Med Surg Session 9: Peri-Operative Nursing

Perioperative nursing

 

Session 9

 

covers Pre, intra and postoperative care

 

There are a vast range in the types of surgeries, but there are consistencies throughout the nursing care.

  • ie. safety, advocacy, outcomes, and surgical scrubs

 

Pre-op

    • Call the patient: hold/take meds, history, questions that the patient may have
    • administer pre-op meds: ativan, antibiotics,maybe zofran, fluids, robinul (anticholinergic to dry up secretions)
    • Prepare meds to be administered.
    • be aware of cultural factors: will they accept blood, do they want to bury an amputated limbs.
    • showing competence to the patient, comfort, honesty, actively listening, promotes trust.

 

  • Double check the site of operation and ask them “where do you understand that we will be operating on?”.

 

  • Isolation precautions: if the person has an open MRSA would it will be scheduled as the last op of the day and “terminally cleaned” afterwards.
  • Preop anesthesia assessment at bedside: Mallampati score of mouth and throat opening, history of anesthesia, respiration.

 

intraoperative

  • starts in the transfer to OR and ends in the transfer to post-op.
  • Circulation nurse and scrub nurse in the OR
  • patient concerns: everyone’s face is covered, patient is exposed, left support system, a ton of question, and it can be noisy.
  • who is in the OR: Circulator RN, Scrub RN, Anesthesia, surgical team,
    • secondary: students, perfusion, neuromonitoring, radiology, orientees.
  • surgical team:
    • anesthesia provider: anesthetic plan, attending resident, CRNA, and/or Student CRNA, anesthesia tech.
    • this is interprofessional!
  • measure blood loss
  • count the tools before during and after, to protect from something being left behind.

 

PACU

  • airway breathing circulation,
  • drains OK?
  • bleeding too much
  • urinating?
  • Pain control
  • Lines drains and Airway
  • could take an hour or 2 in the PACU
  • assessments:
    • Airway management, circulation, pain level assessment and trend,
  • Alcohol pad under the nose to relieve nausea for a short time.

 

QSEN – (quality and safety education of nurses) teamwork and collaboration

  • it is a continuous plan of care and should be throughout
  • CAUTI
  • RCA – Root cause analysis
Advertisements

Med Surg 8: Oncology

Class 8: Cancer

 

Hyperplasia: proliferation of cells that are still organised

dysplasia: proliferation of cells that are becoming disorganized.

situ: in the normal location.

  • so if there is dysplasia in situ this means that the cancer is not yet invasive to other tissues.

 

Proto – oncogene: allows apoptosis to occur.

  • oncogene: a protooncogene that has been damaged and can no longer signal apoptosis at the right time or at all.

 

Tumor suppressor gene:

 

Immune system

  • T lymphocytes: deal with INtracellular foreign substances
  • B lymphocytes: deal with EXtracellular foreign substances
  • Immunologic escape: the process where the cancer can avoid our immune system safeguards.
  • Oncofetal antigens: in tumor cells as well as fetal cells
    • are not well differentiated

 

mutations in genes:

  • Primary cancer related genes: Oncogenes, tumor suppressor genes, DNA repair genes

 

screening

  • self exams
  • cervical
  • breast
  • prostate – do not run psa on everyone any more no
  • ovarian – no general test
  • colon – at and after 50

 

biopsy will allow us to see the differentiation in the cell types

  • styles: Needle aspiration, Core or incisional, and excisional
  • all of these will give us a tissue sample of the cancer.

 

Stages – the extent of the disease and how invasive it is

  • 0 – situ (precancer, some dysplastic cells)
  • 1 – local tumor
  • 2 – limited local (lymph nodes)
  • 3 – extensive spread
  • 4 – metastasis

TNM classification

  • T = tumor size T1-T4
  • N = spread in the lymph nodes N0 – N3
  • M = metastasis 0 or 1

 

Grades – the differentiation of the cell types

 

Karnofsky scale 100% is perfect, and 0% is death

 

ECOG – eastern cooperative oncology group

  • 0 full active, 4 completely disabled, 5 death

 

hysterectomy types

  • Subtotal – remove uterus
  • total – and cervix
  • total and bilateral salpingo oophorectomy – and fallopian tubes and ovaries
  • Radical – and upper vagina, other tissue, and lymph nodes

 

palliation – comfort and symptom management

 

drug therapy – the goal is to combine drugs to minimize s/s and maximize the cancer killing effectiveness

  • chemo is an adjuvant to surgery (meaning that it is supportive therapy after the surgery to clean up the excess
  • only chemo certified RNs can give chemo.
  • be careful with waste/spills
  • special protocol for extravasation of IV
  • Ask when the last dose of chemo was and what was it?

Study tips:

  • Potential complications of dxs
  • what would I will

Med Surg Session 7: Neurologic Disorders

Session 7: Neurologic disorders

strokes:

  • TIA – stroke signs and symptoms but with no dead tissue, this is a warning sign for another TIA or stroke
    • not a stroke
  • CVA – an incident that ends in the death of tissue that occurs under twenty four hours
  • FAST – face drooping, Arm weakness, Speech difficulty, time to dial 911
  • change in level of consciousness.
  • risk factors: DM, HTN, obesity
  • Nursing diagnosis: “risk for ineffective cerebral tissue perfusion related to reduction vessel blood flow and cerebral edema”
  • Be sure that the patient has a viable gag reflex.
    • aspiration is a high risk for stroke patients
  • Right sided CVA
    • left side paralysis
    • more impulsive
    • short attention span
    • no issues
  • Left sided CVA
    • right side paralysis
    • problem identifying left from right, and their own limbs
    • short attention span, uncontrollable emotional swings.
    • impaired speech (
      • global aphasia – cannot understand or get the words out/not real words
      • expressive aphasia – cannot express themselves with speech appropriately. Broca’s aphasia (trouble finding words, takes effort to speak),
      • receptive aphasia – cannot understand what other people are trying to communicate to them, the patient.  Wernicke’s aphasia (impaired ability to understand language)
  • Rehab
    • MSK – help set good posture, and encourage movement

 

  • thicken water and puree food due to the impaired gag reflex

 

  • Encephalitis case study (Acute inflammation of the brain)
    • summary: 59yo, change in LOC, expressive aphasia, HA 5/10, 39 degrees C, poor skin turgor and dry mucous membranes.
    • d/t: herpes zoster virus
    • treat with antiviral – acyclovir.
    • seroquel – to improve mental status, (mood stabilization)

 

Myasthenia Gravis

Define: A weakness and rapid fatigue of muscles under voluntary control that fluctuates.

Pathophysiology: Genetic disorder that leads to an autoimmune response that attacks Ach receptor.

S/Sx: first weakness with no pain, then eventually fatigue once the Dx progresses. Eye lid and ball droop, difficulty swallowing and chewing, change in voice, drooping face/jaw, cannot hold head upright.

Diagnosis: Neuro test, Edrophonium test (if MM strength comes back after the med is administered MG is indicated), ice pack test, Blood test to look for the antibodies that attack the ach receptors.  

Treatment: Cholinesterase inhibitors, steroids, and immunosuppressants

 

Multiple Sclerosis

Define: A disease of unknown etiology that causes damage to the myelin sheath and disrupts the nerve path.

Pathophysiology: the creation of plaques (lesions), and the degradation of myelin sheath.

S/Sx: Pain in the eyes and back, tremors, difficulty walking, slurred speech, double or blurred vision.  

Diagnosis: there are multiple parts to the diagnosis medical history and neurological assessment then tests are done to reveal damage and reactions (MRI, Spinal Tap, Evoked potentials).

Treatment: cannot cure, only slow progression and speed up recovery from acute attacks. give steroids, and do a plasma exchange if this is a new onset that did not respond to the steroids.

 


Seizures

Define: abnormal electrical activity in the brain. Generalized is when both sides of the brain are affected, and partial is when a specific area is affected these can spread throughout the brain though.

Pathophysiology: paroxysmal manifestations of the electrical properties of the cerebral cortex. A seizure results when a sudden imbalance occurs between the excitatory and inhibitory forces within the network of cortical neurons in favor of a sudden-onset net excitation.

S/Sx: mm contractions or spasms, an Aura, pain, fatigue

Diagnosis: EEG, Neuro test, blood test for infection and genetic disposition

Treatment: carbamazepine, diazepam, anticonvulsants

 

Parkinson’s disease

Define: CNS dx that can cause tremors

Pathophysiology: a gradual loss in the levels of dopamine. throwing off the atch dopamine balance.

S/Sx: tremors, bradykinesia, and rigidity

Diagnosis: no specific diagnosis, just ordering tests to rule out other diseases

Treatment: increase dopamine in the brain: levodopa with carbidopa, MAOBs(eldepryl), COMP-T inhibitors(Entacapone), amantadine, and anticholinergics.

 

Bacterial Meningitis

Define: inflammation of the brain and spinal cord membranes caused by bacterial infection

Pathophysiology: bacteria such as streptococcus pneumoniae invade the bloodstream, cross the blood brain barrier, then colonize in the CSF

S/Sx: pain in the back and neck from inflammation, then infection s/s

Diagnosis: spinal puncture to get A sample of the CSF and grow a culture to find out what is in the chord.

Treatment: IV antibiotics, and corticosteroids,

  • Vancomycin – check ototoxicity and nephrotoxicity, it is a vesicant, kills gram-positive bacteria by binding to the cell wall. ANAPHYLAXIS and Red Man syndrome can develop
    • for meningitis, endocarditis, osteomyelitis
  • To prevent get a vaccine, then stress hand washing.

 

Guillain Barre

Define: paralysis that starts in the legs and moves up the levels of the spinal cord triggered by an infection

Pathophysiology: demyelination in an ascending pattern

S/Sx: ascending paralysis

Diagnosis: peripheral neuro exam, and electrolyte imbalances

Treatment: Plasma exchange(to remove harmful antibodies), and immunoglobulin therapy (put in immunoglobulins that block the antibodies that contribute to GB).

 

Med Surg session 6: Cardiovascular

 

 

Session 6

 

Cardiovascular

 

Cardiac index is the CO when the size of the person is taken into account.

  • normal is 2-4
  • This accounts for: 100lb person with 8L CO and a 300 lb person with a 8L CO


the higher the SVR the tighter the blood vessels are.

  • Systemic vascular resistance
  • this is low in neurogenic shock, and septic shock.

 

Men often present with Heart disease around 50 yo and have generic symptoms

  • Chest, jaw, left shoulder pain, SOB

Women present in a less typical way and onset around 60 yo

  • nausea, vomiting, anxiety, back or arm pain, fatigue

 

HTN

 

  • JNC8 are the new guidelines
  • keep DM and CKD pts under 140/90
  • HT crisis
  • emergency
  • severe HA, seizures, coma
  • HCT (hydrochlorothiazide) is the first line drug for HTN

 

CAD

  • to prevent the increase of this disease, Exercise, blood glucose management
  • Drugs that this person would be on: ASA, plavix, Beta blocker, (not a diuretic necessarily because we are trying to directly decrease HR and the ability to form a thromboembolism)

 

Angina

  • Chronic stable angina – pain upon exertion that is relieved with nitro and rest. Predictable.
    • the cause is usually atherosclerosis
    • medications for this: nitro, beta blockers, ASA, CCB
      • take 8-12hr time off of nitro (usually at night) because when used too chronically it loses effectiveness.
  • Vasospastic angina (prinzmetal)
    • doesn’t happen upon exertion, happens randomly
    • treat with CCBs relax vessels and make them less spastic
  • When to worry
    • persisting longer than 5 mins call 911, then take two more tablets total in five minute intervals

 

Myocardial Infarction

  • irreversible necrotic tissue
  • troponins labs will be high
  • usually in the left ventricle
  • Diagnostics for MIs
    • ECG changes
      • STEMI – st elevation MI
  • Clot busters () (fibrinolytic therapy) are given if there is no cath lab in the hospital to use a balloon to move the clot against the artery wall.  
    • TPA, alteplase, streptokinase
  • Cardiac catheterization (PCI)
    • inserted through the femoral artery (sometimes the radial)
    • goes into the heart arteries to balloon open up the artery section.
    • Check KIDNEY FXN! the dye used to visualize the clot and PCI are hard on the kidneys
  • MONA – morphine (pain, vasodilation, and cheap), O2, Nitro, ASA

 

Heart failure

  • left sided
    • EF > 40% (normal is 50%-70%
    • systolic HF (HFrEF)- reserved (decreased) ejection fraction
    • diastolic HY(HFpEF) – preserved ejection fraction
  • Drugs to increase CO
    • diuretics, ACE, ARBs, Beta and CCBs (if the EF is not too small)
  • VAD – Ventricular assist Device – used so the heart does not have to work. it is inside the person’s body.

 

Cardiomyopathy

  • 3 types: dilated, hypertrophic, and restrictive
  • Dilated: most common, decrease in CO,
    • the volume in the heart chambers increases, and there are thin walls
  • Hypertrophy: Increased O2 consumption in the Heart muscle, and decreased volume of blood that can flow into the ventricles during diastole.
    • volume in the chambers decreases, the heart walls are thick.

 

PVD (peripheral Vascular Disease)

  • decreased peripheral perfusion from a decrease in the size of peripheral blood vessels
  • pathology similar to atherosclerosis, but in the periphery
  • s/s: slows healing, pain, decreased pulses, ulcers, and edema
  • can affect the arteries, or venous system (tends to affect the venous system more often)

 

Peripheral venous disease –

  • Risk factors: venous stasis, Immobile, hypercoagulability, increased viscosity (often from dehydration),
  • s/s: increase in: heat, malaise, erythema
  • Encourage mobility

 

DVT – deep vein thrombosis

  • prevent with: tight stockings, auto compression devices (compress the legs at regular intervals to increase venous return and decrease stasis), AMBULATE.
  • If a clot develops then put the patient on bed rest so they do not throw the clot
    • Drugs once there is a clot: (thrombolytics) TPA, alteplase, and streptokinase
  • If the clot detaches it will end up in the lungs (if there is a patent foramen ovale (hole in the septum in the heart) the clot can pass through that hole then end up in the brain).

 

Aneurysms

  • aortic aneurysm – out pouch of the aorta
    • can repair with surgery by adding in a graft to strengthen the wall and bypass the aneurysm site.
    • Diagnosis from a CT scan with Dye to visualise the pouch
    • TAA- thoracic Aortic aneurysm
      • send embolisms to the brain and extremities
    • AAA – Abdominal aortic aneurysm
      • sends embolisms to the kidneys and lower extremities (cannot get to the upper extremities or brain because of the low position of the aneurysm)

 

patients with DM and now has angina may present differently when their heart is ischemic

  • Hyperglycemia, nausea, malaise
  • Also Pioglitazone (actos) may increase the chance of exacerbating the patient’s HF

 

Lasix (furosemide) things to look for to measure effectiveness

  • decreased weight, urine output, BP decreasing, decreased edema
  • Monitor these labs: K, BUN and Creatinine, (electrolytes and kidney function)

 

Med Surg: Class 5

 

Class 5 MSK

 

MSK assessment

  • History
  • Physical assessment
    • inspection, Palpation, motion, strength opposition, gait
  • PTH, Ca levels, Phosphorus PO4, Vit D, Creatinine Kinase (CK)
  • X-ray, and bone density scan

 

Broad issues

  • Pain, Neurovascular compromise (edema, mm spasm, loss of peripheral pulses, cap refill, and neurologic sensitivity), Immobility

 

Osteoporosis

  • loss of bone density over time.
  • diagnosis when 25%-40% of bone calcium lost.
  • x-ray or bone density scan
  • manifests as: pathological fractures, may not present with s/s, bone pain,
  • Drugs: fosamax (alledramate), keep the Ca in the bone and prevent absorption
    • Omeprazole may (PPI’s) may decrease Ca absorption.  
  • Lifestyle changes: Weight bearing exercise, Ca and Vit D supplementation,
  • avoid: alcohol smoking, and carbonated beverages
  • Risk Factors: small thin women, inactive lifestyle, white/asian, ETOH, Chronic Steroid use, Postmenopausal (lower estrogen levels)

 

Fractures

  • reduction – realigning the bone
  • closed reduction is “pulling traction” and the bone is realigned without
  • ORIF -open reduction internal fixation (surgical procedure)
  • Healing: hematoma, granulation tissue, callus formation, ossification, consolidation, remodeling.
  • complications: NEUROVASCULAR IMPAIRMENT, Pain, DVT, Fat embolism, Osteomyelitis, Myoglobinuria (leads to acute renal failure because it is a protein that is hard on the kidneys)

 

Fat embolism – comes from the bone marrow often in long bone fractures.

    • includes the micro vasculature, can go into ARDS (acute resp. distress syndrome), petechiae, neuro issues (change in LOC).
    • the issues arise from the emboli getting stuck in the lungs, brain, or other microvasculature.
    • Cannot really treat this once it is lodged.

 

Compartment syndrome

  • from MM trauma, the muscle swells and pressure increases
  • 6 Ps: pain, paresthesia, pallor, pulseless, pressure, paralysis.
  • treat with a fasciotomy to relieve the pressure

 

Traction

  • pulling the bone to allow for realignment to occur correctly.
  • types
    • Manual, Skin or Bucks, and skeletal(drill into bone)
  • complications
    • sheer, urine retention (from pain meds and positioning), DVT, constipation, psychological issues, and fat emboli.
    • AWFUL: Atelectasis, Wasting bone, Functional MM loss, Urine retention, Lastly constipation

Internal fixation

  • adding screws or plates, to help the bone heal correctly
  • stay in permanently

 

External fixation:

  • drill into the bone to anchor, then a system outside the body holds those anchors until it is healed then they are taken out,
  • Clean the Pins consistently, about TID

 

Rheumatoid arthritis

  • There are many many types and can affect the whole body not just the joints.

 

Gout

  • buildup of uric acid in blood, then the crystals collect (especially in the big toe)
  • Med: NSAID’s, colchicine, ibuprofen

 

THA – total hip arthroplasty (Replacement)

TKA – total knee arthroplasty (replacement)

 

Med Surg: Class 4:

Diabetes Mellitus

 

Class 4

 

Insulin vs. Glucagon, GH, epinephrine, cortisol

 

Glucagon – turns glycogen and fat into fuel

 

insulin – moving glucose and nutrients into cells

 

Type 1 – autoimmune dx, destroys beta cells

  • some genetic and environmental factors contribute to this
  • onset is not always young
  • scandinavian countries have the highest rates.
  • antibodies that can be tested for to diagnose DM1
    • GAD antibodies
    • insulin autoantibodies
    • c-peptide levels

 

type 2 DM

  • factors that contribute to insulin resistance:
    • genetic factors
    • diet
    • obesity
    • physical inactivity
  • if both parents have DM2 the child has a 50% chance of getting DM2
  • Progressive decline of Beta cell function

 

Gestational DM

  • DM that is diagnosed during pregnancy and leaves after
  • 20% of pregnant woman will get this
  • HPL – human placental lactogen, increases glucose levels to allow the baby to get more glucose
    • If there is too much glu the baby can become too fat and cause birth issues

 

secondary DM

  • chronic pancreatitis
  • Hormonal disorders
    • cushing’s disorder
    • acromegaly
  • cystic fibrosis
  • down syndrome
  • drug induced
    • nicotinic acid
    • HIV meds
    • anti rejection meds – prograph
    • glucocorticoids – dexamethasone
    • chemotherapy –

 

Diagnose DM2 (above these normal ranges)

  • A1c 5.7-6.5%
  • fasting plasma glucose 100-125 mg/dL
  • 2 hour PG 140 – 199 mg/dL in the OGTT

 

Prevention

  • metformin decreases chance by 30%
  • metformin + lifestyle is a decrease of 60% chance

 

Inpatient glu targets

  • non ICU
  • pre meal >140
  • random > 180
  • ICU
    • 140-180

 

Diabetes Meds

 

  • Metformin
    • reduction of insulin resistance, decrease liver glu production
    • PO route
    • S/E: gastrointestinal discomfort
    • if creatinine is above 1.5 risk of renal disease
  • Sulfonureas (glyburide, glipizide)
    • stim insulin production
    • S/E: hypoglycemia
  • Meglitinides
    • short term insulin secretion
  • thiazolidinediones (pioglitazone Actos)
    • reduction of insulin resistance
    • gain about 10 lbs of water weight
    • use with caution in CHF and liver Dx
    • 4 week onset, bone loss
  • SGLT2 inhibitors (invokana Canagliflozin) (jardiance Empagliflozin)
    • reduce renal glu reabsorption and increase secretion
    • S/E: weight loss, UTI
  • Incretin mimetics (bayetta bid) (bydureon 1x week)
    • stim insulin secretion, suppress glucagon, slows gastric emptying
    • GLP- Agonist
    • S/E: weight loss, N/V/D

 

Insulin

  • Basal insulin (best injected in the abdomen)
    • Long acting (detemir and glargine)
      • no peak duration of 24hr
    • intermediate acting (NPH)
      • peak 6-12hr duration of 12-20hr
  • bolus insulins (given after the meal to be sure that they ate it. the injection can go any where you can pinch an inch)
    • rapid acting (humalog, Novolog) 5-15min onset
    • short acting (regular (humulin, Novolin) 30-60min onset

 

  • Insulin pumps
    • rapid acting insulin that is infused all day to replace the basal. when the person eats they put in their blood sugar and amount of carbs about to eat.
    • there are also sensors that can track the glucose level in the blood using and sensor that needs to be calibrated with a finger stick BID. This is very helpful with trending the glucose level.
    • Nursing considerations
      • the person needs to be alert and oriented to use it
      • double check what the person is telling you about the pump
      • still use finger stick in the hospital as a double check because we are liable
      • still a SQ catheter injection to deliver the medication

 

Acute complications:

 

  • Diabetic acidosis
    • increase in ketone acid from the body breaking down fat rapidly
    • Labs
      • glucose >250
      • CO2 <15
      • Anion Gap [Na – (Cl + HCO3)] increased (acidic) 
    • almost always in people with DM1
    • s/s: n/v, polyuria, polydipsia, kussmaul respirations, tachycardia

 

  • HHNK
    • higher blood glucose than with DKA
    • spill glucose in urine
    • more common in DM2
    • same treatment as DKA

 

Hypoglycemia

  • treatment
    • Glucagon to increase hepatic glucose release
    • Epinephrine to reduce glucose uptake and increase hepatic glu production
  • s/s HTN, diaphoresis, unique to the person and there may be no symptoms
  • hypoglycemia unawareness – lowers the level that the hypoglycemia is felt by the person

 

Long term complications

 

Retinopathy

  • blood vessels are damaged
  • create black spots in vision
  • nonproliferative – occurs in about 10 years
  • Proliferative – neovascularization, from retinal hypoxia
  • macular edema –

macular edema

Glaucoma

cataracts

 

Nephropathy

  • stage 1 functional change gfr increases (GFR >90)
  • Stage 2 glomerular damage (GFR 60-89)
  • stage 3 overt nephropathy (GFR 30-59)
  • Stage 4 severe nephropathy (GFR 15-29)
  • Stage 5 end stage need dialysis (>15)

 

  • need a renal diet low potassium, refined foods ( doesn’t mesh well with DM diet)

 

Neuropathy

  • first painfull then painless once the nerve is full glycosylated
  • fall risk, (have bad proprioception)

 

Autonomic neuropathy

  • Gastrointestinal – gastroparesis
    • anorexia, nausea, vomiting
    • diagnosis from radioactive food(eggs) visualised by medical scintigraphy

 

  • cystopathy
    • cannot sense full bladder
  • ED
    • Poor blood flow (most meds do not work because it just works to increase blood flow not nerve response)
  • female sexual dysfunction  

 

Cardiovascular disease

 

  • from increased platelet aggregation, decreased fibrinolytic activity, HTN, Hyperlipidemia
  • s/s: are not common MI s/s and can be “silent”

Med Surg: Class 3

Class 3

 

Respiratory

 

  • Lower resp. diseases: PHTN, pneumonia, tuberculous
  • Upper resp. diseases: Asthma, COPD, cystic fibrosis

 

  • Thoracentesis – a needle is put in the the pleural space to take out specimens, or to inject medications.
    • we are worried about a pneumothorax after this procedure

 

  • Give O2 if the patient drops below 90% for the pulse oximetry
    • the O2 is dry, so be sure to add water to the chamber to moisturize the O2.
    • room air is about 21% O2
    • add about 4% per litre/min via nasal cannula

 

Lower respiratory

 

  • Pneumonia
    • the risk for pneumonia goes up with: age, smoking, increased aspiration risk, air pollution, and intubation.
    • In the elderly the first s/s can be changes in LOC
    • s/s: Productive cough, Intake is less than output (the are becoming dehydrated), fever, increased white count, hypoxemia, Pleuritic pain (pain from inspiration)
    • VAP – ventilator associated pneumonia
    • there are four main types of pneumonia:
      • Community acquired pneumonia
        • from seasonal, viral, influenza,  causes
      • Hospital acquired pn.
        • caused by bacteria often staph, pseudomonas, klebsiella
      • Opportunistic pn
        • viral, or fungal cause
        • affects people that have compromised immune system.
      • Aspirational pn
        • chemical irritation, people that are bad a swallowing
        • if a person coughs every time they have a drink of water they could be aspirating
    • What should the nurse do to manage?
      • Hydrate the patient(to thin secretions), increasing the input to at least equal to the output of the patient.
      • do pulmonary assessments
      • educate the patient on how to avoid getting this in the future.
      • cough deep breath, incentive spirometer
  • What can this lead to?
    • Atelectasis, empyema, meningitis, endocarditis, pleurisy (inflammation of the pleural space, lung abscess (need to drain)

 

  • Atelectasis
    • Loosing of usable lung space though collapse of alveoli.
    • From: trauma, secretions, cough
    • s/s: fever, decreased breath sounds in the affected area, dyspnea, centrally cyanotic
    • care plan: chest tube to expand lung, ambulate the person, manage pain.

 

  • Tuberculosis
    • people that are immunocompromised are at a very high risk to develop TB
      • HIV, Nursing homes
    • PPD test is the skin test for this
    • Drug treatment: 4 drug combined therapy for active dx. If the infection is latent then the person is treated with INR for 6-9 months.
      • Don’t take with ETOH because of the liver load.
    • s/s: fatigue, similar to pneumonia, night sweats
    • Put them into a negative airflow room, everyone need a TB mask, educate them to stop the spread of the dx.
    • Miliary TB – the dx spreads throughout the body:
      • hepatomegaly, splenomegaly, lymphadenopathy
    • Pleural effusions and empyema can develop as well (bacterial infection of the pleural space
    • TB pneumonia can happen due to the tubercle bacilli discharge into the lung

 

  • Lung Abscess
    • An enclosure in the lungs that contains pus
    • can be caused by aspiration, Smoking, other inhaled carcinogens, and having a preexisting pulmonary Dx.
  • Lung cancer
    • B symptoms – weight loss, fever, night sweats
    • treatments:
      • Radiation therapy
        • rad burns and rashes, dysphagia if the location is near throat,
      • Surgery
    • Types are not too important to this class:
    • squamous cell is slow growing and central
      • from smoking
    • Adenocarcinoma: most common, more aggressive, located in the periphery, early metastasis,
      • risk is independent of smoking, and women have a higher chance of diagnosis of this type.
    • Small cell carcinoma
      • Most severe, 10% survival after 2 years
      • metastasis through the blood
      • starts in the bronchus
      • SIADH is a complication for people with this.
    • Large cell carcinoma
      • peripherally located
      • Bulky large tumor
      • Highly related to smoking

 

  • Pulmonary HTN (PH)
    • survival rate less than three years after diagnosis
    • An arteriole pressure of greater than 25 mmHg at rest, or 30 mmHg for exercise
    • normal is about 15 mmHg
    • Primary PH
      • unknown etiology, risk increases with family history, smoking, and possible autoimmune
  • Secondary PH
    • Known etiology
    • Collagen vascular disease, congenital heart disease, mitral valve stenosis, COPD, undiagnosed sleep apnea.
  • Can be treated with a lung transplant
      • Drugs to treat: coumadin, Ca channel blockers, digitalis, lasix
    • very fluid sensitive
    • diagnosis with: echocardiography, doppler, pulmonary angiography, RV cath
  • asthma
    • edema and inflammation of the airway
    • can have attacks, that are exacerbated by triggers
    • PFT – pulmonary function tests: diagnose asthma
    • chest x-ray to rule out other pulmonary issues
    • Peak flow meter
    • these people can eventually have barrel chest due to air trapping
    • drugs: aminophylline (decrease wheezing), corticosteroids (decrease inflammation), b2 agonist as a rescue
    • Wheezing and dyspnea are from the narrowing of the airway.

 

  • COPD
    • chronic bronchitis and emphysema
    • chronically low O2 levels
    • chronic productive cough
    • barrel chest
    • complications with COPD
      • carbon dioxide narcosis
      • O2 above 5L for more than 24h is potentially toxic
    • the O2 should be kept as low as possible to prevent toxicity
  • Cystic fibrosis
    • thick secretions in airway, pancreas, sweat glands
    • percus the back to allow secretions to break free, and make breathing easier.
    • may need pancreatic enzymes to help digestion.
  • Obstructive sleep apnea
    • OSA
    • stop breathing more than 5 times an hour