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Summary NUR 463 Essential HESI STUDY GUIDE

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University Of Rhode Island

This is a comprehensive and detailed hesi study guide that contains all the key concepts and terms to know for Nur 463. *Essential Study Material!!

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nurs 463
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rhode island
university
isa
advanced
medical
surgical
nursing
class notes
kingston
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summary
university of rhode island
advanced medical surgical nursing
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Med Surg Everything

Chest Tube and Water or Dry Seal Management
 Inserted into pleural space to remove air/fluid, restore intrathoracic
pressure, allowing lung to reexpand
 3 compartments/chambers
o Collection chamber (1)
 Air/fluid collected from pleural or mediastinal space
 Fluid remains, air vented to second compartment
(water-seal chamber)
o Water-Seal chamber (2)
 Contains 2 cm water; prevents backflow; one-way valve
 Fluctuations in water level “tidaling”
 Water moves up with inspiration and down with
expiration
o Suction control chamber (3)
 Water suction uses 20 cm water to drain chest
 Dry suction: safe and effective vacuum
 Patient Safety
o Maintain 2 cm water q shift; add sterile water if needed
o Keep lower than pt chest
o Keep straight and tubing coiled loosely below chest level w/
connections tight/taped
o Monitor fluid drainage; mark time and measurement of fluid level
 Notify HCP if >70ml/hr of drainage
o Monitor WOB and pain level
o Assess for tidaling (bubbling in water-seal chamber)
o Replace unit when full
o Crackles around tube are normal
o If system breaks, insert 1 inch of tubing into bottle of
sterile water; do not clamp!
o Removal: pre-medicate for pain, position semi-fowlers,
Valsalva maneuver and hold breath, CXR to reassess
o If chest tube dislodged
 Cover area with dry, sterile dressing
 If air leak, tape dressing on 3 sides only (allows air to
escape; prevents tension pneumothorax)
 Notify HCP ASAP

JP Drain; Hemovac
 Prevent fluid at surgical wound site and promote wound healing
 Empty q 4-12 hrs unless it is .5-2/3 full before then
 Drainage tube patency and negative pressure in reservoir (bulb) must
be maintained to provide adequate drainage

1

,Pneumonia
 Inflammation of lung tissues causing consolidation of exudate
 Sx: green, yellow, thick sputum, coarse crackles
o Bacterial: confusion, tachycardia, general deterioration,
increased RR/HR
 Risk factors
o Age >65 or <2 yo
o Recent surgery (abdominal, thoracic)
o Altered LOC (alcoholism, head injury, seizure, smoking, splenic
dysfunction, anesthesia, drug OD, CVA), depressed or absent
gag/cough reflexes
o Prolonged immobility
o Immunosuppressed pt
 Complications
o Sepsis, ARDS, pleural effusion, emphysema, pleurisy, lung
abscess
 Prevention/Management
o Pneumococcal vaccine (children <5, adults >65,
immunocompromised, smokers)
o Seasonal flu vaccine yearly
o Meticulous hang hygiene
o Sedation interruptions
o HOB 30-45˚
o Oral care q 2 hrs
o Routine peptic ulcer prophylaxis
o Subglottic suctioning
o Sedation/weaning
o Early mobilization
o Blood and sputum culture
o Isolation
o Encourage fluids and rest
o Antipyretics, pain meds
o Monitor O2 sat and admin O2 (humidified to loosen
secretions)
o CDB
o IS
o Comatose and immobile pt: elevate 30˚ for feeding and for 1 hr
after; turn frequently
 Nursing Assessment
o Tachypnea, productive cough, pleuritic pain, fever of
abrupt onset, dyspnea, increased tactile fremitus, mental
status changes, crackles, decreased breath sounds, dullness
on percussion, ABG indicates hypoxemia

2

,  Hypoxemia: PaO2 55% and SpO2 is 88%
 Can also be caused by hypothermia SaO2 85% and
PaO2 of 50 mmHg
o TURN UP OXYGEN
o Whispered pectoriloquy
 Normal: spoken word can’t be heard
(muffled/unclear)
 Increased clarity indicates consolidation (tumor,
pna); abnormal
 If lungs are filled with more air, breath/voice sounds
are absent or diminished (pneumothorax, severe
emphysema)
o Fever
 Increased temp increases metabolism and demand for O2;
can cause dehydration d/t excessive fluid loss d/t
diaphoresis
 Hydration is essential; 300-400 ml fluid lost daily by lungs
through evaporation

Peritonsillar Abscess
 Complication of acute pharyngitis or acute tonsillitis when bacterial
infection invades one or both tonsils
 Tonsil may enlarge and threaten airway patency
 Known as hot potato voice
 Sx: high fever, leukocytosis, chills

Age Related Changes of for Older Adult
 Decreased cough reflex, decreased ciliary action, lungs stiffer,
decreased alveolar surface for gas exchange, loss of lean body mass,
skeletal changes of chest
 Increased protein in urine, slightly increased serum glucose levels
o Result of kidney changes or subclinical UTI
 USG declines by age 80 from 1.030 1.024

Chronic Airflow Limitation
 Asthma (reversible)
 COPD (chronic progressive)
o Emphysema
o Chronic bronchitis
o d/t smoking, environmental/occupational exposure, genetic
predisposition)
o Temp is most important assessment; infection most
common factor precipitating respiratory distress; pt
taking long term steroids are predisposed to infection
o Severe  polycythemia

3

,  Diet: soft diet that doesn’t require much chewing and digestion; assist
with feeding if needed; eating consumes energy needed for breathing
 Prevent secondary infections, report changes in characteristic of
sputum, encourage ≥3 L/day of fluids and decreased caffeine d/t
diuretic effect, obtain immunizations when needed
 Expect H&H to be elevated

Chronic Bronchitis
 Chronic sputum with cough production on daily basis for
minimum of 3 mo/year
 Chronic hypoxemia, increased mucus production, exacerbations d/t
infections, increased CO2 retention/acidemia
 Insufficient oxygenation leads to generalized cyanosis and often Right
HF
 Absence of sputum, edematous, cyanotic, shallow respirations
 “blue bloater”

Emphysema
 Abnormal enlargement of air spaces distal to terminal alveolar walls
 Increased dyspnea/WOB
o Reduced gas exchange, increased air trapping, decreased
capillary network, increased work and O2 consumption
 Advanced emphysema hypercarbia is a problem; imperative that
baseline data is obtained for pt
 “pink puffer”; normal skin coloring but puffing respirations, fine “rice
crispy” crackles, positive crepitus if you push on chest
 Total lung capacity increased because of hyperinflated lungs
 ABG normal
 Copious amounts of thick, white sputum

COPD
 Nursing assessment
o Bronchitis
 Right side HF, cyanosis, distended neck veins
 Bronchial breath sounds heard over areas of density or
consolidation; sound waves easily transmitted over
consolidated tissue
o Emphysema
 Pursed lip breathing, non-cyanotic, thin
 Pursed lip: relax shoulders, purse lips, exhale
 Distant, quiet breath sounds, wheezes
o Auscultation
 Crackles, rhonchi, expiratory wheezes
o Low PaO2, high PaCO2, low pH, high HCO3
 Acute complications: repeated/prolonged respiratory infections,
acute respiratory failure, pneumothorax
4

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