Flashcards: Med surg Exam 2

-Conditions that affect both reproduction, sexuality and urinary elimination

-PT may be anxious/embarrased

-Urinary function and symptoms

(How often do you urinate, are you sexually active, protection?, blood in urine, nocturia, blood in ejaculation?)

-Sexual function/manifestations of sexual dysfunction

-Presence of conditions that may affect sexual function (diabetes, cardiac disease, multiple sclerosis)

-Increased urinary frequency

-Decreased force of stream

-"Double"/ "Triple" voiding

-Nocturia, dysuria, Hematuria, hematospermia

-Digital rectal exam

*Recommended annually for men over 50

*Recommended 45 and older for high risk

*African American and men with family History

-Testicular Exam

*Instruct on testicular self-examination (TSE)

-GFFFF. Feeling for symmetry

-Prostate-specific antigen (PSA)

-Ultrasonography

-Prostate fluid or tissue analysis

-Tests of male sexual function

-Erectile dysfunction

>Psychogenic causes: anxiety, fatigue, depression, absence of desire

>Organic causes: vascular, endocrine, hematologic, and neurological disorders; trauma, alcohol; meds; and drug abuse

>Medications associated with erectile dysfunction

-Ejaculation problems

>premature ejaculation

>retrograde ejaculation

•Pharmacologic therapy

–Oral medications—sildenafil (Viagra)

•Side effects include headache, flushing, dyspepsia

•Caution with retinopathy

•Contraindicated with nitrate use

–Injected vasoactive agents

•Complications include priapism (persistent abnormal erection)

–Urethral gel

•Penile implants and transplants

•Negative pressure devices

Prostatitis: inflammation caused by an infectious agent

-acute bacterial: sudden onset of fever dysuria, perineal prostatic pain

-Chronic bacterial: typically asymptomatic

-Chronic prostatitis/chronic pelvic pain syndrome: genitourinary symptoms with no bacteria in urine

-Asymptomatic inflammatory prostatitis: diagnosed incidentally, elevated PSA

-Treatment includes appropriate anti-infective agents and measures to alleviate pain and spasm

Benign prostatic hyperplasia (BPH; enlarged prostate)

-Affects half of men older than 40 years of age and 50% of men older than 60 years of age

-Manifestations are those of urinary obstruction, urinary retention, and urinary tract infections

-Develops over a period of time; changes In urinary tract slow and insidious

-symptoms depend on severity: dysuria, hesitancy, sensation of incomplete bladder emptying

•Medical treatment

–Alpha-adrenergic blockers

–Measures to reduce pain and spasms

–Catheter for acute condition; unable to void

•Surgical treatment

–Minimal invasive therapy

–Surgical resection

–TURP

•Second most common cancer and the second most common cause of cancer death in men

•Risk factors include increasing age, familial predisposition, and African American race

•Manifestations:

–Early disease has few or no symptoms

–Symptoms of urinary obstruction, blood in urine or semen, painful ejaculation

–Symptoms of metastasis may be the first manifestations

•Treatment may include therapeutic vaccine, prostatectomy, radiation therapy, hormonal therapy, or chemotherapy   

•Assess how the underlying disorder (BPH or prostate cancer) has affected the patient’s lifestyle

•Urinary and sexual function(painful/blood?,oliguria,nocturia)

•Health history (family have history)

•Nutritional status(how’s the diet)

•Activity level and abilities(tired fatigues, SOB)

•Anxiety about surgery outcome

•Acute pain preoperatively/acute pain postoperatively

•Risk for imbalanced fluid volume postoperatively

•Deficient knowledge

•Hemorrhage and shock

•Infection

•Venous thromboembolism

•Catheter obstruction (Clots) (continuous bladder irrigation)

•Complications with catheter removal

•Urinary incontinence

•Sexual dysfunction

•Major goals preoperatively include:

–Adequate preparation

–Reduction of anxiety and pain(morphine, oxy-ween off)

•Major goals postoperatively include:

–Maintenance of fluid volume balance

–Relief of pain and discomfort (PCA)

–Ability to perform self-care activities

–Absence of complications

•Monitor urinary drainage and keep catheter patent

•Assessment of pain

–Bladder spasms cause feelings of pressure and fullness, urgency to void, and bleeding from the urethra around the catheter

•Medication and warm compresses or sitz baths to relieve spasms

•Administer analgesics and antispasmodics as needed

•Encourage patient to walk but to avoid sitting for prolonged periods.

•Prevent constipation (stool softener/ fluids)-pain meds cause this

Irrigate catheter as prescribed

(really bad constipation can cause hemorrhoids(straining)/obstruction)

•Reduction of anxiety:

–Be sensitive to potentially embarrassing and culturally charged issues

–Establish a professional, trusting relationship 

–Provide privacy

–Allow patient to verbalize concerns

–Provide and reinforce information

•Provide patient education, including explanations of anatomy and function, diagnostic tests and surgery, and the surgical experience

•Patient and family education for home care, including care of urinary drainage devices and recognition and prevention of complications

•Regain bladder continence

–Information that regaining control is a gradual process (dribbling may continue for up to 1 year depending on type of surgery)

–Perineal exercises

•Avoidance of straining, heavy lifting, long car trips (6 to 8 weeks)

•Diet: encourage fluids and avoid coffee, alcohol, and spicy foods(cause spasm,anxiety, loss of bladder control)

•Assessment and referral of sexual issues

•Orchitis-one or both inflammation

•Epididymitis

•Testicular torsion-blood supply cut off at the testes

•Testicular cancer

•Most common cancer in men ages 15 to 40 years

•Highly treatable and curable

Risk factors:

-undescended testicles, positive family history, cancer of one testicle, caucasian American race

Manifestations:

-painless lump or mass in the testes

Early diagnosis:

-monthly testicular self-exam and annual testicular exam

Treatment:

-orchidectomy, retroperitoneal lymph node dissection (open or laparoscopic), radiation therapy, chemotherapy

•Assessment of physical and psychological status

•Support of coping

•Address issues of body image and sexuality

•Encourage a positive attitude

•Patient education

•TSE and follow-up care

•Hypospadias and epispadias

•Phimosis

•Penile cancer

–Bowen disease

•Priapism-

•Peyronie’s disease

•Urethral stricture

•Circumcision

The most commonly used oxygen delivery system

What type of pt? Used for patients that need low levels of oxygen to maintain

adequate oxygenation

How much oxygen delivered? Oxygen concentration of the nasal cannula

ranges from 22% to 44% (2-6 L)

Important Info:Has two soft prongs that are placed into both of the patient’s

nares (Placed with the prongs facing down).

important to inspect behind the ears and the nasal septum for skin breakdown.

Simple oxygen face mask are single pt use and are low-flow mask which entrain the air from the atmosphere

-Oxygen flow rates between 5 and 10 L/min and can deliver oxygen concentrations from 40% to 60%

Important info:

- Used when the patient needs a moderate amount of oxygen

- Assess for skin breakdown under the mask and behind the ears

- Must be removed for the patient to eat. The patient is placed on a nasal

cannula when eating, and the mask is replaced after eating

A fixed performance device that delivers a constant concentration of oxygen despite the patient's respiratory pattern

What type of pt? Used on pts with chronic lung disorder

-Venturi mask deliver 24% to 60% by using

different adapters and by adjusting the oxygen flow from 2 to 15 L/min.

Important info:

- Most commonly used for high-flow delivery

- Delivers most accurate oxygen concentration (concentrates it)

- The mask is fitted to the face (pinch the nose piece to secure and place

the strap around their head)

- An adaptor is attached to the bottom of mask

- Some masks that have an adapter with a dial to determine the oxygen

concentration to be delivered to the patient.

- Remove mask and check skin every 2-3 hours

Two-one way valves between bag and mask that prevents exhaled air from entering the bag

What type of pt? Can be used in emergency situations with patients who need a lot of oxygen at once (trauma injury or smoke inhalation).

-Hard to use on patients who are anxious or claustrophobic, use nasal cannula instead.

-Can provide up to 100% oxygen, minimum flow 10mL/min

Important info:

- One-way valves on both sides of the mask to prevent room air from

entering mask on inhalation

- Reservoir bag must be kept inflated at one-third to one-half full on

inspiration so the patient receives the optimal amount of oxygen

- Forms a seal around nose and mouth, check for skin irritation

- Can only breathe while mask is hooked up to an oxygen tank

A partial rebreather will provide high concentrations of oxygen to pt's without risk of suffocation. use a two-way valve instead of a one-way to promote oxygen recycling.

What type of pt? patients who need high concentration oxygen but no help breathing. Used in emergency situations such as traumatic injuries, smoke inhalation, carbon monoxide poisoning

-Partial rebreather masks typically administer between 50% and 70% oxygen to the patient. 10-15 L/min.

information- first attach the end of the tube to the oxygen source and turn up the oxygen to at least 10 L. Close valve with fingers to ensure the bag will inflate with oxygen properly. mask covers the nose and mouth but not with a tight seal. Monitor patient for skin irritation from the mask

Provides the patient with a preset of

continuous positive pressure throughout the respiratory cycle with each breath; constant pressure keep the alveoli open during inspiration and exhalation.

Range: The usual range for C-PAP is 5-15 cm H2O

Who uses C-PAP? For patients with obstructive sleep apnea and COPD, may be worn continuously or intermittently depending on the patient respiratory need.

BIPAP is used to help push pressurized air into the lungs. The BIPAP has two pressures. One pressure is delivered during inspiration

and the other at the end of exhalation.

Range: 4 cm to 30 cm of H₂O

Recommended for: Patients who are requiring

assistance with oxygenation and ventilation. (ex.COPD)

-Wait 30 min to eat, let food digest then put back

A form of life support that helps a patient breathe or breathes for them when they cannot breathe on their own

What type of pt? Ones with conditions that cause either low oxygen (ex: pneumonia) or high carbon dioxide levels (ex: COPD)

- Depending on lung compliance, the range is

anywhere from 20% to 100%

Important info:

- MV moves air into and out of the lungs, to deliver oxygen and get rid of carbon dioxide

- keeps your airways open, delivers oxygen and removes carbon dioxide

▪Presenting problems & associated symptoms

▪Onset(when)

▪Location(where)

▪Duration(how long)

▪Aggravating factors(better,worse)

▪Orthopnea (sleeping w/ multiple pillows)

▪Associated signs/symptoms

▪sputum production – color/consistency

▪Impact on ADL’s

▪Past social and family history

▪Childhood illnesses

▪Immunizations

▪Diet and exercise

▪Genetics

▪Risk factors

▪Exposure to indoor pollutants (smoke, gas, asbestos, mold)

▪Smoker (cigarettes, vape, marijuana, hooka)

▪Obesity

▪Exposed to infection (flu, PNA, covid)

Does it affect eating-when too full it pushes up on diaphragm

▪A sign of chronic hypoxic conditions

▪Chronic infections

▪Malignancies

▪Congenital heart disease

▪Inflammatory process

▪Endocarditis

▪Inflammatory bowel disease

COPD

▪Occurs when oxygenation to the tissues is poor

▪Late sign of hypoxemia

▪Most reliable – tongue/mucous membranes of mouth

▪Cyanotic fingers/toes can occur when patients are cold; Raynaud’s Syndrome

▪Use a penlight – exam mouth, throat

call code and give oxygen

▪Occurs in 4 steps

▪Inspection

▪Palpation

▪Percussion

▪Auscultation

▪Examine the back first

▪Always compare on side to the other

▪Repeat the same in the front

▪Chest wall should be smooth, rice crispy crackling under the skin is known as crepitus

▪Indicates air is leaking from airways or lungs

▪Palpate for painful areas

▪Palpate for tactile fremitus, ask patient to repeat “99”

▪Vibrations that feel more intense on one side, indicate consolidation

▪Percuss areas for different sounds

▪Flat – consolidation

▪Dull -  pleural effusion

▪Resonant – normal

▪Use of accessory muscles to breath

▪Pursed lip breathing

▪Nasal flaring

▪Tripoding(sitting

▪Sternal retractions

▪Shallow breathing

▪Tachypneic

▪Fatigued

▪Barrel chest

▪Concave chest – pectus excavatum

▪Scoliosis

▪Tracheal position

▪Tracheal breath sounds – harsh, high-pitched, heard over the trachea; on inhalation and exhalation

▪Bronchial breath sounds – loud, high-pitched, heard next to trachea; loudest on exhalation

▪Bronchovesicular sounds – medium-pitched, heard near the sternum, between scapula; on inhalation and exhalation

▪Vesicular sounds – soft, low-pitched, heard over the rest of the lungs; prolonged during inhalation and shortened during exhalation

▪Crackles – popping sound heard usually on inspiration, (Heart failure/Pulmonary fibrosis)

▪Course crackles – popping sound heard early on inspiration and throughout expiration (Obstructive pulmonary disease)

▪Fine crackles – sound of hair rubbing together heard in mid-late inspiration

(Pneumonia/Bronchitis)

▪Wheezes – musical high-pitched sound, narrowing of the airway

▪Rhonchi – deep, low-pitched sound, secretions

▪Pleural friction rub – rubbing sound - inflammation

▪Stridor – heard without a stethoscope - emergent situation – narrowing of upper respiratory tract

▪Absent – no sound at all – tumor, pleural effusions, lung collapse

▪Functional residual capacity (FRC). This is the amount of air left in lungs after exhaling normally.

▪Residual volume. This is the amount of air left in the lungs after exhaling as much as you can.

▪Total lung capacity. This is the total volume of the lungs when filled with as much air as possible.

▪Forced vital capacity (FVC). This is the amount of air exhaled forcefully and quickly after inhaling as much as you can.

▪Forced expiratory volume (FEV). This is the amount of air expired during the first, second, and third seconds of the FVC test.

▪Forced expiratory flow (FEF). This is the average rate of flow during the middle half of the FVC test.

▪Peak expiratory flow rate (PEFR). This is the fastest rate that you can force air out of your lungs.

▪Arterial blood gases(respiratory therapist/doctor)

▪Venous blood gases(nurses)

▪Pulse Oximetry

▪Cultures - throat, nasal, & nasopharyngeal

▪Sputum studies – ideally 1^st thing in the morning, prior to eating or drinking, determines pathogenic organisms &/or malignant cells

▪End-tidal carbon dioxide (ETCO2) – non-invasive method (capnometry device ) of monitoring CO2 at end exhalation, standard for general anesthesia & mechanically vented patients

▪X-rays – shows contrasts between bone, soft tissue, & air (patient must be able to stand for PA/Lateral; should be able to take deep breath & hold)

▪CT scans – thoracic imaging allows for 3D, evaluates masses/tumors, abscesses, etc. (w/contrast contraindicated in decreased kidney function, hold metformin dose, NPO for 4 hrsprior)

▪MRIs – better distinguishes between normal & abnormal tissues (prepare for claustrophobic pts, no metal anywhere inside/outside body)

▪Nuclear/radioisotope scans – V/Q scan, gallium scan, positron emission tomography (PET) scan (contraindicated in pregnancy, patient may eat/drink but must avoid caffeine, alcohol, & tobacco)

▪Pulmonary angiography – radiopaque agent injected via IV to visualize pulmonary vascular tree

▪Fluoroscopic studies – live X-ray images displayed on screen via a camera, used for invasive procedures like needle biopsies

▪Endoscopic procedures (Invasive) (hold PO intake 4-8 hrsprior, remove dentures)

▪Bronchoscopy – uses a flexible tube to exam larynx, trachea, & bronchi

▪Thoracoscopy – surgeon makes small incision, inserts endoscope to examine pleural cavity

▪Thoracentesis – aspiration of fluid & air from pleural space

▪Biopsies – lung, pleural, lymph node

•Chronic inflammatory disease of the airways that causes hyperresponsiveness, mucosal edema, and mucus production

•This inflammation affects the major pathways of the lungs: The Bronchi and the Bronchioles (Not the Alveoli)

•Asthma comes and goes! There are flare-ups or exacerbation or attacks. 

•Asthma is Reversible

•Inflammation leads to cough, chest tightness,

      wheezing, and dyspnea

•Cough

•Dyspnea

•Wheezing

•Exacerbation

•Cough, productive or not

•Generalized wheezing

•Chest tightness and dyspnea

•Diaphoresis

•Tachycardia

•Hypoxemia and central cyanosis

•Spirometry testing assesses the presence and degree of disease and can determine the response to treatment

•Peak Expiratory Flow Rate Measurement - Measures maximum flow of air that can be forcefully exhaled

•Bronchoprovocation Testing - done to identify inhaled allergens; mucous membranes are directly exposed to suspected allergen in increasing amounts

•Skin Testing: Done to identify specific allergens

•Exercise Challenges - used to identify the occurrence of exercise-induced bronchospasm.

•The most severe form of an asthma attack

•Unresponsive to repeated courses of beta-agonist therapy

•This is a medical emergency that can result in respiratory failure and death

•Mechanical ventilation required

S&S

-tachycardic

-use of excessory muscles

Causes

-irritants

Main cause of death

-not being responsive quickly

•Beta-2 adrenergic agonists

•Albuterol, levalbuterol, terbutaline

•The only rescue drug for asthma attacks. 

•Can use inhaler or nebulizer

•Anticholinergics

•Ipratropium (Atrovent), tiotropium

•Assists with drying out the secretions and dilating the airways.

•May cause dehydration

•Methylxanthines

•Theophylline

•Bronchodilator and stimulant (caffeine)

•Can cause tachycardia

•Not the first drug of choice, used more for bradycardia

Corticosteroids

•Beclomethasone (Inhaler), Prednisone (Oral), Methylprednisolone/ SoluMedrol (IV)

•Can cause thrush

•Increases risk for infection by inhibiting the bodies inflammatory response

•BG may be elevated.

•Long-acting beta-2 adrenergic agonists

•Salmeterol, Formoterol  (inhaled)

Bronchodilator

•Inhaled, can come in the form of a diskus

•May cause increased HR

Leukotriene modifiers

•Montelukast (Singular) Oral

•Inhibits the effect of leukotrienes (inflammation)

Steroids- lower immune system

-increases glucose,increased HR,Jittery

•Allergens Outdoor: Trees, shrubs, weeds, grasses, molds, pollen, air pollution, sand dust, spores

•Indoor: Dust, dust mites, mold, cockroach antigen

•Irritants: Tobacco smoke, wood smoke, odors, sprays Exposure to Occupational Irritants

•Cold Air Changes in Weather or Temperature

•Colds and Infections; Exercise

•Animals: Cats, dogs, rodents, horses

•Medications: Aspirin, nonsteroidal anti-inflammatory drugs, antibiotics, beta blockers

•Strong Emotions: Fear, anger, laughing, crying

•Proper inhalation techniques

•How to perform peak flow monitoring

•How to implement an action plan

•When and how to seek assistance

•How to identify and avoid triggers

Peak Flow Monitoring

•This can determine if how well asthma is controlled

•Depending on the zone preventative measures can be implemented

Action Plan

•Recognizing symptoms

•Cold, URI, mild wheeze, cough, tight chest

•Medications that can be used

•When to call Provider

When to call 911 

•Medicine is not helping

•Breathing is hard and fast

•Nose flaring

•Out of Breath

•Accessory muscles

•Sit upright

•Set scale to 0

•Take a deep breath

•Place mouthpiece in mouth and seal well with lips

•Exhale with as much force as possible as quickly as possible

•Repeat 2 more times and record highest score

•Hemorrhage from the nose

•Anterior septum, most common site

•Serious problem, may result in airway compromise or significant blood loss

Risk factors,

-drugs through nose

-constant itching

-too rough

•Identify cause and location

•Pinch soft portion of nose for 5 to 10 minutes, patient sits upright

•Phenylephrine spray, vasoconstriction

•Cauterize with silver nitrate or electrocautery

•Gauze packing or balloon-inflated catheter inserted into nasal cavity for 3 to 4 days

•Antibiotic therapy 

•Airway, breathing, circulation

•Vital signs, possible cardiac monitoring and pulse oximetry

•Reduce anxiety

•Patient teaching:

•Avoid nasal trauma, nose picking, forceful blowing, spicy foods, tobacco, exercise

•Adequate humidification to prevent dryness

•Pinch nose to stop bleeding; if bleeding does not stop in 15 minutes, seek medical attention

-Elevate head

-Ice collar to reduce inflammation and bleeding

-Hot packs to reduce congestion

-Analgesics for pain - vix

-Topical anesthetics

-Monitor for severe complications

•Gargles for sore throat

•Use alternative communication

•Encourage liquids and use of room vaporizers or steam inhalation to keep secretions loose and moist for easier expectoration

•Rest

•Health history (smoking?

•Physical, psychosocial, and spiritual  assessment

•Nutrition, BMI, albumin, glucose, electrolytes

•Literacy, hearing, and vision; may impact  communication after surgery

•Coping skills and available support systems for patient and family after surgery

-Cancer

•Respiratory distress

•Hemorrhage

•Infection

•Wound breakdown

•Aspiration!!!!

•Tracheostomal stenosis (narrowing, airway compromised)

Treacheostomy mask

•Preoperative teaching

•Reduce anxiety

•Maintain patent airway, control secretions (Pre-oxygenate before suctioning)

•Support alternative communication

•Promote adequate nutrition and hydration

•Promote positive body image, self-esteem

•Monitor for potential complications

•Self-care management; homecare (Chart 18-7)

•Chronic obstructive pulmonary disease (COPD) is a slowly progressive respiratory disease of airflow obstruction

•Chronic bronchitis, emphysema (barrel chest)

•Preventable and treatable but not fully reversible

•Involving the airways, pulmonary parenchyma, or both

•Fourth leading cause of death in the United States for people of all ages

•Other chronic pulmonary diseases

•Bronchiectasis, asthma, cystic fibrosis

•A condition in which the bronchial tubes become inflamed and excessive mucus production occurs as a result from irritants or injury

•COPD leads to pulmonary insufficiency

•A condition in which the air sacs in the lungs are damaged and enlarged, resulting in hyperinflation and breathlessness

•COPD leads to pulmonary HTN & Cor pulmonale

•Airflow limitation is progressive, associated with abnormal inflammatory response to noxious particles or gases

•Chronic inflammation damages tissue

•Scar tissue in airways results in narrowing

•Scar tissue in the parenchyma decreases elastic recoil (compliance)

•Scar tissue in pulmonary vasculature causes thickened vessel lining and hypertrophy of smooth muscle (pulmonary hypertension)

Poor nutrition – out of breath

Gain weight- immobile because of SOB

-anxious

More common in the morning

•Chronic cough

•Sputum production

•Dyspnea

•Weight loss due to dyspnea- takes energy to breathe & becomes difficult to eat

•“Barrel chest”

•Use of accessory muscles for breathing

•Prolonged expiration

•Orthopnea- breathe better upright

•Cough and sputum production for at least 3 months in each of 2 consecutive years

•Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucous may plug airways

•Inflammation causes airway obstruction, resulting in inadequate gas exchange

•Alveoli become damaged, fibrosed, and alveolar macrophage function diminishes

•The patient is more susceptible to respiratory infections

Suction

Mucolytics

Chest pt

•Exposure to tobacco smoke

•Older adults

•Occupational exposure

•Pollution

•Genetic abnormalities

•Several differential diagnoses must be ruled out including Asthma

•It may be difficult to differentiate between a patient with COPD and a patient with chronic Asthma

•Other differential diagnosis include

•Heart disease

•Bronchiectasis

•Tuberculosis

•Key factors in determining the diagnosis are pt’s history, severity of symptoms, and responsiveness to bronchodilators

Differene between asthma and copd

-asthama is reversible

-COPD chronic

-asthma does NOT affect alveoli

•Health history

•Pulmonary function tests

•Spirometry

•Arterial blood gas

•Chest x-ray

•Respiratory insufficiency and failure

•Pneumonia

•Chronic atelectasis

•Pneumothorax

•Cor pulmonale- right sided heart failure

•Promote smoking cessation

•Reducing risk factors

•Managing exacerbations

•Providing supplemental oxygen therapy

•Pneumococcal vaccine

•Influenza vaccine

•Pulmonary rehabilitation

•Managing exacerbations

2-3 liters of oxygen

•Bronchodilators, MDIs

•Beta-adrenergic agonists

•Muscarinic antagonists (anticholinergics)

ipratropium

•Combination agents

•Corticosteroids

fluticasone,beclomethasone, mometasone prednisone, hydrocortisone, prednisolone dexamethasone

•Antibiotics

Amoxicillin/clavulanate/Azithromycin/Doxycycline

•Mucolytics

acetylcysteine, dornase alfa

•Antitussives

hydrocodone, codeine,dextromethorphan

•Helps open airways, relaxes the smooth muscle of the bronchi and dilates airways to improve breathing

•Long acting for long term symptom control or short acting for symptom flair ups

•Delivered via pressured metered-dose inhaler (MDI), dry powered inhaler (DPI), small-volume nebulizer

•Can be via oral route in pill or liquid, but rare

•Nursing MUST train patient in proper inhalation technique, involve RT if needed, critical pts learn proper use of inhaler

•TACHYCARDIA

•ARRHYTHMIAS

•CENTRAL NERVOUS SYSTEM EXCITATION

•NAUSEA & VOMITING

•Levalbuterol

•Albuterol

•Salmeterol

•Indacaterol

•Formoterol

•Terbutaline

•IPRATROPIUM BROMIDE

•TIOTROPIUM BROMIDE

Side effects

-dry mouth

-urinary retention

-diarrhea

-increased heart rate

-urinary obstruction

•Long term beta2-agonists plus corticosteroids in one inhaler

•Formoterol/budesonide

•Vilanterol/fluticasone furoate

•Salmeterol/fluticasone

•Bullectomy – select patients with bullous emphysema performed via video-assisted thoracoscope or thoracotomy incision

•Bullae – enlarged airspaces that do not contribute to ventilation

•Lung volume reduction surgery – for advanced, grade IV COPD

•Palliative surgery

•Removal of a portion of diseased lung, allowing functional tissue to expand

•Lung transplant – limited due to shortage of donors

•Assessing the patient: obtain history, review diagnostic tests

•Achieving airway clearance

•Improving breathing patterns

•Improving activity tolerance

MDI patient education

•Evaluate exposure to respiratory irritants

•Nursing interventions to promote oxygenation

•Incentive spirometry

•Postural drainage

•Chest percussion and vibration

•Breathing exercises

•Administer medications to promote gas exchange and oxygenation

•Oxygen

•Bronchodilators

•Smoking cessation

•Medication administration

•Breathing exercises

•Regular exercise

•Realistic goals

•Emergency management

•Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles

•Caused by:

•Airway obstruction, pulmonary infections

•Diffuse airway injury

•Genetic disorders

•Abnormal host defenses

•Idiopathic causes

•Cystic fibrosis

•Recurrent, inadequately treated bacterial infections

•TB

•PNA’s

•Inhalation of corrosive gases

•Repeated aspiration of gastric contents-gtubes, ng tube

•Immunologic disorders – deficits in immune system

•Chronic cough that produces copious, foul-smelling secretions

•Coarse crackles during inspiration over involved lung fields

•Dyspnea

•Clubbing of nails

•Malaise, weight loss

•Flare-ups cause fatigue, fever, chills

•Focus is on alleviating symptoms and clearing pulmonary secretions

Patient teaching

•Smoking cessation

•Postural drainage

•Early signs and symptoms of respiratory infections

•Conserving energy

•Administration of oxygen at greater than 21% to provide adequate transport of oxygen in the blood while:

•Decreasing the work of breathing and reducing stress on the myocardium

•Hypoxemia: a decrease in the arterial oxygen tension in the blood

•Hypoxia: a decrease in oxygen supply to the tissues and cells that can also be caused by problems outside the respiratory system

Severe hypoxia can be life threatening

•May occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period

•Symptoms include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates on x-ray

•Prevention:

•Use lowest effective concentrations of oxygen

•PEEP or CPAP prevent or reverse atelectasis and allow lower oxygen percentages to be used

•Nurse instructs the patient about oxygen:

•Safe methods for administering in the home

•Available in gas, liquid, concentrated

•Portable devices

•Humidity must be provided

•Community resources

Beta-blockers, non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, and ACE inhibitors can trigger asthma symptoms. Narcotics like OxyContin, Percocet, and Vicodin can also lead to dangerously slow breathing in people having a severe asthma attack. 

Foods and drinks

Some foods and drinks, like beer, wine, potatoes, dried fruit, and shrimp, may contain sulfites that can make asthma worse.

urological procedure that removes tissue from the prostate to treat benign prostatic hyperplasia (BPH)

Recovery

Patients typically stay in the hospital for 1–2 days and have a urinary catheter for at least 24–48 hours. It can take 4–6 weeks to fully recover. 

Side effects

Common side effects include blood in the urine, painful urination, and a frequent or urgent need to urinate. 

Risks

A possible risk is narrowing of the urethra, which can cause symptoms like straining to urinate or a split-stream

Monitor for hemorrhage. Observe for symptoms of urethral stricture (dysuria, straining, weak urinary stream).

-Health history- previous cardiac history

-Demographic information- socioeconomic influences

-Family/genetic history- women, African Americans and older clients may delay treatment

-Cultural/social factors-

Risk factors

*Modifiable- smoking, hypertension, high cholesterol, diabetes, obesity, inactivity

*Nonmodifiable- genetic predisposition, age, gender

•Common symptoms

•Chest pain/discomfort

•Pain/discomfort in other areas of the upper body

•SOB/dyspnea

•Peripheral edema, weight gain, abdominal distention

•Palpitations

•Unusual fatigue, dizziness, syncope, change in LOC

•Medications

•Nutrition

•Elimination

•Activity, exercise

•Sleep, rest

•Self-perception/self-concept

•Roles and relationships

•Sexuality and reproduction

•Coping and stress tolerance (cortisol levels rise)

Vitamins, herbs, OTC meds

•General appearance

•Skin and extremities(Pale)

•Pulse pressure

•Blood pressure; orthostatic changes

•Arterial pulses

•Jugular venous pulsations

•Heart inspection, palpation, auscultation

•Assessment of other systems

Use of excessory muscles

Distended jugular veins

Obese

Activity induced angina

nocturia

Stress, anxiety, depression

Twice common in women than men

Women over 35/men over 45

Orthostatic hypotension- sustained decrease of at least 20 in systolic or 10 in diastolic in about 3 min

When testing wait a minute between each laying down, sitting up, standing

•Lungs: may hear crackles, wheezes, cough. May see hemoptysis- pink frothy sputum associated with pulmonary edema

•Abdomen: potential for ascites secondary to liver distension secondary to right-sided heart failure

•Bladder distention: Urine output is an important indicator of cardiac function. Reduced urine output may indicate decreased cardiac output.

•HTN affects 46% of older adults- untreated HTN increases mortality and morbidity

•Pain

•Pallor

•Pulselessness

•Paresthesia- pins & needles)

•Poikilothermic (cold)

•Paralysis

•Cardiac biomarkers

•Blood chemistry, hematology, coagulation

•Lipid profile-Cholesterol LDL Bad HDL Good

•Brain (B-type) natriuretic peptide

•C-reactive protein

•Homocysteine

Trponum, ckmb,creatinine conase, myoglobin levels (blood)

EKG

-Cholesterol

LDL-deposit cholesterol in wall of artery

HDL-absorbs cholesterol from other parts of your body and carries it back to your liver, where it's removed from your body.

BNP-indicator of heart failure (more than 100)

C-Reactive protein-inflammation, puts pt for coronary artery disease

Homocysteine- amino acid damage lining of artery and formation of thrombosis formation

•12-lead ECG

•Continuous monitoring

•Hardwire

•Telemetry

•Lead systems

•Ambulatory monitoring

Exercise stress test-NPO

•Patient walks on treadmill with intensity progressing according to protocols

•ECG, V/S, symptoms monitored

•Terminated when target HR is achieved

Pharmacologic stress testing(immobile-adenosine)

•Vasodilating agents given to mimic exercise in those unable to comply with directions

•Noninvasive ultrasound test that is used to:

•Measure the ejection fraction

•Examine the size, shape, and motion of cardiac structures

•Transthoracic- doppler

•Transesophageal- provides better images

Ejection of blood 65-70

If ejection is really low  <15 –pacemaker

TEE- camera down throat NPO, sedate,

After check neuro, respirations, gag reflex

•Invasive procedure used to diagnose structural and functional diseases of the heart and great vessels

•Right heart catheterization

•Pulmonary artery pressure and oxygen saturations may be obtained; biopsy of myocardial tissue may be obtained

•Left heart catheterization

•Involves use of contrast agent

Look to see if there are any blockages

Monitor kidneys and allergies

CABBAGE

Coronary artery bypass …

Observe

•Observe cath site for bleeding, hematoma

Assess

•Assess peripheral pulses

Evaluate

•Evaluate temperature, color, and capillary refill of affected extremity

Screen

•Screen for arrhythmias

Maintain

•Maintain bed rest 2 to 6 hours

Instruct

•Instruct patient to report chest pain, bleeding

Monitor

•Monitor for contrast-induced nephropathy

Ensure

•Ensure patient safety

•Central venous pressure

•Pulmonary artery pressure

•Intra-arterial B/P monitoring

•Minimally invasive cardiac output monitoring devices

-Atherosclerosis is the abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen

-In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium

-Symptoms are caused by myocardial ischemia

-Symptoms and complications are related to the location and degree of vessel obstruction

-Angina pectoris (most common manifestation)

-Other symptoms: epigastric distress, pain that radiates to jaw or left arm, SOB, atypical symptoms in women

-Myocardial infarction

-Heart failure

-Sudden cardiac death

•Four modifiable risk factors cited as major (cholesterol abnormalities, tobacco use, HTN, and diabetes, chronic inflammatory conditions, hyperlipidemia, metabolic syndrome, obesity, physical inactivity)

•Nonmodifiable: family history, increasing age, gender, race, history of premature menopause, history of pregnancy preeclampsia, and hypercholesterolemia (genetic condition)

•Elevated LDL: primary target for cholesterol-lowering medication

•Framingham risk calculator

•Metabolic syndrome

•hs-CRP (high-sensitivity C-reactive protein)

DietSmoking

Diabetes

Genetics

•Control cholesterol

•Dietary measures

•Physical activity

•Medications

•Cessation of tobacco use

•Manage HTN

•Control diabetes

-3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (or statins)

-Nicotinic acids

-Fibric acids (or fibrates)

-Bile acid sequestrants (or resins)

-Cholesterol absorption inhibitors

-Omega-3 acid-ethyl esters

-Atorvastin, Simvastatin, Rosuvastatin

-These decrease total cholesterol, LDL cholesterol and triglycerides. They can increase HDL

-Monitor liver function tests

-Contraindicated in liver disease

-Myalgia(muscle pain) and arthralgia(joint pain) – common side effects

-Indicated as well in ACS(acute coronary syndrome) and CVA(cerebrovascular accident)

-Administer in the evening

LDL lower than 100

HDL women over 50 men over 40

Cholesterol less than 200

Triglycerides less than 150

-Fenofibrate & Gemfibrozil

-Increases HDL, decreases triglycerides

-Adverse effects include diarrhea, flatulence, rash

-Contraindicated in severe kidney and liver disease

-Serious adverse effects: pancreatitis, hepatotoxicity, rhabdomyolysis

-Cholestryamine, Cholestipol, Colesavelum

-Work by oxidizing cholesterol into bile acids, which decrease fat absorption

-Used as adjunct therapy when statins alone are insufficient

-Side effects: constipation, abdominal pain, GI bleeding

Take before meals

-Ezetimibe- decreases HDL

-Inhibits absorption of cholesterol in the small instestine

-Better tolerated than bile acid sequestrants

-Contraindicated in liver disease

-Often used with another agent, such as statins

•Alirocumab, Evolocumab

•Only given via a subcutaneous injection pen device once/twice a month

•Side effects- rhinitis, sore throat, flu-like symptoms

-A syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow

-Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand

-Types of angina

-Refer to Chart 23-2

-Stable angina- predictable and consistent- responds to rest or NTG

-Unstable angina- symptoms increase in severity and may not be relieved with rest/NTG(Under tongues (sublingual 3x 5 min apart)(vasodialotor))

-Refractory angina- severe incapacitating chest pain

-Variant angina (Prinzmetal’s)- pain at rest with reversible ST-segment elevation

-Silent ischemia- pt. is asymptomatic but ECG shows changes consistent with ischemia

•May be described as tightness, choking, or a heavy sensation

•Frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left)

•Anxiety frequently accompanies the pain

•Other symptoms may occur: dyspnea or shortness of breath, dizziness, nausea, and vomiting

•The pain of typical angina subsides with rest or NTG 

•Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG.  Requires medical intervention!

-Diminished pain transition that occurs with aging may affect presentation of symptoms

-“Silent” CAD

-Teach older adults to recognize their “chest pain–like” symptoms (i.e., weakness) SOB

-Pharmacologic stress testing; cardiac catheterization

-Medications should be used cautiously!

-Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply

-Medications

-Oxygen

-Reduce and control risk factors

-Reperfusion therapy may also be done

MONA-

Morphine

Oxygen

Nitraglycerin

Aspirin

-Beta-adrenergic blocking agents

-Calcium channel blocking agents

-Antiplatelet and anticoagulant medications

-Clopidogrel and ticlopidine

-Heparin

-Glycoprotein IIb/IIIa agents

-Symptoms and activities, especially those that precede and precipitate attacks (Chart 23-4)

-Risk factors, lifestyle, and health promotion activities

-Patient and family knowledge

-Adherence to the plan of care

-ACS, MI, or both

-Arhythmias and cardiac arrest

-Heart failure

-Cardiogenic shock

Goals

-Immediate and appropriate treatment of angina

-Prevention of angina

-Reduction of anxiety

-Awareness of the disease process

-Understanding of prescribed care and adherence to the self-care program

-Absence of complications

•Treat angina

•Reduce anxiety

•Prevent pain

•Educate patients about self-care

•Continuing care

Risk for impaired cardiac function

Anxiety associated with cardiac symptoms and possible death

Lack of knowledge about the underlying disease and methods for avoiding

complications

Able to perform self care

-Priority

-Patient is to stop all activities and sit or rest in bed (semi-Fowler positioning)

-Assess the patient while performing other necessary interventions. Assessment includes VS, observation for respiratory distress, and assessment of pain. In the hospital setting, the ECG is assessed or obtained

-Administer medications as ordered or by protocol, usually NTG. Reassess pain and administer NTG up to three doses

-Administer oxygen 2 L/min by nasal cannula

-Use a calm manner

-Stress-reduction techniques

-Patient teaching

-Addressing patients spiritual needs may assist in allaying anxieties

-Address both patient and family needs

-Identify level of activity that causes patients prodromal S&S

-Plan activities accordingly

-Alternate activities with rest periods

-Educate patient and family

-Balance activity with rest

-Follow prescribed exercise regimen

-Avoid exercising in extreme temps

-Use resources for emotional support (counselor)

-Avoid OTC meds that may increase HR/BP before consulting with healthcare provider

-Stop using tobacco products(increases HR and BP)

-Diet low in fat and high in fiber

-Medication teaching (carry NTG at all times!! In dark colored bottle do not transfer to other bottles)

-Follow up with healthcare provider

Report increase in S&S to provider

-Maintain normal BP and blood glucose levels