NUTC 3013 Adult 2 Hesi Exam with Answers
Respiratory System
Pneumonia
Description: Inflammation of the lower respiratory tract
• A. Infectious
... [Show More] agents can cause pneumonia.
• B. Organisms that cause pneumonia reach the lungs by three methods.
•
o 1. Aspiration
o 2. Inhalation
o 3. Hematogenous spread
• C. Pneumonia is generally classified according to causative agent.
•
o 1. Bacterial (gram-positive and gram-negative)
o 2. Viral
o 3. Fungal (rare)
o 4. Chemical
• D. Pneumonia may be community-acquired or medical care–associated pneumonia that encompasses hospital-associated, ventilator-associated, and health care–associated pneumonia.
• E. High-risk groups include individuals who are
•
o 1. Debilitated by accumulated lung secretions (e.g., asthma, chronic obstructive pulmonary disease [COPD], sickle cell anemia)
o 2. Cigarette smokers
o 3. Immobile
o 4. Immunosuppressed
o 5. Experiencing a depressed gag and/or cough reflex
o 6. Sedated
o 7. Experiencing neuromuscular disorders
o 8. Nasogastric (NG)/orogastric intubation
o 9. Hospitalized client
Nursing Assessment
• A. Tachypnea: shallow respirations, often with use of accessory muscles
• B. Abrupt onset of fever with shaking and chills (not reliable in older adults)
• C. Productive cough with pleuritic pain
• D. Rapid, bounding pulse
• E. In older adults, symptoms include
•
o 1. Confusion
o 2. Lethargy/malaise
o 3. Anorexia
o 4. Rapid respiratory rate
o 5. Tachycardia
• F. Pain and dullness to percussion over the affected lung area
• G. Bronchial breath sounds, crackles
•
o 1. Bronchial breath sounds “E” to “A” changes in lungs (egophony); client says letter “E” while nurse listens to the chest. Pneumonia may cause “E” to sound like letter “A” when heard via stethoscope.
o 2. Tactile fremitus: nurse can feel the chest vibrations when client says “99.” Increased fremitus is heard because solid tissue conducts sound in the pneumonia client.
• H. Chest radiograph indication of infiltrates with consolidation or pleural effusion
• I. Elevated white blood cell (WBC) count
• J. Arterial blood gas (ABG) indication of hypoxemia
• K. On pulse oximetry, a decrease in oxygen (O2) saturation (should be >90%, ideally >95%)
Nursing Plans and Interventions
• A. Assess sputum for volume, color, consistency, clarity, and distinct odors like Pseudomonas.
• B. Assist client to cough productively by
•
o 1. Deep breathing every 2 hours (may use incentive spirometer)
o 2. Using humidity to loosen secretions (may be oxygenated)
o 3. Suctioning the airway, if necessary
o 4. Chest physiotherapy
• C. Provide fluids up to 3 L/day unless contraindicated (helps liquefy lung secretions).
• D. Assess lung sounds before and after coughing.
• E. Assess rate, depth, and pattern of respirations regularly (normal adult rate is 16 to 20 breaths/min; assess for accessory muscle).
• F. Monitor ABGs (partial pressure of oxygen [PO 2] >80 mm Hg; partial pressure of carbon dioxide [PCO 2] <45 mm Hg).
• G. Monitor O2 saturation with pulse oximetry (ideally >95%).
• H. Assess skin color (nail beds, mucous membranes, color for appropriate ethnic population).
• I. Assess mental status, restlessness, and irritability.
• J. Administer humidified O2 as prescribed.
• K. Monitor temperature regularly.
• L. Provide adequate rest periods throughout the day, including uninterrupted sleep.
• M. Administer antibiotics as prescribed (Table 4.2).
• N. Teach high-risk clients and their families about risk factors and include preventive measures.
• O. Encourage at-risk groups to get pneumonia and annual influenza (“flu”) vaccinations. Healthy adults develop protection within 2 to 3 weeks after receiving the vaccine (CDC).
• P. Promote rest and conserve energy.
Chronic Airflow Limitation (CAL)
Description: Chronic lung disease includes chronic bronchitis, pulmonary emphysema, and asthma (Table 4.3).
• A. Emphysema and chronic bronchitis, termed chronic obstructive pulmonary disease (COPD), are characterized by bronchospasm and dyspnea. The damage to the lung is not reversible and increases in severity.
• B. Asthma, unlike COPD, is an intermittent disease with reversible airflow obstruction and wheezing.
Nursing Assessment
• A. Changes in breathing pattern (e.g., an increase in rate with a decrease in depth)
• B. Overinflation of the lungs causes the rib cage to remain partially expanded (barrel chest)
• C. Generalized cyanosis of lips, mucous membranes, face, nail beds (“blue bloater”)
• D. Cough (dry or productive)
• E. Higher CO2 than average
• F. Low O2, as determined by pulse oximetry (<90% to 92%)
• G. Decreased breath sounds
• H. Coarse crackles in lung fields that tend to disappear after coughing, wheezing
• I. Dyspnea, orthopnea
• J. Poor nutrition, weight loss
• K. Activity intolerance
• L. Anxiety concerning breathing; manifested by
o 1. Anger
o 2. Fear of being alone
o 3. Fear of not being able to catch breath
Anti infectives
• Penicillins
o Indications
▪ • Antiinfectives
▪ • Used primarily for gram-positive infections
o Adverse Reactions
▪ • Allergic reactions
▪ • Anaphylaxis
▪ • Phlebitis at IV site
▪ • Diarrhea
▪ • GI distress
▪ • Superinfection
o Nursing Implications
▪ • Use with caution in clients allergic to cephalosporins.
▪ • Monitor for allergic reactions.
▪ • Observe all clients for at least 30 minutes after parenteral administration.
▪ • Oral penicillin G should be taken on an empty stomach.
▪ • Probenecid decreases renal excretion, thereby resulting in an increased blood level of the drug.
▪ • Alters contraceptive effectiveness
• Tetracyclines
o Indications
▪ Antiinfectives
o Adverse Reactions
▪ • Hypersensitivity reactions
▪ • Photosensitivity
o Nursing Implications
▪ • Decrease the effectiveness of oral contraceptives
▪ • Avoid concurrent use of antacids, milk products
▪ • Inspect IV site frequently.
▪ • Monitor for superinfections.
▪ • Avoid exposure to sunlight during use.
▪ • Avoid use in pregnant clients and children under 8 years; can cause yellow- brown discoloration of teeth and growth retardation
• Aminoglycosides (Gentamicin, Tobramycin)
o Indications
▪ • Antiinfectives
▪ • Used with gram-negative bacteria
o Adverse Reactions
▪ Neuromuscular blockade
▪ • Nephrotoxicity
▪ • Ototoxicity
o Nursing Implications
▪ • Monitor renal function, BUN, creatinine, and I&O.
▪ • Monitor for ototoxicity: headache, dizziness, hearing loss, tinnitus.
▪ • Monitor for superinfection.
▪ • Peak and trough levels required
• Macrolides (Clarithromycin, Azithromycin, Erythromycin)
o Indications
▪ • Clarithromycin (PO): URI, including streptococci; as adjunct treatment for H. pylori
▪ • Clarithromycin (IV): gram-negative and gram-positive organisms
o Adverse Reactions
▪ Pseudomembranous colitis
▪ • Phlebitis: a vesicant
▪ • Superinfections
▪ • Dizziness
▪ • Dyspnea
o Nursing Implications
▪ • Give clarithromycin XL with food.
▪ • Space monoamine oxidase inhibitors (MAOI) 14 days before start and after end of clarithromycin
▪ • Report diarrhea, abdominal cramping (all macrolides).
▪ • Monitor liver and renal laboratories.
▪ • PO clarithromycin give on empty stomach.
• Fluoroquinolones (Ciprofloxacin, Levofloxacin, Moxifloxacin)
o Indications
▪ • Used to treat respiratory infections, UTIs, skin, bone, and joint infections
▪ • Has been used as conjunctive treatment for TB and AIDS
o Adverse Reactions
▪ • Superinfections
▪ • CNS disturbances
▪ • Arroyos and cataracts possible with ciprofloxacin
▪ • Ciprofloxacin: a vesicant
o Nursing Implications
▪ • Prompt onset
▪ • Crosses placenta and in breast milk
▪ • Can lower seizure threshold
▪ • Monitor liver, renal, and blood counts.
▪ • Safety for children not known
▪ • Many drug–drug interactions
• Clindamycin
o Indications
▪ • Soft tissue infections caused by streptococci, staphylococci, and anaerobes
▪ • Infections resistant to penicillins and cephalosporins
▪ • Used in penicillin- and erythromycin-sensitive clients
o Adverse Reactions
▪ • Agranulocytosis
▪ • Pseudomembranous colitis
▪ • Superinfections
o Nursing Implications
▪ • Periodic liver, renal, and blood count monitoring
▪ • Report diarrhea immediately.
Chronic Airflow Limitation
• Chronic Bronchitis
o Pathophysiology
▪ • Chronic sputum with cough production on a daily basis for a minimum of 3 months in each of 2 consecutive years
▪ • Chronic hypoxemia, cor pulmonale
▪ • Increase in mucus, cilia production
▪ • Increase in bronchial wall thickness (obstructs air flow)
▪ • Reduced responsiveness of respiratory center to hypoxemic stimuli
o Precipitating Factors
▪ Higher incidence in smokers
o Assessment
▪ • Generalized cyanosis
▪ • “Blue bloaters”
▪ • Right-sided HF
▪ • Distended neck veins
▪ • Crackles
▪ • Expiratory wheezes
o Nursing Implications
▪ • Lowest FiO 2 possible to prevent CO2 retention
▪ • Monitor for signs and symptoms of fluid overload
▪ • Maintain PO 2 between 55 and 60
▪ • Baseline ABGs
▪ • Teach pursed-lip breathing and diaphragmatic breathing.
▪ • Teach tripod position.
▪ • Administer bronchodilators and antiinflammatory agents.
• Emphysema
o Pathophysiology
▪ • Reduced gas exchange surface area
▪ • Increased air trapping (increased AP diameter)
▪ • Decreased capillary network
▪ • Increased work, increased O2 consumption
o Precipitating Factors
▪ • Cigarette smoking
▪ • Environmental and/or occupational exposure
▪ • Genetic
o Assessment
▪ • “Pink puffers”
▪ • Barrel chest
▪ • Pursed-lip breathers
▪ • Distant, quiet breath sounds
▪ • Wheezes
▪ • Pulmonary blebs on radiograph
o Nursing Implications
▪ Same as chronic bronchitis
• Asthma
o Pathophysiology
▪ Narrowing or closure of airway due to a variety of stimulants
o Precipitating Factors
▪ • Mucosal edema
▪ • image abnormalities
▪ • Increased work of breathing
▪ • Beta blockers
▪ • Respiratory infection
▪ • Allergic reaction
▪ • Emotional stress
▪ • Exercise
▪ • Environmental or occupational exposure
▪ • Reflux esophagitis
o Assessment
▪ • Dyspnea, wheezing, chest tightness
▪ • Assess precipitating factors.
▪ • Medication history
o Nursing Intervention
▪ • Administer bronchodilators.
▪ • Administer fluids and humidification.
▪ • Education (causes, medication regimen)
▪ • ABGs
▪ • Ventilatory patterns
▪ • C-PAP and Bi-PAP
Nursing Plans and Interventions
• A.Teachclientosituprightandbendslightlyforwardtopromotebreathing.
•
o 1.Inbed:Teachclientositwitharmsrestingonoverbedtable(tripodposition).
o 2.Inchair:Teachclientoleanforwardwithelbowsrestingonknes(tripod position;Fig.4.2).
• B. Teach diaphragmatic and pursed-lip breathing. Teach prolonged expiratory phase to prevent bronchiolar collapse and prevent air trapping.
• C. Administer O2 at 1 to 2 L per nasal cannula (Table 4.4).
• D. Pace activities to conserve energy.
• E. Maintain adequate dietary intake.
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