Rasmussen College: MDC III 1234/NUR2502 Exam 2 Focused Review LATEST 2021
• Neck cancer-
o S/S
▪ Pain
▪ Lump in mouth, throat or
... [Show More] neck
▪ Difficulty swallowing
▪ Color changes in mouth
▪ Numbness of mouth, lips, or face
▪ Persistent, unilateral ear pain
▪ SOB
▪ Anorexia and weight loss
o Nursing interventions
▪ Improve preoperational preparation
▪ Optimal in-hospice care
▪ Discharge planning and teaching
▪ Monitor gas exchange
▪ Assess RR and breath sounds Teach patient to use fowlers for best gas exchange
o Treatment
▪ Surgery
▪ Radiation
▪ Chemotherapy
▪ Biotherapy
o Teaching regarding treatment
▪ Weight gain is not a sign of neck cancer
▪ Radiation
• Most patients have hoarseness, dysphagia, skin problems, and dry mouth for a few weeks after therapy
• Hoarseness may become worse during therapy and difficulty swallowing
• Gargle with saline or sucking ice may help
• Avoid exposing the site to the sun
• Use fluoride to prevent tooth decay
▪ Chemotherapy
• Can be used with radiation and intensifies all the side effects of radiation
• Breaks can occur due to the comfortability of the side effects, but it affects the outcome of the cancer so they do not recommend
▪ Biotherapy
• Severe skin reactions are common and difficult for the patient
• Nasal fractures-
o S/S
▪ Unaligned nasal bridge, change in breathing, crackling of skin (crepitus), bruising, pain
▪ Blood or clear fluid (cerebrospinal fluid) leaking from nose indicates a serious skull fracture
• Cerebrospinal fluid will contain glucose when tested with a dipstick
o Treatment
▪ Closed reduction- realigning the bones by moving them from exterior within first 24 hours of injury
▪ Rhinoplasty- surgical reconstruction
▪ Nasoseptoplasty- submucous resection to fix blocked septum
o Nursing interventions (including post op care and teachings)
▪ Cold compresses and pain relief for simple closed fractures to decrease swelling
▪ Manage the packing in both nostrils after rhinoplasty to prevent bleeding and support procedure
▪ Change the drip pad in place after rhinoplasty as necessary or teach patient how to
▪ Observe for edema and bleeding after surgery, vital signs q4h until discharge
▪ Educate to stay in semi fowlers and move slowly
▪ Educate to eat soft foods after anesthesia and drink 2500 mL/day
▪ Educate to decrease bleeding by limiting sniffing, coughing, or straining
• Rhinosinusitis-
o S/S
▪ Purulent drainage from both nares
▪ Fever
▪ Lack of response to decongestant therapy
▪ Pain over cheek
▪ Tenderness over sinuses
▪ Erythema
▪ Swelling
▪ Fatigue
o Treatment or medical interventions
▪ Use of broad-spectrum antibiotics, analgesics for pain, decongestants
▪ Nasal saline irrigations
▪ Hot and wet packs
▪ Mast cell stabilizers
▪ Antipyretics
o Diagnosis
▪ Made on basis of patients history and manifestations
▪ Sinus x-rays
▪ Endoscopic examination
▪ Computed tomography
• Differentiating CSF from nasal drainage
o Blood or clear fluid (cerebrospinal fluid) leaking from nose indicates a serious skull fracture
o Cerebrospinal fluid will contain glucose when tested with a dipstick
• COPD and oxygen
o Cyanosis, delayed cap refill
o Finger clubbing
o Eating with mouth open; hard to breath with it closed
o Potential complications
▪ Hypoxemia/ tissue anoxia
• Obstructive sleep apnea-
o Pathophysiology
▪ Breathing disruptions during sleep that lasts 10 seconds with a minimum of 5 times per hour
▪ During sleep, the muscles relax and the tongue is displaced
▪ Common cause is upper airway obstruction
o Risk factors
▪ Obesity
▪ Large uvula
▪ Short neck
▪ Smoking
▪ Enlarged tonsils or adenoids
▪ Oropharyngeal edema
o S/S
▪ Impaired gas exchange
▪ Increased blood CO2 levels and decreased pH
▪ Disrupted sleep cycle; exhaustion; day time sleepiness
▪ Irritability, personality changes
▪
o Treatment or medical interventions
▪ Overnight sleep study using EEG, ECG, EMG, pulse ox
▪ Position fixing devices may correct mild sleep apnea
▪ Noninvasive positive-pressure ventilation to hold open airway
▪ Nasal mask or full face mask (BiPAP or CPAP)
▪ Surgery to take out the uvula or adenoid could correct issue
o Nursing interventions
▪ Have patient complete Epworth Sleepiness Scale (ESS)- 18 or above are at risk for severe sleep apnea
o Complications
▪ HTN
▪ Stroke
▪ Neurocognitive deficits
▪ Weight gain
▪ Diabetes
▪ Pulmonary and cardiovascular disease
• Non-invasive ventilation techniques
o Using an oxygen mask to administer O2 and help prevent poor gas exchange
o CPAP provide constant fixed positive pressure throughout inspiration and expiration causing airways to remain open
o BiPAP provides differing airway pressure depending on inspiration and expiration. Inspiratory pressure is higher than than expiratory pressure
o Negative pressure ventilation provides ventilatory support using a device that encases the thoracic cage
• Epistaxis- treatment, nursing interventions
o Pathophysiology
▪ Nosebleed due to many capillaries within nose
o Treatment or medical interventions
▪ Anterior packing
▪ Nose plugs with blood clotting agent
▪ Gel tampon, posterior packing or epistaxis catheters used for posterior nasal bleeding
o Nursing interventions
▪ Observe for respiratory distress
▪ Provide oxygen, bed rest and antibiotics that are prescribed
▪ Monitor for hypoxemia
▪ Apply ice or cool compresses to nose if possible
▪ Reassure patient and keep blood pressure lowered if possible
• Asthma-
o Pathophysiology
▪ Chronic, reversible airway obstruction only affecting the airways
▪ No issue with the alveoli
▪ Occurs in two ways: inflammation or airway hyperresponsiveness (sensitivity) leading to bronchoconstriction
▪ Smooth muscle contraction or edema, which leads to a narrow lumen
o Risk factors
▪ General irritants
▪ Exercise
▪ Upper respiratory illness
▪ Aspirin and other NSAIDs
▪ GERD
o S/S
▪ Audible wheeze, increase RR
▪ Increased cough
▪ Use of accessory muscles
▪ Barrel chest from air trapping
▪ Long breathing cycle
▪ Cyanosis
▪ Hypoxemia
▪ Tachycardia
o Treatment or medical interventions
▪ Laboratory assessment
• ABGs
• Decreased PaO2
• PaCO2 may be normal or decreased at first
▪ Pulmonary function tests
▪ Drug therapy
▪ Positioning to high fowlers or tripod position to promote gas exchange
▪ Deep breathing and coughing exercises
▪ Get patient up and moving
▪ Oxygen therapy
o Nursing interventions
▪ Improve air flow and gas exchange and relieve symptoms
• Administer medications
• Oxygen
▪ Self-management education
• Personal asthma action plan
• Assess PEF at least daily
• Review chart 30-5
o Potential complications
▪ Status asthmaticus
• Acute episode of airway obstruction
• Can develop pneumothorax and cardiac/respiratory arrest
o Prevent or treat complications
▪ Status asthmaticus- IV fluids, potent systemic bronchodilators, steroids, epinephrine, oxygen, magnesium sulfate (helps with opening airway)
o Education
▪ Identify asthma action plan
▪ Assess asthma severity at least daily with a peak flow meter and to adjust drugs according to the action plan
▪ Establish peak expiratory flow to get a baseline
▪ Keep a symptoms and intervention diary to learn specific triggers of asthma, early cues for impending attack, and personal response to drugs
• Dyspnea management in respiratory disorders
• Dyspnea management in lung cancer
o Place in fowlers to help ease breathing
o Administer oxygen as prescribed and humidification to moisten and loosen secretions
o Provide respiratory treatments
o Provide activity as tolerated, rest periods, active and passive ROM
• Bronchitis vs. emphysema (elaborate more??)
o Emphysema
▪ Loss of lung elasticity and hyperinflation of lung
o Chronic bronchitis
▪ Inflammation of bronchi and bronchioles caused by chronic exposure of irritants
• Pneumonia-
o Risk factors
o S/S
▪ Older adult
▪ Never received pneumococcal vaccine
▪ No influenza vaccine year before
▪ Exposed to respiratory viral or influenza infections
▪ Chronic lung disease
▪ Altered LOC
▪ Recent aspiration event
▪ Poor nutritional status
▪ Receiving mechanical ventilation
▪ Edema
▪ Exudate
▪ Reduced gas exchange
▪ Hypoxia
▪ Empyema (pus in pleural cavity)
▪ Alveolar collapse (Atelectasis)
▪ Chest pain or discomfort
▪ Myalgia, HA, fever, chills
▪ Tachypnea
▪ Crackles during breath sounds
o Treatment or medical interventions
▪ Antibiotics- azithromycin, tetracycline, doxycycline
▪ Cough suppressants
▪ Antipyretics, mucolytic agents, and expectorants
o Diagnosis
▪ Sputum culture
o Nursing interventions
▪ Teach proper handwashing, avoid large gatherings during cold and flu season
▪ Respiratory equipment needs to be cleaned and maintained/ decontaminated
▪ Oxygen therapy
▪ Have patient use incentive spirometer
o Vaccinations
▪ 65+ receive pneumonia vaccine
▪ Have the annual influenza vaccine
o Reduction of risk
▪ Avoid public places
▪ Handwashing
▪ Clean respiratory equipment
▪ Avoid outdoor pollutants
▪ Stop smoking
▪ Eat healthy diet
▪ Drink at least 3 liters of water a day
• COPD –
o Pathophysiology
▪ Emphysema
• Loss of lung elasticity and hyperinflation of lung
▪ Chronic bronchitis
o Risk factors
• Inflammation of bronchi and bronchioles caused by chronic exposure of irritants
o S/S
▪ Cigarette smoking
▪ Alpha 1- antitrypsin deficiency
▪ Asthma
▪
▪ Thin with decreased muscle mass, slow moving, slightly stooped, tripod position
▪ Breathing rate and pattern
▪ Barrel chest
▪ Cyanosis, delayed cap refill
▪ Finger clubbing
▪ Swelling of feet and ankles due to right sided heart failure
▪ Eating with mouth open; hard to breath with it closed
▪ Hepatomegaly
o Treatment or medical interventions
▪ Lab assessment
• ABG values
• Sputum samples
• CBC
• Hgb and Hematocrit
• Electrolytes
• Chest x-ray
• Pulmonary function test
▪ Drug therapy
▪ Lung reduction surgery
o Nursing interventions
▪ Improve gas exchange
▪ Reduction of CO2 retention
▪ Prevent weight loss and minimize anxiety
▪ Increase endurance
▪ Prevent respiratory infection
▪ Positioning
▪ Exercising conditioning
▪ Suctioning
▪ Hydration
▪ Vibratory positive pressure device
▪ Energy conservation education
▪ Nutrition
o Potential complications
▪ Hypoxemia/ tissue anoxia
▪ Acidosis
▪ Respiratory infections
▪ Cardiac failure (cor pulmonale, which is right side heart failure)
▪ Cardiac dysrhythmias
o Education
▪ Quit smoking and make referrals
▪ Weight loss can occur so ask to recall a typical day’s meals and fluid intake
▪ Teach to plan and pace daily activities with rest periods
▪ Avoid working with arms raised
▪ Don’t talk when engages in other activities that require energy
▪ Positioning upright with HOB elevated
▪ Exercise plan to increase pulmonary rehabilitation and to maintain adequate hydration
▪ Nebulizer treatments with normal saline or mucolytic agent to help thin secretions
▪ Coughing to remove excess mucus. Cough when waking up in the morning, before meal times, and before bedtime
• Hug a pillow, sit down and turn shoulders in when coughing
▪ Breathing techniques to be used during all activities to reduce amount of stale air in lungs and manage dyspnea
• Diaphragmatic- lie on back with knees bent, book on abdomen to create resistance, breathe and have book rise and fall
• Pursed lip- breathe in through nose and out through kissy lips
• Energy conservation in lower respiratory disorders
o The planning and pacing of ADLs
o Avoid working with arms raised
o Keep arm movements smooth and flowing to prevent jerky movements
o Organize work place so items used most often are within eay reach
• Cystic fibrosis-
o S/S
▪ Abdominal distention
▪ GERD
▪ Rectal prolapse
▪ Foul smelling stools
▪ Steatorrhea (fat in stools)
▪ Malnourishment
▪ Vitamin deficiency (ADEK) Fat soluble vitamin
▪ Respiratory infections
▪ Chest congestion and sputum production
▪ Decreased pulmonary function
▪ Limited exercise tolerance
▪ Increased WBC
▪ Decreased O2 stat
▪ Tachypnea
▪ Tachycardia
▪ Intercostal retractions
▪ Weight loss
▪ Increase fatigue
o Treatment or medical interventions
▪ Nutritional management
▪ Drug therapy
▪ Infection prevention
▪ Pulmonary hygiene
▪ Exercise and nutrition
▪ Sweat chloride test- makes pt sweat and look at chloride in it
▪ Lung transplantation- extends life 1-15 years
▪
o Nursing interventions
▪ Enhance gas exchange
▪ Administer bronchodilators, anti-inflammatories, mucolytics and antibiotics
▪ Preventative/ maintenance therapy
• Positive expiratory pressure
• Active cycle breathing technique
• Exercise program specified for patient
o Diagnosis
▪ Sweat chloride test positive when it ranges between 60 and 200 mEq/L (normal value is 40)
▪ Genetic testing to determine specific mutation
o Education
▪ There is no cure to this disease
▪ Teach to avoid hand shakes, large crowds, kissing people
▪ Teach that handwashing is critical
▪ Ways to help clear mucous
• Chest physiotherapy uses chest percussion, chest vibration and dependent drainage to loosen secretions
• Chest physiotherapy vest inflates and deflates to help cause mini-coughs that dislodge mucus from bronchial walls
• Pulmonary fibrosis-
o Pathophysiology
▪ Common restrictive lung disease with excessive wound healing with loss of cellular regulation
▪ Cigarette smoking, chronic exposure to inhalation or irritants
o S/S
▪ Decreased gas exchange
▪ Dyspnea
▪ Decreased forced vital capacity
▪ Hypoxemia
▪ Rapid and shallow respirations
o Treatment
▪ Corticosteroids
▪ Cytotoxic drugs
• Respiratory medications
o Bronchodilators- open up airways
o Corticosteroids- inhibit cells involved in inflammatory purposes
o Mast cell stabilizers- prohibit histamines, leukotrienes, and cytokines
o Leukotriene receptor antagonists- block the effects of leukotrienes in inflammatory cascade
o Antihistamines and epinephrine
o Pulmonary surfactants
o Antimicrobial and antivirals
• Influenza-
o S/S
▪ Fever
▪ Chills
▪ Fatigue
▪ Weakness
▪ Anorexia
▪ HA
▪ Muscle ache
o Treatment or medical interventions
▪ Vaccinations are recommended
▪ Antivirals given
o Nursing interventions
▪ Promote rest
▪ Increase fluid intake
▪ Gargle salt water
▪ Administer antihistamines
▪ Educate to wash hands
• Pulmonary hypertension-
o Pathophysiology
▪ Blood vessels constrict with increasing vascular resistance in the lung
▪ Occurs in absence in other lung disorders
▪ Caused by complication of other lung disorders
▪ Could be caused by exposure to some drugs such as fenfluramine/phentermine or dasatinib
o S/S
▪ Dyspnea and fatigue doing normal activities
▪ Pulmonary blood pressure rises
▪ Blood flow decreases through lungs
▪ Poor perfusion and gas exchange
▪ Damage to the lungs and heart
o Treatment or medical interventions
▪ Drug therapy
• Warfarin
• Calcium CB
• Digoxin and diuretics
• O2 therapy
• Natural and synthetic prostacyclin agents
• Endothelin-receptor antagonists
o Complications
▪ Death occurs within 2 years after diagnosis
▪ Poor perfusion and gas exchange
▪ Cor pulmonale (remember SE of right side heart failure)
▪ Enlarged heart
• Respiratory failure as a complication of respiratory disorders
o Mismatched ventilation or perfusion
o Acute failure can be ventilatory failure, oxygenation failure, or a combination of both ventilatory and oxygenation failure
o PaO2 < 60
o PaCO2>45
o Always hypoxemic
o Ventilatory failure
▪ Problem with intake
▪ Blood flow/perfusion is normal, but air movement is inadequate
• Lung cancer-
o S/S
▪ Hoarseness
▪ Cough
▪ Sputum production
▪ SOB
▪ Change in endurance
▪ Chest pain
▪ Labored or painful breathing
▪ Wheezing
▪ Dyspnea
▪ Respiratory distress
▪ Cardiac tamponade
▪ Dysrhythmias
▪ Bone pain or pathologic fractures
▪ Clubbing of fingers
o Nursing interventions
▪ Teach patient about precautions to reduce risk of infection
▪ Monitor VS
▪ Relieve anxiety and promote patient’s participation
▪ Encourage to express fears and concerns, answer any questions and teach about the chest tube placement information
▪ Teach about probable locations for surgery
▪ Ensure the integrity of the system, promote comfort, ensure chest tube patency, and prevent complications
▪ Control pain for patient and educate on PCA devices
o Palliative care
▪ Oxygen therapy
▪ Drug therapy
▪ Radiation therapy
▪ Thoracentesis r/t dyspnea, discomfort, risk for infection
▪ Pain management
• Tuberculosis-
o S/S
▪ Fatigue
▪ Lethargy
▪ N/V
▪ Anorexia (weight loss)
▪ Irregular menses
▪ Low-grade fever
▪ Night sweats
▪ Bloody cough
▪ Chest tightness
o Treatments
▪ Antimicrobial therapy
▪ Combination drug therapy
▪ First line therapy drugs like isoniazid and pyrazinamide (8 weeks)
▪ Bedaquilline used for multidrug- resistant TB (deadly so give under observation)
o Nursing interventions
▪ After sputum culture ordered, get the sample
▪ Place patient on airborne precautions
▪ Have patient wear mask in public
▪ Teach deep breathing, coughing, use of incentive spirometer
▪ Increase fluids
▪ Manage anxiety
▪ Improve nutrition (increase vitamins A,B,C,E, avoid alcohol, frequent small meals)
▪ Give antiemetics
▪ Manage fatigue and slow activity/get plenty of rest
o Diagnosis
▪ Chest x-ray
▪ Nucleic acid amplification test. Results available less than 2 hours
▪ Blood analysis by enzyme- linked immunosorbent assay using QuantiFERON-TB Gold
▪ Sputum culture confirms the diagnosis
▪ The tuberculin test (Mantoux test) is the most reliable SCREENING test
o Education
▪ Follow drug regimen
▪ Disease isn’t contagious after 2-3 weeks of drugs
▪ Proper nutrition to prevent weight loss
▪ Educate on TB, what it is, what the treatment is
• Peritonsillar abscess-
o S/S
▪ Collection of pus behind tonsil
▪ Swelling on one side of throat, pushing uvula toward unaffected side
▪ Severe throat pain
▪ Muffled voice
▪ Fever
▪ Difficulty swallowing
▪ Tonic contraction of the muscles of chewing
▪ Difficulty breathing
▪ Bad breath and swollen lymph nodes
o Diagnosis
▪ Based on patients symptoms
▪ Needle aspiration and culture of pus collected is preferred test
o Treatment
▪ Antibiotics
▪ Steroids
▪ Drainage of the abscess
o Nursing Interventions
▪ Pain control through topical anesthetics, OTC analgesics and opioids
o Education
▪ Stress importance of completing antibiotics completely
▪ Come to ED if symptoms of obstruction appear (drooling and stridor)
▪ Hospitalization needed when infection does not respond to antibiotics
▪ Tonsillectomy may be needed to prevent recurrence
• Dosage and calculation [Show Less]