Advanced Med-Surg Proctored ATI Review

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Arterial Blood Gas
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Terms in this set (151)
Arterial Blood Gas
ABG's via arterial puncture or arterial line: allows the most accurate method of assessing respiratory function.
Steps for collecting ABG's
a. Perform Allen test if no arterial line
b. sample is drawn into heparinized syringe
c. keep on ice and transport to laboratory immediately
d. document amount and method of oxygen delivered for accurate results
e. apply direct pressure to puncture site at least 5 min (longer for clients at risk for bleeding)
Bronchoscopy
visualizes the larynx, trachea, bronchi; obtains tissue biopsy; and removes foreign bodies.
Steps for a bronchoscopy procedure
a. obtain informed consent
b. maintain NPO 8 to 12 hr.
c. Provide local anesthetic throat spray
d. position upright
e. administer medications as prescribed, such as atropine (to reduce oral secretions), sedation, and/or anti-anxiety.
f. label specimen
g. observe postprocedure
-gag reflex
-bleeding
-respiratory status, vital signs, and level of consciousness
Mantoux test
Positive test indicates exposure to tuberculosis. Diagnosis must be confirmed with sputum culture for presence of acid-fast bacillus (AFB).
Mantoux test steps
a. administer 0.1 mL of purified protein derivation intradermal to upper half inner surface of forearm (insert needle bevel up)
b. Assess for reaction in 48 to 72 hr following injection; induration (hardening) of 10 mm or greater is considered a positive test; 5 mm may be considered significant if immunocompromised.
QuantiFERON-TB Gold test (QFT-GT) and T-SPOT.TB
Identify the presence of Mycobacterium tuberculosis infection by measuring the immune response to the TB bacteria in whole blood.
Thoracentesis
Surgical perforation of the pleural space to obtain specimen, to remove fluid or air, or to instill medication.
Steps for Thoracentesis
a. informed consent
b. educate client: remain still, feeling of pressure, positioning
c. position upright
d. monitor respiratory status and vital signs
e. label specimens
f. Document client response, amount, color and viscosity of fluid (maximum amount of fluid to be removed at a time is 1L).
g. Chest tube at bedside
h. Obtain CXR before and after procedure
Asthma
Chronic inflammatory disorder of the airways resulting in intermittent and reversible airflow obstruction of the bronchioles.
Contributing factors of asthma-Extrinsic: antigen-antibody reaction triggered by food, medications, or inhaled substances -Intrinsic: pathophysiological abnormalities within the respiratory tract -Older clients: beta receptors are less responsive to agonist and trigger bronchospasms.Manifestations of asthma-Sudden, severe dyspnea with use of accessory muscles -sitting up, leaning forward -diaphoresis and anxiety -wheezing, gasping -coughing -cyanosis (late sign) -barrel chestDiagnostic procedures for asthma-ABGs -sputum cultures -pulmonary function testsNursing interventions for asthma-remain with the client during the attack -position in high-fowler's -assess lung sounds and pulse oximetry -administer oxygen therapy -maintain oxygen accessMedications for athmaAdminister bronchodilators before anti-inflammatory 1. Bronchodilators -short-acting inhaled: albuterol; for rapid relief -Methylxanthines: theophylline; monitor therapeutic range for toxicity. 2. Anti-inflammatory -corticosteriods: fluticasone and prednisone -Leukotriene antagonist: montelukast 3. Combination agents -Ipratropium and albuterol (Combivent) -Fluticasone and salmeterol (Advair)Therapeutic measures for asthma-respiratory treatments -oxygen administrationClient Education for asthma-avoidance of allergens and triggers -proper use of inhaler and peak flow monitoringStatus asthmaticuslife-threatening episode of airway obstruction this is often unresponsive to treatmentManifestations of status asthmaticus-extreme wheezing -labored breathing -use of accessory muscles -distended neck veins -high risk for cardiac and/or respiratory arrestNursing interventions for status asthmaticus-place in high-fowler's -prepare for emergency intubation -administer oxygen, epinephrine, and systemic steroid as prescribed -provide emotional supportChronic Obstructive Pulmonary Diseaseencompasses pulmonary emphysema and chronic bronchitis. COPD is not reversible.Pulmonary emphysema-destruction of alveoli, narrowing of bronchioles, and trapping of air resulting in loss of lung elasticityContributing factors of pulmonary emphysema-cigarette smoking (main causative factor); passive smoke inhalation -advanced age -exposure to air pollution -Alpha-antitrypsin deficiency (inability to break down pollutants) -Occupational dust and chemical exposureManifestations of emphysema-dyspnea with productive cough -difficult exhalation, use of pursed-lip breathing -wheezing, crackles -barrel chest -shallow, rapid respirations -respiratory acidosis with hypoxia -weight loss -clubbed fingernails -fatigueChronic bronchitisinflammation and hypersecretion of mucus in the bronchi and bronchioles caused by chronic exposure to irritantsContributing factors to chronic bronchitis-cigarette smoking (main causative factor) -exposure to air pollution and other environmental irritatantsManifestations of chronic bronchitis-productive cough -thick, tenacious sputum -hypoxemia -respiratory acidosisDiagnostic procedure for COPD-chest x-ray -pulmonary function test: air remains trapped in lungs -pulse oximetry: often less than 90% -ABGs: chronic respiratory acidosis -CT-scanNursing interventions for COPD-assess respiratory status -assess cardiac status for signs of right-sided failure -position upright and leaning forward -schedule activities to allow for frequent rest periods -administer oxygen therapy as prescribed -use incentive spirometry -encourage fluids 2 to 3 L per day unless contraindicated -encourage high-calorie diet -provide emotional supportMedications for COPD-bronchodilators -methylxanthines -anti-inflammatory agents -mucolytic agentsTherapeutic measures for COPD-chest physiotherapy/pulmonary drainage -lung reduction surgeryEducation and referral for COPD-breathing techniques -oxygen therapy -medications -nutrition -promote smoking cessation -infection prevention measures -encourage immunizations for pneumonia and influenza -pulmonary rehabilitation -activity pacingComplications of COPDCor Pulmonale: right-sided heart failure caused by pulmonary disease.Manifestations of Cor Pulmonale-hypoxia (deficient perfusion) and hypoxemia (deficient oxygen in blood) -extreme dyspnea -cyanotic lips -JVD -dependent edema -hepatomegaly (enlarged liver) -pulmonary hypertensionNursing interventions of Cor Pulmonale-monitor respiratory status -monitor cardiac status and assess for indications of right-sided heart failure -administer oxygen therapy as prescribed -ensure adequate rest periods -encourage low-sodium diet -maintain fluid balance; possible fluid restriction -administer medications as prescribedMedications for Cor PulmonaleDiuretics DigoxinTherapeutic measures for Cor Pulmonale-Mechanical ventilationCarbon Dioxide ToxicityStuporous secondary to increased CO2 retentionContributing factors for Carbon Dioxide Toxicity-carbon dioxide retention -excessive oxygen deliveryManifestations of Carbon Dioxide Toxicity-alteration in level of consciousness -tachypnea -increased blood pressure -tachycardia with dysrhythmiasCollaborative care for Carbon Dioxide Toxicity-monitor pulse oximetry and ABGs -avoid excessive concentration of oxygen -provide pulmonary hygiene -provide ventilatory support with CPAP, BiPAP, or mechanical ventilation.Pneumoniainflammatory process in the lungs that produces excess fluid and exudate that fill the alveoli; classified as bacterial, viral, fungal, or chemicalContributing factors for pneumonia-advanced age -chronic lung disease -immunocompromised -mechanical ventilation -postoperative -sedation and opioid use -prolonged immobility -tobacco use -enteral tube feedingManifestations of pneumonia-tachypnea and tachycardia -sudden onset of chills, fever, flushing, diaphoresis -productive cough -dyspnea with pleuritic pain -crackles -elevated WBC -decreased O2 saturationDiagnostic procedures for pneumonia-chest x-ray -pulse oximetry -sputum culture and sensitivityNursing Interventions for penumonia-assess respiratory status -administer oxygen -assess sputum -monitor vital signs -encourage 3 L of fluid per day -provide pulmonary hygiene -encourage mouth care -promote nutritionMedications for penumonia-Anti-infectives (antibiotics) -antipyretics -bronchodilators -anti-inflammatoriesClient education for pneumonia-medication administration -preventative measures -pneumonia and influenza vaccineTuberculosisan infectious disease caused by Mycobacterium tuberculosis and transmitted through aerosolization (airborne route).Contributing factors for TB-older and homeless population -lower socioeconomic status -foreign immigrants -those in frequent contact with untreated persons -overcrowded living conditionsManifestations of TB-cough, hypoptysis -positive sputum culture for acid-fast bacillus -low-grade fever with night sweats -anorexia, weight loss -malaise, fatigueDiagnostic procedures for TB-Mantoux -sputum culture and smear for AFB to confirm diagnosis -serum analysis, QFT-G -chest x-rayNursing interventions for TB-initiate airborne isolation precautions -obtain sputum sample before administering medications -maintain adequate nutritional status -teach the client to avoid foods containing tyramine (aged cheese, cured meats like pepperoni, soy sauce, fermented cabbage) when taking INH. -inform the client that rifampin can alter the metabolism of certain other medications -monitor laboratory findings for liver and kidney functionMedications for TB-administer medications on an empty stomach at the same time every day -medications should be taken for 6 to 12 months, as directed -Instruct the client to watch for indications of hepatotoxicity, nephrotoxicity, and/or visual changes, and to notify a provider if any of these are noted. -isoniazid (INH) -Rifampin -Pyrazinamide -streptomycin -ethambutolClient education for TB-Encourage the client to practice good hand hygiene and to always cover her nose and mouth when sneezing or coughing. -Ensure medication compliance and follow-up care -All cases of TB are reported to the state health departmentLaryngeal Cancer-Malignant cells occurring in the mucosal tissue of the larynx; more common in men between the ages of 55 and 70.Contributing factors for laryngeal cancer-smoking -radiation exposure -chronic laryngitis and/or straining of vocal cordsManifestations of laryngeal cancer-hoarseness extending longer than 2 weeks -dysphagia -dyspnea -cough -persistent sore throat -hard, immobile lymph nodes in neck -weight loss, anorexiaDiagnostic procedures for laryngeal cancer-MRI -direct laryngoscopy with biopsy -X-ray and CT -Bone scan and PET scanNursing interventions for laryngeal cancer-maintain patient airway -swallowing precautions -emotional support -nutrition -pain management -administer medications as elixir when possibleTherapeutic measures for Laryngeal cancer-partial or total laryngectomy -radiation therapyClient Education for laryngeal cancer-communication method -stoma care -swallowing maneuvers -speech therapyLung CancerLeading cause of cancer-related deaths for both med and women in the U.S.; primary or metastatic disease; most commonly occurs between the ages of 45 and 70 years.Contributing factors for lung cancer-smoking (first- and second-hand smoke) -radiation exposure -chronic exposure to inhaled irritants -older adultManifestations of lung cancer-chronic cough -chronic dyspnea -hemoptysis -hoarseness -fatigue, weight loss, anorexia -clubbing of fingers -chest wall painDiagnostic procedures for lung cancer-chest x-ray and CT scan -CT guided needle aspiration -bronchoscopy with biopsy -TNM system for staging -T-Tumor -N-Nodes -M-MetastasisNursing interventions for lung cancer-maintain patient airway -suction as indicated by assessment -monitor vital signs and pulse oximetry -monitor nutritional status -position in high-fowler's -provide emotional support -assess and treat stomatitis -ensure protection for immunocompromised clientMedications for lung cancer-chemotherapeutic agents -opioid narcoticsTherapeutic measures for lung cancer-Palliative care -medication -Thoracentesis -Surgical -tumor excision -pneumonectomy, lobectomy, wedge resection -radiationClient education for lung cancer-medications -constipation prevention and management -mouth and skin care -nutrition -respiratory services -radiology -rehabilitation -nutrition -hospicePulmonary EmbolismA life-threatening hypoxic condition caused by a collection of particular matter (solid, gas, or liquid) that enters venous circulation and lodges in the pulmonary vessels causing pulmonary blood flow obstructionContributing factors to pulmonary embolism-chronic atrial fibrillation -hypercoagulability -long bone fracture -long-term immobility -oral contraceptive or estrogen therapy -obesity -postoperative -PVD, DVT -sickle cell anemiaManifestations of pulmonary embolism-dyspnea, tachypnea -chest pain -tachycardia -anxiety -diaphoresis -decreased SaO2 -Pleural effusion -crackles and coughDiagnostic procedures of pulmonary embolism-ABGs -D-dimer -Chest x-ray -V/Q Scan -Pulmonary angiographyNursing Interventions for Pulmonary Embolism-Assess respiratory status and vital signs -Provide respiratory support -provide oxygen therapy -position in high-fowler's -initiate IV access -provide emotional supportMedications for PE-thrombolytics -anticoagulantsTherapeutic measures for PE-embolectomy -vena cava filterClient education and referral for PE-preventative measures -dietary precautions with Vit. K -Follow-up for PT or INR -Bleeding precautions -Cardiology and pulmonary services (respiratory care)PneumothoraxA collection of air or gas in the chest or pleural space that causes part or all of a lung to collapse due to a loss of negative pressureTension PneumothoraxOccurs when air enters the pleural space during inspiration through one-way valve and is not able to exit upon expiration. The trapped air causes pressure on the heart and the lung. As a result, the increase in pressure compresses blood vessels and limits venous return, leading to a decrease in cardiac output. Death can result if not treated immediately.HemothoraxAccumulation of blood in the pleural cavityContributing factors to hemothorax-blunt chest trauma -COPD -closed/occluded chest tube -advanced age -penetrating chest woundsManifestations of hemothorax-respiratory distress -tracheal deviation to unaffected side (tension pneumothorax) -reduced or absent breath sound (affected side) -asymmetrical chest wall movement -hyperresonance on percussion due to trapped air (pneumothroax) -subcutaneous emphysema -chest painDiagnostic procedures for hemothroax-chest x-ray -thoracentesis (hemothorax)Nursing interventions for hemothorax-monitor respiratory status -administer oxygen -position in high-fowler's -monitor chest tube and dressing -provide emotional supportTherapeutic measures for hemothorax-chest tube insertion: inserted to pleural space for draining fluid, blood, or air; reestablishes a negative pressure, facilitates lung expansionProcedures for chest tube insertion-position supine or semi-fowler's -verify informed consent is signed -prepare chest drainage system prior to insertion -administer pain and sedation medication as ordered -assist provider as needed during insertion -apply dressing to insertion site -maintain chest tube system -monitor respiratory status, pulse oximetry, vital signs, and client response -monitor for complicationsChest tube complications-Air leak (continuous rapid bubbling in the water seal chamber) -No tidaling in water seal chamber -No bubbling in suction control chamber -Chest tube is disconnected from system -Chest tube accidentally pulled from chestEARLY clinical manifestations of hypoxia and hypoxemia-tachypnea -tachycardia -restlessness -pale skin and mucous membranes -elevated blood pressure -use of accessory muscles, nasal flaring, adventitious lung soundsLATE clinical manifestations of hypoxia and hypoxemia-bradypnea -bradycardia -confusion and stupor -cyanotic skin and mucous membranes -hypotension -cardiac dysrythmiasOxygen Delivery devicesNasal cannula (2-6 L) 24-44% Simple face mask (6-8 L) 40-60% Partial rebreather mask (8-11L) 50-75% Non-rebreather mask (12L) 80-100% Venturi mask (4-8 L) 24-40% Aerosol mask, face tent (8-10 L) 30-100 T-piece (8-10 L) 30-100%Client education when oxygen is in use-assess for electrical hazards -Post "oxygen in use" sign -Wear a cotton gown -No smokingSuctioning-hyperoxygenate client -suction 10-15 seconds (rotating motion); limit 2-3 attempts -Allow 20-30 sec recovery between attempts -Document amount , color, and consistency of secretions as well as client's responseTracheostomy care-keep two extra tracheostomy tubes (one the client's size and one a smaller size) at the bedside in the event of accidental decannulation -Only suction client as clinically indicated -Tracheostomy care every 8 hours or as neededadequate BP is maintained by...peripheral vasculatureDiagnostic procedures fo cardiovascular system disordersserum electrolytes erythrocyte sedimentation rate C-reactive protein blood coagulation tests -PTT (30-40 sec): heparin -PT (11-12.5 sec): warfarin INR (0.7-1.8): if the client requires anticoagulation, the desired value is approximately 2-3. BUN and creatinine: reflect renal function and perfusion; levels may increase in MI, CHF, and cardiomyopathy Total cholesterol: <200; LDL <130; HDL men >35-65, women >35-80B-type natriuretic peptideIndicator for diagnosing heart failure -BNP <100 (none) -BNP 100-300 (possible) -BNP >300 (mild) -BNP >600 (moderate) -BNP >900 (severe)Enzymes that indicate death of myocardial muscles; heart attack-creatinine phosphokinase MB (CK-MB) isoenzyme increases within 4-6 hours following a MI and remains elevated from 24-72 hours -Troponin is a protein that is considered the gold standard in diagnosing MI. It remains elevated for 2-3 weeks following an event. Normal level is <0.2 ng/dLECG: wave areas showing types of injury to the heart-T-wave inversion: ischemia -ST-Segment elevation: injury -Q-wave enlargement: infarctionTypes of Percutaneous Coronary Intervention (PCI)Coronary angioplasty: balloon tipped catheter is used to press the coronary blockage open to improve blood flow. Coronary stent: a procedure performed during angioplasty that leaves a metal mesh in place as a structural support to prevent the blockage from reoccurring.Purpose of Cardiac Catheterization-Perform angiography -Perform PCI -Obtain information about cardiac structure and blood flow -obtain blood samples -determine cardiac outputNursing interventions for cardiac catheterization-prior to catheterization -verify procedural consent has been obtained -know approach for shave prep-R venous or L arterial -NPO for 6 hr prior -distal baseline pulses -procedure may leave a metallic taste in the client's mouth and they may feel flushed when the dye is injected. -after catheterization -monitor BP and apical pulse every 15 min for 2-4 hrs -monitor for bleeding and/or hematoma at catheter insertion site -apply pressure for a min of 15 min to prevent bleeding or hematoma formation -monitor for vasospasm, dysrhythmia, or rupture of the coronary vessel. -assess the client for chest pain -keep the extremity extended for 4-6 hours -maintain bed rest; no hip flexion or sitting up in bed -increase fluid intake to enhance flushing of dyeWhen is a trough level measured?15 min before the next scheduled dose.Average times for drawing peak levels-oral intake: 1-2 hrs -IM: 1 hr -IV: 30 minInfiltrationPrevention: use smallest catheter for prescribed therapy, stabilize port-access, assess blood return Treatment: stop infusion, remove peripheral catheters, apply COLD compress, ELEVATE extremity, insert new catheter in OPPOSITE extremity.ExtravasationPrevention: know vesicant potential before giving medication Treatment: stop infusion, discontinue administration set, aspirate drug if possible, apply COLD compress, document condition of site (may photograph).Phlebitis/thrombophlebitisPrevention: rotate sites every 72-96 hrs; secure catheter; use aseptic technique; for PICCs, avoid excessive activity with the extremity. Treatment: stop infusion; remove peripheral IV catheter; apply HEAT compress; insert new catheter in opposite extremity.HematomaPrevention: avoid veins not easily seen or palpated; obtain homeostasis after insertion. Treatment: remove IV device and apply light pressure if bleeding; monitor for signs of phlebitis and treat.Venous SpasmPrevention: allow time for vein diameter to return after tourniquet removed; infuse fluids at room temperature. Treatment: temporarily slow infusion rate; apply WARM compress.Total Parenteral NutritionHYPERTONIC solution containing dextrose, proteins, electrolytes, minerals, trace elements; and insulin prescribed according to the client's needs and administration via central venous device (PICC line, subclavian, or internal jugular veinComplications of central venous cathetersPneumothorax Air embolism Lumen occlusion Bloodstream infectionPenumothoraxPrevention: use ultrasound to locate veins; avoid subclavian insertion when possible Treatment: administer oxygen; assist provider with chest tube insertion.Air embolismPrevention: have client lie flat when changing administration set or needleless connectors; ask client to perform Valsalva maneuver if possible. Treatment: Place client in left lateral Trendelenburg; administer oxygenLumen occlusionPrevention: flush promptly with NS between, before, and after each medication Treatment: use 10 mL syringe with a pulsing motionBloodstream infectionPrevention: maintain sterile technique Treatment: change entire infusion system; notify provider; obtain cultures; and administer antibioticsAntidote for AcetaminophenacetylcysteineAntidote for BenzodiazepineflumazenilAntidote for CurareedrophoniumAntidote for Cyanide poisoningmethylene blueAntidote for Digitalisdigoxin immune FABAntidote for Ethylene poisoningfomepizoleAntidote for Heparin and enoxaparinprotamine sulfateAntidote for irondeferoxamineAntidote for leadsuccimerAntidote for Magnesium sulfatecalcium gluconate 10%Antidote for narcoticsnaloxoneAntidote for warfarinphytonadione-dipineCa+ channel blockers-afilerectile dysfunction-caineanesthetics-prilACE inhibitor-pam, -lamBenzodiazepine-statinantilipidemic-asone, -solonecorticosteroid-ololBeta Blocker-cillinPenicillin-ideOral hypoglycemic-prazoleproton pump inhibitor-virantiviral-asethrombolytic-azineantiemetic-phyllinebronchodilator-arinanticoagulant-tidineantiulcer-zineantihistamine-cyclineantibiotic-mycinaminoglycoside-floxacinantibiotic-tylinetricyclic antidepressants-pram, -ineSSRIsCommon postoperative Complications-Atelectasis -Hypostatic pneumonia -Respiratory depression -Hypoxia -Nausea -Shock -Urinary retention/hesitancy -Decreased peristalsis/Paralytic ileus -Wound hemorrhage -Thrombophlebitis -Delayed Wound healing -Wound infection -Wound dehiscence/evisceration -Urinary tract infection