Advanced Med Surg (Med Surg III) Final Exam Respiratory , Neuro, Burns, and Previous Exams
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Course
Advanced Med Surg III
Institution
Advanced Med Surg III
Advanced Med Surg (Med Surg III)
Final Exam
Respiratory
, Neuro, Burns, and Previous Exams
Key:
III = Important.
III = V
ery Important.
III = Direct answers to questions from the professor
’s previous study guides.
1.
Acute Respiratory Distress Syndrome
●
T
reatment for
ARDS:
I
...
12/1/23, 7:13 AM Final Exam Study Guide (Med Surg III)
Advanced Med Surg (Med Surg III)
Final Exam
Respiratory, Neuro, Burns, and Previous Exams.
*Created by: Carlos. Maria, Andrea, Yuri, Liliany, Marcos, Olga.
*This study guide will contain information from previous study guides as well.
*Bioterrorism will not be included on the exam.
Key:
III = Important.
III = Very Important.
III = Direct answers to questions from the professor’s previous study guides.
1. Acute Respiratory Distress Syndrome
● Treatment for ARDS: Identification and treatment of underlying cause, need
aggressive and supportive care.
● How to position the patient: Prone position (It is best for oxygenation) Reposition
the patient frequently, it's important to avoid complications.
● Ventilator treatment: Mechanical ventilation with PEEP(positive end expiratory
pressure) to keep alveoli open (needed as hypoxemia progresses) ventilatory
PEEP support is a critical part of the treatment of ARDS because it improves
oxygenation. The goal is a PaO2 greater than 60 mm Hg or an oxygen saturation
level of greater than 90% at the lowest possible FiO2.
● Role of methylprednisolone in the treatment: Prolonged methylprednisolone
treatment suppresses systemic inflammation in patients with unresolving acute
respiratory distress syndrome. This can also help with hypotension.
● IV fluids: how should it be administered, how much? Precautions? Systemic
hypotension may occur in ARDS as a result of hypovolemia secondary to leakage
of fluid into the interstitial spaces and depressed cardiac output from high levels of
PEEP therapy. Hypovolemia must be carefully treated without causing further
overload. Inotropic or vasopressor agents may be required to be at bedside to
prevent fluid overload
● Early signs of ARDS: It closely resembles severe pulmonary edema. The acute
phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs
less than 72 hours after the precipitating event. Arterial hypoxemia with no
response to O2. increased alveolar dead space, lung becomes stiff, decreased
pulmonary compliance.
● Role of PEEP in ARDS: PEEP is critical in the treatment of ARDS because it will
improve oxygenation, and decrease the amount of oxygen given to the client. but it
does not influence the natural history of the syndrome. The use of PEEP helps
increase functional residual capacity and reverse alveolar collapse by keeping the
alveoli open, resulting in improved arterial oxygenation and a reduction in the
severity of the V./Q. imbalance. By using PEEP, a lower FiO2 may be required. The
goal is a PaO2 greater than 60 mm or 90% O2.
● What is PEEP: Positive end-expiratory pressure. Positive pressure maintained at
the end of exhalation (instead of a normal zero pressure) to increase functional
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residual capacity and open collapsed alveoli
● A ventilation/perfusion lung scan, also called a V/Q lung scan, or
ventilation/perfusion scintigraphy, is a type of medical imaging using scintigraphy
and medical isotopes to evaluate the circulation of air and blood within a patient's
lungs, in order to determine the ventilation/perfusion ratio.
● Complications with PEEP:
- It's an unnatural pattern of breathing and feels strange to the patient. The patient
may be anxious, and patient-ventilator dyssynchrony may be the consequence.
- Assess for tube blockage = kinking or retained secretions, other acute respiratory
problems (pneumothorax and pain), a sudden decrease in the oxygen level, the
level of dyspnea, or ventilator malfunction. (Sedation may be required to decrease
the patient’s oxygen consumption, allow the ventilator to provide full support of
ventilation, and decrease the patient’s anxiety. Sedatives that may be prescribed
are lorazepam, midazolam, dexmedetomidine, propofol, and short-acting
barbiturates, Paralytics too)
- Pneumothorax can lead to lung collapse, which would lead to asymmetric lung
expansion.
- Peripheral nerve stimulators = assess nerve impulse transmissions at the
neuromuscular junction of select skeletal muscles when neuromuscular blocking
agents are used. Four equal muscle contractions, seen as “twitches,” = no
neuromuscular blockade.
- Be sure pt. Is not disconnected from the ventilator since respiratory muscles are
paralyzed= patient will be apneic. (REALLY IMPORTANT)
- Eye care = pt. cannot blink. Increasing the risk for cornea lacerations.
- Risk for venous thromboembolism (VTE), muscle atrophy, foot drop, peptic ulcer
disease, and skin breakdown. (Complications of immobility.)
- Do not talk about the patient, he can hear you
- Anticipate patients' pain and inform family about patient status.
● ABG values:
- PH: 7.35-7.45
- PCO2: 35-45
- PO2: > 80
PaO2 greater than 60 mm or 90% oxygenation at lowest FiO2 possible. (GOAL)
● Ventilator: Know VAP bundle and what it consists of. Vap care, indication for
ventilator
- Ventilator Associated Pneumonia: Current best practices can include the
implementation of specific evidence-based bundle interventions that, when used
together (i.e., as a “bundle”), improve patient outcomes.
- What are the five key elements of the VAP bundle? Elevation of the head of the
bed (30° to 45°) Daily “sedation vacations” and assessment of readiness to
extubate (see below) Peptic ulcer disease prophylaxis Deep venous thrombosis
(DVT) prophylaxis Daily oral care with chlorhexidine (0.12% oral rinses)
*Fluids must be given cautiously when indicated in these patients because they have pulmonary
edema. Too many fluids can cause fluid overload.
*Vasopressors are given to help prevent fluid overload. Diuretics may also be given.
*These patients will be on 35-45 Kcal enteral feedings per day.
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2. Pulmonary Embolism
● What is it: Obstruction of the pulmonary artery or one of its branches by a
thrombus (or thrombi) that originates somewhere in the venous system or in the
right side of the heart. Inflammatory process obstructs area, results in diminished
or absent blood flow
● Signs and symptoms: Signs and symptoms depend on the size and location of the
thrombus. Dyspnea is the most common symptom, accompanied by sudden
pleuritic chest pain. Other symptoms include anxiety, fever, tachycardia,
apprehension, cough, diaphoresis, hemoptysis, and syncope. Most frequent sign
is tachypnea.
● How to diagnose it: D- Dimer (for clot presence), Chest X ray (normal but shows
infiltrate), pulse oximeter, MDCTA (the criteria standard for PE. This is the
diagnostic test.)
● How to treat it: Measures to improve respiration
● Emergency Tx: Nasal oxygen (hypoxemia), severe hypoxemia (emergent
endotracheal intubation and mechanical ventilatory support).
- IV infusion lines (meds and IV fluids); Increase fluid intake to 2-3L/day.
- Hypotension: vasopressors (dobutamine, dopamine, or norepinephrine).
- For massive embolism, hypotensive = indwelling urinary catheter (I&Os).
- IV morphine or sedatives-- to relieve patient anxiety, chest discomfort, improve
tolerance of the endotracheal tube, & ease adaptation to the mechanical ventilator.
- Anticoagulation and thrombolytic therapy: immediate therapy = up to 10 days;
long-term = 10 days to 3 months f/w PE; or indefinitely for high-risk patients.
- Stable: low molecular weight heparin (enoxaparin [Lovenox]), unfractionated
heparin, or new oral anticoagulants (NOACs): direct thrombin inhibitor (dabigatran
[Pradaxa]), or a Factor Xa inhibitor (fondaparinux [Arixtra], rivaroxaban [Xarelto],
apixaban [Eliquis], or edoxaban [Savaysa]. NOACs are contraindicated for pts.
Who may need thrombolytic therapy. Unfractionated heparins are preferred.
- Unstable: Thrombolytic therapy= acute PE, low BP, no bleeding risk=recombinant
tissue plasminogen activator (Activase) (TPA).
- Contraindications to thrombolytic therapy = CVA w/in past 2 months, active
intracranial processes, active bleeding, surgery w/in 10 days of the thrombotic
event, recent labor and delivery, trauma, or severe hypertension. Consequently,
thrombolytic agents are advocated only for PE affecting a significant area of blood
flow to the lung and causing hemodynamic instability.
- INR, partial thromboplastin time (PTT), hematocrit, and platelet counts before
initiation
- Avoid invasive procedures
● Indication for administration of heparin drip: monitor PTT, PTT goal 50-70 on drip.
● Warfarin (coumadin): What to monitor? INR, goal 2-3
- Vitamin K intake, Risk for bleeding, Monitor INR weekly until levels are WNR
● Activity for a client with pulmonary embolism (Bedrest) how to prevent blood clot
formation in a bedridden patient? (Compression stockings, SCDs, etc.)
*Brand new patients will be on bed rest to avoid dislodging of the embolism.
*Patients should wear a medic alert band at all times after discharge.
*Place the client in a high fowler position when they are anxious.
3. Spinal Cord Injury:
● What is it? The result of concussion, contusion, laceration, or compression of
spinal cord
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● How to care for the patient?
o Goal is to prevent the injury from further developing to permanent damage.
o Monitor respirations and breathing pattern
o Lung sounds and cough
o Monitor for changes in motor or sensory function, report immediately
o Assess for spinal shock and neurogenic shock.
o Spinal Shock:
▪ A sudden depression of reflex activity below the level of spinal injury
▪ Muscular flaccidity, lack of sensation and reflexes
o Neurogenic Shock:
▪ Caused by the loss of function of the autonomic nervous system
▪ Blood pressure, heart rate, and cardiac output decrease. (Overall
decrease of the patient’s vitals.)
▪ Venous pooling occurs because of peripheral vasodilation
▪ Paralyzed portions of the body do not perspire.
o Monitor for bladder retention or distention, gastric dilation, and ileus
o Temperature; potential hyperthermia
o Possible Nursing Dx:
▪ Ineffective breathing pattern
● Goal: improved breathing pattern and airway clearance
● Monitor to detect potential respiratory failure: ABGs, pulse
oximetry, lung sounds
● Early and vigorous pulmonary care to prevent and remove
secretions
● Suctioning with caution
● Breathing exercises
● Assisted coughing
● Humidification and hydration
▪ Ineffective airway clearance
▪ Impaired physical mobility
● Goal: improve mobility
● Maintain proper body alignment
● Turn only if spine is stable and as indicated by physician
● Monitor blood pressure with position changes
● PROM at least four times a day
● Use neck brace or collar, as prescribed, when patient is
mobilized
● Move gradually to erect position
▪ Disturbed sensory perception
● Goal: improved sensory and perceptual awareness
▪ Risk for impaired skin integrity
● Goal: maintenance of skin integrity
● Traction pin care
● Hygiene and skin care related to traction devices
▪ Impaired urinary elimination
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