Advanced Concepts of Medical-Surgical Nursing Exam 2 Study Guide
Lungs Physiology
● 2 Pleural, 1 attached to outside of lungs and 1 attached to inside
... [Show More] of ribs.
● Space between the 2 pleural is negative to atmosphere
● When inhale becomes more positive and atmosphere more negative. Exhaling is passive
● Most of lower lobes are posterior, must listen to lungs posteriorly
● Breath sounds
o Bronchial: High pitched & loud, normal in tracheal & larynx
o Bronchovesicular: Moderate pitched & amplitude, normal over major bronchi
o Vesicular: Low pitched & soft, like wind through trees, normal in lower lung fields where smaller bronchioles &
alveoli are.
Pulmonary Emboli (P 603)
● Occlusion of portion of pulmonary artery by a blood clot – from venous circulation – lower extremities or heart.
● Causes ventilation-perfusion mismatch (V/Q) – Ventilated alveoli no longer perfused due to clotted artery.
● Risk Factors
o Venous stasis (w/prolonged immobility); Central venous catheters; Surgery (NPO, dehydrated, immobilized
pts); Obesity; Advanced age; Hypercoagulability (Platelets >400K and not enough fluids; sticky blood); Hx of
thromboembolism.
o Greatest r/f in the young is the combo of smoking and hormone based contraceptives.
● Nursing Assessment Findings
o Respiratory Classic Manifestations (Hypoxia drives all s/s)
▪ Dyspnea (sudden onset); Chest pain (sharp & stabbing); Apprehension, restlessness; Feeling of
impending doom; Cough; Hemoptysis (blood in sputum).
o Respiratory Signs
▪ Pleural friction rub (scratching sounds from pleura rubbing together & pain on deep inspiration);
Tachypnea; Crackles (or normal); S3 or S4; Diaphoresis; Low grade fever; Petechiae over chest and
axillae; Decreased arterial oxygen saturation (SaO2)
o Many pts w/ a PE do not have “classic” sx (i.e. hypoxia), but instead have vague sx resembling the flu (n/v &
general malaise)
o Cardiac Manifestations
▪ Decreased tissue perfusion: tachycardia, JVD, Syncope (loss of consciousness), Cyanosis, &
Hypotension.
o In patients with r/f for PE, JVD (RSHF), syncope (decreased blood flow to brain), cyanosis (severe hypoxia) and
hypotension together, NEED RAPID RESPONSE TEAM CALLED. HAVE HELP ON WAY B4 O2 APPLIED
o When pt has sudden onset of dyspnea, chest pain, and/or hypotension, immediately notify Rapid Response
Team. Reassure pt. and elevate HOB. Prepare for O2 therapy and ABG analysis
o Saddle Emboli – Embolism at split of pulmonary artery that blocks both branches to the lungs
● Medical Dx
o Chest X-ray – May show PE if large but will help r/o other things
o CT scan – Most often used to dx PE
o TEE (Transesophageal Echocardiography) – See if there are clots in the atria
o Ventilation Perfusion scan (V/Q)
▪ Considered if pt is allergic to contrast dye done w/CT scan
▪ Radioactive substance to see if air is getting into the alveoli; injected into blood to look at clot and can
also detect pneumothorax. Done 2x
o ABGs▪ Respiratory Alkalosis FIRST from hyperventilation
▪ THEN Respiratory Acidosis from shunting
● Shunting of blood from the right side of the heart to the left side w/o picking up O2 from lungs
– causes PaCO2 level to rise resulting in respiratory acidosis.
▪ LATER Metabolic Acidosis & lactic acid buildup from tissue hypoxia [Show Less]