Oxygen Needs

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History of Present Illness: -Onset, duration, allergies, toxic exposure, lifestyle and dietary habits, smoking habits
-Symptoms patient is reporting: dyspnea, tachypnea, orthopnea, paroxysmalnoctural dyspnea (PND)
-Cough: productive, non-productive, sputum (1L with cold) production, hemoptysis (assess mouth and gums first)
Cardiopulmonary Symptoms: -Chest discomfort:
*angina
*causes: fluid in the lungs, pneumona, pleurisy, esophogeal, astma
-Edema, wght gain (2.2lbs = 1L)
-Dizziness, palpitations
-Fatigue, pallor
-Leg claudication: leg cramps w/activity and goes away when activity is stopped
(arterial insufficiency)
Cardiopulmonary Assessment: -Overall appearance of pt
*coloring
*vital signs
*circumoral pallor (around mouth and nose)
-Auscultation of the heart and lungs
-*wheezing (constriction of the bronchi), crackles (fluid and air hitting one another), pleural rubs (sand paper)
-Respiratory: rate, depth, rhythm, equal expansion
-Observe for use of accessory muscles to breath
Observe for abnormalities:
*clubbing, barrel chest, sternal retractions, nasal flaring, changes in mental status
*intercostal retracting and diaphram breathing usually seen in kids
-Evaluate the extremeties
*Heart murmurs
Diagnostic Tests: -O2 saturation
-ABGs: arterial blood gasses
-CBC: complete blood count
-PFTs: pulmonary function tests
-Chest x-ray
-Echocardiogram
-Heart catheterization
-EKG
Upper Airway: -Anything above the larynx
Respiratory Conditions: -Common cold
-Sinusitis (acute or chronic)
*Pain over affected sinuses and headache
*maxillary (eyes and jaw)
*Frontal (forehead)
*Ethmoid (whole face)
-Tx: antibiotics, analgesics, decongestants, surgery
-Causes: deviated septum
*hypertrophy of turbinate bones (scrape away at the turbinates)
Laryngitis: -Can be viral (cold) or bacterial or mechanincal (singers, speakers, intubation)
-*Chronic problem due to smoking, vocal abuse, endotracheal intubation, alcohol
-Can become severe enough to close off airway
Croup: -Only in young children
-Dry cough
-AKA spasmotic laryngitis
-partial airway obstruction
-Comes on suddenly following a cold (usually in middle of night)
-Barking seal cough
-Temp seldom elevated
-Tx: moist heat to relieve obstruction (shower)
(airway for babies dime size,
nickle for children)
Tracheobronchitits: -Inflammation of larynx, trachea, bronchi
-Very serious, complications of a cold
-Only in children < 4
-Thick sputum, high temp, couphing
-Tx: maintain airways, antibiotics, humidified O2
Other Upper Respiratory Problems: -Sore throat > 3 days: should have a throat culture
*can lead to endocarditis if not treated
-Pharyngitis: usually viral, can be bacterial
*group B-hemolytic strept: very common
-Tonsillitis: if not treated can lead to Peritonsillar abscess
Pneumonia: -AKA PNA
-Causative agents:
*bacterial: 1. strept, 2. staph A, 3. pseudomonis (over watering plants)
*viral: CMV
*Fungal (aspergillus)
*Aspiration pneumonia: any dysphagic pt
*mycoplasmic, legionnaire's
-Pneumnocystitis (common w/HIV)
-Symptoms: SOB, extreme fatigue, crackles, wheezing, pleural effusions, increased WBCs
-Mortality increases > 70yoa
-x-ray: black is air, white is fluid
Pneumonia Risk Factors: -Elderly (more chronic illness... anything respiratory, CHF, diabetes, renal failure)
-Chronic medical condition
-Nutritional defects
-Alcoholism/drug abusers
-Neuro problems: impaired gag reflex, dementia
Nursing Management of Pneumonia: -Assess oxygenation status
-Obtain sputum specimen before antibiotics (in the am before breakfast)
-Avoid cough suppressants
-Respiratory therapy for mucolytic agents
-Ample rest periods (space activities)
-Patient teaching
*flu vaccine for those at risk
*pneumovax shot
Pneumonia Classification: -community acquired (CAP)
-Hospital acquired
-pneumonia in the immunocompromised host
-aspiration pneumonia
Dx of Pneumonia: -History (especially of recent resp. tract infection)
-chest x-ray
-blood culture (bacteremia occurs frequently)
-sputum examination
Epistaxis: -Nose bleed
-Causes:
*trauma, chronic infection, violent sneezing, blowing, picking
*blood thinners
*low platelet count
*hypertension
-Tx: apply pressure on nose, ice packs, FORWARD tilt of head, nasal packing
*drugs: neosanerphrine, silver nitrate
*surgery: caterize
Deviated Septum: -Submucosal resection
-Nasal septoplasty
*both usually done as an out patient procedure
Nasal Fractures: ORIF (open reduction internal fixation) ASAP becuase of swelling makes landmarks hard to see
-Nursing considerations: *watch for covert and overt bleeding
*maintain airway
*appetite problems
Vocal Cord Polyps and Nodules: -Interference with voice production
-Usually develops because of voice abuse, smoking, allergies
-Tx:
*surgical stripping (bronchoscopy)
*watch for bleeding and airway
*Lung Abscesses*: -Encapsulated infections
-Causes:
*TB, pulmonary embolus, CA, COPD, open trauma
-Tx: bronchoscopy to drain it
-Hard to treat d/t being encapsulated
-High doses of antibacterial (antibiotics)
Pleural Effusions: -Accumulation of fluid in the pleural space
-Causes: fluid overload, chest CA, CABG, TB, pneumonia, thoracotmy: open up of the chest (open heart surgery)
-Common Terms:
*hemothorax: bloody fluid
*Chylothorax: Chyle is usually a milky fluid comprised of lymph drainage
*Empyema: accumulation of pus in the pleural space.
Pleural Effusions Symptoms: -SOB
-Absent or decreased breath sounds
-Assymetrical chest expansion
-Dullness with percussion
-3rd spacing fluid (can't be removed easily)
Pleural Effusions Treatment: -Thoracentis (complication includes pneumothorax)
*Positioning pt
*done at the bedside
*stat x-ray after
*reassure pt that they should feel much better after procedure
Pleurisy: -Inflammation of the pleura
-Symptoms: pleural friction rub, pain on inspiration, gaurded breathing
-Often follows resp. infection or occurs where chest tubes were inserted
-Tx: NSAIDs or steroids
Chronic Obstructive Pulmonary Disease (COPD): -Broad term used to describe conditions with a chronic obstruction to EXPIRATORY airflow
COPD: -Emphysema
-Chronic Bronchitis
-Asthma
-Bronchiectasis
*saO2 often clouds status of pt (need ABGs for accurate assessment)
-Air remains trapped in the lungs
-CO2 is usually the driving mechanism for breathing
Emphysema: -D/t cigarette smoking
*which causes connective tissue damage to the alveoli
*the alveoli overinflate and lose their elasticity then aren't able to deflate enough to expel the air
-Other causes: chronic infections, asthma, dust, age
*occurs more in men and those with reduced income and lack of education
Treatment for Emphysema: -Purpose is to improve the quality of life
-NO CURE
-Bronchodilators
-Steroids (anti-inflammatory)
-Antibiotic prophylaxis
O2 therapy for Empysema: -Because of the high levels of CO2 in the blood over a long period of time, the primary stimulus to breath is from a reduction in O2 rather than an increase in CO2 in normal patients
Effects of Smoking: -Increases blood pressure and heart rate (vasoconstriction of vessels)
-Carbon monoxide damages arterial wall encouraging fatty build up of cholesterol
-It increases the adhesiveness of platelets
-Increases the thickness of blood
-Damage of alveoli (butterfly to brocolli)
-Causes CA, heart disease, and lung disease
How To Quit: -Cold turkey (with help): best results
*Bupropion (zyban) and nicotine patch: taken 7-12 weeks is highly effective
-Nicotine fading: not effective just inhale more
-Nicoting patch or gum: s/e similar to smoking
Asthma: -AKA airway reactive disease
-Airways react to allergens, exposure to irritants, exercise
*cause increase mucus production which causes a cough
*Bronchi narrow, dyspnea occurs
*Wheezing can occur with bronchospasm
-Not all asthmatics wheeze
-Secretions form with inflammation
Asthma Etiology: -Allergies
-Infections: asthma exacerbates an infection in the lungs
-Drugs
-Exercise
-Family hx
-Stress
-Temperature changes: bronchospasms
Treatment of Asthma: -Inhaler for pt to use in respiratory distress
-Rescue inhaler: beta agonist
*albuterol (prevention), alupent, maxair, tornalate, brethaire,
-Epinephrine: SQ (potent pulmonary dilator)
-Steroid use: not a rescue medication
*prednisone, medrol, prelone, pediapred orally, IVP (solumedrol), inhaled, syrup
*with inhaled steroids: rinse mouth after use to avoid infection from candida albicans
*types: vanceril, azmacort, flovent
-NSAIDs: intal, tilade
-Leukotriene Inhibitors: accolate, singulair
Other COPD: -Chronic Bronchitis
*inflammation of the bronchi
*excessive mucus at least 3 months out of the year
-Bronchiectasis:
*pockets in main stem bronchus where mucus and bacteria love to flourish
Sleep Apnea: -Characterized by excessive daytime sleepiness, increased incidence with obesity, snoring
-Usually upper airway obstruction of soft palate and tongue
-C-PAP machine to control: continuous positive airway pressure
-Sleep study
-Monitor EEG, O2, as it can be related to pulmonary heart issues, Ears, nose, throat problems
Restrictive Lung Disease: -AKA stiff lung
-Irreversible
-No cure
-Tx with O2 only
-permanent damage to the lung tissue
-Examples: coal miner's lung (silicosis), asbestosis
Arterioslcerosis: -AKA: arterialsclerotic heart disease (ASHD), Coronary artery disease (CAD), Peripheral vascular disease (PVD), renal artery disease, aortic aneurysm...
-Hardening of the arteries
-Minor risk factors:
*obesity, exercise, diabetes
-Major: cholesterol, smoking, high blood pressure
-Male higher than women until menopause
-Family hx
Cholesterol Management: -Nutritional Education: mono/polyunsaturated fats
*avoid red meat and dairy
-Medical Therapy:
*mevacor, pravachol, zocor, lipitor, lescol, crestor, zeita: statins inhibit cholesterol production (liver panel fx should be done)
*Lopid: decreases triglycerides
*Folic Acid: decreases Homocysteine
*Anti-oxidants: nyacin (causes more liver damage than statins), vitamin B
Diagnostic Tests for ASHD: -Angiogram: infection of Dye into an artery (femoral)
-Treadmill
-Thallium treadmill
-Doppler Study: carotid artery disease
-Echocardiogram: structure of the heart (resting and with exercise)
-12 lead EKG
-TEE: Transesophogeal echocardiogram
Angiogram Complications: -Allergic reaction to the dye
-Hematoma
-Hemorrhage
-Occlusion (most common): check distal pusles
Peripheral Vascular Disease: -Any form of artery disease not pertaining to the heart
-Arterial vascular insufficiency
-A form of ASHD which includes all vascular structures:
*ateries, veins, arterioles, venules
-PVD Assessment:
*pulses
*color
*temperature
*edema
*skin changes
Chronic Arterial Insufficiency: -Pulses: decreased or absent
-Color: pale, dusky, red on depression
-Temp: cool
-Edema: absent/mild
-Skin:
*thin/shiny
*atrophic/loss of hair over foot
*toe nails thickened and rigid
*Ulceration: if present involves toes or points of trauma
*gangrene may develop
Chronic Venous Insufficiency: -Pulses: normal (may be difficult to feel d/t edema)
-Color: normal or cyanotic
-Temp: normal
-Edema: present
-Skin: brown pigmentation around ankles, stasis dermatitis
-Ulceration: does not develop
-Gangrene: does not develop
Assessing Edema: -Go up the bone to determine edema score
PVD Symptoms and Nursing Dx: -Intermittent claudication pain
-Burning pain
-leg cramps
-deformed nails, hair changes
-bruits
-necrosis
-decreased cap. refill
-cyanosis
-RN Dx: altered tissue profusion, activity intolerance, sleep pattern disturbance, pain
PVD Medical Management: -Drug therapy
-Angoiplasty
-Surgical manangement
*aorto-illiac bypass
*aorto-bifemoral bypass
*endarterectomy: cleaning of the carotids (c/p STROKE)
*Amputation
-Neurogenic Pain:
*tricyclic antidepressants (Elavil: amitriptyline, Pamelor: nortriptyline)
*antisiezure: neurontin, tegretol
Acute Arterial Occlusion: -Usually thrombosis or embolus (always an emergency)
-Symptoms: acute ischemia, pain, cool to touch, discolored
-Tx: anticoagulation and/or surgical embolectomy
Aneursyms: -Out-pouching of vessels
*abdominal aorta most common
*ASHD main cause
*2.5cm normal
*5cm palpable
*blow out at 6cm
Raynaud's Disease: -Spasms of the arteries
-Leads to ischemia
-Usually fingers and toes
-Medical therapy
-Pt education
-Avoid cold climates and smoking
-Tx: calcium channel blockers
*diltiazem, procardia XL
Thrombophlepbitis: -Superficial vs deep vein thrombosis (DVT) (leads to pulmonary embolism)
-Venous stasis (bedrest, hypovolemia, tissue injury, a-fib)
-Hypercoagulability of blood
*smoking, birth control, hormone replacement
Risk factors: post-op, irregular heart beat, infection in general
-Thrombus: stay put
-Embolus: travels
-Tx:
*thrombus: keep clot where it is
DVT Symptoms: -Unilateral: redness, pain, edema, +Homan's sign, inflammation
-Diagnostic Tests: veinogram, ultrasounds
-Tx:
*prevention is ideal: early ambulation, pneumatic stockings, prophylactic anticoagulation
*antigoagulatoin for a clot
Normal Clotting Cycle: Platelets-thromboplastin-prothrombin-fibrinogen-fibrin-formed elements (wbcs, rbcs) = clot
Anticoagulation Therapy: -Coumadin: works by blocking the formation of prothrombin
-Heparin & Lovenox: work by preventing the conversion of fibrinogen to fibrin
-None of these drugs dissolve the clot, just keeps them from getting bigger
Heparin: -Advantages: *consistant results across all patients
*fast acting
*reverses in seconds
-Disadvantages: *kill pt if given to much IV or SC
*Illness called Heparin Induced Thrombocytopenia
-Test Used: PTT (partial thromboplastin time): measured in seconds (1.5-2.5 secs longer than normal)
-Reversal drug: protamine sulfate
-Complications: hematoma, hemorrhage, HIT
-Administer: *subcut. same as lovenox
*IV: needs to be on pump, to RNs to be present during changes in programming (critical drip)
Coumadin: -Advantages: oral, inexpensive
-Disadvantages: inconsistant across pts, 2-5 days to reach therapeutic blood levels, pts are often on 2 blood thinners
-Test Used: PT (protime): measured in seconds (1.3-2.0 times the normal, INR of 1.5-2.5)
-Reversal drug: vitamin K
-Complications: hemorrhage pregnancy deformities, long metabolic time (in system long after it has been d/c)
-Administer: oral: ask why is pt getting this, and what is their PT, given at 1800 so the MD can be notified of the daily INR
Lovenox: -Advantages: consistant results
-Disadvantages: Subcut. admin
-Lab work: don't need daily labs, Platelet count
-How to admin:
-Complications: hemorrhage
Thrombolytic Therapy: -Actually dissolves the clot
-Streptokinase, Urokinase (aslo used to declot a central line), Activase, TPA, Repro
*all IV critical drip infusions
*heparin is given after thrombolytics
-Given for:
*acute stroke
*acute coronary syndrome(Acute myocardial ischemia)
*embolism
-TPA most common: tissue plasmainogen activator
DVT: surgical management: -Thrombectomy
-Home care education on coumadin:
*s/s of bleeding (black tary stool)
*outpatient visits
*Don't change dose or skip, or double-up on a dose
*Call MD if forgot dose
*Informing other MDs on coumadin
*don't get pregnant
*Dietary considerations (don't change diet)
*talk with MD before taking any supplements
Pulmonary Emboli: -Obstruction of blood flow to a pulmonary artery causing necrosis (life-threatening event)
-Most commonly from a DVT
-S/S:
*dyspnea
*hemoptysis
*pleural friction rub
*chest pain
*tachycardia
-Risk factors:
*DVT, veinastatsis, hypercoagulability
-Tx: anticoagulation therapy (coumadin for rest of lifes)
-Surgical Intervention:
*vena cava umbrella (interruption)
Hypertension: -1 in 4 develop HTN
-#1 reason people go to MDs and for prescription drugs
-Mostly without symptoms
-95% unknown cause
-5%: pheochromocytoma 240/140, tumor on the adrenal gland, 24h urine test for catecholamine) or renal artery stenosis (BP can't be controlled)
-Pregnancy induced, white coat hypertension
-Women with toxemia increased risk for HTN later in life
-Systolic BP influenced by emotions
Factors Which Influence HTN: -Family hx
-Ethnicity: increased in blacks (usually requires multiple drug therapy)
-Age
-Gender: men get it at slightly earlier age
-Personality type A
-wght
-Exercise
-Alcohol (especially with excessive drinking)
-Caffeine
S/S of HTN: -retinal changes
-arteriol narrowing
-asymptomatic
Management of HTN: -Modify risk factors
-dietary considerations:
*modify salt intake (2g normal)
*don't eat: milk, cheese, breads, canned soups
Medical Management of HTN: -Diuretics
-Beta Blockers: end in olol
-Alpha 1 blockers: mine
-Calcium channel blockers: pine
-ACE inhibitors: pril
-Angiotension II receptor blockers: artan
-Vasodilators:
-Adrenergic inhibitors:
Heart Failure: -The inability of the heart to pump enough blood to meet tissue needs
-Wide range of severity: mild to cardiogenic shock (80% mortality)
-Causes: CAD, myocardial infarction, cardiomyopathy, valvular or congenital disease, HTN
Pathophysiology of CHF: -Problem with muscle contractility
-Muscle tone (illness where muscle becomes stiff and unfunctioning)
-Fluid volume overload
Left-Sided Heart Failure: -Most common
-D/t impaired ejection of blood from left ventricle
-Blood backs up into lungs
*can back up into right side of heart
-S/S:
*pulmonary congestion (Crackles, listen at bases)
*repiratory distress
*PND (paroxysimal nocturnal dyspnea)
*wght gain
*increased heart rate
*right sided heart failure symptoms
-Pt dx w/CHF needs to be weighed daily
Right-Sided Heart Failure: -Due to impaired ejection of blood from the right ventricle
-Often due to left-sided HF or pulmonary disease
-Backs up into systemic circulation
-S/S: *peripheral edema
*distended neck veins (JVD)
*Liver enlargement
*wght gain
*increased heart failure
*lethargy, fatigue, activity intolerance
*pedal edema while standing
*generalized edema while lying down
Cor pulmonale: -an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system.
Goal of Medical Management: -Blood test to dx: BNP (type B natiuretic Peptide)
-To restore balance between oxygen supply and demand by:
*improving heart contractility
*reducing heart rate
*improving activity tolerance
*reducing afterload (blood pressure)
-Done using:
*antihypertensive drugs: so the heart can pump the blood out against less pressure
Treatment of CHF: -Optimize oxygen of pt
-Vasodilation drugs:
*nitrate therapy
-Inotropic Drugs: to improve the contractility of the heart
*Digoxin, dopamine, dobutamine)
-Drugs to reduce HR:
*Beta blockers (Cardioselective)
-Drugs to reduce B/P:
-Drugs to reduce blood volume
*diuretics
Non-Pharmological Approach to CHF: -Reduce:
*oral intake of fluids
*IV fluids
*sodium and alcohol intake
-Treat underlying problem
-Avoid:
*altitude
*overexertion
*prolonged traveling
*extreme weather
Nursing Interventions for CHF: -Assess Resp. status often
-Keep HOB elevated
-Avoid stenuous activity
-Daily wght
-I&O
-Assess for postural hypotension
-Urinal close by (diuretics)
-Discharge teaching: palpations of heart, extra ankle edema, sleeping with more pillows
Digitalis Toxicity: -Anorexia (usually first sign)
-N/V
-Blurred vision (halo/rings around lights)
-EKG changes, arrhythmias
-Abdominal pain
-Fatigue/disorientation
-Normal dig serum level:
*0.8-2.0ng/ml
-Tx: d/c or reduce dose
Cardiomyopathy: -Any abnormality of the heart muscle:
*dilated (congestive)
*hypertropic
*Restrictive
Dilated Cardiomyopathy: -idiopathic
-postpardum
-drugs from chemotherapy
-virus
-Medical management same as CHF
Hypertropic Cardiomyopathy: -heart is contracting too much
Restrictive Cardiomyopathy: -Makes the heart stiff
Rheumatic Heart Disease: -pt's who have untreated strept
-Mitral stenosis main problem
Anemias and other abnormalities: -hypoproliferative
*reduced # of RBCs d/t bone marrow malfunction
*iron deficiency: RBCs have decreased level of HGB, caused by bleeding, elderly fixed income, pregnancy, side effects of meds: black stool, constipation, must be z-tracked in IM, allergy rx
-Excessive destruction or loss:
*hemolytic anemia: antibodies developed against RBCs, jaundice, tx corticosteroids
*sickle cell anemia:
Common disorders of WBCs: infectious mononucleosis
Normal Lab Values: -Hematoglobin: m(13.5-17.5 g/dl)
f(11.5-15.5 g/dl)
-Hematocrit: m(44-52%) f(39-47%)
-Albumin: (3.5-5.5 g/dl)
-Electrolytes:
*Sodium: 136-145
*Potassium: 3.5-5.2
*Chloride: 96-106
-Glucose: 70-110 mg/dl
-Total Cholesterol: <200 mg/dl
*HDL: 35-85 mg/dl
*LDL: <130 mg/dl
-BUN: 8-28 mg/dl
-Calcium: 8.5-10.5 mg.dl
-Creatine: 0.6-1.2 mg/dl
-Uric Acid: 2.5-8 mg/dl
-Magnesium: 1.8-3.0 mg/dl
-Phosphorus: 2.3-4.7 mg/dl

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