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

 

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