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Anatomy and Physiology9th EditionKenneth Saladin 2,065 solutions What is a bronchoscopy? Procedure in which the bronchi are visualized through a fiberoptic tube. Maybe used for diagnostic purposes to obtain biopsy specimens and assess changes resulting from treatments. What can a bronchoscopy diagnose? (4) - persistent cough What can a bronchoscopy treat? (2) 1) washout excess secretions that are in the airways Before bronchoscopy what five things need to be done 1) Make sure consent is signed and the pt is educated on the procedure (MDs job) After bronchoscopy (4) considerations - High fowlers position The nurse is caring for a client who has just had a bronchoscopy. In which of the following positions should the nurse position this client? Supine Prone Head of bed 30 degrees High-Fowler's High-Fowler's A nurse is preparing a client for a flexible fiberoptic bronchoscopy to diagnose a pulmonary disease. Which of the following nursing actions is appropriate to prepare the client for this procedure? Assess the results of coagulation studies Ensure that the client had a food with fiber prior to the procedure Help the client into the prone position Confirm dentures are placed properly in client's mouth "Assess the results of coagulation studies" is correct. Bronchoscopy involves inserting a tube into the patients airway to visualize the structure of the lungs. This is an invasive procedure in which bleeding can occur, so the nurse should confirm that the client's coagulation studies are appropriate prior to the procedure. Which of the following are classified as reasons for performing a bronchoscopy? Select all that apply. Visualizing a tumor in the lung Removing a hematoma that has developed in the pleural space Monitoring oxygen saturation levels of the client Aspirating sputum from the main bronchus for testing Removing a foreign object that has accidentally been inhaled Visualizing a tumor in the lung Aspirating sputum from the main bronchus for testing A nurse is caring for a client who is being discharged after having a bronchoscopy. The nurse is discussing which signs or symptoms require the client to contact the provider for after going home. Which of the following signs or symptoms should the client contact the provider about after a bronchoscopy? A mild fever that develops in the first 24 hours A hoarse voice Persistent cough and bloody sputum Pain with swallowing "Persistent cough and bloody sputum" is correct. Following a bronchoscopy, the nurse should teach the client signs or symptoms to look for that can indicate damage to the lung tissue or other serious complications, such as infection. It is not uncommon for the client to develop a mild fever in the first 24 hours following a bronchoscopy. This is not a cause for concern unless the fever is high or is not resolved. If the client develops a cough and bloody sputum, he should contact the provider, as these signs can indicate trauma to the lung tissue or internal bleeding. "A mild fever that develops in the first 24 hours", "Pain with swallowing", and "A hoarse voice" are incorrect. These symptoms are common following a bronchoscopy and do not warrant a call to the provider. Purpose of Thoracentesis to remove excess fluid (pleural fluid) or air in pleural cavity as result of injury, infection, or other pathology Removing fluid or air to improve breathing pattern and decrease pressure on vital organs Before a thoracentesis: - over the beside table, upright, leaning forward During a thoracentesis... - do you stay with the pt at the bedside? - yes, stay with them the whole time After a thoracentesis: - What four complications - bleeding, infection, sub q emphysema, and pneumothorax - Side lying position with the good lung DOWN (ensures good perfusion to the good lung, and reduces bleeding - 15x4, 30x2, etc - monitor site for bleeding Before thoracentesis (2) - Consent and pain/sedation A nurse is assisting a provider with performing a thoracentesis on a client. Which information would the nurse most likely provide to the client prior to the procedure? Tell the client they will be sitting upright at the bedside Explain to the client that he will need to be monitored overnight in hospital postprocedure Inform the client that the procedure is done while taking an x-ray Remind the client that he will be asleep during the procedure Tell the client they will be sitting upright at the bedside A nurse is caring for a 55-year-old client who needs a thoracentesis after a cancer diagnosis. The nurse stays with the client during the procedure. Which of the following interventions will the nurse employ to assist with this procedure? Help the client to lie in the dorsal recumbent position Tell the client that the procedure will take approximately two hours Instruct the client not to talk during the procedure Prepare the client to undergo anesthesia for the procedure Instruct the client not to talk during the procedure A nurse is providing instructions to a client who is undergoing a thoracentesis to assess for malignant tissue. The nurse should instruct the client to do which of the following related to the procedure? Select all that apply. Assess the site for crepitus post-procedure Lie in the side-lying position for ten minutes after the procedure Position the client upright with trunk slightly forward Perform diaphragmatic breathing exercises for 30 minutes following the procedure Ensure client does not cough or deep breathe during the procedure - Assess the site for crepitus post-procedure - Position the client upright with trunk slightly forward - Perform diaphragmatic breathing exercises for 30 minutes following the procedure - Ensure client does not cough or deep breathe during the procedure The patient should remain on their side for how long after a thoracentesis 1 hour Nursing priority for rib fracture encourage what Treat pain!! If pt is in pain, this leads to shallow breathing --> atelectasis --> PNA encourage deep breathing, walking, IS Two complications with rib fx 1) atelectasis -->PNA RN interventions for rib fx Pain and chest expansion - IS pulmonary contusion ...a lung bruise - Can lead to ARDS pulmonary contusion intervention - IS Chest trauma pt education (4) - IS use Main RN concepts of chest trauma 1) Oxygenation 2) Gas exchange 3) Comfort What is a pneumothorax? It prevents the lung from doing what Pneumothorax - air rushes into pleural space (air escapes out of the lungs and into the pleural space) - it prevents the lung from expanding What is a hemothorax? Hemothorax - blood accumulates in pleural space Causes of pneumothorax (4) 1) Spontaneous -- no obvious injury 2)Secondary: ruptured of distended alveoli What is a tension pneumothorax? Air has built up so much that it puts pressure on the heart. It can shift organs to the right or left Why is
tension pneumothorax life-threatening? - puts pressure on vessels and heart, blood cannot get out or in the heart **DECREASED CARDIAC OUTPUT What is a hemothorax? -- three causes Are the S&S the same as pneuothorax? - Caused by penetrating or blunt trauma -- vessels can rupture because of rib fractures - another cause is a bleeding lesion/mass/tumor Assessment of a hemothorax 1) decreased or absent breath sounds on affected side 2) decreased or asymmetrical chest expansion on affected side - decreased SPO2 -Dyspnea 3) Dullness on percussion Assessment of pneumothroax 1) decreased or absent breath sounds on affected side 2) decreased or asymmetrical chest expansion on affected side - decreased SPO2 -Dyspnea **SOUNDS HOLLOW Assessment of a tension pneumothorax 1) decreased or absent breath sounds on affected side 2) decreased or asymmetrical chest expansion on affected side - decreased SPO2 -Dyspnea ***Tracheal deviation toward unaffected side Therapeutic management for pneumo/hemeo/tension thorax 1) High fowlers position 4)**NEEDLE DECOMPRESSION FOR TENSION*(air needs to be let out) 5) For fluid or blood -- throacentesis (allows for drainage) Nursing concepts (important ideas) for Pneumothorax & Hemothorax 1) how do you promote ___ exchange 2) _____ Oxygen exchange Comfort A nurse is caring for a client in the ICU who requires a ventilator. The nurse is aware that a ventilator may increase the risk of a pneumothorax in the client who uses it. Which best describes how this machine can cause a pneumothorax The use of a ventilator is associated with an increase in the risk of infection, which ultimately breaks down lung tissue Increased oxygen delivered by the ventilator damages the lungs and leads to a pneumothorax The pressure from the ventilator causes a rupture in the lung tissue The endotracheal tube causes damage to the structures of the respiratory system, which leads to an air leak The pressure from the ventilator causes a rupture in the lung tissue A nurse walks into a client's room and discovers that the client is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? Chest tube insertion on the left side Tracheostomy Chest tube insertion on the right side Intubation Chest tube insertion on the left side "Chest tube insertion on the left side" is correct. Tracheal deviation most commonly indicates a pneumothorax. The trachea will deviate toward the side that is away from the pneumothorax. So, if the trachea is deviating to the right, then the pneumothorax is on the left. The treatment for this is a chest tube on the side of the deflated lung. A nurse is orienting a new graduate nurse on a cardiopulmonary nursing unit, caring for a client with a chest tube. Which of the follow actions by the new graduate nurse requires immediate intervention? Coiling the tubing in the bed Placing the drainage system below the level of the chest Connecting suction tubing to the drainage system Clamping the chest tube Clamping the chest tube Clamping the tube of a chest tube creates increased pressure and puts the patient at risk for tension pneumothorax. This is only done in very specific circumstances, and often by an advanced practice provider. A nurse is caring for a patient who is receiving a TPN infusion. The nurse suspects that the patient has developed a pneumothorax because of placement of the central line. Which action would the nurse perform in response? Ask the patient to raise his arms above his head Remove the central catheter Check the tubing for kinks Ask the patient to raise his arms above his head Remove the central catheter Check the tubing for kinks Stop the infusion and get a chest x-ray Stop the infusion and get a chest x-ray The nurse is caring for a client with a chest tube. The nurse will refrain from clamping the chest tube because which of the following could happen? Barrel chest Tension pneumothorax Pneumonia Airway constriction Tension pneumothorax A nurse is caring for a client admitted to the emergency department. The client has just been diagnosed with a hemothorax. What is the priority nursing intervention at this time? Chest tube insertion A student nurse assesses four clients in the emergency room and reports to the nurse with the client's symptoms. The nurse would be most concerned with which of the following findings? Heart rate of 135 Uneven chest rise and fall Diaphoretic Respiration rate of 40 Uneven chest rise and fall Uneven chest rise is concerning because the client might have a pneumothorax. This is when the lining of their lungs might have a hole in it and that will collapse the lung. This is the emergency at this time. Of note - there is nothing that could cause uneven chest rise and fall that would NOT be concerning - this finding should always alert the nurse to a significant issue. What are the three purposes of a chest tube -
Drain fluid, blood, or air Where is the chest tube inserted? The pleural space What is a pleural effusion? fluid in the pleural space What does the water-seal chamber do on the chest tube? It helps creates the one way valve (its like blowing through a straw into a glass of water. you need the bubble for pressure) When the pt breathes in and out, the water goes up and down What kind of dressing do you need for a chest tube Occlusive dressing like Vaseline gauze Chest tube assessment --- Tidaling -
movement with respiration Water seal -- 2 cm line Output -- quantity and quality Air leak -- continuous bubbling Ability to breathe SpO2 Two chest tube complications 1) Air leak 2) Dislodgment Where do you clamp the chest tube? By the patient What is ARDS acute respiratory distress syndrome A progressive disorder that prevents appropriate gas exchange How does ARDS happen a form of inflammatory or immune response occurs in the lungs. What causes ARDS (7) 1) Sepsis Patho of ARDS -- 3 1) increased capillary permeability (the allow more fluid in the alveoli, and the fluid leaks out) 2) Inflammatory cytokines damage the lung tissue which further harms the alveoli 3) causes scarring lung tissue, and the lungs cant expand and perform gas exchange Diagnostics of ARDS 1) look at symptoms Normal PaO2 60-100 ARDS assessment findings -SOB ARDS nursing priorities - what type of support - TREAT THE UNDERLYING CAUSE ex:PNA - Vent support - High levels of PEEP (Helps keeps alveoli open) - Prone position ( allows for better expansion of the lungs) What is a flail chest make sure the patient has adequate what Multiple fractures on the same rib -- "floating pieces" (the middle piece is moving) What is a paradoxical chest movement Why are these patients sometimes vented? When we exhale, the piece floats out instead of in, opposite of what the chest is doing Pain with respirations, the lung cant expand like we want it to, the positive pressure forces the piece out when it wants to go in Why would someone need to be on a vent (2) for people who CANNOT PROTECT or MANAGE their own airway - ex: excessive secretions Reasons for an endotracheal tube (3) - not breathing effectively What is the purpose of the balloon on an ET tube not to anchor in place, we do not want the air to escape A nurse is working in the recovery room and caring for a client who was just brought in following surgery. The nurse removes the client's endotracheal tube and the client begins to have a laryngospasm. Which responses of the nurse are most appropriate? Select all that apply. Administer midazolam as ordered Perform a chin lift Apply a blood pressure monitor Provide supplemental oxygen via nasal cannula Place the client flat and supine Administer midazolam as ordered Perform a chin lift "Perform a chin lift" and "Administer midazolam as ordered" are correct. A laryngospasm occurs after extubation when the client's vocal cords freeze up, making it difficult for the client to breathe. The nurse may insert an oral airway or perform a chin lift to keep the airway open. Midazolam or propofol is sometimes administered to relax the larynx and facilitate easier breathing. "Provide supplemental oxygen via nasal cannula" is incorrect. Supplemental oxygen should be given, but at 100% via face mask in the situation of laryngospasm. "Apply a blood pressure monitor" is incorrect. A blood pressure monitor is not relevant to treating laryngospasm. "Place the client flat and supine" is incorrect, because this increases the work of breathing. Elevating the head of the bed for ease of breathing is more appropriate. What is a high pressure alarm The vent is trying to put pressure into the lungs, but it is meeting a lot of resistance, and it is not able to get air in Causes of a high pressure alarm (4) - Kinked tubing What is a low pressure alarm The vent does not sense any resistance to flow at all and cannot inflate anything Causes of low pressure alarms (2) - the circuit is disconnected How to fix a high-pressure alarm #1 ASSESS THE PATIENT - un-kink tubing What do you do if a patient self-extubates 1)
ASSESS OXYGENATION The nurse is caring for a client who is on a ventilator. An alarm goes off on the ventilator. What is the first thing the nurse should do? Assess the client for abnormalities Shut off the ventilator and restart it to reset the alarm Empty the ventilator tubing of excess moisture Check the ventilator settings Assess the client for abnormalities The nurse should always respond to a ventilator alarm by checking the client first, then checking the ventilator. Checking the client includes checking oxygenation status, vital signs, breathing rate and quality, skin color, bilateral expansion of the chest, secretion amounts, and whether the client is biting on the tube. What is capnography and capnography measures the CO2, it is on the nasal cannula. Reads the CO2 when the pt exhales Normal range is 20-40 Is a patient intubated for a bronchoscopy? Yes in ICU or OR How much fluid can you remove during a thoracentesis finger - 1L What are the three different types of clots -- finger 1) Blood S/S of PE -- finger Resp -- dyspnea, tachypnea, dry
cough, bloody sputum RN treatment for a PE PER FINGER two things what is the purpose of anticoagulation therapy ABC -- their airway is clear, they cannot oxygenate 1. oxygen therapy prevent clots from getting larger and to prevent new clots from forming -- its not going to break up the clot How long is warfarin therapy for pts who do not have a hx of clots? How long if they DO have a history 6 weeks life time Heparin and warfarin lab values Heparin -- PTT (40-60) but we want 1-2x their baseline Can you use TPA for a PE yes is Xalerto an option? yes -- too expensive finger If they are not a candidate for blood thinners what can you do? TWO THINGS Embolectomy -- go to IR and they vacum or grasp it out OR and IVC filter -- placed in IR and catches future clots Finger Nursing intervenions for PE - Frequent vital assessments STABLE VS UNSTABLE - watch our oxygen -- are they getting better or worse, do we need to titrate - Assess respiratory system every 30 min when they are unstable - assess neuro status to make sure there is no hypoxia/ stroke - Assess labs - REMOVE SCDs (massages the clots) - hydration to prevent hypotension - assess for bleeding after treatment is implemented Chest trauma first two assessments AIRWAY AND BREATHING Pulmonary contusion nursing priorities 1) Sit the pt up Rib fracture aligned vs not aligned if it is not aligned, then surgery Difference between pneumothorax and hemothorax lung sounds pneumothorax -- air travels up, so absent lung sounds at the top hemothorax -- blood settles down with gravity -- absent lung sounds in the bases
FINGER -- priorities for pneumothorax -- two 1) oxygenation and the chest tube to reinflate the lung FINGER tension pneumothorax - First priority - once ___ is inserted, then you place what WE DO NOT HAVE TIME. THINGS HAPPEN FAST -- #1 SPINAL NEEDLE FIRST TO DECOMPRESS IN THE SECOND INTERCOSTAL SPACE -- air can start to escape and THEN has time to place the chest tube FINGER hemothorax priorities when it first happens - three main priorities if you have x about over how many hours, should you notify the MD? Or if the patient is in what state - oxygen - if we have > 150 ml over 3 consecutive hours, CALL MD Chest tube consideratioins 1. consistent bubbling in the water seal chamber. We need to find out where that air leak is 2. this is OK, if it is a 1 in diameter around the insertion site FINGER what to do if chest tube falls out -
place vasaline or nonadhesive dressing over the site to seal it, TAPE on 3 SIDES (we want air to escape out, not to come in) What to have at beside for a chest tube (4) - padded clamp if there is a leak Which nursing action is priority for a patient immediately following a bronchoscopy?The nurse should be aware of these post-procedure nursing interventions after bronchoscopy: Assess bleeding episodes. Observe the patient's sputum and report for any excessive bleeding. Explain that a minimal amount of blood streak is expected and normal for few hours after the procedure.
Which immediate action does the nurse take when discovering that a patient's chest tube is disconnected from the chest drainage unit?A chest tube drainage system disconnecting from the chest tube inside the patient is an emergency. Immediately clamp the tube and place the end of chest tube in sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected. Bleeding may occur after insertion of the chest tube.
Which action would the nurse perform when preparing a patient for a thoracentesis?Rationale: During a thoracentesis a needle is inserted into the intercostal space, so the nurse should assist the client to sit at the edge of the bed while leaning forward with their arms supported on a bedside table and a pillow or folded towel.
Which actions will the nurse take to prepare a patient for pulmonary function test?To prepare for your pulmonary function test, follow these instructions:. No bronchodilator medication for four hours.. No smoking for four hours before the test.. No heavy meals.. Do not wear any tight clothing.. The complete pulmonary function test takes around one and a half hours.. |
Which nursing action is the priority for a patient immediately following a bronchoscopy Quizlet
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