Nursing Management of Client with Respiratory Disorders (NC1) – Flashcards
Unlock all answers in this set
Unlock answersquestion
Obstructive Sleep Apnea Pathophysiology
answer
Airway Blocked Reduces O2 May have breathing cessation Middle aged men and Obesity= higher Risk for OSA
question
Obstructive Sleep Apnea Manifestations
answer
Excessive daytime sleepiness Headache Risk for Cardiac issues (bc heart is compensating) Higher risk for postop complications
question
Obstructive Sleep Apnea Treatment
answer
CPAP Oral Device that keeps tongue in place Removal of tonsils will help widen airway Placement of Permanent trache for extreme cases
question
Obstructive Sleep Apnea: Nursing Management
answer
HOB elevated Encourage use of CPAP Sleep on side
question
Obstructive Sleep Apnea Education
answer
Explain why need CPAP -help with daytime sleepiness -prevent apneic periods at night -increase LOC during day If you don't treat, the heart will compensate=overwork
question
Cancer of Larynx Pathophysiology
answer
Removal of Larynx Malignant
question
Cancer of Larynx Manifestations
answer
Hoarseness Sore throat Dyspnea Pain with swelling
question
Cancer of Larynx Nursing Management
answer
ASSESS AIRWAY: O2 sats, RR, etc Deliver humidified O2 Round frequently Have notepads in room (way of communication)
question
Cancer of Larynx Education
answer
Teach need to have suction Elevate HOB Inform they will wake up from surgery with tubes They will not have a voice postop-notepad Teach what to do in Emergency No smoking/alcohol
question
Pneumonia (PNA) Pathophysiology
answer
*Acute Infection of Pulmonary Tissue Bacterial: Strep Virus: Flu, RSV Asparation: geriatrics (food, h2o) decreased gag Reflex Community Acquired: -Airborne 48h after pt in hospital setting Lung Edema Stiff and Hypoxic 90% PNA r/t Strep Exudate fills Alveoli causing infiltrates and CXR
question
PNA Manifestations
answer
*FEVER *INCREASE WBC *CRACKLES CXR showing Infiltration/Consolidation increased HR SOB Possible Chest pain
question
PNA Treatment (Tx)
answer
*ABX (antibiotics) for Bacterial *Bronchodialtors *Increase Fluids (flush system) --Check gag reflex o2 Analgesic Supportive Therapy for Viral Bronchoscopy for Last Resort
question
PNA Nursing Management
answer
High Fowlers AMB (ambulate) IS (incentive spirometer) TCDB (turn,cough,deep breath) ASSESS RESP STATUS Administer opiods and abx
question
Tuberculosis (TB) Pathophysiology
answer
Calcification in Lung Local Inflammation Response Very Contagious CHRONIC *AIRBORNE BACTERIAL Active and Latent Tissue can erode and spread to other organs, bones, blood, lymph
question
TB Manifestations
answer
Night Sweats Low-grade Fever PRODUCTIVE COUGH fatigue Positive Montoux Test (TB test) CXR will show Calcification
question
TB Tx
answer
**INH Meds for 6-12 months NEGATIVE PRESSURE ROOM --Keep private room (airborne) Abx if exacerbation
question
TB Nursing Management
answer
ASSESS RESP STATUS Encourage Fluids Private Room Contact Precautions -puffer suits -tb mask -cluster cares
question
Pleural Effusion Pathophysiology
answer
*Fluid in Pleural Space Systemic and local Causes: CHF, Liver/Renal Fx, PNA, TB, Cancer
question
Pleural Effusion Manifestations
answer
Dull Percussion Dyspnea with activity Absent/Dull lung sounds SOB Pain Limited Chest Wall Movement
question
Pleural Effusion Tx
answer
Treat underlying disease process -abx O2 thorocotomy thorocentesis Chest tubes
question
Pleural Effusion Nursing Management
answer
Assist with Thorocentesis High Fowlers ASSESS RESP STATUS Apply Dressings
question
Lung Cancer Pathophysiology
answer
Caused by: -smoking -asbestos -Metastasis -Malignant Cells Bronchial Epithelial Cells mutate & become neoplastic
question
Lung Cancer Manifestations
answer
Wheezing Dull Chest Pain Chronic Cough Dyspnea
question
Lung cancer Tx
answer
Palliative Care O2 Chemo/Radiation Lobectomy Pneumonectomy (remove complete lung) Lobectomy (remove lobe of lung) Lung Biopsy (to diagnose)
question
Lung Cancer Nursing Management
answer
ASSESS RESP STATUS Psychological Support REST Pain Meds!
question
Bronchiolitis (RSV) Pathophysiology
answer
Common in young children Inflammation of Bronchioles Spread by HANDS AND DROPLETS Can lead to PNA
question
Bronchiolitis (RSV) Manifestations
answer
Low grade fever Malaise Sore Throat
question
Bronchiolitis (RSV) Tx
answer
Fluids Percussion --pat children on back --Shaking vest for adults Bronchodilators CXR to check for PNA
question
Bronchiolitis (RSV) Nursing Management
answer
ABX Isolate Infant ASSESS RESP STATUS Suctions Secretions
question
Bronchiolitis (RSV) Education
answer
Teach parent how to use nebulizer @ home SS (signs symptoms) Respiratory Distress in infant: --using assessory muscles to breath --nostril flaring Use Ball Suction in Infants *Watch for Dehydration Px (prevention) is Key: --handwashing --coughing --clean environment
question
Asthma Pathophysiology
answer
Excessive Mucous Secretions Bronchioconstriction Smoking Spontaneous Chronic Inflammation Disease in Bronchioles
question
Asthma Manifestations
answer
Chest Tightness Wheezing SOB During Attack: --tachycardia --prolonged expiration --tripod --cyanotic
question
Asthma Tx
answer
Bronchodilators Avoid Stimulants Corticosteroids Leukotrain Modifiers High Fowlers O2
question
Asthma Nursing Management
answer
ASSESS RESP STATUS Have Rest Periods Use Calm Approach Remove Stimulus Mx (monitor) PEAK FLOW meter: --Green: 100-80% --Yellow: 80-50% --Red: <50%
question
COPD-Chronic Bronchitis Pathophysiology
answer
*Productive cough >3months thick mucous Impaired Cilia Bronchial Edema No Cure
question
COPD-Chronic Bronchitis Manifestations
answer
Diminished Lung Sounds Dyspnea *very PRODUCTIVE cough BLUE BLOATER(bloated bc full of CO2) Exposure to smoke/pollution hypoxic Increased RR hypercapnia Crackles Heavier weight
question
COPD-Chronic Bronchitis Tx
answer
Low Rate O2 Bronchodilators Corticosteroids Abx with Exacerbation REST
question
COPD-Chronic Bronchitis Nursing Managment
answer
ASSESS RESP STATUS Adm Abx High Fowlers Frequent Rest Breaks ***Watch anesthetics
question
COPD-Chronic Bronchitis Education
answer
Smoking cessation Limit Exposure PNA Vaccination
question
COPD-Emphysema Pathophysiology
answer
Destruction of Alveoli Enlargement of Abdominal air space leads to loss of corresponding capillary beds SLOW ONSET o2 is getting trapped and cant get CO2 out
question
COPD- Emphysema Manifestations
answer
*Pink Puffer dyspnea BARREL CHEST SOB Wheeze Skinny because working so hard to breath
question
COPD- Emphysema Tx
answer
Corticosteroids Bronchodilators Abx BiPAP/CPAP Low Rate O2 Pulmonary Rehab
question
COPD- Emphysema Nursing Management
answer
**Teach Pursed Lip Breathing ASSESS RESP STATUS Smoking Cessation Elevate HOB Mx LOC ***watch anesthetics
question
COPD- Emphysema Education
answer
Avoid Climate Change PNA Vaccination
question
Atelectasis Pathophysiology
answer
Collapsed Alveoli
question
Atelectasis Manifestations
answer
Diminished Breath Sounds Dyspnea Tachycardia Low grade fever Pleuratic Pain CXR showing infiltrate/consolidation
question
Atelectasis Tx
answer
TCDB IS AMB O2
question
Atelectasis Nursing Management
answer
ASSESS RESP STATUS TCBD IS AMB O2 Prevention is Key
question
Bronchietasis Pathophysiology
answer
Increase in Mucous leads to airway obstruction Destruction of wall
question
Bronchietasis Manifestations
answer
Lots of Sputum Crackles Bronchi Lung Sounds r/t PNA, TB, cystic fibrosis
question
Bronchietasis Tx
answer
High Fowlers Percussion /vest Bronchodilators Last Resort: Lung dissection
question
Bronchietasis Nursing Management
answer
MX RESP STATUS TCDB IS AMB with rest Increase fluids to thin mucous
question
Bronchietasis Education
answer
Conserve Energy Vaccinate no smoking Support System
question
Low Flow O2 Nasal Canula
answer
1-6 Liters fiO2= 24-44% *watch nostril/ear breakdown Minimal support
question
Low Flow Face Mask
answer
1-15 Liters fiO2=40-60% *more humidifier abilites *dont put on confused pt
question
Partial Rebreather
answer
6-15 liters (usually 15) fio2= 60-75% Captures exhaled air then when they inhale again, they breath in their air + extra oxygenated air
question
Low Flow Nonrebreather Mask
answer
Make sure bag is inflated Concentrated O2: -their air+extra air
question
High Flow Venturi Mask
answer
Used with COPD-->extra ability to give o2 & rid CO2 Lowers CO2 Retention
question
High Flow Nasal Canula
answer
15-40 Liters This is the backup if they dont tolerate the face mask
question
High Flow Face Tent
answer
Backup Mask for people with claustrophobia or bloody nose, etc Encourage humidified air
question
5 Key Points in Nursing Management of Patient with Respiratory disease
answer
1) Physical Assessment- color, comfort, LOC, cough 2) Palpation- Pain 3) Percussion: Dullness 4) Auscultation: Rales (crackles), Rhonchi, Wheezes 5) Oxygen Delivery Method
