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104 Cards in this Set
- Front
- Back
Defining characteristics of ARF?
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PaO2 <80 (hypoxemic)
PaCO2 >45 + acidosis (hypercapnic) COPD w/severe ABG deterioration & clinical deterioration |
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What is Alveolar hypoventilation? And causes?
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deficient movement of air into & out of the alveoli (usually from obstruction)
other causes- restrictive lung diseases, CNS disease/depression, chest wall dysfunction (pneumothorax), acute asthma, neuromuscular disease |
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What is V/Q mismatch (hypoxemia)?
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ventilation/perfusion mismatch
decreases ventilation w/normal blood flow (increased secretions in airways/alveoli, bronchospasm, atelectasis, pain) OR normal ventilation w/decreased blood flow (PE) |
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Tx of V/Q mismatch?
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tx underlying cause
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Consequences of untx ARF in each system?
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Resp- Increased rate at 1st, decreased w/worsening & muscle fatigue
Cardio- tachycardia, decreased CO CNS- permanent brain damage Renal- Acute tubular necrosis GI- ischemia, bacterial translocation |
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2 major consequences of untx of ARF?
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hypoxemia - tissue hypoxia - anaerobic metabolism & lactic acidosis = need NaHCO3 to buffer
renal hypoxia - release of erythropoietin from renal cells - bone marrow increases RBC to attempt to increase the blood's O2 carrying capacity- may lead to ATN |
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Early S&S of ARF? And tx?
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dyspnea, restlessness, anxiety, H/A, fatigue, cool & dry skin, HTN, tachycardia
tx- elevate HOB, O2 |
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Intermediate S&S of ARF? And tx?
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confusion, lethargy, tachypnea, hypotension, dysrhythmias, ischemia
tx- Elevate HOB, O2 NC, may need to intubate |
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Late S&S of ARF? And tx?
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cyanosis, diaphoresis, coma, resp arrest
tx- intubate, call code |
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What is a PE?
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obstruction of the pulmonary arterial bed by a dislodged thrombus, fat or air embolus, heart valve growths or a foreign substance
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What is the patho of PE?
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vascular wall damage, venostasis, & hypercoagulability of blood cause thrombus formation, thrombus loosens from trauma, clot dissolution, muscle spasm, intravascular pressure change, or peripheral blood flow change, embolus travels to the R side of the heart, enters the lung through the pulmonary artery, embolus dissolves, fragments or grows
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What happens with an untx PE?
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alveoli are prevented from producing enough surfactant to maintain alveolar integrity, alveoli collapse = atelectasis
large enough embolus will clog pulmonary vessels = death |
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Complications of PE?
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pulmonary infarction
pulmonary HTN |
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S&S of PE?
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sudden unexplained dyspnea- hallmark sign
angina, pleuritic chest pain, tachycardia, air hunger, impending doom, productive cough that may be blood tinged |
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Less common S&S of PE?
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low grade fever, pleural effusion, massive hemoptysis, chest splinting, lower extremity edema, cyanosis, syncope, distended neck veins, pleural friction rub, circulatory collapse, hypoxia
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Risk factors of PE?
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long car trips, long plane trips, cancer, pregnancy, hypercoagulability, birth control, previous DVT or PE
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Dx of PE?
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CXR, V/Q scan, pulmonary angiography, EKG, hemodynamics, ABGs, D-Dimer
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What do you see on a CXR for a PE?
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may see PE or other pulmonary conditions
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What do you see on a V/Q scan?
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reveals perfusion defects beyond occluded vessels
injection of radio-isotope, inhalation of radioactive gas can't do on an intubated pt |
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Pulmonary angiography for PE?
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most definitive test
insert cath through antecubital or femoral vein to pulmonary artery where contrast is injected most beneficial when anticoagulation (heparin) is contraindicated |
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EKG for PE?
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used to distinguish PE from MI
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Expected hemodynamics for PE?
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elevated pulmonary systolic pressure, 20-30
diastolic pressure, 8-15 mean pressure, 10-20 & wedge pressure 6-12 if no wedge pressure ordered go off of diastolic pressure |
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Early ABG results from PE?
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hypoxemia
hypocapnia resp alkalosis (CO2- <35, pH > 7.45) |
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ABG if embolus is large?
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hypoxia, hypercapnia, resp acidosis
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How to tx Shunting?
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intubate, increase O2, increase peep
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What is SaO2?
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% of O2 on Hgb
90-100 |
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What is PaO2?
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O2 dissolved in arterial blood
80-100 |
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D-Dimer for PE?
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measures amount of cross-linked fibrin fragments after clotting event ( DVT, acute MI, angina, acute CVA)
not specific or sensitive to PE or clot anywhere |
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When do you use an IVC filter?
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when you can't use anticoagulants
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Best tx for PE?
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1st admin O2 then give heparin 60-70
if levels high, stop for 1 hr decrease rate |
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Other tx for PE?
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O2 prn, Heparin, SCDs, fibrinolytics, surgery
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What is Pulmonary edema?
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accumulation of fluid in extravascular spaces of the lungs
extravascular spaces = interstitium & alveoli |
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What are the causes of Pulmonary edema?
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L sided heart failure d/t arteriosclerosis, cardiomyopathy, HTN, valvular heart disease
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Patho of Pulmonary edema?
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changes in pulmonary capillary hydostatic pressure, capillary oncotic pressure, capillary permeability, & lymphatic drainage
prevents fluid infiltration into the lungs because the fluid leaks into the interstitial space & alveoli causing impaired gas exchange & edema |
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What are the Early S&S of Acute pulmonary edema? And tx?
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S3 audible- hallmark
exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, cough, mild tachypnea, HTN, basilar crackles, tachycardia O2, elevate HOB, Lasix |
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What are the Late S&S of APE & tx?
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labored, rapid resps, diffuse crackles, blood tinged frothy sputum, increasing tachycardia, arrhythmias, cold clammy skin, diaphoresis, cyanosis, hypotension, weak pulses
Pt is drowning r/t forced fluid in alveoli |
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Dx for APE?
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ABGs, CXR, Pox, Swan, EKG
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ABGs will show what for an APE?
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hypoxemia, & variable PaCO2
PaCO2- dependent on pt's level of fatigue, increased fatigue = increased CO2 |
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CXR of APE will show what?
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diffuse haziness (whited out) of lung fields, cardiomegaly r/t increased pumping, pleural effusion
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Normal Cardiac output & cardiac index?
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4-8L
2-4 (pt specific) |
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Pulse Ox will show what w/APE?
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decreasing SaO2
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Swan will show what for APE?
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shows L sided heart failure & can be used to r/o ARDS
decreased CO & CI |
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EKG for an APE?
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previous or current MI
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Tx for APE?
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elevate HOB, high concentrate O2 usually by NC (pt can't tolerate face mask, feels like they're suffocating more), meds
if can't tx soon enough intubate & mechanical vent |
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Meds for APE?
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diuretics (Lasix), positive isotropes, vasopressors (Levofed), antiarrhythmics (Cardizem), arterial vasodilators (Tridil, nitropreside), Morphine, Natrecol, venous dilator (nitroglycerin IV)
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Preload affects what?
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fluid
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Afterload affects what?
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pressure
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What is ARDS?
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pulmonary edema in the absence of cardiac failure
NO L SIDED HEART FAILURE- NOT CAUSED BY L VENT FAILURE |
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What is primary pulmonary insult?
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directly affects lung tissue/alveolar membranes
aspiration, near drowning, toxic inhalation, pulmonary contusion, pneumonia, thoracic trauma, O2 toxicity |
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What is secondary pulmonary insult?
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Anywhere but the lungs
sepsis, non-thoracic trauma (immobility), excessive blood transfusions, pancreatitis, shock, PE, DIC, opioid overdose |
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What is the patho of exudative phase?
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pulmonary capillary wall damage, fluid leaks into interstitial space, impaired gas exchange r/t widening of gap between alveoli & pulmonary capillaries, increased fluid volume that increases pressure exerted on alveoli causing atelectasis w/decreased lung volume
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R-L shunt in Exudative phase?
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blood passes from R to L w/o being oxygenated causing hypoxemia, hypoxia, multi system organ faliure
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S&S of exudative phase in ARDS?
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restless, apprehensive/afraid, progressive dyspnea & tachycardia, moderate use of accessory muscles, clear breath sounds, ABG of resp alkalosis & normal PaO2
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Patho of Proliferative phase?
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decreased lung compliance, decreased surfactant production, & refractory hypoxemia
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Proliferative phase S&S of ARDS?
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increased resp distress, increased tachypnea, increased accesory muscle use, fine crackles, mental status changes/agitation, resp acidosis
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Patho of Fibrotic phase of ARDS?
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irreversible, diffuse interstitial & alveolar fibrosis, increased dead space vent, increased hypoxemia & hypoxia, multiple organ dysfunction syndrome
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Fibrotic S&S of ARDS?
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increased tachycardia, hypotension, cool mottled ischemic skin, renal & liver failure, severe agitation, hallucinations, coma, death
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Long-term effects in recovery phase of ARDS?
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permanent loss of lung tissue, fibrotic = can't change
mild-moderate diminished vital capacity impaired gas exchange difficulty exercising, socializing & completing ADLs |
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Dx of ARDS?
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decreased PaO2 despite increased FIO2- hallmark
CXR- diffuse, bilateral infiltrates NO CHF |
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Tx of ARDS?
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mechanical vent
goal- normal PaCo2 PEEP |
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Good causes of PEEP in ARDS?
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decreases alveolar collapse, increases Functional Residual Capacity, increased lung compliance, decreased R-L shunt, increased clearing of lung fields
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Risks of PEEP in ARDS?
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increased alveolar distention causing weakness of alveolar walls causing rupture & decreased CO
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Other tx of ARDS?
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coughing, hyperoxygenate prior to in-line suctioning, turn, prone, specialty tube feedings, infection control techniques
DON'T INTERRUPT PEEP |
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Meds for ARDS?
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antibiotics, corticosteroids, vasodilators, bronchodilators, mucolytics, diuretics, colloids, opioids/sedatives/neuromuscular block (Nimbex)
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Cause of SARS?
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coronavirus
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How is SARS transmitted?
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person-person contact
droplet precautions |
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DX of SARS?
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pt hx (travel to area w/SARS, close contact w/other person w/SARS)
CXR- hazy opacities/ground glass appearance, progression to bilateral consolidation in 24-48hrs, culture from blood, stool, nasophary or orophary |
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Tx of SARS?
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antipyretics, O2, vent support, IV fluids, antibiotics, antiviral, corticosteroids
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Isolation precautions for SARS?
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negative pressure
full barrier- gloves, gown, resp mask, eye shield put hands together after leaving room to go wash hands |
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What is a Pneumonectomy?
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removal of entire lung
empty space fills w/fluid usually w/thoracoplasty |
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What do I do for a pneumonectomy & chest tube?
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NO CHEST TUBE
Lay pt good lung up |
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What is a Lobectomy?
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removal of lobe/lobes
lung over expands filling entire cavity |
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What do I do after lobectomy?
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turn pt onto both sides
2 CHEST TUBES |
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What is an open lung biopsy?
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resection of a small portion of lung for biopsy
CHEST TUBE |
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What is Decortication?
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removal of visceral pleura
CHEST TUBE |
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What is a thoracotomy?
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incision in thorax
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What is VATS?
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dx procedure
scope w/camera & video projector biopsy specimen CHEST TUBE |
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What are the benefits of VATS?
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decrease blood loss, less invasive, decrease post-op rehab
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2 types of thoracotomy & what are they?
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median sternotomy- smaller tubes, split sternum; used for heart pts
posterolateral- anterior axillary line in 4, 5, 6 intercostal anterolateral- sternal border to mid axillary line used for trauma pts |
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What to teach pt Pre-op for thoracotomy?
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cough & deep breath techs, incentive spirometry, pain/comfort, stop smoking
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What to teach pt post-op for thoracotomy?
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pain, chest tube, arm movement, frequent assessment of breathing
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What is a thoracentesis?
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drains fluid from pleural spaces, test fluids for dx, if pneumothorax may need chest tube, monitor for pneumothorax
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Post op care for lung surgeries?
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assessment, auscultate, S&S hypoxemia/hypoxia, RR, ABG, oxygenation & ventilation, incentive spirometry, no suction unless absolute necessary, pain measurement using CPOT or WILDA, prevent atelectasis w/pt getting OOB, coughing & deep breathing, pain control, hydration
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Post-op complications?
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ARF, bronchopleural fistula, hemorrhage, subcutaneous emphysema, cardiovascular disturbances, pulmonary edema
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Stages of bubbling?
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initial bubbling-ok
intermittent bubbling continuous bubbling- persistent air leak fluctuations = tidaling |
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Nursing care w/chest tubes?
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mark drainage levels, keep system below chest, monitor drainage amounts, check dressings, monitor crepitus, tubing, assess lungs sounds & PaO2, suction @ -20
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Emergency equipment for chest tubes?
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vasoline gauze, sterile water, clamps
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Complications of chest tubes?
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no drainage= malpositioning, kinks, suction, tubing, no milking or stripping
can gently manipulate |
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D/C of chest tubes when?
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< 5% pneumo, no air leak, drainage, CXR
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Procedure for D/C chest tubes?
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explain procedure, medicate, position, MD removes, occlusive dressing, CXR
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What to monitor for after chest tube removal?
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bleeding, fluid leak, air leak, resp distress
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Fx rib sites & areas affected at each site?
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1 & 2- great vessels & brachial plexus
middle ribs- lung injuries lower ribs- abd injuries R sided 8th & below ribs- liver L sided 8th & below- spleen |
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Dx of rib fx?
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CXR
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Complications of rib fx?
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atelectasis, puncture/pneumothorax, spleen & liver injuries, flail chest, hemothorax, pneumonia
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What is flail chest?
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loss of stability r/t multiple rib fxs on 2 or more places fx on 1 rib
paradoxical resp- hallmark sign possible contusion or hemopneumothorax |
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Tx for Flail chest?
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stablize chest segment- no surgery/external fixation, mechanical vent, lie on affected side, IV fluids, pain control
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What is a closed pneumothorax?
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rupture in visceral or parietal pleural & chest wall
air source inside chest that separates 2 pleura & lung recoils by collapsing |
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What is a spontaneous pneumothorax & S&S?
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unexpected air leak into visceral pleural space that can cause tension pneumothorax (life threatening)
sudden SOB at rest w/o exertion- hallmark decreased breath sounds or absent |
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Tx for pneumothorax?
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Chest tube
pleurodesis/mechanical abrasion, partial pleurectomy |
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What is an open pneumothorax?
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air enters parietal pleural space through opening in chest wall causing barometric pressure in pleural space
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What is a tension pneumothorax?
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rapid accumulation of air in pleural space w/tension on heart & great vessels
one way valve effect, air trapping occurs TRUE EMERGENCY |
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Tension pneumothorax can cause?
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mediastinal shift or tracheal deviation
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Tx for pneumothorax & hemothorax?
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CHEST TUBE
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Tx for tension pneumothorax?
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medical emergency
needle decompression- 14G stick in chest to let air out |