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Study Guide Units 1-3

UNIT1:

• Respiratory disorders often are one of the most frightening disorders. When the patient is unable to exchange air, fear and panic can occur.

• Additional assessment techniques include:

• Voice sounds

• Bronchophony

• Whispered pectoriloquy

• Egophony

• Skin and mucous membranes

• General appearance

• Endurance

• Physical assessment should include special attention to anatomical structure problems and respiratory functions.

• Psychosocial assessment focuses on current complaints that are affecting the patient’s lifestyle.

• Some respiratory problems may be worsened by stress.

• Chronic respiratory disease may cause changes in family roles, social isolation, and financial problems due to unemployment or disability.

• Discuss coping mechanisms and offer access to support systems.

• Diagnostic testing for patients with respiratory problems includes:

• Laboratory tests:

• Blood tests

• Sputum tests

• Radiographic examinations including standard chest x-rays, digital chest radiography, CT

• Ventilation and perfusion scanning

• Pulse oximetry

• Pulmonary function testing: These tests evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation.

• Exercise testing

• Skin testing

• Special invasive diagnostic tests needed for patients with oxygenation problems include:

• Endoscopic examinations

• Thoracentesis: aspiration of pleural fluid or air from the pleural space

• Patient preparation for stinging sensation and feeling of pressure

• Correct position

• Motionless patient

• Risk for ineffective airway clearance: Interventions include:

• Excessive tumor involvement and tenacious secretions can inhibit airway patency.

• Nursing measures for maintaining airway patency is primary focus.

• Assessment should focus on patient’s dyspnea, inability to cough effectively, or inability to swallow.

• Nonsurgical management:

• Airway management

• Cough management

• Aspiration precautions

• Patient teaching about prevention and treatment with medications and diet

Care of Patients Requiring Oxygen Therapy or Tracheostomy

• Oxygen therapy:

• Hypoxemia: low levels of oxygen in the blood

• Hypoxia: decreased tissue oxygenation

• Goal of oxygen therapy: to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects

• Low-flow oxygen delivery systems:

• Nasal cannula

• Simple face mask

• Partial rebreather mask

• Non–rebreather mask

• High-flow oxygen delivery systems:

• Venturi mask

• Face tent

• Aerosol mask

• Tracheostomy collar

• T-piece

• Noninvasive positive-pressure ventilation:

• Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation.

• BiPAP cycling machine delivers a set inspiratory positive airway pressure each time the patient begins to inspire. At exhalation, it delivers a lower set end-expiratory pressure. Together the two pressures improve tidal volume.

• Continuous nasal positive airway pressure:

• Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation.

• Effect is to open collapsed alveoli.

• Patients who may benefit include those with atelectasis after surgery or cardiac-induced pulmonary edema; it may be used for sleep apnea.

• Transtracheal oxygen delivery:

• Used for long-term delivery of oxygen directly into the lungs

• Avoids the irritation that nasal prongs cause and is more comfortable

• Flow rate prescribed for rest and for activity

• Home oxygen therapy:

• Criteria for home oxygen therapy equipment

• Patient education for use

• Compressed gas in a tank or cylinder

• Liquid oxygen in a reservoir

• Oxygen concentrator

• Care for patients with a tracheostomy:

• Prevention of tissue damage: Cuff pressure can cause mucosal ischemia.

• Use minimal leak technique and occlusive technique.

• Check cuff pressure often.

• Prevent tube friction and movement.

• Prevent and treat malnutrition, hemodynamic instability, or hypoxia.

• Use air warming and humidification.

• Observe for hypoxia in the tracheostomy.

• Evaluate for possible complications of suctioning.

• Provide tracheostomy care and bronchial and oral hygiene.

• Nursing care for patients with oxygenation problems is centered on the following nursing diagnoses:

• Impaired Gas Exchange

• Ineffective Breathing Pattern

• Ineffective Airway Clearance

• Imbalanced Nutrition

• Anxiety

• Activity Intolerance

• Potential for Pneumonia or Other Respiratory Infections

• Chest tubes:

• Placement after thoracotomy

• Drainage system

• Care required:

• Monitor hourly to ensure sterility and patency.

• Tape tubing junctions.

• Keep occlusive dressing at insertion site.

• Position correctly to prevent kinks and large loops.

UNIT 2

• Nurses and physicians use a physical assessment of the patient’s general appearance, skin color, skin temperature, vital signs, venous and arterial pulses, central and jugular venous pressures, and jugular venous distention as well as pain assessment to help determine patients’ condition that have cardiac output and tissue perfusion problems.

• Radiographic examinations include standard radiography:

• Electrocardiography

• Electrophysiologic study

• Exercise electrocardiography

• Echocardiography

• Pharmacologic stress echocardiogram

• Transesophageal echocardiogram

• Imaging

• Cardiac catheterization

• Lipid level, including cholesterol and triglycerides, is elevated in atherosclerosis patients.

• High serum levels of homocysteine can allow cell walls to become vulnerable to plaque buildup.

• Myocardial perfusion imaging

• Drug therapy should include:

• Diuretics

• Calcium channel-blocking agents

• ACE inhibitors

• Angiotensin II receptor antagonists

• Aldosterone receptor antagonists

• Beta-adrenergic blockers

• Central alpha agonists

• Alpha-adrenergic agonists

• Aspirin

• Beta-adrenergic blocking agents

• ACE inhibitors

• Calcium channel blockers

• Heparin

• Warfarin

• Thrombolytics

• Cardiac glycosides

• Statins, etc.

• Diseases include:

• Heart failure

• Mitral stenosis

• Mitral regurgitation (insufficiency)

• Mitral valve prolapse

• Aortic stenosis

• Aortic regurgitation (insufficiency)

• Infective endocarditis

• Pericarditis

• Cardiomyopathy

• Subacute or chronic disease of cardiac muscle

• Dilated cardiomyopathy

• Hypertrophic cardiomyopathy

• Restrictive cardiomyopathy

• Hypertension

• Acute peripheral arterial occlusion

• Aneurysms of central arteries:

• Abdominal aortic aneurysm (AAA)

• Thoracic aortic aneurysm

• Buerger’s disease

• Raynaud’s phenomenon

• Venous thromboembolism

• Varicose veins

• Phlebitis

• Coronary artery disease

• Stable angina pectoris

• Acute coronary syndrome

• Myocardial infarction

• Common nursing diagnoses:

• Impaired gas exchange

• Decreased cardiac output

• Activity intolerance

• Potential for pulmonary edema

• Decreased cardiac output related to altered stroke volume

• Impaired gas exchange related to ventilation perfusion imbalance

• Activity intolerance related to inability of the heart to meet metabolic demands during activity

• Acute pain related to physiologic injury agent (hypoxia)

• Health teaching:

• Smoking cessation

• Diet control

• Complementary and alternative therapies

• Physical activity

• Sexual activity

• Blood pressure, blood glucose control

• Cardiac medications

• Self-monitoring; seeking medical assistance if needed

UNIT 3

Coronary Arterial Disorders

• Stable angina pectoris

• Acute coronary syndrome: 29% die from MI within 5 years.

• Myocardial infarction:

• Most serious acute coronary syndrome

• Occurs when myocardial tissue is abruptly and severely deprived of oxygen

• Dynamic process that does not occur instantly but evolves over several hours

• Assessment includes:

• Pain assessment

• Discomfort in the chest, epigastric area, jaw, back, or arm is noted. (Rate discomfort on scale of 0 to 10.)

• Discomfort is often described as tightness, burning, pressure, or indigestion.

• Anginal pain improves with rest and nitroglycerine; MI does not.

• Other manifestations include nausea and vomiting, diaphoresis, dizziness, weakness, palpitations, and shortness of breath.

• Gender-specific assessment: women vs. men clinical manifestation

• Diagnostic assessment:

• Electrocardiogram

• Stress test

• Myocardial perfusion imaging

• Magnetic response imaging

• Cardiac catheterization

• Nursing diagnoses include:

• Pain Management

• Ineffective Tissue Perfusion (Cardiopulmonary)

• Activity Intolerance

• Ineffective Coping Interventions

• Potential for Dysrhythmias

• Potential for Heart Failure Interventions

• Complications can include:

• Cardiogenic shock

• Necrosis of more than 40% of the left ventricle

• Tachycardia

• Hypotension

• Blood pressure < 90 mm Hg, or 30 mm Hg < patient’s baseline

• Urine output < 30 mL/hr

• Cold, clammy skin

• Poor peripheral pulses

• Agitation, restlessness, confusion

• Pulmonary congestion

• Tachypnea

• Continuing chest discomfort

• Dysrhythmias

• Potential for recurrent symptoms and extension of injury interventions

• Treatment can include:

• Percutaneous transluminal coronary angioplasty (PTCA)

• Coronary artery bypass graft surgery (CABG)

• Minimally invasive direct coronary artery bypass

• Transmyocardial laser revascularization

• Off-pump coronary artery bypass

• Robotics

Hematologic Disorders

• Diagnostic assessment:

• Tests of cell number and function:

• Complete blood count

• Reticulocyte count

• Hemoglobin electrophoresis

• Leukocyte alkaline phosphatase

• Coombs’ test

• Serum ferritin, transferrin, and total iron-binding capacity

• Tests measuring bleeding and coagulation:

• Capillary fragility test

• Bleeding time test

• Prothrombin time

• International normalized ratio

• Partial thromboplastin time

• Platelet agglutination/aggregation

• Bone marrow aspiration and biopsy

• Follow-up care:

• Give patient education.

• Cover with dressing; observe for 24 hours.

• Administer mild analgesic.

• Apply ice pack.

• Avoid contact sports or any activity that might result in trauma to the area.

• Care for patients with hematologic problems:

• Anemia

• Reduction in either the number of red blood cells, the amount of hemoglobin, or the hematocrit

• Clinical sign (not a specific disease); a manifestation of several abnormal conditions

• Sickle cell disease:

• Genetic disorder resulting in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death

• Formation of abnormal hemoglobin chains

• Conditions causing sickling: hypoxia, dehydration, infections, venous stasis, low environmental body temperatures, acidosis, strenuous exercise, and anesthesia

• Interventions:

• Pain most common problem

• Potential for sepsis

• Potential for multiple organ dysfunction

• Glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia

• Iron deficiency anemia

• Vitamin B12 deficiency anemia

• Folic acid deficiency anemia

• Polycythemia Vera

• Leukemia

• Hodgkin’s lymphoma

• Non-Hodgkin’s lymphoma

• Multiple myeloma

• Autoimmune thrombocytopenic purpura

• Thrombotic thrombocytopenic purpura

• Hemophilia:

• Hemophilia A is deficiency of factor VIII and accounts for 80% of cases.

• Hemophilia B (Christmas disease) is deficiency of factor IX and accounts for 20% of cases.

• For hemophilia A with blood transfusion and factor VIII therapy, survival time has increased greatly.

• Transfusion therapy

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