Study Guide Test 1 Medsurg
Transcript of Study Guide Test 1 Medsurg
STUDY GUIDE TEST 1Rhinitis
Definition – inflammation of nasal cavities
Allergic rhinitis: pollens
Acute viral rhinitis: coryza, spread by droplets.
Home care: fluids, bedrest, humidification, Echinacea, Vit. C, Zinc, Handwashing.
Etiology: Allergen- plant, food: hay fever, complication: otitis media, hearing loss, pneumonia.
Virus, bacterial, excessive medication use
Transmission: droplet or direct contact (Table 25-3, p. 447, PPE review: Table 25-2, p. 446)
Assessment: rhinorrhea, congestion, sore throat (initial symptom if viral), HA, fever
Implementation: Pharmocological: OTC medications : Antihistamines, decongestants, nasal steroids,
Analgesics, antipyretics, antibiotics (bacterial), desensitization
Complemenary/Alternative:
Nursing: Deficient Knowledge-
Sinusitis:
Definition- inflammation of mucous membranes of one or more sinus cavity
Acute- Etiology- bacteria, virus
Chronic- Etiology- repeated infections causing mucous membranes to thicken resulting in : h/a, dull aching pain, facial swelling, chronic cough, sleeplessness.
Obstruction of drainage
Assessment- HA, facial pain, nasal congestion, fever, purulent nasal drainage, tenderness, bad breath
Complications: orbital celulitis, meningitis, abscess.
Implementation: Medical: Pharmacologic-Broad spectrum antibiotics, analgesics, decongestants, expectorants
Surgical:
Maxillary Antral Irrigation- under local anesthesia, antral puncture+lavage, outpt. Procedure- irrigated w/saline.
Caldwell Luc Procedure- incision under upper lip into maxillary sinus. Infection removed- may have difficulty eating b/c pain and swelling.
Ice packs, oral hygiene (Gentle), change dressing prn, limit valsalva maneuver, no coughing or blowing nose, no lifting, situate in semi-fowlers, eat soft foods, use analgesics, increase fluid intake.
Nursing: Post-op (Iggy, Chart 33-1, p. 655)
Education: Post-op-
Conservative treatment- Use of meds, comfort measures, humidification, saline irrigations,
hot wet packs over sinus, increase fluids
Influenza:
Definition: Acute viral resp infection, seasonal
Etiology: Virus A, B, C, H1N1 (3-7 day duration, malaise 14 days after)
Assessment: Initial- severe HA, myalgia, fever, chills, fatigue
1-2 weeks later- sore throat, cough, rhinorrhea, fatigue
Implementation: Acute- Antiviral agents, antihistamines
BR, increase fluids
Prevention- Immunizations
Complications- pneumonia CDC. Seasonal Influenza: complications: bronchitis, pneumonia, worsen COPD.
Symptoms begin 2-4 days after exposure and last 5-6 days.
MRSA
- transmitted by infection (hands) or colonized carriers (nares).
-eradicate with topical agent (bactroban) to nares & oral Ab (Bactrim).
-tx. Of infectious patients Vancomycin or Rifampin IV. Alcohol foam can be used for MRSA but can NOT be used for C-diff.
-contact/ airborne/ droplet isolation- wearing gloves & gown if direct contact, mask, private room-------don’t use shared equipment or do not allow to touch bed or bedstand------clean room items daily with antiseptic. Pts are in negative pressure room.
- they might need fit tested masks, that are different than a regular surgical mask. M95 mask
Pneumonia: 8 th leading cause of death in US + 3 rd leading cause of death in persons >85 y/o.
Description- Acute infectious process of bronchioles, alveoli, interstitial spaces
Decreasing compliance & causing hypoxemia
Pathophysiology: organisms: streptococcus (pneumococcal pneumonia, hemophilous influenza, staphylococcus aureus, pneumocystitis carnii (AIDS).
Classification-
Bacterial vs viral: Bacterial- acute onset, chills, fever, productive cough, pleuric chest pain, crackles, tachypnea, tachycardia. VIRAL—sudden, gradual, mild, and flu-like.
Community acquired (CAP) vs hospital acquired (HAP)
Location- bronchopneumonia, lobar
Etiology- Infectious- bacteria, virus, mycoplasma, fungi, protozoa
Non-infectious- toxic gases, chemicals, smoke, aspiration
Risk factors: older, institutionalized, ventilator.
Assessment- (Iggy, Table 33-3, p. 663)
Subjective: Exposure? Risk factors?
Objective: fever (high in bacterial), cough, pleuritic chest pain
VS- tachypnea, tachycardia, BP____low_____
Adventitious lung sounds-
Sputum- hemoptysis, rust, bloody-colored, creamy yellow, green, white, cleareen.
Sputum: pneumococcal- rusty brown, blood tinged. Staph—creamy yellow. Pseudomonas—green.
Diagnostics- sputum C&S, CBC, ABGs, CXR (diffuse patches or consolidation), blood cultures,
Pulse oximetry, electrolytes
White count elevated, pulse ox lowered, check BUN and Na+ for dehydration.
Droplet Precautions- (Table 25-3, p. 447)
Implementation: Medical- oxygen, supportive, nasotracheal suction as needed
Pharmacologic- antimicrobials, bronchodilators, antitussives, mucolytics, expectorants,
Steroids (aspiration pneumonia), nicotine patches, Goldenseal, immunizations
Nursing- Nursing Diagnosis (Iggy, Concept Map, p. 662; Chart 33-6, p. 664; Chart 33-4,
p. 660) & Guidelines for Preventing Health Care Associated Pneumonia (CDC)
Impaired Gas Exchange- Oxygen therapy, monitor respirations, positioning
Ineffective Airway Clearance- Encourage effective coughing techniques, hydration, position pt sitting straight up, incentive spirometer, have suctioning available.
Acute Pain- analgesics---relieve pleuritic pain
Hyperthermia
Deficient Fluid Volume- Manage fluids, monitor sodium, nutrition--- increase fluids 2500-3000 ml/day.
Deficient Knowledge- Use of meds, activity, infection control, S&S to report----explain about pneumonia vaccine.
Health Promotion- Prevention (pneumococcal & influenza vaccine)
Complications: hypoxemia, hypercapnia (Elevated CO2), atelectasis, pleural effusion, empyema, septicemia
Tuberculosis
Description- Highly communicable acute/chronic, bacterial reportable disease; Insidious onset
Can affect lungs or extra-pulmonary organs-----characterized by formation of tubercles. For curable infections, it is the number one cause of death. Highly contagious, can be acute or chronic. Is found in the lngs, joints, kidneys, or pericardium. When cases are known they must be reported to the health department.
Is an indisious disease so people can have it for a while before knowing it, thus spreading it to others.
Transmitted by infected inhaled droplets entering the lungs, and traveling to the small air sacs (Alveoli). ----suspended in the air or on dust particles for long periods. Spread by coughing, talking, singing, laughing. The inflamed area becomes surrounded by collagen, fibroblasts, and lymphocytes. If there is no tx, the site can become necrotic (caseation), and become a cavity….if still continues, can progress into effusion like pericardial effusion.
2-8 weeks after exposure the immune system walls off the infection with macrophages.
Risk Factors- Repeated close contact, foreign born or travel to high risk countries, known HIV+,
Immunosuppressed, high risk health care worker, IV drug users, malnutrition, inadequately treated
Transmission/Pathogenesis
Mycobacterium tuberculosis- acid fast rod, aerobic
Exposure- Transmitted by airborne route (Table 25-3, p. 447): Concern with exposure to
concentration of droplets and close proximity over prolonged period of time
Infected without Active Disease- Usually immune system competent; usually resolution
Infected with Active Disease- Tubercle lesion encapsulated; caseation; calcification ro liquifiecation;
cavitation; may spread to pleura or other organs
Latent TB Infection (LTBI) which may be reactivated later; No symptoms, not appear ill, not infectious, Usually has +PPD w/ normal chest x-ray, sputum culture negative, TST or blood test results usually positive. Inactive, confined tubercle bacilli in the body.
TB disease in Lungs: Active, multiplying tubercle bacilli in the body, TST or blood test results usually positive, Chest X-ray usually abnormal, Sputum smears and cultures may be positive, Symptoms such as cough, fever, weight loss, Often infectious before tx., A case of TB.
Assessment
History: Recent exposure? Travel to other countries? Previous tests? Past tx? Recent BCG vaccine?
Other risk factors?
Early S&S: persistent cough w/ sputum production, low grade fever (In afternoon), fatigue, night sweats, Anorexia, wt loss.
Later S&S: Bloody sputum (hemoptysis), chest pain, SOB
Diagnostics: Tuberculin Skin Test
Purified Pretein Derivative (PPD)(Mantoux): 0.1ml = 5 U tuberculin, intradermal
Read ______48-72______hrs (Evidence Based Practice)
Measure ONLY induration & record in mm
< 5-9 mm (+) >10-14 mm (+) >15 mm (+)
HIV + Travelers/immigrants No known risk
Immunosuppressed IV drug users
Fibrotic changes consistent w/ old TB on chest x-rays
Residents & workers in crowded
living conditions
Ten mm under normal circumstances, and 5mm in immunocompromised pts.
Other diagnostics: Chest x-ray= does not confirm diagnosis
Sputum smear for AFB- early morning specimens on 3 consecutive days
Sputum culture for M. tuberculosis = Confirms diagnosis
Drug susceptibility testing- ensure appropriate treatment & ID drug resistance
Goal- prevent transmission, control symptoms, & prevent progression of disease
Treatment: active disease—6-12 months tx.
-Direct Observation Therapy- If pts not compliant, health care workers go to the residence and MAKE them take their pills. TXs are: Isoniazid, Rifampin, Pyrazinamide, Ethambutaol.
Implementation:
Medical: Pharmacologic-
Infected without Active Disease- Chemoprophylaxis with INH, PZA
Infected with Active Disease- Combination therapy (Iggy, Chart 33-8, p. 671)
Direct Observed Therapy (DOT)
Length of tx
Be aware of multi-drug resistance
BCG (Bacillus of Calmetter & Guerin) vaccination- not widely used in US; Effectiveness is variable
Nursing: Impaired Gas Exchange
Ineffective Airway Clearance
Deficient Knowledge:
Transmission/Prevention behaviors
Transmission-Based Precautions (Infection Control)-
Airborne Precautions- Pt wears mask if must leave room
HANDWASHING!!!
Medication compliance
Follow-up care- Discontinue precautions when have 3 consecutive negative sputum cultures
Follow-up sputum cultures done q2-4 wks during treatment
KNOW to report S&S of toxicity, monitor compliance, stress follow-up, watch out for multiple drug resistance. After three negative cultures, pt is no longer infectious.
Nutrition
Social Isolation- Co-habitants all tested & prophylactically treated
May return to work after negative cultures
Need good ventilation
Fatigue will diminish
Histoplasmosis
Description- Pulmonary & systemic fungal infection from inhalation of spores found in soil contaminated w/ excreta
Caused by Histoplasma Capsulatum organism found in soil, floors or chicken houses, & in bird droppings
Not transmitted from person to person
Patho – inhaled fungi result in development of a lesion in lung parenchyma. Lesion eventually becomes
Fibrotic & calcified. When clacified, no reactivation of disease. May initially extend to lymph nodes, liver,
& spleen.
Assessment- dyspnea, pleuritic chest pain, respiratory illness similar to TB, fever
Diagnostics- skin test, CXR, positive culture
Intervention: no treatment if mild
Medical: Oxygen, TCDB, semifowlers
Pharmacologic: Antifungal drugs: Amphotericin B (Fungizone) x3 months, also Nizoral, Corticosteroids, Antihistamines----may cause nephrotoxic, ototoxic, hypokalemia, seizures, HA, anaphylaxis. -----TEACH to hose down if working in suspicious areas.
Corticosteroids, antihistamines, analgesics
Nursing- preventive: education- hose down if working in areas where organism may be found;
symptom management- education about meds
Pleurisy (Pleuritis) – inflammation of the pleura
Etiology- pneumonia, TB, chest trauma, chest wall infection
Patho- reddened pleura=>exudates=>inflammation=>adherence=>restricted
Expansion=>TV decreased=>atelectasis=>infection=>hypoxia
Assessment- knife-like pain w/ inspiration, pleural friction rub, cough, hypoxemia
Intervention- treat cause
Severe Acute Respiratory Syndrome (SARS)
Etiology- Coronavirus
Patho- inflammation remains in respiratory system
Transmission by airborne route (Table 25-3, p. 447)
Assessment- high fever (>100.4), HA, malaise, dry cough, hypoxia, dyspnea, cyanosis
No diagnostic test
Intervention- No effective treatment; supportive treatment during infection
Preventative activities
Chronic Bronchitis
Description- condition characterized by chronic airway (not alveoli) inflammation Inflammation of large (bronchi) & small (bronchioles) airways r/t continuous exposure
to irritants; thick mucus + thick bronchial walls = impaired airflow and impaired gas exchange = dec. PaO2 and incr. PaCO2
By definition: experience excess mucus production & recurrent productive cough on most days x 3 months/yr for @ least 2 consecutive years
Incidence- 1 out of every 14 people over 45 y/o; usually begins 5th or 6th decade of life; more common in men, urban, disadvantaged
Etiology-smoking, air pollution, chronic resp infections including sinusitis, heredity
Patho- inflammation=>increased mucus production=>hypertrophy of mucous secreting glands=>more mucus secretion to decrease irritiation=>narrowing of structural airways because thickened bronchial walls
Results in mucous plugs, increased airway resistance, hypoxemia, hypercapnia, & resp acidosis.
Ultimately, hypoxia, central cyanosis, & polycythemia
Clinical Manifestations- productive foul smelling chronic cough, early morning cough, grayish-white sputum, inspiratory crackles, dyspnea, orthopnea tachycardia, Later stages: polycythemia, cor pulmonale (hypoxemia, respiratory acidosis, cyanosis, JVD, hepatomegaly, peripheral edema (See Iggy, Chart 32-8, Cor Pulmonale, p. 623)
“Blue Bloater”- color dusky to cyanotic, increased sputum, hypoxia, hypercapnia, acidosis, edematous, exertional dyspnea, digital clubbing, cardiac enlargement, use of accessory muscles, cor pulmonale.
More common in women than men.
Diagnostics: Elevated RBC, Hgb, Hct, WBC
Pulmonary Function Studies (PFS): Increased Residual Volume (IRV), decreased Vital Capacity (VC), Forced Expiratory Volume (FEV)
Sputum cultures
Management- Improve oxygenation & decrease CO2 retention, O2 @ 1-3L/m, effective cough
Meds: Antibiotics, corticosteroids, bronchodilators, anticholinergics, immunizations
Relaxation exercises, meditation, purse-lip breathing, 3-point position, abdominal
Breathing, isometric exercises, breathe in through the nose and exhale slowly through the mouth.
Avoid pulmonary irritants, smoking cessation PG. 624 in IGGY….look at this picture.
Emphysema
Description: Progressive loss of elasticity (loss of stretch and recoil ability) of alveolar sacs, destruction of alveolar walls, collapse of bronchioles & the alveoli become enlarged permanently. Decreasing quality of life. Long term decline in function of lungs; > 50% of patients report being limited in ability to work.
Results in air trapping, hyperinflation of lung, decreased gas exchange, , & retention of CO2, ventilatory dead space flattened diaphragm .
Ultimately, resp alkalosis progressing to resp acidosis
These changes lead to obstructed air passages
“Pink Puffer” S&S: no cyanosis, purse lip breathing, dyspnea, ineffective cough, hyperresonance on chest percussion, orthopneic, barrel chest, exertional dyspnea, prolonged expiratory time, speaks in short jerky sentences, anxious, use of accessory muscles for breathing, thin appearance, leads to right sided heart failure.
Etiology- smoking, air pollution, enzyme deficiencies
Patho- elastin is destroyed by proteases from neutrophils=>loss of elastic recoil (driving force of expiration lost)=>small airways collapse=>overdistended alveoli=>flattened diaphragm=>chest wall springs out=>inspiratory muscles operate at shortened length
Clinical Manifestations- General appearance- position?
Weight- typically lose weight and can become very thin, leading to protein loss, or nutritional imbalances.
Resp- early dyspnea on exertion, progressing to when at rest
Wheezes, crackles, use of accessory muscles, decreased FEV & VC, increased RV;
Decreased breath sounds, increased A-P diameter (barrel chest)
Acid-Base balance- mild hypoxemia with respiratory alkalosis progressing to severe
Hypoxemia with respiratory acidosis, tachycardia
Diagnostics: ABGs, Pulse ox, Chest x-ray, PFS, electrolyte levels
COPD MANAGEMENT: diaphragamatic breathing, pursed lip breathing, controlled cough, O2 therapy, hydration nd humidification, chest physiotherapy & PD (not routinely), surgical management includes lung reduction surgery, and smoke cessation problems.
CHRONICALLY ELEVATED CO2 IS CALLED CO2 NARCOSIS-------KNOW THIS!!!
Medical Management:
Pharmacologic: (See Iggy, Chart 32-5, pp. 616-618)
Stepped therapy
Bronchodilators: key to managing symptoms of COPD
Bronchodilators: give 1st in sequence – why?____________
Beta2 Adrenergics: Short Acting- Albuterol; Salmeterol Methylxanthines: Theophylline [monitor levels; avoid caffeine] Anticholinergics: Ipratropium [blocks parasympathetic system to allow sympathetic system to increase bronchodilation] Combinations: Ipratropium and Albuterol
Anti-inflammatory
Corticosteroids: Prednisone; Fluticasone [monitor for oral fungal infections]
Pneumonia + influenza vaccines should be given to COPD patients
Airway #1
Controlled Cough: Huff coughing
Chest physiotherapy & Postural Drainage (examples shown, Iggy, p. 632)
Suction
Breathing techniques (See Iggy, Chart 32-10, p. 631)
Diaphragmatic Pursed-Lip- Oxygen therapy Remember- Hypoxic drive (LOW ARTERIAL O2 LEVEL) is pts drive to breathe! 1-3 L/NC Hydration & humidification Exercise
Lifestyle: healthy diet; avoid pollutants
Pulmonary Rehab: focus on prevention and coping with dz
Surgical Management:
Lung reduction surgery – research: risk of death in severe lung obstruction?
Lung transplantation increasing #s (severe emphysema)
EDUCATE (See Iggy, Chart 32-6 & 32-7, p. 619; Fig. 32-5, p. 620)
*Metered Dose Inhaler (MDI) w, w/o spacer & Dry Powder Inhaler (DPI)
MDI: need hand-lung coordination; spacers increase delivery
DPI: breath activated/ease of use
Nebulizer: converts drug to mist via face mask or mouthpiece/portable/slower delivery
*Home Care [ wt mngmt; supplements; monitor for infections; when to call doc; schedule rest; prioritize activities; etc. pulm rehap]
Nursing Management: (See Iggy, Chart 32-9, p. 629)
Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Altered Nutrition, < BR Activity Intolerance
Oxygenation/ Oxygen Use
Goal: Use lowest fraction of inspired oxygen (FIO2) to obtain highest level of oxygenation w/out side effects Consider oxygen a medication! Measurement through ABGs & pulse oximetry Room air is 21%
Methods of Delivery (See Iggy, Table 30-1 & 2, p. 575 & 577)
FIO2 Delivered Nursing Care
Nasal Cannula Low flow--- 1-6 L---24-44% Monitor skin integrity
Simple Face Mask Low flow ----40-60% O2---- Careful in pts with n/v…..can aspirate
Partial Rebreather Mask Low flow-----6-11 L of 60-75%---
Nonrebreather Mask Flow Meter----15 L (all the way up) 80-90% O2
Venturi Mask High flow ----55 %=10 L, and 24%=4L
Monitor skin integrity.
Nursing Management (See Iggy, Chart,30-1 Oxygen Therapy only, p. 572, AND Chart 30-2, p. 574
Oxygenation Complications Nursing Care
Combustion No smoking
Suppresses Ventilation
Oxygen Toxicity Look for s&s, if given more thAN 48 HRS, look for nonproductive cough, SOB, chest pain, and crackles. Call MD who will then prob. Check ABG’s. For COPD, if CO2 is greater than 90 will be big cause for concern
Dry Mucous Membranes Mouth care, encourage fluids
Infection Change out equipment per protocol.