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NUR 265 EXAM TWO STUDY GUIDE.
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NUR 265 EXAM TWO STUDY GUIDE/NUR 265 EXAM TWO STUDY GUIDE/NUR 265 EXAM TWO STUDY GUIDE.
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NUR 265 EXAM TWO STUDY GUIDERESPIRATORY
Pulmonary Embolism:
● PE- is a collection of particulate matter (solids, liquids, or air) that
enters the venous circulation and lodges in the pulmonary vessels
o Large emboli obstruct pulmonary blood flow, leading to reduced
oxygenation, pulmonary tissue hypoxia, decreased perfusion,
and potential death.
o Blood clot is the most common! → DVTs
● Risk factors:
o Immobility
o Central lines
o Surgery
o Obesity
o DVTs
o Birth control pills
o Smoking
● Hypoxemia- low arterial blood oxygen level- occurs when
deoxygenated blood moves into arterial circulation
● Signs/symptoms:
o Dyspnea (sudden onset)
o Sharp, stabbing chest pain
o Apprehensions, restlessness
o Feeling of impending doom
o Cough
o Hemoptysis- bloody sputum
o Tachypnea
o Crackles
o Pleural friction rub- creaking, grating sounds made when
inflamed pleural surfaces move
o Tachycardia
o S2 or S4 heart sounds
o Diaphoresis
o Fever, low grade
o Petechiae over chest and axillae
o Decreased arterial oxygen saturation (SaO2)
o JVD
o EKG changes- due to chest pain
● WHEN YOU HAVE IMMEDIATE CHANGE → RAPID RESPONSE!
, o Then maintain ABCs
o Quick assessment- lungs, vitals, etc.
● Manage the symptoms:
o Airway, breathing, circulation!
▪ Might have to be intubated!
● HOB at 30 degrees or above!
● Once the patient is stable! - fix the PE!
▪ If not vented!
● HOB at 90 degrees!
● Oxygen- 100% nonrebreather mask!
o Anticoagulants!
▪ Heparin/warfarin bridge therapy!
● Get patient in therapeutic level
● PTT- heparin
o 60-70 sec in normal range
o 1.5-2.5x normal range on heparin
● INR- warfarin
o 0.9-1.2 seconds is normal range
o 2-3x normal range on warfarin
● anticoags don’t break up the clot, but allows for
blood to maneuver around the clot, and won’t get
bigger
▪ Fibrinolytics
● Clot busters!
● TPA- alteplase
o Watch for signs of bleeding!!!
o Watch for administering with NSAIDs, or other
anticoags
▪ Do not use these if patient has a GI bleed!
● Body will eventually treat
● ABCs
● Nursing interventions
o Apply oxygen via NC or mask
o Reassure patient correct measures are being taken
o High fowlers!
o Telemetry monitoring!
▪ Hypoxia causes PVCs and dysrhythmias
o Obtain adequate venous access
o Assess oxygenation continuously with pulse ox
o Q 30 min respiratory assessment
▪ Lung sounds
▪ Measuring rate, rhythm, and ease of respirations
▪ Skin color and cap refill
▪ Trachea position
o Assess cardiac status
, ▪ Comparing blood pressure in left and right arms
▪ Pulses for quality
▪ Monitor for dysrhythmias
▪ Watch for JVD
o CT angiogram of the chest, and pulmonary angiography, and
labs STAT
o Watch for petechiae
o Administer anticoagulants
o Assess for bleeding
o Bleeding precautions
● Antidotes:
o Heparin- protamine sulfate
o Warfarin- vitamin K
o Fibrinolytics- clotting factors, fresh frozen plasma
● VQ mismatch
▪ Q- perfusion
▪ V- ventilation
▪ PE is mismatch on perfusion side
● Stuck clot releases chemicals that causes vasoconstriction
o Problem!
o This causes increase in CWP in right side of heart
o Fluid overload
o Decreased cardiac output (due to blockage)- left ventricle
Pleural Effusion:
● Pleural effusion- accumulation of fluid in the pleural sac
● Caused by:
o Pancreatitis
o Local or systemic inflammation
o Increased fluid/pressure in the blood vessels around the lung
causing leakage into the pleural space
o Infection- pneumonia
o CHF
o Cancer/tumors
o Autoimmune diseases
● Signs/symptoms:
o Chest pain
o Difficulty breathing
o Shortness of breath
o Pain when breathing
▪ Deep breathing normally increases the pain
o Cough- dry or productive
o Fever, chills, and loss of appetite often accompany pleural
effusions caused by infectious agents
, ● Treatment: Thoracentesis
o Have patient sit in tripod position!
Acute Respiratory Failure
● Acute respiratory failure can either be ventilatory failure, oxygenation
(gas exchange) failure, or a combination of both ventilatory and
oxygenation failure
o This has to do with V/Q mismatch!
o Patient is always hypoxemic
● Criteria:
o paO2 < 60 mm Hg OR
o pa CO2 > 45 mmHg and O2 sat <90%
● causes:
o not enough O2 getting in
o not enough CO2 getting out
o not enough blood getting to lungs!
o Anything that causes a V/Q mismatch!
● Signs and symptoms:
o Respiratory acidosis
o SOB
o Dyspnea on exertion
o Orthopnea- tripod positioning!
o Tachycardia
o Confusions
o Use of accessory muscles
o As CO 2 raises:
▪ Decreased LOC
▪ Lethargy/fatigue
▪ Headache
● Treatment of respiratory failure
o Oxygen therapy
o Corticosteroids- decrease inflammation
o Bronchodilators- albuterol
o Elevated HOB
o Treat the cause if possible (COPD, CHF, etc.)
o Mechanical ventilation if oxygenation isn’t enough
▪ Last resort!!
Pulmonary Contusion:
● A potentially lethal injury that is a common chest injury and occurs
most often by rapid deceleration during car crashes.
● Respiratory failure develops over time
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