MedSurgATI1

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Temperature Formulas F = C (9/5) + 32 C = (F -32) x 5/9 Defibrillate - start at lowest joules (200-> 300 -> 360)

- indicated for VF and pulseless ventricular tachycardia How to obtain ABG sample - use heparinize syringe - perform Allen''s test prior to puncture to verify patent radial and ulnar circulation; compresses the ulnar and radial arteries while the client pumps fists, then releasing the radial artery slowly -> should turn pink quickly. then repeat for the ulnar artery - place the specimen in basin of ice post care: - apply pressure for 5 min and 20 min for those on anticoagulants Arterial line - use heparinize syringe - place on ice for transport to lab - flush the arterial line with pre-connected flushing system - assess the arterial wave form upon completion Oxygen Toxicity s/s - nonproductive cough, substernal pain, nasal stuffiness and hypoventilation tx: - use of CPAP, BiPAP or PEEP - give the least amount of O2 necessary to maintain SaO2 levels - use Venturi Mask when client needs precise amount of O2 delivered such as those with COPD Types of Ventilator alarms Volume alarm: Ventilator displacement Pressure alarm: Ventilator coughing ... - alarm indicate low exhaled volume dt disconnection, cuff leak, and tube Arterial puncture

- alarm indicate excess secretions, client biting the tubing, kinks and client

Apnea alarm: Ventilator indicate that the ventilator does not detect spontaneous respiration Asthma Chronic inflammatory disorder of the airways. It is INTERMITTENT and REVERSIBLE airflow obstruction tat affects the bronchioles - occurs either by inflammation or airway hyperresponsiveness Manifestation - Mucosal edema - broncoconstriction - excessive secretion production Classification: Asthma - Mild intermittent: < 2x/week - Mild persistent: >2x/week - Moderate persistent: daily with exacerbations 2x/wk - Severe persistent: continuous with frequent exacerabation Triggers: Asthma - strong odors - allergens - exercise - pollutants - stress or emotions - medications (NSAIDS, beta blockers, cholinergic) - chemicals Dx: Asthma - PFTs are most ACCURATE - smoke

- PFR is the fastest airflow rate reached during exhalation - green: 80-100; no changes in meds needed - yellow: 50 -79; increase meds - red: < 50: need to see physician Medications: Asthma ...

Cholinergic antagonists - ipratropium (Atrovent)

- blocks parasympathetic nervous system - allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions. Methylxanthins - theophylline (Theo-Dur) - therapeutic range: 10 -20 mcg/ml Anti-inflammatories - Flovent/Prednisone - side effects: hypokalemia, poor wound healing, fluid retention, immunosuppression, hyperglycemia - Leukotriene antagonists: Singulair - Mast cell stabilizer: Intal - Monoclonal antiboies: omalizumab (Xolair) Status Asthmaticus - s/s - extreme wheezing, labored breathing, use of accessory muscles, distended neck veins, and risk for cardiac and/ or respiratory arrest - tx - EPINEPHRINE (potent bronchodilator) then initiate systemic steroid therapy Older Adults: Asthma receptors - less likely to respond to beta agonists dt decrease sensitivity to beta adrenergic - Life threatening episode, often unresponsive to tx Corticosteroids:

- more susceptible to infections COPD Typically affects the middle age and older adults - Emphysema - Chronic bronchitis Normal SaO2: 94% to 98% Emphysema - characterized by the loss of lung elasticity and hyperinflation of lung tissue. Causes destruction of the alveoli leading to decreased area for gas exchange, carbon dioxide retention and respiratory acidosis Chronic bronchitis S/S: COPD - Is an inflammation of the bronchi and bronchioles dt chronic exposure to irritants

- dyspnea

- cough - hypoxemia - hypercarbia (increased PaCO2) - Respiratory acidosis - crackles - shallow respirations - use of accessory muscles - barrel chest - hyperresonance dt "trapped air" - pallor and cyanosis Nx Interventions: COPD - Position at high- Fowler's - encourage deep breathing and use of incentive spirometer - meds use: same as asthma meds - administer heated and humidified O2 therapy - monitor for skin breakdown - teach: diaphragmatic or abdominal breathing - teach pursed lip breathig - may need only 2-4 L/min per nasal cannula and only 40% per Venturi mask - include plenty of rest - smoking cessation Complications: COPD - administer O2 and abx Right sided Heart Failure - blood flow through lung tissue is difficult. This increased work load leads to enlargement and thickening of the right atrium and ventricle s/s - hypoxia, cyanotic lips, tender liver Respiratory infection

Nx intervention - administer positie inotropic and contractility medications (digoxin) - administer diuretics and IV fluids Older Adults: COPD - make sure influenza vaccination is up to date

- provide plenty of rest period Pneumonia An inflammatory process in the lungs that produces excess fluid. Triggered by infectious organisms or by the aspirations of an irritant, resulting in EDEMA and EXUDATE that fills the alveoli Risk Factors: Pneumonia - advance age

- recent exposure to viral infections - tobacco use - chronic lung disease (asthma) - aspiration - mechanical ventilation - impaired ability to mobilize secretions - immunocompromised status s/s:Pneumonia - Fever - dyspnea, tachypnea - sputum production - CRACKLES - coughing - DULL CHEST PERCUSSION - poor O2 sat Nx: Intervention: - high- Fowler's position - administer abx: PCN and cephalosporins - administer bronchodilators: - short acting beta2 agonists and methylaxanthines - heater and humidified O2 therapy

- administer corticosteroids: to decreased inflamation - monitor for: hypokalemia, hyperglycemia, fluid retention, immunosuppresion and poor wound healing - ensure up dated vaccinations - influenza vaccines - pneumococcal vaccine; administered 1 time. Complications: Pneumonia Atelectasis

- airway inflammation and edema leads to alveolar collapse and increases the risk of hypoxemia - diminished or absent breath sounds over affected area - cxr shows area of density Acute Respiratory Failure - persistent hypoxemia - prepare for intubation Older Adults: Pneumonia - increase susceptibility in infections

- have weak cough reflex and decreased muscle strength -> trouble expectorating with can lead to difficulty in breathing and specimen retrieval s/s - CONFUSION from hypoxia - fever, cough and purulent sputum are often absent - cxr is important dx tool bc sx are often vague Tuberculosis - airborne route - cxr appears Ghon Tubercle - contagious only when s/s of infection is present - TB test will be (+) 2 to 10 weeks of exposure to infection dx: Mantoux caused by Myobacterium tuberculosis

- 10 mm is positive for non immunocompromised - 5 mm is positive for immunocompromised

- cxr to detect active lesions - sputum culture CONFIRMS dx s/s - cough

- NIGHT SWEATS - purulent sputum, blood streaked Nx Interventions: Tuberculosis - Nurse: wear N95 or HEPA respirator - place client in NEGATIVE airflow room with airborne precaution - have client wear mask when transporting - diet: high in protein, iron and vit C - follow up care in 1 year - sputum samples are needed Q2-4 weeks; clients are no longer infectious after 3 negative sputum cultures Medications: Tuberculosis - Isoniazid (INH): - take in empty stomach - take with vit B6 - Rifampin - urine and other secretions will turn ORANGE - monitor for hepatomegaly - Ethambutol (EMB) - obtain baseline visual acuity; determine color discrimination - Streptomycin - check for ototoxicity Complications: Tuberculosis - Meningitis - pericarditis Pack Year History # of packs of cigarettes smoked per day (x) # of years smoked - Miliary TB: spreads through blood stream S.T.R.I.P.E.

Superior Venal Cava Syndrome results from pressure placed on the vena cava by tumors. This is a medical emergency - early signs - facial edema - tight ness of shirt collars - nosebleeds - dyspnea - late signs - hypotension - change in metnal status - cyanosis - hemorrhage Tx: Radiation and stent placement provide temp relief Metastasis (lung cancer) - to the bones can cause bone pain and increase the risk of pathologic fractures. Encourage to ambulate carefully - to the CNS can lead to changes in mentation, lethargy and bowel and bladder malfunction. Reorient the client as needed Pulmonary Embolism Occurs when a substance (solid, gaseous, or liquid) enters venous circulation and terminates in the pulmonary vasculature - common origin from DVT Risk Factors: Pulmonary Embolism - oral contraceptive; estrogen therapy - smoking - HYPERCOAGULABILITY - obesity - surgery - ATRIAL FIBRILLATION - sickle cell disease - immobility

- LONG BONE FRACTURES s/s: Pulmonary Embolism - anxiey - S3, S4 - decreased SaO2 - CRACKLES - petechiae, cyanosis Medications: Pulmonary Embolism ... - Tachycardia

Anticoagulants Enoxaparin (Lovenox), heparin, warfarin (Coumadin) - used to prevent clot from getting larger or other clots from forming - contraindicated: active bleeding, PUD, hx of stroke and recent trauma. - Monitor bleeding times - side effects: thrombocytopenia, anemia, hemorrhage Fibrinolytic therapy Alteplase, Streptokinase

- used to BREAK UP clots - side effects is similar to anticoagulants Client Education: Pulmonary Embolism - Avoid long periods of immobility - monitor intake of food high in vit K Nx Interventions: Pulmonary Embolism - avoid IM injections - avoid rectal temperatures or enemas - administer fluids and blood products as required Angiogram Indications:

- A cerebral angiogram is used to assess the blood flow to and within the brain, identify aneurysms, and define the vascularity of tumors (useful for surgical planning). It may also be used therapeutically to inject medications that treat blood c