EXAM 3 NOTES
System: Respiratory
Topic: COPD
Questions/Main Ideas
What is COPD?
Notes
A slowly progressive respiratory disorder that causes airway
obstruction.
What is the patho of
chronic inflammation leads to airway narrowing and scarring over
COPD?
time
COPD includes chronic
bronchitis and
emphysema.
What is the patho of
constant exposure to irritant in airway (cigarette smoke, factory
chronic bronchitis?
fumes, toxins in air) → inflammatory response → leakage → mucus
production → impaired gas exchange
What are the S/S specific
must have symptoms of cough (which gets rid of secretions) and
to chronic bronchitis?
sputum production for 2 consecutive years
What is the patho of
abnormal enlargement of airspaces and alveoli wall destruction
emphysema?

irritant causes constant vasoconstriction → alveoli sac loses
elasticity due to destruction and overextension → doesn’t recoil
as much → doesn’t contract and relax efficiently → impairs gas
exchange → impairs oxygenation → acute hypoxia

Cigarette smoke causes constant vasoconstriction inside of
upper respiratory tract or inside capillaries in the respiratory
tract → loses elasticity because vasoconstriction increases the
resistance that blood vessels or capillaries have to overcome
(increases pressure)
What are the risk factors
o
for COPD?
How is COPD classified?
age (vasoconstriction and calcification of blood vessels →
hypertension)
o
environmental exposures (smoking or secondhand smoking)
o
exposure to occupational chemicals (mine workers, contractors)
o
deficiency in alpha1 antitrypsin (protects lungs from injury)
Different stages of COPD are classified based on severity: mild,
moderate, severe
What are the clinical
o
chronic cough (due to mucus production)
manifestations of COPD?
o
sputum production
o
dyspnea (impaired gas exchange initiates stress response →
SOB)
o
weight loss (stress response causes hypoperfusion of the gut)
o
barrel chest (CO2 building up → impaired gas exchange →
hypoventilation → hypercapnia → air gets trapped →
circumference of chest increases → chronic respiratory acidosis
with chronic hypoxia)
o
AP diameter 1:1 (because of air trapping; normal is 2:1)
o
clubbing (chronically hypoxic, nail bed is greater than or equal to
180 degrees)
Initially may be on BIPAP - gives patient pressure and keeps alveoli
in lungs open; patient can get a certain amount of FiO2 to keep
alveoli inflated and get them out of a hypoxic state
SpO2: 88-92% is normal
o
Patient is acutely hypoxic and hyperventilating → increased
retention of CO2 → increasing O2 increases CO2 → patient
retains more CO2 → you don’t want to give more O2 since they
don’t have the ability to remove CO2
What is the management
o
Smoking cessation - #1 way to treat COPD
for COPD (not including
o
Administer supplemental oxygen in low doses to prevent oxygen
meds)?
toxicity

because patient is acutely hypoxic and has loss of drive
to breathe → continuous hyperventilation → increased
CO2 → hypercapnia

If you give too much oxygen → increased hypercapnia
→ becomes sleepy → can’t protect their airway

o
Don’t give non-rebreather mask
Preventative measures to prevent exacerbations (ex. updated
flu vaccine and pneumococcal vaccine) - already chronically
inflamed and hypoxic, so you don’t want to worsen the
problems
o
Pulmonary rehab to reduce symptoms
o
Chest PT can be utilized to move secretions - more common in
chronic bronchitis than emphysema
o
Allocate extra time to complete activities and conserve energy do slow AM care and ADLs
o
A balanced diet helps to reverse weight loss - need adequate
protein
o
Advanced disease → lung transplant or
lobectomy/pneumonectomy to remove a piece of the lung
Medications used for
COPD depend on
severity. What are the 3
main meds?
Antibiotics, Bronchodilators, Corticosteroids

Antibiotics: given to patients with chronic bronchitis (NOT
emphysema) to help with mucus production
o
antibiotic of choice - respiratory fluoroquinolones (ex.
Levaquin)

causes Achilles tendon rupture and sun
sensitivity

In this case, patient doesn’t need to have
elevated WBC

Bronchodilators: dilates bronchioles → increases
permeability → more O2 can get through membrane and
into bronchioles
o
Rescue drug: Albuterol

Complication is tachycardia → give
ipratropium bromide → anticholinergic effects
(dry mouth, constipation, paralytic ileus,
urinary retention) → don’t give to BPH
patients because it will cause more urinary
retention
o
Xopenex (levalbuterol) for maintenance - combo of
Albuterol and ipratropium at lower concentrations

Corticosteroids: reduces inflammation in airway
o
Give IV: Methylprednisone (methylprednisolone)
o
Complications: delays wound healing,
hyperglycemia, Cushing’s if too aggressive,
Addison’s if abruptly stopped
o
Inhaled corticosteroids are also given, but short-term
only
Summary: COPD includes chronic bronchitis and emphysema. Both are commonly due to
cigarette smoke that causes vasoconstriction of the airway, leading to impaired gas exchange.
This is directly due to sputum production in chronic bronchitis. In emphysema, it is due to the
abnormal enlargement of airspaces and alveolar wall destruction. COPD is medically treated
with bronchodilators, corticosteroids, and antibiotics.
System: Respiratory
Topic: Asthma
Questions/Main Ideas
What is asthma?
Notes
Chronic airway inflammation due to exposure to airway irritants or
allergens
What are the S/S of

Histamine is the problem - constricts smooth muscle in airway
o
Cough with or without sputum (different from chronic bronchitis -
asthma?
always with sputum)
o
Dyspnea
o
Wheezing - indicates air going through a tight airway and is not
specific to asthma
o
Also associated with eczema from exposure to an allergen (ex. latex,
tree nuts, bananas) due to eosinophil release during immune
response
o
Chest tightness in acute asthma → respiratory alkalosis from
hyperventilation → acute hypoxemia → hypercapnia → if sustained
over time without treatment → respiratory acidosis
How is Asthma diagnosed?
H&P
What labs are done for a
Labs to assess for Eosinophilia and IgE
patient with asthma?
What is a Major
respiratory failure – caused by hypoventilation
complication of asthma?
How is asthma managed?
o
Rescue meds:

SABA (short-acting beta-agonists) - ex. Albuterol (causes
tachycardia)

Anticholinergics – ex. Ipratropium (not for BPH patients)
o
Long-term/daily meds:

Corticosteroids – ex. Beclomethasone, Advair
o
For inhalers, educate patient on rinsing mouth after using
to prevent oral thrush/candida

Leukotriene modifiers – ex. Montelukast/Singulair (prevents
asthma attacks)
o
All clients must have an asthma management plan – use peak flow
and document levels daily, and know when to notify the provider
o
Peak flow: measures the highest airflow during forced expiration

Must be documented in a journal daily to prevent status
asthmaticus
What do the different levels
Green Zone (>80%): good
mean on the peak flow
Yellow Zone (60-80%): caution - something
meter?
may be going on and patient may be
symptomatic → should call provider for
treatment of symptoms (i.e. corticosteroid
inhaler) and return for follow-up within 1-2
days
Red Zone (<60%): GO TO ER! → goal is to
prevent status asthmaticus - patient may
need more medication to take long term to
help manage their asthma
Summary: Asthma is caused by exposure to irritants or allergens that lead to chronic airway
inflammation. If it’s not treated appropriately, asthma can lead to respiratory failure. Therefore, asthma
should be managed with rescue meds—such as albuterol and ipratropium—and daily meds—such as
beclomethasone and montelukast. All asthma patients should have an asthma management plan with
daily usage of a peak flow meter.
System: Respiratory
Topic: Laryngeal Cancer
Questions/Main Ideas
Notes
Larynx cancer accounts for
½ of head and neck
cancers.
What are the risk factors for
o
Smoking - #1 risk factor
laryngeal CA?
o
Alcohol - main risk factor along with smoking (both cause
vasoconstriction)
o
Men
o
Adults older than 65
o
Exposure to toxins (ex. asbestos) - causes inflammation which over
time, causes cell differentiation → cancer
What are the S/S of
o
laryngeal CA?
hoarseness for more than 2 weeks (patient’s main complaint) - due to
compression of vocal cords from the tumor growing
o
Raspy voice and low pitch
o
Persistent cough
o
Sore throat
o
Lump in neck and dysphagia – occurs as cancer progresses and
becomes more advanced → tumor gets bigger and compresses vocal
cords and makes it difficult for food to go down
o
Weight loss – nothing goes down when they eat
What are the diagnostic
o
Definitive diagnosis - fine needle aspiration (FNA) biopsy
tests for laryngeal CA?
o
Barium swallow study – for dysphagia
o
CT scan, MRI, and PET scan – for metastasis
How is laryngeal CA
Depends on the stage
treated?
o
Chemotherapy and radiation
o
Surgery:
o
cordectomy (incision and removal of vocal cords) in mild
cancer
o
[rare] laryngectomy in severe disease - partial or total removal
of larynx depending on severity and complications
What is the pre-op care for a o
educate patient on loss of voice post-op and explore alternative
laryngectomy?
methods of communication (i.e. pen and paper)
o
What is the post-op care for
Will be NPO post-op for about 1 week → enteral feeding or TPN
o
a laryngectomy?
The airway is a priority post-op! Monitor for respiratory distress
(ex. SOB, using accessory muscles, agitation, nasal flaring, JVD,
increased respirations) and report any findings ASAP
o
Explain to the client with a complete laryngectomy that the natural
voice will be gone.
o
NPO for 7 days, so will have enteral feeding or TPN.
o
Because smoking and alcoholism are main causes of laryngeal
cancer:
o
Monitor for alcohol withdrawal (delirium tremens
symptoms): tremors, sweating/diaphoresis, tachycardia,
agitation, nausea, vomiting → treatment: Ativan
(lorazepam), Librium (chlordiazepoxide)
o
Monitor for nicotine withdrawal: headache → treatment:
nicotine patch
o
Psychosocial assessment: assess patient for disturbed body
image, knowledge deficit, and anxiety → RN should address these
issues and allow patient to discuss how they feel
When is enteral feeding
Enteral feeding (NGT, PEG) is used with a patient who still has the ability
used vs. TPN feeds?
to absorb in the gut.
TPN (IV) feeding is utilized when a patient has issues with absorption
inside of the gut.
What must the RN monitor

Electrolytes
with enteral feeding?

Blood sugar

Risk for aspiration - Notify UAP/CNA to hold feeds when turning
patient

Dumping Syndrome – food goes quickly through GI tract → S/S:
nausea, vomiting, diarrhea, bloating
What must the RN monitor

Blood sugar - TPN includes glucose and insulin
with TPN?

Don't abruptly stop – will cause rebound hypoglycemia
o
Instead put them on D10 and slowly taper them down
How is speech managed
Speech therapy: alternate methods to communicate. Utilize writing, lip-
post-laryngectomy?
reading, and electronic devices such as iPads or cell phones. Will work
with speech pathologist during acute phase post-op.
o
Different types of speech:

Esophageal speech – works with speech pathologist on using
muscles to speak

Artificial larynx – electrolarynx

Tracheoesophageal puncture – valve placed in stoma →
covering valve produces speech
What education is

showering (don’t cover too tightly)
necessary for the client and
family post-laryngectomy?
Wear a loose-fitting bib or hold your hand over your stoma when

AVOID swimming

Humidification is needed in the house – dry air will dry out site

Proper care and management of tracheostomy – nothing goes inside
stoma because anything inside will cause systemic infection → sepsis
Summary: Cancer of the larynx is due to a tumor compressing the vocal cords. Treatment may involve
surgical removal of the vocal cords or larynx depending on severity. The patient will need speech
therapy post-op and will require enteral or TPN feeds within the first 7 days. The nurse must monitor for
complications of Dumping Syndrome that comes with enteral feeds and rebound hypoglycemia from TPN
feeds. Proper care and of the stoma prevents sepsis.
System: Cardiovascular
Topic: Coronary Artery Disease (CAD)
Questions/Main Ideas
Why are the coronary arteries
Notes/Answers
They provide blood, oxygen, and nutrients to the myocardium.
important?
What are the 3 levels of
1. BEGINS with ischemia: insufficient oxygen supply to meet requirements of the
damage caused by CAD?
myocardium
2. Ischemia leads to injury.
3. Prolonged injury leads to infarction.
What is the patho of CAD?
o
uncontrolled hypertension → vasoconstriction of blood vessels → changes
structure of blood vessels and makes them more prone to inflammation
o
HLD (from high cholesterol, fatty foods) → plaque buildup → obstruction - lumen
of artery gets smaller → not enough blood to meet oxygen demands → reduced
blood flow to myocardium and reduced oxygen to blood vessels → ischemia
(presents as headache, chest pain) → over time, this activates stress response
→ vasoconstriction as compensatory mechanism for decreased oxygenation in
blood vessels (on top of plaque buildup) AND inflammation occurring at the same
time → coronary arteries become more diseased and less oxygen is going
through them → prolonged injury → acute coronary syndrome → complete
occlusion from plaque → infarction: STEMI or NSTEMI
o
Long term: inflammation (since plaque is considered foreign) → clot from plaque
breaks off → stroke or MI
What are the modifiable risk

Elevated serum cholesterol (normal is <200)
factors for CAD?

Cigarette smoking

Hypertension - if vasoconstriction of blood vessels becomes chronic → left
ventricle works harder→ increases afterload → left ventricular hypertrophy →
heart failure

Impaired glucose tolerance/DM - glucose molecules stick to capillaries → affe
oxygenation - impairs gas exchange → teach patients to consistently take
antidiabetic meds, exercise, and watch what they eat

Obesity
o
Most likely has metabolic syndrome – patient has 5 risk factors for CV
and will have an MI in 5-10 years
1. hypertension (normal BP should be <130/80)
2. elevated waist circumference >35.4 for males and >31.4 for females
3. elevated triglycerides ≥175
4. reduced HDL (normal should be >40 in males and >50 in females)
5. elevated fasting glucose >100

Excessive alcohol – causes vasoconstriction

Limited physical activity – increased fat stores leads to increased risk for
metabolic syndrome

Stress – stress response causes vasoconstriction
What are the non-modifiable

Age (older adults) – can be middle-aged and at risk if they have other risk fac
risk factors for CAD?

Male gender

Family history of CAD

African American ethnic background
When does someone with or
Testing for CAD (lipid panel) occurs with every annual physical exam if you have
without risk factors get a lipid
factors or every 5 years if you don’t have risk factors
panel test?
What are the typical S/S of
o
CAD?
Chest pain that radiates to left shoulder or jaw (due to decreased oxygenation
heart)
o
Nausea and vomiting (stress response causes decreased blood flow to the gu
o
Diaphoresis (sympathetic nervous system/stress response)
o
How do men with CAD mainly
Shortness of breath (stress response)
chest pain (pressure on chest) that radiates to left shoulder, diaphoresis/sweating
present?
How do women and older
70% present with atypical (mostly GI) symptoms: indigestion, nausea and vomiting,
adults with CAD mainly
palpitations (increased blood flow to the heart), and numbness
present?
What are the labs and
o
CBC - to check WBC count, hemoglobin, hematocrit, platelet count
diagnostics for CAD?
o
BMET (measures BUN and Creatinine) – to check kidney function (in addition to
GFR)
How would you educate a
o
CRP – inflammatory marker
o
Educate on importance of consuming plant foods and minimizing processed
patient with CAD?
foods and red meats - heart healthy foods include oatmeal, salmon, whole grains
almonds, green vegetables, fruits
o
Connect them to social work to provide resources in the community for
affordable food options
o
Encourage participation in regular, moderate physical activity - must break a
sweat 3 times a week
o
Educate on the importance of smoking cessation
o
Educate on the importance of BP control and tight glycemic control and adhering
to medications (to prevent chronic massive vasoconstriction → calcification of
blood vessels → reduces oxygen supply to the myocardium)
What are the 4 elements of fat
Lipid panel:
metabolism that can lead to
1. Total cholesterol
CAD?
2. LDL
3. HDL
o
cardioprotective - gets rid of bad cholesterol through liver
o
The higher the HDL, the lower the risk for getting an MI
4. Triglycerides
o
From fatty foods, but oral contraceptives and steroids can also increas
triglycerides
What are the 2 types of meds
HMG-CoA reductase inhibitors (statins)
used for managing
Fibric acids (fibrates)
cholesterol?
What do statins do?

Inhibit enzymes involved in lipid synthesis

Gets rid of bad cholesterol – given to patients with really high total cholesterol
levels
What are examples of statins?
Creator, Lipitor, Mevacor, Lescol
What are the side effects of

statins?
rhabdomyolysis (muscle pain and weakness) - indicates increased risk for ren
failure and liver failure (statins are excreted by the liver) → notify provider, nee
a liver function test (LFT) → AST and ALT levels will be high
 Monitor for S/S of liver failure and notify provider:
1. Tea-colored dark urine
2. Clay-colored stool
3. Jaundice
What do fibrates do?
Decrease synthesis of TGL and other lipids – given to patients with high TGL
What are the side effects of
Cholesterol is made in the liver → check liver function → monitor for rhabdo, S/S
fibrates?
liver failure, pancreatitis (pancreas has digestive enzymes to break down fats and
lipids)
Summary: Coronary artery disease begins with ischemia and can eventually lead to a myocardial infarction. It occ
due to chronic massive vasoconstriction and HLD. The signs and symptoms differ between men and women, with
women commonly experiencing GI symptoms. Lifestyle modifications are necessary on top of medication adheren
to prevent a stroke or MI. Statins and fibrates are the main medications given to control cholesterol and prevent CA
System: Cardiovascular
Questions/Main Ideas
What is hypertension?
Summary:
Topic: HTN
Notes
When the force of the blood against the artery walls (BP) is too
high
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