Transcript NCLEX Cram * Module II

NCLEX Cram – Module II
Respiratory and Cardiac
Prepared by
Lori Baker, RN, BSN
2013
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Pneumonia
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• Primary Indicators of Respiratory Disorders
• Sputum production
• Cough
• Dyspnea
• Hemoptysis
• Pleuritic chest pain
• Fatigue
• Change in voice
• Wheezing
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Normal ABG Values
What you’re looking at
Abbreviation
Value
Acidity index
pH
7.35-7.45
Partial pressure of
dissolved oxygen
PaO2
80-100
Percentage of
hemoglobin saturated
with oxygen
O2 saturation
95% or above
Partial pressure of
dissolved carbon dioxide
PaCO2
35-45
Bicarbonate
concentration
HCO3-
22-28
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Breath Sounds
• Table of Normal and Adventitious Breath Sounds
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Pneumonia
• Classified by causative agent
• Viral
• Bacterial
• Aspiration
• Leads to
• Obstruction of bronchioles
• Decreased gas exchange
• Increased exudate
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Pneumonia
• Symptoms
• Couth
• Fever
• Chills
• Tachycardia
• Dyspnea
• Pleural pain
• Malaise
• Respiratory distress
• Decreased breath sounds
In infants, may see
difficulty breathing
as they are typically
nose breathers
An older client may
initially present with
mental confusion
and volume
depletion.
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Pneumonia
• Treatment
• Antibiotic according to organism identified
• Bronchodilators
• Inhalation therapy
• Cool oxygen mist
Always obtain
• Postural drainage
specimens PRIOR
to starting antibiotic
• Bronchodilators
therapy
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Pneumonia
• Nursing Care
• Deep breathing every 2 hours – may use IS
• Humidity to loosen secretions
• Fluids up to 3L/day to thin secretions
• Monitor RR (normal 12-20/min)
• O2 sat ideally >95%
• ABG’s ideally with PO2 more than 80 and PCO2 less
than 45
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COPD
• An umbrella term for a group of respiratory diseases
characterized by chronic obstruction of airflow (chronic
airflow limitation or CAL)
• Typically used as a term for chronic bronchitis and
emphysema
• Asthma is classified as a reactive airway disorder (or
RAD)
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COPD
Clinical Manifestations
• Exertional dyspnea or
dyspnea at rest
• Chronic cough
• Wheezing
• Frequent respiratory tract
infections
• Pursed-lip breathing
• Prolonged expiration with
diminished breath sounds
• Easily fatigued
• Use of accessory
muscles of respiration
• Digital clubbing
• Barrel chest
• Orthopnea
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COPD
Chronic Bronchitis
• Pathophysiology
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Chronic sputum with cough
production on a daily basis for a
minimum of 3 months per year
Chronic hypoxemia, cor
pulmonale
Increase in mucus, cilia
production
Increase in bronchial wall
thickness
Reduced responsiveness of
respiratory center to hypoxemic
stimuli
• Assessment
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Generalized cyanosis
Known as “Blue bloaters”
Right-sided heart failure
Distended neck veins crackles
Expiratory wheezes
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COPD
Chronic Bronchitis
(cont’d)
• Nursing Interventions
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Lowest FiO2 possible to prevent CO2 retention
Monitor for signs and symptoms of fluid overload
Maintain PAO2 between 55 and 60
Baseline ABGs
Teach pursed-lip breathing and diaphragmatic
breathing
Teach tripod position
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COPD
Emphysema
• Pathophysiology
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Reduced gas exchange surface
area
Increased air trapping – increased
A-P diameter
Decreased capillary network
Increased work, increased O2
consumption
• Assessment
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Known as “Pink Puffers” (the
person works harder to breathe,
but the amount of O2 taken in is
adequate to oxygenate the
tissues)
Barrel chest
Pursed-lip breathing
Distant,
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Chest Tube Tips
• If chest tube becomes disconnected, DO NOT clamp
• Immediately place the end of the tube in a container of sterile
saline or water until a new drainage system can be connected
• If the chest tube is accidentally removed…
• Apply pressure immediately with an occlusive dressing and
notify the healthcare provider
• Fluctuations (tidaling) in the fluid will occur if there is no external
suction
• These fluctuating movements are a good indicator that the
system is intact and should move upward with each inspiration
and downward with each expiration
• If fluctuations cease…
• Check for kinks, occlusions, or change in client’s position or
condition
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Chest Tubes – Nursing Interventions
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Keep all tubing coiled loosely below chest level with connections tight and
taped
Keep water seal and suction control chamber at the appropriate water levels
monitor the fluid drainage and mark the time of measurement and the
fluid level
Observe for air bubbling in the water seal chamber and fluctuations
(tidaling)
Monitor the client’s clinical status
Check the position of the chest drainage system (which should be below the
level of the chest
Encourage the client to breathe deeply periodically
Do not strip or “milk” chest tubes
Maintain dry occlusive dressing
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Nursing Skills for the Respiratory Client
• Suctioning (tracheal)
• Suction when adventitious breath sounds are heard, when secretions
are present at endotracheal tube, or when gurgling sounds are noted
• Use aseptic/sterile technique throughout procedure
• Wear mask and goggles
• May liquefy secretions with 3 mL saline instilled prior to suctioning
• Advance catheter until resistance is felt
• Apply suction only when withdrawing catheter (gently rotate catheter
when withdrawing
• Never suction more than 10-15 seconds and only pass the catheter 3
times or less
• Oxygenate with 100% oxygen for 1-2 minutes before and after
suctioning to prevent hypoxia
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Nursing Skills for the Respiratory Client
• Maintain Ventilator Settings
• Verify that alarms are on
• Maintain settings and check often to insure they are
specifically set as prescribed by healthcare provider
• Verify functioning of ventilator at least every 4 hours
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Nursing Skills for the Respiratory Client
• Oxygen Administration
• Nasal cannula: low oxygen flow for low oxygen concentrations
(good for COPD)
• Simple face mask: low flow but effectively delivers high oxygen
concentrations cannot deliver less than 40% oxygen
• Non rebreather mask; low flow but delivers high oxygen
concentrations (60-90%)
• Partial rebreather mask low flow oxygen reservoir bag attached;
can deliver high oxygen concentrations
• Venturi mask; high flow system; can deliver exact oxygen
concentrations
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Nursing Skills for the Respiratory Client
• Pulse oximetry
• Easy measurement of oxygen saturation
• Should be greater than 90% - ideally above 95%
• Noninvasive, fastens to finger, toe, or earlobe
• Tracheostomy Care
• Aseptic technique (remove inner cannula only)
• Clean disposable inner cannula with hydrogen
peroxide-rinse with sterile saline
• 4x4 gauze dressing is butterfly folded
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Nursing Skills for the Respiratory Client
• Respiratory Isolation Technique
• Mask required for anyone entering room
• Private room required
• Client must wear mask if leaving room
• Proper Use of an Inhaler
• Have client exhale completely
• Only grip (in mouth) if client has a spacer; otherwise keep mouth
open to bring in volume of air with misted medication. While
inhaling slowly, push down firmly on the inhaler to release the
medication
• Use bronchodilator inhaler before steroid inhaler
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NCLEX Hints for Respiratory
• When asked to prioritize, use the ABC rule
• Airway
• Breathing
• Circulation
• In that order – always
• Look and Listen! If breath sounds are clear, but the
client is cyanotic and lethargic, adequate oxygenation is
not occurring
• The key to respiratory status is auscultate breath sounds
as well as visualization of the client.
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NCLEX Hints for Respiratory
• Watch for NCLEX questions that deal with oxygen
delivery.
• In adults, oxygen must bubble through some type of
water solution so it can be humidified if given at more
than 4L/min or delivered directly to the trachea
• If given at 1-4 L/min or by mask or nasal prongs, the
oropharynx and nasal pharynx provide adequate
humidification
• Tracheostomy care involves cleaning the inner cannula,
suctioning, and applying a clean dressing
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NCLEX Hints for Respiratory
• Laryngectomy Patients
• Typically done for cancer of the larynx
• If air is not humidified before entering the lungs, secretions tend
to thicken and become crusty
• A laryngectomy tube has a larger lumen and is shorter than the
tracheostomy tube. Observer the client for any signs of bleeding
or occlusion, which are the greatest immediately postoperative
risks (first 24 hours)
• Fear of choking is very real for the laryngectomy clients. They
cannot cough as before because the glottis is gone. (teach
glottal stop – deep breath, momentarily occlude tube, cough,
simultaneously remove the finger from the tube)
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Cardiovascular Review
• Description of angina pain
• Squeezing, heavy, burning, radiates to left arm or shoulder,
transient, or prolonged
• Nitroglycerin teaching plan
• Take at first sign of angina pain
• Take no more than three, 5 minutes apart
• Call for emergency attention if no relief in 10 min
• Differentiation between essential and secondary HTN
• Essential – no known cause
• Secondary – develops in response to an identifiable mechanism
• Teaching – cease smoking, control weight, exercise regularly,
and maintain a low-fat, low-cholesterol diet
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Cardiovascular Review
• Teaching plan for antihypertensive medications
• Explain how and when to take medication
• Reason for medication
• Necessity of compliance
• Need for follow-up visits
• Need for certain lab tests
• Vital sign parameters while initiating therapy
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Cardiovascular Review
• Intermittent claudication
• Pain related to peripheral vascular disease occurring with
exercise and disappearing with rest
• Discharge instructions for venous peripheral vascular
disease
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Keep extremities elevated when sitting
Rest at first sign of pain
Keep extremities warm but do NOT use heating pad
Change position often
Avoid crossing legs
Wear unrestrictive clothing
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Cardiovascular Review
• Underlying cause of abdominal aortic aneurysm…
• Atherosclerosis
• Lab values to be monitored daily for anticoagulant
therapy
• PTT – if on heparin
• PT – if on Coumadin
• Hgb, Hct, and platelets
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Cardiovascular Review
• The danger of PVC’s (premature ventricular contractions
• When they begin to occur more often than once in 10
beats
• When they occur in 2s or 3s
• When the land near the T wave
• When they take on multiple configurations
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Cardiovascular Review
• Heart Failure
• Left-sided
• Results in pulmonary congestion due to back-up of
circulation in the left ventricle
• Right-sided
• Results in peripheral congestion due to back-up of
circulation in the right ventricle
• For any heart failure
• Restrict sodium which reduces water retention,
thereby reducing vascular volume and preload
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Cardiovascular Review
• Heart Failure (cont’d)
• Digitalis preparations given for HF
• Side effects are increased when the client is
hypokalemic (more common when dig and diuretics are
given together)
• Dig has a negative chronotropic effect (it slows the
heart rate)
• Hold dig if the pulse rate is less than 60 or more than
120, or has markedly changed rhythm (notify
healthcare provider)
• Signs of dig toxicity – bradycardia, tachycardia, or
dysrhythmias, nausea, vomiting, and headache
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Cardiovascular Review
• Endocarditis
• Damages heart valves due to vegetative lesions on
leaflets
• Vegetation poses risk of embolization
• Most commonly affected is mitral valve
• Could lead to left-sided or right-sided heart failure
• Pericarditis
• Inflammation of the lining of the heart
• Signs include friction rub, ST segment elevation and
T wave inversion are also signs of pericarditis
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Cardiovascular Review
• MI
• Place client on immediate strict bed rest to lower
oxygen demands of heart
• Administer oxygen by nasal cannula at 2-5L/min
• Take measures to alleviate pain and anxiety
• Drug of choice to reduce pain and increase oxygen
perfusion is Morphine sulfate IV – it acts as a
peripheral vasodilator and decreases venous return
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Cardiovascular Review
• MI – Common Medications Ordered
• Nitrates
• Beta-blockers
• Calcium channel blockers
• Aspirin
• Antiplatelet aggregates
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Cardiovascular Review
• Know your EKG Basics
• Calculate HR (6 sec strip; count R waves; multiply by
10
• Know basic rhythms
• Sinus rhythm
• A-fib
• A-flutter
• V-fib
• V-tach
• PVC’s
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Cardiovascular Review
• Defibrillation and Cardioversion
• Both are used to “shock” the heart back into normal
rhythm
• The difference
• Defibrillation is used in an emergency for lifethreatening dysrhythmias and uses higher
electrical shocks
• Cardioversion is an elective procedure for certain
dysrhythmias and uses lower electrical shocks.
Cardioversion is also synchronized to have the
electrical shock delivered at a specific time on the
rhythm
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Cardiovascular Review
• Heart Sounds
• S1 and S2 are normal heart sounds
• S3 – also called a ventricular gallop
• Normal in children
• Indicates heart failure in adults
• S4 - also called an atrial gallop
• Not normal in any age group
• Associated with hypertensive heart disease
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