk for falls, and blood pressure. Electrolyte Imbalances o Sodium 135-145:  Hyponatremia- causes- decreased sodium intake, sweating, gi suctioning, V/D, SIADH, diuretics, water intox. SS- confusion, tired, abdominal cramping, increased urination, crave salt, seizures, rapid thread pulse, BP will increase if due to hypervolemia or decrease if due to hypovolemia. Interventions- salty foods first, then 2-3% NACL.  Hypernatremia- causes- rapid infusion of saline, kidney failure, inadequate water intake or increased water loss, too much salt in food. SS- tachycardia, crave water, have hypo/hypertension, dry mucous membranes, weakness, convulsion, decreased LOC, flushed skin, and lower skin turgor. Interventions- sodium restricted diet, loop diuretics, hypotonic solution, increased water intake o Potassium 3.5-5:  Hypokalemia- causes- vomiting, heavy sweating, k wasting diuretics, poor intake of K. SScardiac arrhythmias presence of U wave and depressed T waves, leg cramps, lethargy, shallow respiratory rate, decreased GI. Interventions- potassium supplement, diet high in potassium such as meat, fish, fruit, milk, veggies, potatoes, and salt substitutes; monitor pulse pressure, ECG, assess respiratory and O2 stats (will have alkalosis), and if on digoxin monitor for tox.  Hyperkalemia- causes- Diarrhea, renal failure, k sparing diuretics like amiloride or spironolactone; and can be caused by metabolic acidosis. SS – Tall tented T’s, absent P’s, and widened QRS intervals; numbness and tingling of muscles in hands, feet and around mouth called paresthesia. Hyper GI. Interventions- potassium excreting diuretics like furosemide are prescribed, limit potassium foods, can give insulin which will help pot get into the cells (10-20%

o

o

o

glucose will be given with 10-20 units of insulin), ECG monitoring, and if very serious kayexalate or dialysis.  IV Potassium- nursing considerations- A dilution of no greater than 1meq per 10 ml of solution is recommended. The maximum recommended infusion rate is 5-10 meq/hr, and IS NOT to exceed 20meq/hr. It WILL NOT be given by IV push to avoid cardiac arrest. If infiltration happens stop the IV, remove venous access, and notify the health care provider. Assess the IV site hourly, and ask the pt if they feel burning or pain at the site. Calcium 9.5-10.5:  Hypocalcemia- causes- hypoPTH, acute pancritis, diarrhea, decreased Vit D, and increased phosphatemia, inadequate intake, kidney disease, lactose intolerant. SS- positive Chvostek and positive Trousseau’s signs, painful tonic muscle spasms (charley horses), increased GI, laryngeal spasms, numbness and tingling aka paresthesia occurs first (signals the onset of neuromuscular overstimulation- tingling around the mouth), brittle bones, arrhythmias (at late stage prolonged ST and QR), and decreased blood clotting. Interventions- Seizure precautions, give oral calcium lactate or gluconate, and high calcium diet from dairy, dark leafy greens and veggies, and give Vit D, and monitor for bleeding.  Hypercalcemia (too much calcium too calm or bones, moan, groan, stones)- Causes- renal insufficiency, antacids or laxatives containing magnesium, dehydration, excessive Vit D, HyperPTH, immobility. SS- cardio is most severe and at 1st it causes increased HR an BP then severe hypo caused depressed conduction slowing HR, N/V, decreased DTR, headache confusion, (moans= lethargy, groans= constipation, bones= bone pain, stones= kidney stones), blood clots. Interventions- encourage mobilization, discontinues things like antacids, replace fluids, change diuretics if on to loop which encourage loss of calcium, can give phosphorus or calcitonin. Monitor T waves!!! Phosphate 3.0-4.5:  Hypophosphatemia- Causes- vit D deficiency, malnutrition, hyperPTH, alcoholism, when calcium up phos will be low. SS- slow weak pulses, muscle weakness which can lead to muscle breakdown (rhabdomyolysis), weak muscles also lead to ineffective respiratory efforts leading to resp failure, decreased bone density leading to fractures, and CNS changes only with severe hypophosphatemia. Interventions- oral replacement and Vit D supplement, decreasing intake of calcium and increasing phos intake.  Hyperphosphatemia- Causes- renal failure, increased intake of phos, hypoPHT, and chemo. SSdoesn’t cause any problems other than those seen in hypocalcemia (phos up calc down), so you’ll see positive Chvostek and trousseaus, muscles spasms, increased GI, etc. Interventionsincrease calcium, limit phos. Magnesium 1.3-2.1:  Hypomagnesemia- Causes- diarrhea, Chron’s/Celiac disease, low intake, GI suctioning, alcoholism, intestinal fistulas, diuretics. SS- numbness and tingling aka paresthesia, painful muscle contractions, hyperactive DTRs, could have tetany or seizures if it gets really bad, decreased GI motility which can lead to paralytic ileus if severe. Interventions- diet high in magnesium (green leafy veggies, fish, legumes, whole grain, and dried fruits), magnesium sulfate rider (assess DTRs hourly to prevent hypermag)  Hypermagnesemia- Causes- increased magnesium intake by laxatives or IV, kidney failure, and dehydration. SS- vasodilation, sweating and flushing, bradycardia (which can be severe and lead to cardiac arrest), and hypotension. You’ll see a widened QRS and prolonged PR intervals, drowsiness and lethargy, could lead to coma in sever cases, hypoactive DTR. Interventionsfocus on reducing serum levels by giving mag free solutions, loop diuretics, when cardiac problems are severe giving calcium can reverse them.

Respiratory System (20 q’s) 



Diagnostic Assessment: o Pulse Oximetry: Identifies hemoglobin saturation with oxygen. Usually it is almost 100% saturated, and an infrared light is used to determine this. Normal findings are 95-100% and in a little lower in dark skin or elderly. To avoid confusion with the PaO2 on the ABGs it is called SaO2. Causes or low reading can include movement, hypothermia, decreased peripheral blood flow, ambient light, decreased hemoglobin, edema, and nail polish. **Results lower than 91% (and certainly below 86%) are an emergency and require immediate assessment and treatment. When the SpO2 is below 85% body tissues have a difficult time becoming oxygenated. An SpO2 lower than 70% is usually life threatening, but in some cases, it can be just 80%. You will administer O2 and keep monitoring!! o Pulmonary Function Tests (PFTs): assess lung function and breathing problems. They measure lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. The results are interpreted by comparing the pt’s data with expected findings for age, gender, race, height, weight, and smoking status. They can help determine lung disease before it even manifests. Keeping a journal can see improvements or if issue is getting worse. Testing before surgery can determine any possible complications. These tests are not invasive so educate PT on why they are important, how to do them, and also if they should hold any drugs for things like determine broncho dilation. The tests are the FVC-forced vital capacity which records the maximum amount of air that can be expired; FEV- forced expiratory volume in 1 second which determines efforts; FEV/FEC-ratio of total expired volume to that in one second which indicates obstruction to the airflow; FRC- functional residual capacity which indicates hyperinflation or air trapping; TLC- total lung capacity which is the air at the end of maximum inhalation and if it is increased it shows air trapping; RV- residual value which is the amount of air remaining in the lungs at the end of a full forced expiration and it will be increased with things like emphysema. o Bronchoscopy- is the insertion of a tube in the airways, about to the 2nd bronchi, to view airway structures and obtain tissue samples for biopsy or culture. It is used to diagnose or manage pulmonary disease. For a rigid bronchoscopy it usually requires general anesthesia in the OR. Flexible bronchoscopy can usually be performed in the ICU under low dose sedation (it can also be used to remove secretions that aren’t cleared by normal suctioning). Patient preparation includes teaching the patient about the procedure and getting informed consent. Document allergies and obtain all labs and vital signs before the surgery. They most likely will have to be NPO for 4-8 hours B4 to limit the possibility of aspiration. Benzos are most commonly used for sedation and amnesia. Benzocaine spray as a topical anesthetic to numb one’s oropharynx is used cautiously, if at all. It may cause methemoglobinemia which is the conversion of normal hemoglobin to methemoglobin which is an altered iron state that does not carry O2 resulting in tissue hypoxia. o ABGs- Normal ranges for pH are 7.35 to 7.45; PaO2 (partial pressure of arterial oxygen) 80-100; PaCO2 (partial pressure of arterial carbon) 35-45; bicarbonate 21-28. It measures base excess/deficit and assessing gas exchange and perfusion as oxygenation. They are monitor treatment results and evaluating pt’s response. They can also determine if the respiratory system is acidic or alkalotic. If the has too much CO2 they will hyperventilate to blow it off. Asthma: o It is an obstructive disease of the lower respiratory tract. It is most common chronic respiratory disease in children and it affects twice as many boys as girls. In adults it affects equally. Caused often by an allergen so it could be seasonal or year around. o During the early asthmatic response antigen exposure causes B cells to produce antigen IEG, which causes mast cells to break down and release histamine, bradykinin, leuks, and prostaglandins which cause vasodilation, increased capillary permeability, mucosal edema, bronchospasms, and mucus secretion. This causes chest constriction, expiratory wheezing, dyspnea, nonproductive cough,

o

o

o

o



prolonged expiration, tachycardia, tachypnea, and anxiety. Check for hypoxemia by examining oral mucosa and nail beds for cyanosis, changes in cognition or consciousness. Status asthmatics- ***In severe attacks wheezing is heard on both expiration and inspiration and the person will use accessory muscles. This is the classification when the disease isn’t responding to drugs. Person will have hypercapnia which is increased CO2 and or barrel chest. Diagnostic assessments: ABGs, FEV (forced expiratory volume in the first second) and PERF (peak expiratory rate flow- which is a person’s max speed of expiration.  PERF- When doing the test, you want the green zone which is 80-100 (cond under control). There is the yellow zone which is 50-80 and airways are starting to narrow. Lastly the Red zone which is under 50, and airways are severely narrowing so take rescue meds. To do the test you will set the meter at 0, while standing take as deep of a breath as possible, wrap lips tightly around mouthpiece, and blow your breath out as hard and as fast as you can. Reset and perform two more times. The highest of the three is your peak flow rate.  A decrease in either the FEV or the PERF of 15- 20% below the expected value or age, gender, and size is common for the pt with asthma. Asthma is diagnosed when these values increase by 12% or more after treatment with bronchodilators. So, they will test before, then give methacholine which causes bronchoconstriction in susceptible people and test again. Control drugs vs Rescue Drugs and step system: control drugs are used to reduce airway sensitivity (responsiveness) to prevent asthma attacks from occurring. They are taken all the time even if feeling ok. Rescue drugs will stop an attack once it as started. Depending on severity of asthma drugs will be prescribed on a step system  Step 1- No daily drugs and will use a rapid acting B2 as needed (albuterol)  Step 2- PRN B2; daily treatment with low dose ICS (inhaled corticosteroid) or leukotriene modifier both prevents inflammation  Step 3- PRN B2; one of the following combinations: low dose ICS and long acting B2; medium or high dose ICS; low dose ICS and sustained release theophylline; or low dose ICS and leukotriene modifier.  Step 4- PRN B2; the one from step 3 that helped the most plus medium or high ICS and long acting b2 or leukotriene modifier and sustained release theophylline  Step 5- PRN b2- the one from step 4 that helped the most and oral steroids or anti IGE treatment  ***see drug list for the se, interventions, and ma Pt teaching- Seek ER help if you experience grey or blue fingertips; difficulty breathing, walking, or talking; Retractions of the neck, chest, or ribs; nasal flaring; failure of drugs to control worsening symptoms; PERF declining after treatment or results in the Red Zone of 50% or less. You will want to avoid triggers like dust or smoke; avoid drugs that trigger like Nsaids; avoid foods with MSG; if you have exercise induced asthma, use bronchodilator 30 mins B4 exercise; know how to use metered does inhaler; reduce stress and anxiety; wash bedding with hot water; monitor PERF at least twice per day.

COPD: o It is chronic obstructive pulmonary disease characterized by airflow obstruction. Both emphysema and bronchitis fit into the category. The lung damage is not reversible o Emphysema- The two major changes with emphysema are loss of lung elasticity and hyperinflation which result in dyspnea and the need for increased respiratory rate. You’ll notice diminished breath sounds, trouble breathing lying down, anxious, barrel chest, pursed lip breathing. Limbs will be skinny and digital clubbing.  Causes- caused by an enzyme called proteases that normally break down particles that enter the lungs. If AAT is deficient then the protease will do what they want and break everything down including elastins. This damages the alveoli leading to their collapse. There will be less surface for gas exchange too. Since the lungs lose their elasticity there will be more air trapped in the





lungs and it greatly increases the work of breathing and the diaphragm becomes flattened making it even harder. The patient will become air hungry and begin inhalation before exhalation is even over. (respiratory acidosis will occur due to trapped CO2)  Treatment- it will consist of O2 delivery and breathing exercises o Bronchitis- it only affects the airways not the alveoli. It is inflammation of the bronchi or bronchioles, which causes vasodilation, mucosal edema, congestion, and bronco spasms. The chronic inflammation increases the number and size of mucus glands which produce large amounts of mucus. So, the walls are already inflamed impeding airflow then you add the mucus into it and it becomes a lot harder to breathe. Plus, the mucus is a perfect breeding ground for microorganisms, so pts will be sick often. PT will have recurrent cough with mucus, hypoxia, hypercapnia, respiratory acidosis, increased HBG, increased RR, exertional dyspnea, fingertip clubbing, cardiac enlargement, use of accessory muscles to breath, and all of this will lead to right side HF.  Treatment-bronchodilators, antimicrobials, and expectorants o Cor Pulmonale- Cardiac failure- right sided, caused by pulmonary failure. Occurs with bronchial or emphysema. Blood flow more difficult because of air trapping, airway collapse, and stiff alveolar walls. It increases tissue pressure and narrow lung vessels. Increased pressure increases workload on the heart to get blood through. In failure blood backs up into the venous system. Pneumonia- infection in air sacs o What it is- an acute inflammation of the respiratory bronchioles, alveolar sacks, alveolar ducts, and alveoli, resulting in the consolidation of lung tissue as the alveoli fill with exudate (RBC, neutrophils, and fibrin that fill airspaces making them harder. It will have a liver like appearance). The WBC go to the site of inflammation/infection causing local capillary leak, edema, and exudate. These fluids then collect around the alveoli, and the alveolar walls thicken. It is a problem because the fluid that is building up is blocking the gas exchange. It is taking up gas exchange. o You will see- dyspnea, chest pain r/t inflammation, and fever f/t infection. Other signs are a cough with greenish to rust colored sputum, chills, tachycardia, rapid shallow respirations, nasal flaring, use of accessory muscles, dullness to flatness upon percussion, high pitched bronchial breath sounds, crackles progressing to wheezes and if it gets really bad diminished breath sounds, stridor, and tactile fremitus o Most pneumonia is bacterial from streptococcus or influenza, but can also get from mycobacterium or fungus. There are many cases from VAP- think about tube that delivers o2 which is a direct route from the outside to the inside. Can also get from aspiration, and anything that can get caught in the lungs can cause an issue. o It can be bronchopneumonia which is thorough out the lungs the bronchiole and alveoli. Lobar pneumonia, has consolidation or lack of airspaces, in a segment or entire lobe. (***it is a common reason for sepsis, so use a sepsis screening tool to monitor pts) o Risk factors- older adult, never had the pneumococcal vax or it has been over 5 years, did not get flu vax, has a chronic health problem, uses tobacco or alcohol. In addition to the previous, for health careacquired infections it would include has an altered level of consciousness, had a recent aspiration event, poor nutritional status, immunocompromised (including recent doses of antibiotics), or VAT as discussed above. TB o Bacterial infection caused by mycobacterium tuberculosis and is spread via airborne droplets. Once inhaled the organisms implant themselves in the lungs and begin diving slowly causing tubercle, and eventual caseation (little circle holes in lungs that can be seen on CXR), and fibrosis. Infection spreads though out the body by the lymph system when it becomes active. The latent or inactive form (no symptoms) is not contagious, but the disease can grow anytime if the immune system gets weak. o Clinical manifestations- once it is active the pt will develop a cough with yellow mucoid sputum. It will last longer than 3 weeks which is a good indicator it is tb. Then it will lead to anorexia, malaise, weight loss, afternoon low grade fever, pallor, pain, fatigue, and night sweats (being drenched). So, you will

o

o

o

want to assess anyone for TB who has persistent cough, weight loss, anorexia, night sweats, hemoptysis, SOB, and fever or chills. Most people don’t even know they have it until it is advanced. Diagnosis & Labs- If it is suspected the first thing that will be done is a sputum smear to look for acid fast bacillus. If it is positive, then a culture is done to be sure. Cultures take a while so meds would most likely be started. The Mantoux test is injecting bit of tb protein under the skin to test for antibodies. Positive findings and size of induration depends on the person. For example, HIV positive pt will only have to test 5mm, a healthcare worker would be 10mm, and a regular individual would be a 15 mm. The CXR will show the circles, caseations, that will indicate if there is TB present. (The patient is considered infectious until three sputum smears are negative for acid-fast bacilli. Chest x-rays help to determine the presence of active TB but are not utilized to monitor the effectiveness of treatment. Taking the medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Sputum cultures are used to diagnose the presence of active TB, but sputum smears are usually done to establish that treatment has been effective.) Medications- Initial phase of treatment is to give Isoniazid (INH), rifampin, pyrazinamide, and ethambutol for 8 weeks. Then it will be INH + rifampin or INH and rifapentine for 4-7 months. For people who are at high risk INH is given prophylactically for 6-12 months.  Isoniazid (INH)- kills actively growing mycobacterium outside of cell and inhibits the growth of dormant bacteria inside. Can cause liver toxicity so do not drink and to report dark urine and jaundice. It can cause neuro toxicity since it depletes B6, so take a supplement.  Rifampin- Kills slower-growing organisms even those that reside in macrophages. It causes the skin to be stained and will stain soft contact lenses orange. Will make birth control inactive. Don’t drink as it can cause liver damage and report darkening of the urine or jaundice. It interacts with many drugs so check w/ pt  Pyrazinamide- It isn’t inactivated by acidic environment of macrophages, so it can kill things residing in it. Ask the pt if they have ever had gout as it increases uric acid formation and make gout worse. Causes photosensitivity. It can cause liver damage so report dark urine or jaundice.  Ethambutol- Inhibits bacterial RNA synthesis. It can cause N/V if taken with alcohol so advise the pt not to drink. It can cause optic neuritis, which can lead to blindness, so report changes to vision. As if the pt has ever had gout as it causes uric acid formation as will make gout worse. Drink with at least 8 oz of fluid to help prevent uric acid. Interventions- Admin meds as ordered, prevent transmission, promote adequate nutrition, prevent social isolation and help vary routine to help prevent boredom, and teach patient the importance of compliance with treatment as they will die if they don’t. Discharge teaching would include: They are continued on medications for 6-12 months but is considered to be non-contagious after 2-3 weeks of therapy. they should wear a mask if there will be exposure to crowds until medications are effective in preventing spread. There must be 3 negative sputum cultures before return to work. They must also make sure to tell the DR at the first sign of cough, fever, or hemoptysis, and the importance of highprotein, iron, and Vit C and B diets.