Disorders/Diagnoses
COPD and Asthma
Subjective and Objective Assessment
Nursing Interventions and Respiratory Procedures
Pharmacotherapeutics
100
Air accumulating in subcutaneous tissue.
What is subcutaneous emphysema. Signs and symptoms may include a feeling of "rice krispies" popping (crepitus) when palpating the skin around the site and swelling in the tissues.
100
Mechanism of action of theophylline.
What is relaxation of the smooth muscles of the bronchi. Theophylline (Theo-Dur) is a methylxanthine drug. It is a very old bronchodilator. It is often used in cases of COPD. This medication requires frequent monitoring (theophylline level) because the therapeutic range is very narrow.
100
If this test is positive, a client has developed an immune response to TB.
What is the Mantoux test. A positive test indicates that not only has the client been exposed, but has actively developed antibodies to the germ It will be positive within 2-10 weeks after exposure. It does not confirm that active disease is present. Clients who have been treated for TB may retain a positive reaction. Individuals who have latent TB may have a positive Mantoux and may receive treatment to prevent development of an active form of the disease. Clients who have received a Bacillus Calmette-Guerin (BCG) vaccine within the last 10 years may have a positive Mantoux. They will need an xray to evaluate for active infection.
100
The purpose of this intervention is to loosen respiratory secretions and move them into the central airways where they can be removed by coughing or suctioning.
What is CPT (chest physiotherapy). Removing secretions from the airway and not allowing them to accumulate reduces the risk for respiratory infections and atelectasis. CPT is often performed along with other therapies such as bronchodilators, antibiotics, mucolytic agents, and hydration. Combing these therapies helps reduce mucous production and increase airway clearance.
100
Administer this type of drug to a patient who needs frequent coughing and deep breathing related to a respiratory diagnosis or surgery -- in order to assist them to breathe as deeply as possible and expand their lungs and cough most comfortably.
What is analgesia (non narcotic or narcotic). Opiod narcotic medications are also given as antitussives (codeine). Splinting the abdomen during post-operative coughing and deep breathing also helps to reduce pain.
200
Influenza is transmitted in what manner?
What is droplet transmission. The flu can be fatal in even healthy persons, but the ill, those with COPD and the immunocompromised are especially at risk. For this reason, those with COPD should receive routine vaccination, including the flu and pneumonia vaccinations.
200
This type of breathing is an appropriate intervention for a COPD patient. It helps the patient to control their breathing, feel more relaxed, and maintain airway patency during expiration.
What is "pursed lip breathing." The client should form the mouth as if preparing to whistle. Client should take a breath in through the nose and pause then exhale slowly out through the pursed lips/mouth. Client should not puff the cheeks. Client should take breaths deep and slow.
200
These lung sounds are sometimes referred to as "sonorous wheezes." They are at a much much lower pitch than other high pitched, whistling and musical "wheezes" we associate with narrowed airways (like in asthma).
What are "rhonchi." Rhonchi are usually related to narrowing of larger airways, including bronchi, and vibration of secretions within them. Rhonchi are often heard in conditions such as bronchitis, airway edema, tumor, or even foreign body obstruction.
200
They can be difficult to obtain because they are easily contaminated with saliva. They are most accurate when collected in the morning, before the patient has anything to eat or drink.
What is a sputum specimen. For most tests, the sample should contain 1 to 2 teaspoons of sputum. Different methods of laboratory analysis require different transport media. Routine cultures, transported in a sterile container, identify basic bacterial pathology. Sensitivity testing completes the process by determining the correct antibiotic treatment. Acid-fast bacilli (AFB) testing requires a sterile container and is performed on three serial samples to detect tuberculosis. This is the definitive test for TB. The diagnosis of TB is confirmed by a positive culture for Mycobacterium tuberculosis. A positive acid-fast test suggests an active infection. Cytology testing requires a special preservative and identifies which form of lung cancer a patient has (small cell, oat cell, or large cell). For all, you’ll complete the appropriate laboratory requisition form with pertinent patient data and send it with the specimen for analysis.
200
The most common side effect for this very commonly used narcotic analgesic drug, often given to reduce postoperative pain, is respiratory depression.
What is morphine sulfate.
300
Condition wherein structures in the middle of the chest (heart, trachea) deviate to the unaffected side related to pressure.
What is mediastinal shift. The mediastinum is the "middle" section of the chest. Some of the organs included in the mediastinum include the heart, the aorta, the thymus and the chest portion of the trachea. To look for mediastinal shift, check for tracheal deviation. Keep the head in a neutral position to check for tracheal deviation.
300
Common side effects of bronchodilators.
What are palpitations and/or tachycardia and tremor. Clients who use bronchodilators should avoid smoking. Smokers will need more frequent dosing.
300
Your patient has a build up of respiratory secretions and exudate related to a bronchiectasis. The MD has ordered this intervention. It is performed to remove secretions by gravity from different areas of the lungs.
What is postural drainage. Postural drainage is commonly performed two or three times a day, often before meals and at bedtime. It is best to schedule it when the patient’s stomach is empty to avoid gastric reflux and vomiting. If the patient is receiving continuous tube feedings, stop the feeding and check gastric residual at least 30 minutes before performing postural drainage. To drain the affected areas, place the patient in a variety of positions to facilitate drainage by gravity. Not all positions are required for every patient and, depending on the patient’s illness or condition, some positions may be contraindicated. Before starting postural drainage and during the procedure, evaluate the patient’s tolerance of the various positions. The patient usually remains in each position for 10 to 15 minutes. However, this time may be shorter initially and then gradually increased as the patient is better able to tolerate it. When performing postural drainage, first position the patient, then percuss and vibrate, then remove the secretions either by having the patient cough or by suctioning the patient’s airway.
300
Nurses can assist with this device to help expand a client's lungs and prevent atelectasis postoperatively. This device can also be used in treatment and recovery of a client affected by other respiratory dysfunction.
What is an incentive spirometer. Client should take a deep breath in -- slowly -- to expand alveoli.
300
This class of drugs stimulates the flow of respiratory tract secretions through increasing mucous secretion. This promotes increased cough production which decreases chest congestion.
What are expectorants. Give expectorants in the AM so that patients can cough and expectorate during the day, and not during time when they could be sleeping.
400
This condition occurs when air enters the pleural space during inspiration and is not able exit upon expiration.
What is a tension pneumothorax. A pneumothorax is the presence of air or gas in the pleural space which causes lung collapse. (A spontaneous pneumothorax can occur when there has been no trauma. A hemothorax is collection of blood in the pleural space). When a tension pneumothorax occurs, the trapped air causes pressure on the heart and lungs, compresses blood vessels and limits venous return which leads to a decrease in cardiac output. It must be treated immediately to prevent death. When a tension pneumothorax occurs, air pressure continues to rise, causing a mediastinal shift.
400
This class of drugs, often given in combination with a bronchodilator, are used to treat the inflammatory pathophysiology of asthma. Drugs of this class often end in the letters "sone."
What is inhaled corticosteroids. Examples include fluticasone (Flovent) and prednisone (Deltasone). Patients should be advised to rinse the oral cavity after use of inhaled corticosteroids. This will help prevent side effects such as dry mouth, hoarseness and oral candida (fungal infection). Bronchodilators should be given first to allow the corticosteroid to be distributed better -- if separate inhalers are used.
400
Grating sound produced by inflamed, moving pleura. It is often very low pitched and grinding.
What is pleural friction rub.
400
Pulmonary function tests (PFTs) with the use of this device are important in the diagnosis and treatment of asthma.
What is the peak flow meter. A decrease in forced expiratory volume 1 (FEV1) or peak expiratory flow rate (PEFR) by 15% to 20% below the expected value is common in clients who have asthma. An increase in these values by 12% following the administration of bronchodilators is diagnostic for asthma.
400
To assist in thinning of respiratory secretions, the nurse can recommend increased fluid intake. The nurse can also administer this class of drug, if ordered, to thin the secretions.
What is a mucolytic agent.
500
Also called "rales," these sounds can be "fine" or "coarse." They are indicative of popping sounds produced by the sudden opening of collapsed alveoli as air passes through the moisture in small airways as they suddenly reinflate.
What are crackles. To emulate the sound, roll you hair between your fingers right next to your ear.
500
This very serious complication of COPD can be caused by the increased workload of the right side of the heart, leading to enlargement and thickening of the right atrium and ventricle.
What is right sided heart failure (cor pulmonale). Signs and symptoms of right sided heart failure can include low oxygenation levels, cyanotic lips, enlarged/tender liver, distended neck veins (JVD), and dependent edema.
500
Instability of the chest wall caused by fracture of three or more ribs in two or more places. With this condition, breathing is unique: affected chest segment moves inward during inspiration and outward during expiration.
What is flail chest. Flail chest is often associated with pneumothorax.
500
This test is used to obtain accurate measurements of blood oxygen and carbon dioxide. A specimen of the client's blood is obtained from an artery (not a vein). It is often performed on patients in respiratory distress.
What is an ABG (arterial blood gas) measurement. Steps are as follows: 1. Wash your hands, introduce yourself to the patient and clarify their identity. Explain what you would like to do and obtain consent. This is a slightly uncomfortable procedure so you should let the patient know this. 2. Gather the necessary equipment. 3. Position the patient’s arm with the wrist extended. 4. Locate the radial artery with your index and middle fingers. Perform Allen’s test where you compress both the radial and ulnar arteries at the same time. The hand should become white, release the ulnar artery and the colour should return to the hand. This ensures that there will still be a blood supply to the hand should the ABG cause a blockage in the radial artery. 5. Put on your gloves and attach the needle to the heparinised syringe. Also prepare your local anaesthetic and give a small amount over the palpable radial artery. 6. Take the cap off the needle, flush the heparin through the syringe and again locate the radial artery using your non-dominant hand. 7. Let the patient know you are about to proceed and to expect a sharp scratch. 8. Insert the needle at 30 degrees to the skin at the point of maximum pulsation of the radial artery. Advance the needle until arterial blood flushes into the syringe. The arterial pressure will cause the blood to fill the syringe. 9. Remove the needle/syringe placing the needle into the plastic needle holder. Press firmly over the puncture site with the gauze to halt the bleeding. Remain pressed for 5 minutes. 10. Cap the syringe, push out any air within it, and send immediately for analysis ensuring that the sample is packed in ice. Remove your gloves and dispose them in the clinical waste bin. Wash your hands and thank the patient. Limited movement of the extremity is indicated initially after the ABG measurement procedure. http://www.osceskills.com/e-learning/subjects/arterial-blood-gases/
500
White lists first line and second line drugs for TB in Table 35-7: Tuberculosis medications. First line drugs include ethambutol HCl, Isoniazid, er, and rifampin (among others). Second line drugs include cycloserine and para-amino-salicylate (Sodium P.A.S.) -- among others. Many of the drugs include "give with meals" or "give with food" among their nursing considerations. Why?
Giving the medications with meals may help to decrease GI side effects.
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