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Understanding Medical Surgical Nursing ch 28


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Which of the following assessment findings in the pt with pneumonia most indicates a need to remind the pt to cough & deep breathe?

a. The pt co of chest pain.

b. The pt has removed her oxygen.

c. The nurse auscultate
c. The nurse auscultates wheezes & crackles.
The nurse is caring for a pt w/tuberculosis who puts his light on because he needs to use the bathroom. There are green surgical masks in the isolation cabinet outside his room. What should the nurse do?

a. Fit the mask firmly to his/her face
d. Ask the pt to wait while the nurse obtains a special high-efficiency mask.
Which of the following assessment findings does the nurse expect in the pt w/emphysema?

a. Purulent sputum

b. Diminished breath sounds

c. Generalized edema

d. Dull chest pain
b. Diminished breath sounds
Which of the following assessment findings in the pt w/pneumothorax does the nurse report immediately?

a. Positioning of the trachea toward the unaffected side

b. Frequent dry cough

c. Moderate pain at the chest tube site
a. Positioning of the trachea toward the unaffected side
As the nurse enters Mr. Jones's room, he notes that the pt has become confused & combative over the past hour. Which of the following actions is appropriate first?

a. Assess Mr. Jones; check to see if his oxygen is flowing correctly.
a. Assess Mr. Jones; check to see if his oxygen is flowing correctly.
Which of the following interventions is most appropriate for the pt w/an ineffective breathing pattern?

a. Encourage the pt to cough & deep breathe.

b. Encourage oral fluids.

c. Teach the pt controlled diaphragmatic b
c. Teach the pt controlled diaphragmatic breathing.
Mrs. Jackson had an abdominal hysterectomy yesterday. The nurse enters her room & finds her acutely short of breath, w/a look of panic in her eyes. Which of the following additional symptoms is most important as the nurse decides what to do?
b. Mrs. Jackson states that she also has a headache.
inflammation of the bronchial tree

includes R & L bronchi, secondary bronchi, & bronchioles
dilation of the bronchial airways (localized or spread through lungs)

usually secondary to another chronic respiratory dx

S/S: excessive, purulent sputum pooling in airway - cough - inflamed airway - hemoptysis - dyspnea - wheezes & crackles - fever
mucolytic agents
help thin respiratory tract secretions
infectious agent enters & multiplies in lungs of pt

infectious particles can come from cough of infected person, contaminated equipment, aspiration of bacteria from mouth/pharynx/stomach

cause of >10% of hospital admission annually & most common cause of death from infection
Six types of pneumonia are . . .
1. bacterial

2. viral

3. fungal

4. aspiration

5. hypostatic

6. chemical
S/S of pneumonia include . . .
- fever

- chest pain

- dyspnea

- productive cough

- sputum (purulent/blood tinged)

- crackles & wheezes
collapse of alveoli

areas of lungs not well aerated & become plugged w/mucus which prevents inflation of alveoli

most common in postsurgical pts who don't cough & deep breathe effectively

can be caused by anything causing hypoventilation
tuberculosis (TB)
dx primarily affects lungs (can affect kidneys, liver, brain, & bone)

caused by Mycobacterium tuberculosis bacteria

spread by inhalation of infected droplets
S/S of tuberculosis include . . .
- chronic, productive cough

- blood-tinged sputum

- night sweats

- pulmonary fibrosis

- hemoptysis
purified protein derivative (PPD) skin test
screening for TB

+ if raised are of induration occurs w/i 48-72 hours

+ result means person HAS been exposed to TB - but does NOT mean TB is active
Antibiotics used in treatment of TB:
- Isoniazid

- Rifampin

- Streptomycin

- Ethambutol

- Pyrazinamide

(2 or 3 given simultaneously for 6-8 months)
Impaired Gas Exchange Related to Decreased Ventilation or Perfusion

- assess lung sounds, rr, use of accessory muscles

- check skin & mucous membranes for cyanosis

- assess degree of dyspnea (1-10 scale)

- "good lung down"

- monitor ABG values & pulse ox

- obtain order for IV morphine sulfate (causes vasodilation - relieves pulmonary edema & anxiety)
Ineffective Airway Clearance Related to Excessive Secretions

- assess lung sounds q4h

- monitor sputum

- encourage fluids

- use humidifier

- encourage coughing & deep breathing hourly & prn

- suction per orders
Ineffective Breathing Pattern Related to Anxiety or Pain

- assess rr, depth, effort q4h

- monitor ABG & ox sat

- place in Fowler's/semi-Fowler's position

- teach pt to use diaphragmatic breathing (2 sec in - 4 sec out)
elasticity of lungs or chest wall
membranes surround lungs become inflamed causing friction against tissue

usually related to another resp dx

irritation causes increase in pleural fluid which can lead to pleural effusion
S/S of pleurisy include . . .
- sharp chest pain on inspiration, coughing, or sneezing

- shallow, rapid breathing

- fever

- chills

- elevated WBC

- pleural friction rub heard on ausculatation
pleural effusion
excess fluid collects in pleural space

condition causes increase in fluid production OR inadequate reabsorption by lymphatic system

avg amount around each lung is 1-15 mL (>25 mL abnormal)
collection of pus in the pleural space (infected pleural effusion)

usually complication of pneumonia, TB, or lung abscess

S/S: similar to pleural effusion
chronic obstructive pulmonary disease (COPD)
group of pulmonary disorders characterized by difficulty exhaling due to narrowed/blocked airways

develops over at least 30 years before symptoms show

smoking greatest risk factor
affects alveolar membranes causing destruction of alveolar walls & loss of elastic recoil

passive respiration impaired & air trapped in alveoli
S/S of COPD include . . .
- prolonged expiration

- barrel-shaped chest

- chronic productive cough


- activity intolerance

- crackles & wheezes
large air spaces within lung tissue

similar to blisters that can rupture & cause lung collapse

seen in COPD
large air spaces adjacent to pleurae

similar to blisters that can rupture & cause lung collapse

seen in COPD
inflammation of mucosal lining of bronchial tree & spasm of bronchial smooth muscles causing narrowed airways & air trapping

S/S: chest tightness - dyspnea - hypersensitive airways - increased rr - wheezing - prolonged expiration - cough
status asthmaticus
bronchospasm is not controlled & symptoms are prolonged

pt increases rr due to narrowed airway causing excess carbon dioxide to be blown off = respiratory alkalosis
asthma profolactics
- bronchodilator or mast cell in hibitor metered dose inhalor (MDI)

- indoor humidity between 40-50% to reduce mold growth

- avoid ASA, NSAIDS & beta blockers
asthma meds:
- adrenergic bronchodilators
-mast cell inhibitor
cromolyn sodium
nedocromil sodium
-inhaled steroid
-oral theophylline bronchodilators
cystic fibrosis (CF)
disorder of exocrine glands affecting primarily lungs, GI tract, & sweat glands

abnormal Na+ & chloride transport across cell membranes causing thick secretions (difficult to remove) which cause airway obstruction

genetic dx - BOTH parents must be carriers
S/S of cycstic fibrosis include . . .
- sweat high in sodium & chloride (not reabsorbed as they pass through sweat ducts)

- chronic sinusitis

- thick sputum

- frequent respiratory infections

- finger clubbing

- hemoptysis

- loss of lung function

- respiratory failure

- foul-smelling stools due to lack of enzymes

- inability to absorb fat-soluble vitamins
treatment of cystic fibrosis includes . . .
- increased hydration for sputum removal

- exercise

- nebulizer treatments

- breathing exercises, incentive spirometry, & effective coughing techniques
foreign object that travels through the bloodstream

may be blood clot, fat, or air
S/S of pulmonary embolism include . . .
- sudden onset of dyspnea

- tachycardia

- tachypnea

- crackles or friction rub
pulmonary hypertension
arteries that carry deoxygenated blood from the heart to the lungs become narrowed as a result of changes in vascular smooth muscle

results in elevated pressure in pulmonary arteries

R ventricle works harder to push blood into ventricles & eventually fails

most comming in women 20-40 yrs old & is hereditary
air in pleural space outside lungs

can be caused by bullae or blebs

S/S: dyspnea - chest pain - tachypnea - asymetrical chest expansion - absent/diminished breath sounds
presence of blood in the pleural space

can occur w/or w/o accompanying pneumothorax

often due to trauma

can be caused by lung cancer, pulmonary embolism & anticoagulants
creation of adhesions between visceral and parietal pleura to treat pneumothorax

painful procedure
rib fractures
4th - 9th ribs most commonly affected

can lead to flail chest where affected part of chest collapses w/inspiration & bulges w/expiration
paradoxical respiration
ineffective ventilation in which chest collapses w/inspiration & bulges w/expiration

can be caused by multiple rib fractures
A drop in PaO2 of 10 to 1_____ mm Hg or a pH of less than 2____ with associated elevated PaCO2 indicates 3_____ failure.
1 15
2 7.30
3 respiratory
acute respiratory distress (ARDS)
alveolocapillary membranes become inflamed & damaged either by direct contact w/an inhaled irritant or by chemical mediators that are released when systemic injury occurs

membranes become leaky so that proteins, blood cells, & fluid move from capillaries into interstitial space & the into alveoli

surfactant is reduced

atelectasis occurs & fibrotic changes take place causing lungs to become less compliant
lung cancer
- leading cause of cancer death in US

- 169,500 new cases for 2001

- approx 28% of cancer deaths are from lung cancer
types of lung cancer:
1. small cell lung cancer (SCLC) - 20% of LC - caused by smoking - survival time of 9 to 10 months

2. large cell carcinoma - poor prognosis - 10% of LC - grows quickly

3. adenocarcinoma - more common in women - 40% of LC - slow growing - less closely linked w/smoking

4. squamous cell carcinoma - 30% of LC - originate near bronchi - due to smoking - prognosis OK
surgical incision made into chest wall
surgical removal of a lung

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