NR 325 Med Surg ATI HESI Review

HESI Review OXYGEN THERAPY  Oxygen Toxicity – Signs and symptoms include a non-productive cough, substernal pain, nasal stuffiness, nausea and vomiting, fatigue, headache, sore throat, and hypoventilation.  Hypoxemia – Early Signs – Tachypnea, Tachycardia, Restlessness, Pallor, Elevated BP, Accessory muscles, nasal flaring, adventitious lung sounds.  Hypoxemia – Late Signs - Confusion & stupor, cyanosis, bradypnea, bradycardia, hypotension, dysrhythmias  Nasal Cannula – Most appropriate flow rate is 2 to 4 L/min  Face Mask – 5 to 8 L/min is appropriate flow rate (minimum of 5 to flush CO2 out of mask)  Non-rebreather Mask – 10/12 L/min RESPIRATORY SUCTIONING  Should not be performed for more than 15 seconds at a time. Suctioning for periods longer than 15 seconds may cause hypoxemia and trigger a vagal response (results in hypotension & bradycardia).  If suctioning is indicated, it is best to begin with oropharyngeal suctioning since it is better tolerated.  Set pressure on wall canister to 80-120 mm Hg BRONCHOSCOPY  NPO status prior to the procedure, usually 8-12 hours.  Complications – laryngospasm & aspiration due to lack of gag reflex  After the procedure, the nurse should report bronchospasms to the MD because they pose an airway concern.  After the bronchoscopy, the nurse should monitor the vital signs every 15 minutes. CHEST TUBES  Water seals are created by adding sterile fluid to a chamber up to the 2 cm line. The water seal allows air to exit the pleural space on exhalation and prevents air from entering with inhalation.  To maintain the water seal, the chamber must be kept upright and below the chest tube insertion site at all times. The nurse should add fluid to maintain the 2 cm level.  Tidaling – movement of water with respiration.  Continuous bubbling is a sign of an air leak.  Cessation of tidaling in the water seal chamber signals lung re-expansion or an obstruction in the system.  Due to the risk of causing a tension pneumothorax, chest tubes are only clamped per a MD in special circumstances  Do not strip or milk tubing routinely….only with an MD order.  Indications for chest tube draining include: o Pneumothorax o Hemothorax o Postoperative chest drainage o Pleural effusion o Lung abscess o Severe thrombocytopenia is a contraindication to a chest tube – excessive bleeding.  With removal of the chest tube, instruct client to deep breath, exhale and bear down (Valsalva maneuver) or to take a deep breath and hold it (increases intrathoracic pressure and reduces risk of air emboli).  Apply sterile petroleum jelly gauze dressing  If tubing separates, patient is instructed to exhale and cough to remove as much air as possible from the pleural space. The nurse cleanses the tips and reconnects the tubing.  If the drainage system breaks, the nurse immerses the end of the tube in sterile water to maintain the seal.  If chest tube is accidentally removed, occlusive dressing taped on 3 sides is placed. HESI Review THORACENTESIS  Amount of fluid removed is limited to 1 liter at a time to prevent cardiovascular collapse.  Recurrent pleural effusions can be managed by installing an irritant into the pleural space to cause scarring.  Apply dressing over the puncture site and position the patient on the unaffected side for an hour. MECHANICAL VENTILATION  Delivers warm humidified O2 at FiO2 levels of 21 to 100%  Ventilator alarms should never be turned off.  Monitor and document ventilator settings hourly.  Assess cuff pressure every 8 hours. Maintain cuff pressure below 20 mm Hg to reduce the risk of tracheal necrosis.  Reposition the organ endotracheal tube every 24 hours  Fluid retention – due to decreased CO, activation of rennin-angiotensin-aldosterone system ASTHMA  Mild intermittent – symptoms occur less than twice a week  Mild persistent – Symptoms occur more than twice a week but not daily  Moderate persistent – Daily symptoms occur in conjunction with exacerbations twice a week  Severe persistent – Symptoms occur continually, along with frequent exacerbations that limit the client’s physical activity and quality of life.  Forced vital capacity – the volume of air exhaled from full inhalation to full exhalation  Forced expiratory volume – The volume of air able to be blown out as quickly as possible during the first second of a forceful exhalation after inhaling fully  Peak expiratory flow rate: The fastest airflow rate reached during exhalation  A decrease in FEV or PERF by 15-20% is common in clients with asthma.  Medications Bronchodilators o Short acting beta 2 agonists – Albuterol (proventil, ventolin) provide rapid relief of acute symptoms. o Cholinergic antagonists – ipratropium (Atrovent), block the parasympathetic nervous system. This allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions. o Methylxanthines – theophylline – require close monitoring of serum medication Anti-inflammatories  Corticosteroids – fluticasone (flovent) and prednisone  Leukotriene antagonists – montelukast (Singulair)  Mast cell stabilizers – cromolyn sodium (Intal)  Monoclonal antibodies – omalizumab (Xolair) Combination agents – bronchodilator and anti-inflammatory  Ipratropium and albuterol (Combivent)  Fluticasone and salmeterol (Advair)  Older adults have a decreased sensitivity to beta 2 agonists. More medication is needed. COPD  Risk factors include cigarette smoking, air pollution and alpha1-anti trypsin deficiency  ABGs show increased PaCO2 and decreased PaO2  Position client to maximize ventilation (High Fowlers)