Med-Surg Proctored ATI Review With Complete Solution

Med-Surg Proctored ATI Review Arterial Blood Gas Answer- ABG's via arterial puncture or arterial line: allows the most accurate method of assessing respiratory function. Steps for collecting ABG's Answer- a. Perform Allen test if no arterial line b. sample is drawn into heparinized syringe c. keep on ice and transport to laboratory immediately d. document amount and method of oxygen delivered for accurate results e. apply direct pressure to puncture site at least 5 min (longer for clients at risk for bleeding) Bronchoscopy Answer- visualizes the larynx, trachea, bronchi; obtains tissue biopsy; and removes foreign bodies. Steps for a bronchoscopy procedure Answer- a. obtain informed consent b. maintain NPO 8 to 12 hr. c. Provide local anesthetic throat spray d. position upright e. administer medications as prescribed, such as atropine (to reduce oral secretions), sedation, and/or anti-anxiety. f. label specimen g. observe postprocedure -gag reflex -bleeding -respiratory status, vital signs, and level of consciousness Mantoux test Answer- Positive test indicates exposure to tuberculosis. Diagnosis must be confirmed with sputum culture for presence of acid-fast bacillus (AFB). Mantoux test steps Answer- a. administer 0.1 mL of purified protein derivation intradermal to upper half inner surface of forearm (insert needle bevel up) b. Assess for reaction in 48 to 72 hr following injection; induration (hardening) of 10 mm or greater is considered a positive test; 5 mm may be considered significant if immunocompromised. QuantiFERON-TB Gold test (QFT-GT) and T-SPOT.TB Answer- Identify the presence of Mycobacterium tuberculosis infection by measuring the immune response to the TB bacteria in whole blood. Thoracentesis Answer- Surgical perforation of the pleural space to obtain specimen, to remove fluid or air, or to instill medication. Steps for Thoracentesis Answer- a. informed consent b. educate client: remain still, feeling of pressure, positioning c. position upright d. monitor respiratory status and vital signs e. label specimens f. Document client response, amount, color and viscosity of fluid (maximum amount of fluid to be removed at a time is 1L). g. Chest tube at bedside h. Obtain CXR before and after procedure Asthma Answer- Chronic inflammatory disorder of the airways resulting in intermittent and reversible airflow obstruction of the bronchioles. Contributing factors of asthma Answer- -Extrinsic: antigen-antibody reaction triggered by food, medications, or inhaled substances -Intrinsic: pathophysiological abnormalities within the respiratory tract -Older clients: beta receptors are less responsive to agonist and trigger bronchospasms. Manifestations of asthma Answer- -Sudden, severe dyspnea with use of accessory muscles -sitting up, leaning forward -diaphoresis and anxiety -wheezing, gasping -coughing -cyanosis (late sign) -barrel chest Diagnostic procedures for asthma Answer- -ABGs -sputum cultures -pulmonary function tests Nursing interventions for asthma Answer- -remain with the client during the attack -position in high-fowler's -assess lung sounds and pulse oximetry -administer oxygen therapy -maintain oxygen access Medications for athma Answer- Administer bronchodilators before anti-inflammatory 1. Bronchodilators -short-acting inhaled: albuterol; for rapid relief -Methylxanthines: theophylline; monitor therapeutic range for toxicity. 2. Anti-inflammatory -corticosteriods: fluticasone and prednisone -Leukotriene antagonist: montelukast 3. Combination agents -Ipratropium and albuterol (Combivent) -Fluticasone and salmeterol (Advair) Therapeutic measures for asthma Answer- -respiratory treatments -oxygen administration Client Education for asthma Answer- -avoidance of allergens and triggers -proper use of inhaler and peak flow monitoring Status asthmaticus Answer- life-threatening episode of airway obstruction this is often unresponsive to treatment Manifestations of status asthmaticus Answer- -extreme wheezing -labored breathing -use of accessory muscles -distended neck veins -high risk for cardiac and/or respiratory arrest Nursing interventions for status asthmaticus Answer- -place in high-fowler's -prepare for emergency intubation -administer oxygen, epinephrine, and systemic steroid as prescribed -provide emotional support Chronic Obstructive Pulmonary Disease Answer- encompasses pulmonary emphysema and chronic bronchitis. COPD is not reversible. Pulmonary emphysema Answer- -destruction of alveoli, narrowing of bronchioles, and trapping of air resulting in loss of lung elasticity Contributing factors of pulmonary emphysema Answer- -cigarette smoking (main causative factor); passive smoke inhalation -advanced age -exposure to air pollution -Alpha-antitrypsin deficiency (inability to break down pollutants) -Occupational dust and chemical exposure Manifestations of emphysema Answer- -dyspnea with productive cough -difficult exhalation, use of pursed-lip breathing -wheezing, crackles -barrel chest -shallow, rapid respirations -respiratory acidosis with hypoxia -weight loss -clubbed fingernails -fatigue Chronic bronchitis Answer- inflammation and hypersecretion of mucus in the bronchi and bronchioles caused by chronic exposure to irritants Contributing factors to chronic bronchitis Answer- -cigarette smoking (main causative factor) -exposure to air pollution and other environmental irritatants Manifestations of chronic bronchitis Answer- -productive cough -thick, tenacious sputum -hypoxemia -respiratory acidosis Diagnostic procedure for COPD Answer- -chest x-ray -pulmonary function test: air remains trapped in lungs -pulse oximetry: often less than 90% -ABGs: chronic respiratory acidosis -CT-scan Nursing interventions for COPD Answer- -assess respiratory status -assess cardiac status for signs of right-sided failure -position upright and leaning forward -schedule activities to allow for frequent rest periods -administer oxygen therapy as prescribed -use incentive spirometry -encourage fluids 2 to 3 L per day unless contraindicated -encourage high-calorie diet -provide emotional support Medications for COPD Answer- -bronchodilators -methylxanthines -anti-inflammatory agents -mucolytic agents Therapeutic measures for COPD Answer- -chest physiotherapy/pulmonary drainage -lung reduction surgery Education and referral for COPD Answer- -breathing techniques -oxygen therapy -medications -nutrition -promote smoking cessation -infection prevention measures -encourage immunizations for pneumonia and influenza -pulmonary rehabilitation -activity pacing Complications of COPD Answer- Cor Pulmonale: right-sided heart failure caused by pulmonary disease. Manifestations of Cor Pulmonale Answer- -hypoxia (deficient perfusion) and hypoxemia (deficient oxygen in blood) -extreme dyspnea -cyanotic lips -JVD -dependent edema -hepatomegaly (enlarged liver) -pulmonary hypertension Nursing interventions of Cor Pulmonale Answer- -monitor respiratory status -monitor cardiac status and assess for indications of right-sided heart failure -administer oxygen therapy as prescribed -ensure adequate rest periods -encourage low-sodium diet -maintain fluid balance; possible fluid restriction -administer medications as prescribed Medications for Cor Pulmonale Answer- Diuretics Digoxin Therapeutic measures for Cor Pulmonale Answer- -Mechanical ventilation Carbon Dioxide Toxicity Answer- Stuporous secondary to increased CO2 retention Contributing factors for Carbon Dioxide Toxicity Answer- -carbon dioxide retention -excessive oxygen delivery Manifestations of Carbon Dioxide Toxicity Answer- -alteration in level of consciousness -tachypnea -increased blood pressure -tachycardia with dysrhythmias Collaborative care for Carbon Dioxide Toxicity Answer- -monitor pulse oximetry and ABGs -avoid excessive concentration of oxygen -provide pulmonary hygiene -provide ventilatory support with CPAP, BiPAP, or mechanical ventilation. Pneumonia Answer- inflammatory process in the lungs that produces excess fluid and exudate that fill the alveoli; classified as bacterial, viral, fungal, or chemical Contributing factors for pneumonia Answer- -advanced age -chronic lung disease -immunocompromised -mechanical ventilation -postoperative -sedation and opioid use -prolonged immobility -tobacco use -enteral tube feeding Manifestations of pneumonia Answer- -tachypnea and tachycardia -sudden onset of chills, fever, flushing, diaphoresis -productive cough -dyspnea with pleuritic pain -crackles -elevated WBC -decreased O2 saturation Diagnostic procedures for pneumonia Answer- -chest x-ray -pulse oximetry -sputum culture and sensitivity Nursing Interventions for penumonia Answer- -assess respiratory status -administer oxygen -assess sputum -monitor vital signs -encourage 3 L of fluid per day -provide pulmonary hygiene -encourage mouth care -promote nutrition Medications for penumonia Answer- -Anti-infectives (antibiotics) -antipyretics -bronchodilators -anti-inflammatories Client education for pneumonia Answer- -medication administration -preventative measures -pneumonia and influenza vaccine