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Adult Health 2-exam 2 focused review

Terms in this set (80)

What are the 4 diagnoses that you can get with pH balances?
Metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis.
Why are they clinically relevant? If pH is outside the normal range of 7.35 to 7.45, metabolic processes cannot work; hormones and enzymes will not work, essentially the body cannot work, and this can lead to death.
What are 2 major causes of metabolic acidosis (there are many other causes/reasons, but these are the 2 major ones seen commonly in the emergency department)?
i. Diabetic keto acidosis (DKA)
1. Patho-physiologically, how does DKA become acidotic? The body is looking for an alternative energy source; patients with type 1 diabetes do not have insulin to let glucose into the cells to be used for energy, so the body breaks down fatty acids instead. Ketones are the byproduct of the breakdown of fatty acids. It is the fatty acids that cause the acidic environment.
2. Remember that Kussmaul is a breathing pattern secondary to DKA.
a. The respiratory system is the best way to correct metabolic causes of acidosis because it blows off CO2 and CO2 is a form of acid.
ii. Diarrhea- Losing bicarbonate ions from the small intestine.
What are metabolic causes of alkalosis?
i. Excessive vomiting
1. Due to throwing up hydrogen ions (in the form of hydrochloric acid out of the stomach)
ii. NG-Tube
1. iatrogenic ally, you can cause alkalosis with a nasal gastric tube. There are policy procedures in which you can only take out a certain amount of gastric content so that you don't cause alkalosis.
What diagnoses can cause respiratory acidosis?
COPD and asthma
What diseases does COPD comprise of?
i. Chronic bronchitis, emphysema, and Covid.
1. Within these diseases, the disease happens in the alveoli. The alveoli dilate, pocketing and retaining CO2. CO2 is acidic.
2. In chronic bronchitis, the airways are narrowed because of inflammation and mucus.
3. Thus, treatment for COPD, the goal is to get the air flowing by opening the airways and releasing the CO2 ---> bronchodilators and corticosteroids
ii. In asthma, bronchi are reactive and tight, and as a result they cannot expel CO2 (expiratory).
iii. Patient with ARDS (acute respiratory distress syndrome) or ARF (acute respiratory failure), will probably require ventilatory support and you can anticipate them having respiratory acidosis.
1. What is a cause of respiratory alkalosis?
2. What is the mechanism of getting alkalotic with hyperventilation?
a. Hyperventilation
1. Hyperventilation could be due to anxiety, panic attacks, or something wrong with the brainstem (with the brainstem, you can get hyperventilation or hypoventilation)
2. Blowing off way too much CO2 (acid) and becoming more basic (alkalotic)
1. Pneumothorax (open and closed), hemothorax, and chylothorax
a. What is the difference between an open pneumothorax and a closed pneumothorax?
i. Closed is when it happens without some sort of puncture wound from the outside. Example of causes for closed pneumothorax: trauma (like hitting a steering wheel and breaking the lining, resulting with air leaking into the pleural space. Nevertheless, there is no puncture wound; it's just air from inside the body, usually the lung, that starts to leak inside the pleural space.
ii. Closed pneumothorax is less dangerous. You would die quicker from an open pneumothorax
iii. An open pneumothorax is when you get a puncture wound from the outside, such as from a gunshot or a stab wound. This is also known as "sucking chest wound"
1. Negative pressure is sucking air from the outside environment very strongly
What is caused by penetrating trauma; air pressure is sucking air, causing lung collapse faster than closed pneumothorax?
sucking chest wound
What are you concerned about if you have a diagnosis of sucking chest wound?
Rapid cardiac or hemodynamic instability and cardiac decompensation.
a. A lot of pressure is pushing onto the unaffected side.
b. With so much pressure, the hemodynamic instability happens because you tamponade the heart itself by pressing on it. More importantly, you can compress the aorta, affecting blood outflow. Also the venous return can be compressed.
i. You can also get compression to the aortic arch going to the brain.
ii. Essentially, you will get a sharp decrease in cardiac output, resulting to cardiogenic shock.
iii. Cardiogenic shock ----> MODS à death
iv. It is almost like cardiac arrest.
What is the treatment for sucking chest wound?
thoracentesis (to get fluid, air, blood out) and eventually a chest tube.
mediastinal shift (tracheal deviation)
when the pressure pushes everything to the opposite side causes hemodynamic shock and instability
Can tall males get spontaneous closed pneumothorax?
yes (can't explain why)
What kind of thorax is chylo?
Lymphatic fluid.
rationale: Someone who had a mastectomy would have lymphatic fluid end up in their pleural space.
1. Oftentimes, when a mastectomy is done, they also remove the surrounding lymphatic tissue.
2. Removing the lymphatic tissue and vessels means that you do not have lymphatic return, resulting to lymphedema.
3. Intervention for lymphedema? Compression stockings to help milk the lymph back to the heart.
1. What is pleural effusion?
2. What would cause a buildup of fluid in the pleural space?
1. fluid in the pleural space.
2. Heart failure
Number one cause of pleural effusion is Heart Failure.
What is hemothorax?
blood in the pleural space
What other diseases can cause you to retain and build up fluid?
End-stage renal failure, ascites from cirrhosis.
With cirrhosis patients, they have hypoalbuminemia; they cannot keep the fluid balance between the spaces like the vessels and the interstitial space. Fluid regulatory organs are not working and so fluid will end up where it does not belong---> pleural effusion
What are the chambers of the chest tube?
Collection chamber-The water seal valve prevents the air or blood from going back into the pleural space
Water seal chamber (or water seal valve)-You get the gentle bubbling in the suction control chamber
Suction control chamber-This unit will be hooked up to suction on the wall.
1. Typical setting is 20 cm in suction control chamber of the actual unit. You do not want the wall suction to go any higher than this because it could dry out and you do not want your chest tube to be bubbling too rapidly because it will bounce around and fall over.
2. Titrate the wall suction to gentle bubbling.
Heimlich valve- is a little collection unit for very small pneumothoraxes. It is put in the pleural space and the patient wears it on his/her chest and it takes out small amounts of air.
Besides pneumothorax, what is another indication for a chest tube?
Thoracic surgery.
Examples of thoracic surgeries: CABG (coronary artery bypass graft), of which sometimes they will insert chest tubes bilaterally for drainage.
Head & Neck Cancer (for testing purposes)
In general, why would someone need a tracheostomy?
a. Upper airway obstruction (#1 indication for a trach)
b. Will also put a tracheostomy tube for the ventilator.
What are the 3 different forms of ventilatory access?
tracheostomy tube, through endotracheal tube, and through the nose
a. Tracheostomy for laryngeal cancer.
1. What are the Causes of laryngeal cancer?
2. What is the treatment for laryngeal cancer?
1. smoking, secondhand smoke, chewing tobacco.
2. laryngectomy. Post-surgically, a tracheostomy is required.
ARDS (acute respiratory distress syndrome) and ARF (Acute Respiratory Failure)
what are the causes:
a. drug ingestion (especially opioid overdose), pneumonia, COVID, COPD, brainstem stroke, brainstem trauma (your brainstem is important for breathing and for your heart)
b. Goal: to not have patient go from ARDS to full blown respiratory failure; not to have ARDs go to ARF
c. Would need to ventilate ARDS patient, but it depends how far along they are. The goal is actually not to put ARDS patient on ventilator. Why? Because patient gets sicker and can get sick from ventilator acquired pneumonia (pseudomonas is one of the big infections that the patient gets).
Oxygen failure versus Ventilatory failure
i. Ventilatory failure is when they cannot mechanically suck/pull in air into the lungs and cannot expire air on their own; patient cannot breathe on their own mechanically.
1. Pathologies that would cause ventilatory failure: unilateral sucking chest wound (one of the findings is deviation of the trachea- trachea is moving to one side); tension pneumothorax
2. One of the big causes of ventilatory failure is tension pneumothorax because they cannot inflate the affected, collapsed lung.
Other causes are diseases that affect the diaphragm (paralysis of the diaphragm), which prevents the patient from breathing in: multiple sclerosis, Guillain barre (starts from toes and ascend up), spinal cord injury (will cause diaphragmatic paralysis), brainstem stroke or brainstem bleed or injury to the brain causing ICP to go 1. up and the resultant swelling will lead to brain tissue to herniate and thus destroy the medulla, and opioid overdose.
What is the mechanism of ventilatory failure in an opioid overdose? Respiratory depression.
a. During an opioid overdose, patient is not breathing and ventilating adequately. Therefore, this patient has ventilatory failure AND oxygenation failure.
ii. Can have both oxygen and ventilatory failure at the same time à definitely need ventilator.
iii. Oxygenation failure occurs at the level of the alveoli; involves diseases that prevent person from oxygenating.
1. One of the primary problems is inflammation. You get inflammation with any infectious process like in pneumonia and COVID. In COVID, there was localized alveolar inflammation. What happens when you get localized inflammation? A release of histamine
With inflammation in any place in the body, whether systemic or localized, you will get a release of histamine.
a. Release of histamine leads to capillary leak, which then results to the alveoli filling up with fluid.
b. COPD has an inflammatory component with chronic bronchitis and especially emphysema.
Fluid buildup in the alveoli will impede oxygenation
What is a pathology that will impact oxygenation?
Shock (hypoperfusion); capillary bed (which surrounds the alveoli) is not getting enough oxygenation to the alveoli; shock in general will prevent blood and oxygen getting into the capillary bed (lack of perfusion). This would be a form of oxygen failure because the alveoli are not getting enough oxygen.
What is another pathology that will result in oxygen failure?
Pulmonary embolism (blood clot that gets lodged in an artery in the lung, blocking blood flow to part of the lung).
a. Depending on the size of the pulmonary embolism will determine how many alveoli are going to be affected.
PE cuts off the circulation to that part of the lung and ultimately the capillary bed.
What is the mechanism of oxygenation failure?
Alveoli is not getting enough oxygenation, due to the following reasons: decreased respiratory rate (like in an opioid overdose), there is some sort of blockage, or there is generalized lack of perfusion to the lungs (like in shock)
A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV?
A. "It keeps the alveoli open and prevents atelectasis."
B. "It allows preset pressure delivered during spontaneous ventilation."
C. "It guarantees minimal minute ventilator."
D. "It delivers a preset ventilatory rate and tidal volume to the client."
B. CORRECT: PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing.
A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevated blood pressure
B. CORRECT: Pale skin is an early manifestation of hypoxemia.
E. CORRECT: Elevated blood pressure is an early manifestation of hypoxemia.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
A. Apply a vest restraint if self‑extubation is attempted.
B. Monitor ventilator settings every 8 hr.
C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 4 hr.
D. CORRECT: The nurse should assess the breath sounds of a client receiving mechanical ventilation every 4 hr.
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask
B. CORRECT: A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered.
A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? (Select all that apply.) A. Assist‑control
B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
E. Independent lung ventilation
B. CORRECT: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths.
C. CORRECT: Continuous positive airway pressure requires that the client generate force to take spontaneous breaths.
D. CORRECT: Pressure support ventilation requires that the client generate force to take spontaneous breaths
Chapter 19-There are three types of ventilator alarms:
Volume (low pressure) alarms- indicate a low exhaled volume due to a disconnection, cuff leak, and/or tube displacement.
Pressure (high pressure) alarms- indicate excess secretions, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, or pneumothorax.
Apnea alarms- indicate that the ventilator does not detect spontaneous respiration in a preset time period.
Pay close attention to high pressure alarm
Who sets up the ventilator?
Respiratory Therapist
a. Two other very important settings are: pressure and volume. There is a pressure limit and volume limit.
b. Pulmonary doctor will order a very specific prescription for each patient; it is very individualized.
assist control ventilation
is one of the highest ventilator supports you can provide
1. For example, you have a patient that is has both oxygenation failure and ventilatory failure, meaning that patient essentially cannot breathe on their own (due to an overdose, trauma, brainstem stroke, or a paralyzed diaphragm)
2. At this point, ventilator will breathe 100% for the patient.
3. Assist control pushes air in and it allows for expiration.
i. When patient needs less ventilatory support, there are settings that will facilitate this:
1. For instance, patient may be able to start breathing on their own midway through the course on a ventilator. This would change it from full support to a ventilator setting that is prompted by patient's voluntary breath because the patient is now starting to breathe again.
2. Patient will graduate through different ventilator settings.
3. You can also have a bunch of different settings at the same time (ex: you can have ventilator pushing air in first, while also having patient on PEEP)
What is PEEP?
Positive End-Expiratory Pressure (PEEP) therapy keeps a certain amount of air in the alveoli for the sole purpose of keeping the alveoli inflated.
-For patient who needs assistance to keep their alveoli open. In normal functioning, every time you breathe you inflate the alveoli
Just by virtue of being on ventilator, can you get atelectasis?
YES
-Primary reason for putting patient on PEEP is to prevent atelectasis. What is atelectasis? A condition in which you have a collapsed or several collapsed alveoli (alveoli are really small)
What are causes of atelectasis?
COPD- especially emphysema. In COPD, particularly emphysema, alveoli are damaged, dilated, and weak.
Prolonged bed rest- Lying in bed for any extended period of time will make patient sicker, muscles will atrophy, and patient cannot inflate their lungs as normal when it is working against gravity. (**Side note: prolong bed rest also affects venous return to the heart, putting patient at risk for blood clots)
Anesthesia- (a hospital-caused/iatrogenic cause). Drugs like general anesthetics, benzodiazepines, or opioid narcotics that patient receives during surgery makes patient breathe less and less per minute. When this happens, the walls of alveoli get closer and closer together since they are not getting fully inflated. Inside the alveoli, there is fluid surfactant lining (lines the alveoli inner walls) that helps to keep the alveoli open and inflated. When the fluid in the lining gets really close to each other, it will slap shut (like water in a zip lock bag); the fluid will bond strongly together.
i. **Therefore, any disease that has a fluid regulatory problem (COVID, pneumonia, any capillary leak, even heart failure), you could start filling up the
alveoli with fluid and ultimately drown
ii. Outside of surgery, this can happen in a benzo overdose and an opioid overdose because the respirations go way down.
If a patient overdosed from opioids and had respiratory failure as a result, what should you do for the patient (besides giving the opioid reversal Narcan)?
Administer oxygen, and then proceed to have patient do incentive spirometry to help oxygenate him/her.
What does an incentive spirometer do? It recruits the atelectasis alveoli (collapsed alveoli) to open up. It helps to expand and exercise the lung capacity
-Need to coach patient on how to use the incentive spirometer properly. Tell them to use it like a bong.
-When using the incentive spirometer, patient deeply inhales and then holds their breath (for at least 5 sec), which helps pop open the alveoli again
are PEEP and incentive spirometry exactly the same concept?
Yes, However with PEEP, the ventilator will push air into the lungs but when patient expires, there is a certain amount of air left in there to keep alveoli inflated.
Be careful with the volume controls on ventilator because you can apply too much pressure and you could blow out the alveoli (called volume trauma or pressure trauma)
ABG
o PaO2 <60 mm Hg
o SaO2 <90%; or PaCO2 >50 mm Hg with pH <7.30
What is a Pulmonary embolism? PE
a physical, mechanical blockage in one or more arteries in the lungs, usually by a blood clot that travels from the legs (DVT-deep vein thrombosis)
Blood clot travels in the venous return, moves to the right atrium of heart, then to the right ventricle, and then enters the pulmonary system (venous blood going to the lungs to get oxygenated). The blood clots can vary in size. Depending on the size of the clot, it can prevent lung tissue/capillary bed from being perfused and could lead to death
How do you diagnose a DVT in the leg?
a. Bilateral doppler ultrasound (you have to make sure they do not have a blood clot in both legs)
You can also get clots in the arms- a PICC line can cause a clot in the upper extremities. This is often done iatrogenic ally. But majority of PE are caused by clots that originated from the leg
a. post-surgery, patients are immobile, which puts them at risk for developing PE.
i. Need to give anticoagulant to patient post-surgically. Usually, Lovenox or subcutaneous heparin. When patient goes home, they are put on a month-long course of coumadin (this is typically done for orthopedic patients). The reason is because patient can still form clots
ii. In the past, they would do a bilateral venous doppler before discharging patient. They do not do that anymore.
-Sitting for too long, such as traveling for long hours, puts someone at risk for developing blood clots because you are compressing the vessels in your legs
What are the clinical findings of a PE?
a. It can be pretty dramatic.
i. Starts out as a sudden dramatic onset of sharp pain
ii. Shortness of breath, dyspnea
iii. Low oxygen saturation; rapid oxygen desaturation
iv. Blood pressure will start off high, and then tank fairly quickly
Hemodynamics of the heart can quickly change, especially if you have a big blocked off pulmonary artery--->dramatic hemodynamic decline.
What are the two-gold standard diagnostic tests for PE?
D-dimer- lab sees if you have a blood clot
VQ scan-scans to see if you are getting adequate and blood flow
-Other diagnostics: chest x-ray, CT scan (sometimes it is not needed, but it is frequently ordered), ABGs
What is the treatment regimen for PE?
i. Get patient into bed (if patient was ambulating prior to PE event)
ii. Need to get a set of baseline vital signs.
iii. Initiate oxygen; get O2 stat to at least a 90%
iv. Initiate heparin drip or administer lovenox (enoxaparin)
1. Lovenox can be given prophylactically post-surgery. It can also be given to treat a clot. It is dose-dependent, depending on whether it is for prophylaxis or actually treating an existing clot.
2. Plunger on lovenox come in different colors: 30 mg is blue, 40 mg is yellow, 60 mg is orange, 80 mg is brown, 100 mg is black, and 120 mg is purple. Anything given past 40 mg--->you are treating 1. the clot. At least 60 mg and above is for the treatment of PE. Can also give regular heparin SUBQ, usually 5 to 10 units.
3. Can also give tissue plasminogen activator (TPA). This is a thrombolytic, a clot buster. But the problem with using a TPA for a PE is that it can break down the clot and result to more embolic material in the vessel. Thus, TPA is used less often.
What are your coagulation measurements for heparin drip?
i. PTT, aPTT, heparin Xa, and unfractionated heparin.
ii. If worse comes to worse, surgery will be doneà embolectomy
What other interventions would you have to do for a PE?
i. Pain management (usually opioids)
ii. Incentive spirometry
iii. Strict bed rest! No ambulation b/c ambulating can bust off more of the clot.
iv. Do not perform the Homan sign test (dorsiflexion sign test used to test for DVT) because it could potentially break up more of the clot. Homan's sign was used as a diagnostic tool for DVT because there would be pain upon dorsiflexion.
No sequential stockings (or TED stockings) because they could milk the clot and dislodge it
RENAL SYSTEM: What are things that kidneys do for you?
i. They remove nitrogenous waste
ii. Produce urine through the nephrons
iii. Control electrolytes in very fine measures - in very fine measures, kidneys will allow for certain amount of electrolytes to escape or to be retained
iv. Regulate acid base balance by dumping a certain amount of hydrogen ions and/or bicarbonate ions.
a. Think of kidneys as a big filter.
b. Kidneys requires adequate perfusion in order to function. If they do not get enough blood to them, they will stop functioning and die.
For instance, diabetes can destroy the kidneys. How?
Nephrosclerosis of vessels in the kidneys; it is the hardening of the walls of the small arteries and arterioles (small arteries that convey blood from the arteries to the even smaller capillaries). These vessels are crucial to be in good shape for kidney function. In diabetes, the glucose destroys the inner lumen of the vessels, making it sclerotic, hard, narrow, and hypertensive---> prevents blood from getting inside kidney, thus decrease in perfusion.
-Kidneys require a certain perfusion pressure for kidneys to work optimally.
How can you tell that a patient has renal issues?
They cannot urinate and they're swollen. The following diagnostic labs will be ordered: BUN, creatinine, and GFR
i. Normal GFR has to be 60 or greater.
ii. BUN- Blood urea nitrogen; urea is one of the nitrogenous wastes.
iii. Creatinine is another nitrogenous waste.
-Kidneys have a tight relationship with the liver. Some substances like medications and biologic waste are metabolized through the liver and excreted through the kidneys
a. Nitrogenous waste is the result of body breaking down protein. Other waste includes environmental wastes and pollutants.
b. If kidneys are not functioning, body will start building up the nitrogenous waste, which can be seen and measured in the blood draw. If you do a U/A, you will find protein in urine (in normal functioning, there is no protein in the urine)
c. In regard to the regulation of electrolytes in very fine measures- if kidneys do not work, you would have potentially life-threatening electrolyte imbalances.
-Specifically in chronic renal failure, oftentimes the worst one is hyperkalemia (this can lead patient to go into an arrhythmia)
What are the 3 regulatory mechanisms that the body has to regulate pH balance (involves regulating levels of hydrogen ions and bicarbonate ions)?
Breathing, the blood, and kidneys.
i. Kidneys are the slowest to regulate pH balance, but it is the strongest. When they are working, they will dump a certain amount of hydrogen ions and/or retain a certain amount of bicarbonate ions to keep pH within normal limits.
ii. Patients with chronic renal disease will usually have metabolic acidosis because they have an inability to excrete hydrogen ions (hydrogen ions are acidic)
iii. Abnormal pH balance can lead to death. Why? pH imbalance can change the shape of hormones and enzymes, thus if you do not have proper hormonal or enzyme function, nothing will work; metabolic processes that depend on hormones and enzymes will not occur.
How do the kidneys regulate water balance and blood pressure balance?
i. RAAS: Renin-Angiotensin-Aldosterone-System; this system starts in the kidneys and serves to regulate the blood pressure.
1. Renin comes from the kidneys
2. Angiotensin 1 gets converted to Angiotensin 2 by ACE (angiotensin converting enzyme) à results to vasoconstriction.
3. Aldosterone regulates blood pressure. How? It retains salt (memory trick: associate the "st" in aldosterone with salt).
4. **RAAS is mainly for blood pressure control- Why? Because you have vasoconstriction from angiotensin 2, and you have aldosterone for the volume.
a. Remember: what do you need to increase BP? Vasoconstriction and add volume to the vessels
ii. ADH (anti-diuretic hormone) comes from the posterior pituitary gland. It is secreted during times of hypo-volume or low blood pressure; it is a protective mechanism to gain volume in the vessels---> increase in blood pressure. Essentially, ADH prevents hemodynamic collapse.
1. ADH will stimulate kidneys to hold unto water; it ONLY pulls back water.
2. When you get too much salt in the body or if there is a high concentration of salt in the serum, ADH will kick in to dilute the serum. Therefore, ADH is involved in water AND salt regulation
What is aldosterone?
Secreted from the adrenal cortex and promotes sodium, chloride, and water reabsorption in the kidneys. (bp regulatory system)
What is ADH?
Anti-diuretic hormone - it controls the concentration of urine and is released into the bloodstream by the pituitary gland (this is another bp regulatory system)
In renal clearance, what are we clearing?
Creatinine
i. 24-hour urine creatinine clearance - involves collecting your urine over a 24-hour period of time and then having your blood drawn. These samples are then tested to see how much creatinine was filtered through your kidneys over the 24-hour window.
ii. Must have patient void FIRST before starting urine collection, and then 24 hours later, you need to collect the last urine right at the 24-hour mark.
Patient urinates in a urinal or a foley, and the urine is collected in a round bottle each time. The several bottles containing the urine are kept in ice for 24 hours. After the 24 hours, the bottles containing urine are sent to the lab to be analyzed.
How do the kidneys regulate blood cells?
a. ? Kidneys release erythropoietin, which stimulates the bone marrow to produce red blood cells.
i. RBCs, platelets, and WBCs are made in the bone marrow.
ii. Patients with chronic end-stage renal disease will get a shot of Epogen (erythropoietin) 3x per week at hemodialysis clinic. These patients cannot make erythropoietin; thus they are anemic all the time.
If patient is myelo-suppressed (such as when receiving radiation or chemotherapy), they will have low WBCs, low RBCs, and low platelets. You can give Neupogen to help increase WBC count
iii. Vitamin D deficiency is common in patients with chronic kidney disease and end-stage renal disease, including patients on dialysis.
-Give Vitamin D to these patients; used to calcify the bones/bring calcium to the bones
Prostaglandins
You are born with several different types of prostaglandins. Kidneys secrete prostaglandins. There are prostaglandins that dilate the vessels in the kidneys and keep the vessels patent, thereby allowing for adequate perfusion to the kidney
What is one of the big causes of renal disease?
Nephrotoxic medications
i. Examples of nephrotoxic medications: NSAIDs (OTC or IV push); ketorolac (Toradol) is an NSAID that is given IV push.
1. Giving more than 3 doses of ketorolac can kill out the kidneys; giving it for too long and/or giving a strong dose will absolutely damage the kidneys.
The mechanism of toxicity with NSAIDs and other nephrotoxic medications: they inhibit the prostaglandins that keep the vessels in the kidneys open/patent. Inhibiting the prostaglandins will result in the vessels getting tight.
-Kidneys also regulate calcium and phosphorus balance and activates growth hormone.
Glomerulonephritis-
1. inflammation of the glomeruli (the tiny filters in the kidneys); the excess fluid and waste that glomeruli remove from the bloodstream exit body as urine.
a. What is the particular organism that causes glomerulonephritis? Streptococcus
i. This means that kids can get glomerulonephritis.
ii. Parent brings child in and says that child cannot pee and is swollen. What is the question you ask? Has child had a recent strep throat?
iii. Treatment/interventions
1. Need to then run a rapid strep to see if child still has some reactivity to it.
2. Might give some diuretics, depending on how bad the glomerulonephritis is. Diuretics can actually be hard on the kidneys.
3. Nephrology and infectious disease consultation.
4. Main treatment: antibiotics
DO NOT GIVE TORADOL! Remember that it is nephrotoxic
What is nephrotoxicity?
if your prostaglandins are inhibited/Damage to the nephron/kidneys
What is pyelonephritis?
1. kidney infection; inflammation of the kidney due to a bacterial infection.
a. Can be hospitalized, but not always. However, you can be one of the sickest people ever with pyelonephritis.
i. Intense flank pain (very specific to pyelonephritis)
ii. Very high temp: extremely febrile (some of the highest temps you will ever see as an RN in acute care are going to come from pyelonephritis and peritonitis)
b. Most likely caused by a UTI that migrated from the bladder.
c. Treatment/Interventions
i. Obtain blood culture x2. Why do you need to do 2 sets of blood cultures? One can be contaminated, so you have to get two different sites for samples. Why are you doing a culture? So you know what is the causative bacterial agent and which antibiotic to use against it.
ii. Also, why do you have to get your blood cultures x2 first? If you give the antibiotics first and then get the blood cultures, you're going to have a skewed result (similar to nitro and EKG)
iii. Hang the antibiotic drip as quickly as you can.
iv. To treat high temp: acetaminophen
1. Can treat the pain and temp at the same time by giving Percocet (contains a combination of acetaminophen and oxycodone) or Vicodin (contains acetaminophen and hydrocodone)
2. Do not give 2 tabs of Percocet or 2 tabs of Vicodin because that is a big hit of opioids and patient may not be able to tolerate it. Also, it could potentially stop the patient's breathing
3. Only give 1 tab of Percocet or 1 tab of Vicodin, and then give an additional Tylenol as needed.
ii. Can also send out urine culture too.
Can patient with pyelonephritis go sepsis? YES (this is an infectious process)
...
Peritonitis secondary to peritoneal dialysis
a. In peritoneal dialysis, there is a Tenckhoff catheter that goes into the peritoneum and it will administer the dialysate in a certain concentration. The dialysate dwells in there for a certain number of hours (determined by the prescription; ex: 3-4 hours). Afterwards, you release the clamp and it drains into a bag on the floor. The fluid that comes out into the bag is called effluent.
i. When it comes out, effluent looks like urine (despite it coming from the peritoneal cavity). The effluent should be clear. If it is not and it looks cloudy ---->infection. This is very serious! This indicates peritonitis, which can kill the patient in a very short amount of time.
b. Clinical findings: pain, rigid abdomen (because inflammation is starting), high elevated WBC count, very high temp (fever)
c. Peritonitis can turn into systemic inflammatory response system (SIRS) very quickly! (Remember: the 2 pathophysiological mechanisms in SIRS is widespread vasodilation and capillary leak à causing hemodynamic instability).
i. This can turn into sepsis: patient's BP tanks and ultimately, they die from MODS.
ii. Why is peritonitis so dangerous? There is a big surface area of infection. Whether patient goes into sepsis or not (whether infection has gone into the bloodstream or not), they will still get SIRS.
iii. Infection is causing inflammation in the gut.
1. You can have inflammation without infection ---------->Patient will have SIRS with or without systemic septicemia
Broad spectrum antibiotics is prescribed immediately, given IV piggyback
nephrotic syndrome
1. not really a disease in itself
a. It is damage to the inter-renal structures
b. Loss of proteins in the urine because the proteins leak out
i. What happens when you lose serum proteins? It messes up the fluid distribution of fluid throughout the spaces. The fluid goes out of the vessels
ii. Kidneys dump proteins or some of the proteins go out into the body -----> patient will look like the Michelin man. This is anasarca
Anasarca is generalized edema
Acute kidney injury/acute kidney failure
a. Pre-renal causes- anything that causes a lack of perfusion to the kidneys, like shock; it is any of the shocks
i. One of the biggest causes is MI, especially left ventricular infarction
ii. Big zona necrosis and left ventricle is not pumping
b. Intra-renal causes- tissue damage of any of the structures inside the kidney, like the glomeruli. This causes the kidney not to function properly.
i. Pyelonephritis
ii. Nephrolithiasis, which are kidney stones
Post-renal causes- BPH or a migrated stone that is blocking the urethra, causing reflux back into the kidneys, causing hydronephrosis and damage
chronic kidney disease
CKD is a progressive, irreversible kidney disease.
RISK FACTORS ● Acute kidney injury ● Diabetes mellitus ● Chronic glomerulonephritis ● Nephrotoxic medications (gentamicin, NSAIDs) or chemicals ● Hypertension, especially in African American clients ● Autoimmune disorders (systemic lupus erythematosus) ● Polycystic kidney disease ● Pyelonephrosis ● Renal artery stenosis ● Recurrent severe infections
1. For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube?
A. Hyperoxygenate before and after suctioning
B. Repeat suctioning until the tube is clear
C. Apply suction during insertion of the tube
D. Suction for 30 seconds.
A. Hyper-oxygenate before and after suctioning
Rationale: The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyper-oxygenated for 1-5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits
Dislodgement with a chronic tracheostomy
Most trachs over 7 days old have healed sufficiently for the stoma to stay open if the trach is removed. Here's what you're going to do:
Provide oxygen
Monitor the patient for VS changes, increased WOB, signs of hypoxia
Alert MD and RT
Anticipate trach tube being replaced (hopefully you have supplies at the bedside!)
If the patient shows signs of respiratory compromise...CALL A CODE!
Monitor the patient for VS changes, increased WOB, signs of hypoxia
Alert MD and RT
Anticipate trach tube being replaced (hopefully you have supplies at the bedside!)
If the patient shows signs of respiratory compromise...CALL A CODE!
Dislodgement with a fresh tracheostomy
Most likely, your patient with a fresh tracheostomy (less than 7 days old) will become unstable if a dislodgement occurs (after all, there's a reason they have a trach in the first place!). Note that most fresh tracheostomies will be sutured in place...but this does not mean dislodgement can't occur. And, of course, it is an EMERGENCY!
Call a code
Grab the Ambu-Bag and ventilate your patient
If the trach is still sutured in place (and it probably is), cut the sutures and remove the tube
The MD may try to reinsert the tracheostomy tube OR orally intubate the patient
A client has just arrived in the PACU following a successful tracheostomy procedure. Which nursing action must be taken first?
A. Suction as needed
B. Clean the tracheostomy inner cannula and stoma
C. Listen to lung sounds
D. Change the tracheostomy dressing as needed
C. Listen to lung sounds
Assessment is the first phase of the nursing process. All other actions and procedures are driven by assessment findings. The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs.
Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse?
A. Humidifying the oxygen source
B. Increasing oxygenation
C. Removing the inner cannula of the tracheostomy
D. Suctioning the client
D. Suctioning the client
Rationale: Suctioning the client will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern.
A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and SaO2 92% on room air. Which of the following actions should the nurse take first?
A. Obtain a chest x‑ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via a high‑flow mask.
D. Initiate IV access.
C. CORRECT: According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high‑flow mask to restore optimal breathing because the client is experiencing dyspnea and has decreased lung sounds
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS ). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection."
B. "This medication is given to facilitate ventilation."
C. "This medication is given to decrease inflammation."
D. "This medication is given to reduce anxiety."
B. CORRECT: Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption
A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.)
A. A client who experienced a near‑drowning incident
B. A client following coronary artery bypass graft surgery
C. A client who has a hemoglobin of 15.1 mg/dL
D. A client who has dysphagia
E. A client who experienced acute drug toxicity
A. CORRECT: A client who experienced a near‑drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema.
B. CORRECT: A client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. ARDS .
D. CORRECT: A client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration.
E. CORRECT: A client who experienced acute drug toxicity is at risk for developing ARDS due to damage to the central nervous system.
A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should the nurse include? (Select all that apply.)
A. Administer antibiotics. B. Provide supplemental oxygen.
C. Administer antiviral medications.
D. Administer of bronchodilators.
E. Maintain ventilatory support
B. CORRECT: Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered to treat severe hypoxemia.
D. CORRECT: Administration of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client's airway.
E. CORRECT: Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway.
A nurse is caring for a client who is receiving vecuronium during mechanical ventilation. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.)
A. Fentanyl
B. Furosemide
C. Midazolam
D. Famotidine
E. Dexamethasone
A. CORRECT: Fentanyl is a pain medication administered to clients when a neuromuscular blocking agent, such as vecuronium, is administered. C. CORRECT: Midazolam is a sedative medication administered to clients when a neuromuscular blocking agent, such as vecuronium, is administered
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply.)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter E. Occlusive dressing
A. CORRECT: Oxygen should be readily available in case the client develops respiratory distress following chest tube placement. The nurse should monitor respiration, oxygen saturation, and lung sounds.
B. CORRECT: If the chest tubing becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal.
C. CORRECT: Hemostat clamps should be available for the nurse to use to check for air leaks.
CORRECT: If the chest tubing becomes disconnected, the nurse should immediately place a gauze dressing over the site. An occlusive dressing can also be necessary to prevent the redevelopment of a pneumothorax.
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?
A. Obtain a chest x‑ray.
B. Apply sterile gauze to the insertion site.
C. Place tape around the insertion site.
D. Assess respiratory status.
B. CORRECT: Using the airway, breathing, and circulation (ABC) priority‑setting framework, application of a sterile gauze to the site should be the first action for the nurse to take. This allows air to escape and reduces the risk for development of a tension pneumothorax
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level
B. CORRECT: Gentle bubbling in the suction control chamber is an expected finding as air is being removed.
C. CORRECT: A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly
. A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take?
A. Instruct the client to lie prone with arms by the sides.
B. Complete a surgical checklist on the client.
C. Remind the client that there is minimal discomfort during the removal process.
D. Place an occlusive dressing over the site once the tube is removed.
D. CORRECT: The nurse should place an occlusive dressing over the site once the tube is removed and observe the site for drainage.
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.)
A. Encourage the client to cough and deep breathe.
B. Check for continuous bubbling in the suction chamber.
C. Strip the drainage tubing every 4 hr.
D. Clamp the tube once a day.
E. Obtain a chest x‑ray
A. CORRECT: The nurse should instruct the client to cough and deep breathe. This promotes oxygenation and lung re-expansion.
B. CORRECT: The nurse should check for continuous bubbling in the suction chamber to verify that suction is being maintained at an appropriate level.
E. CORRECT: A chest x‑ray is obtained following the procedure to verify chest tube placement.
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