LO 4- Pneumonia

Questions Notes
What is atelectasis Collapse of alveoli caused by hypoventilation, obstruction to airways, or
compression
Severity of atelectasis symptoms Tachypnea, dyspnea, mild to moderate hypoxemia
What is Pneumonia Inflammation of the lung caused by various microorganisms, causing
bronchospasm, which leads to poor diffusion of O2 and CO2, resulting
ventilation perfusion mismatch
Briefly describe 4 classifications of Pneumonia 1. Community acquired pneumonia
- acquired in the community within 48 hours of hospitalization
2. Hospital acquired pneumonia
- Nosocomial; onset of sx > 48 hours after admission to hospital- a condition
has to exist first (vulnerable, organism is highly virulent, antibiotic
resistance)
3. Health Care Assoc Pneumonia
- non hospitalized pt with extensive HC; been hospitalized >2 days within 90
days or a residence in LTC
4. Ventilator Assoc Pneumonia
- develops 48 hours after endotracheal intubation
Clinical Manifestations of Pneumonia Sudden onset
- fever > 38.5
- Pleuritic chest pain
- tachypnea; increased pulse
- > WOB and SOB
Gradual Onset
- HA, crackles on auscultation
- pleuritic pain, sore muscles
- diaphoretic, poor appetite
Late sign
- cyanotic nail beds and lips
Gerontologic Consideration
- confusion, malaise
- sxs masked
Antibiotic Therapy Determined by gram stain results and officially with culture
- antibiotics DOESN’T KILL VIRUS
- results should be seen within 1-2 days; should have < fever, dyspnea, > O2
sat and wellness
- don’t use BROAD SPECTRUM, can for NARROW
Assessment Changes in physical ax, inspection and auscultation of the chest; changes in
mental status, fatigue, dehydration, concomitant HF
Diagnosis Ineffective airway clearance
Deficient knowledge
Imbalance nutrition
Planning Improve airway clearance
Pt understanding tx and prevention
Maintenance of adequate nutrition

Interventions - encourage hydration of 2-3 L/day unless contraindicated

- humidification with a mask or O2 to loosen secretions
- coughing techniques; deep breathing, pursed lip, nasotracheal suctioning
- chest physiotherapy; incentive spirometer
- position changes- semi fowler to promote rest and breathing
 - O2 therapy

LO 4- COPD
What is Chronic Obstructive Pulmonary Disorder? It’s preventable and slowly progressive resp disease of airflow; not fully
reversible
- abnormal inflammatory response of the lungs to noxious agents causing
scar tissue and narrowing
- inflammatory response causes changes in pulmonary vasculature causing
thickening of the wall
What are 3 pathological changes that occur with 1. bronchoconstriction
COPD 2. Inflammation of airway
3. Hypersecretion of mucous
Describe Chronic Bronchitis Presence of cough and sputum production for at least 3 months
- Irritation of airways causing inflammation
- Increase in mucus secreting glands and goblet cells
- Bronchial walls thicken, bronchial airways narrow = alveoli damage
- Alveolar macrophage function diminishes
Describe Emphysema Abnormal distention of air spaces and destruction of walls of the alveoli; <
alveolar surface area causing > in dead space = no gas exchange which could
cause right sided HF
Clinical Manifestations of Emphysema - more work during inspiration
- forced expiration
- Barrell chest due to chronic hyperinflation
- tripod posture; leaning forward, use of accessory muscles
Primary symptoms of COPD Chronic cough, sputum production, dyspnea
Diagnostic Pulmonary Function Test
- spirometer that measure volume and time simultaneously
- to measure severity and progression
Bronchodilators vs Corticosteroids Broncho: open airway and improve expiratory flow; reduce airway
obstruction; reverse bronchospasm in emphysema
Cotri: reduce inflammation and improve expiratory volume- improve sx
Indication for hospitalization of COPD Severe dyspnea, confusion, or lethargy, resp muscle fatigue, paradoxical
chest wall movement
Assessment Monitor for complications
- resp failure, atelectasis, pulmonary infection, pneumonia, Cor pulmonale
Diagnosis Impaired gas exchange
Activity intolerance
Ineffective breathing pattern
Interventions - administration of bronchodilators and corticosteroids
- directed coughing
- more fluids
- breathing exercises to reduce air tapping: diaphragmatic and purse lip
- walking aid
Directed coughing Slow, maximal inspiration followed by holding breath for a few sec, then
cough 2-3x
Diaphragmatic breathing Alveoli ventilate and expel air
- Place one hand on chest and one on abd
- Inhale through nose, feeling your abd expand as far as possible
-Exhale through pursed lips while tightening abd muscles
- Repeat for 1 min; ret period of 2 mins
- Increase duration up to 5 mins, several times a day; before meals and at
bedtime
Pursed lip breathing Control rate and depth; help prevent collapse of small airways
- Inhale through nose; say "smell a rose"
- Exhale slowly against pursed lips while tightening abd muscles
- Count to 7 while slowly exhaling

LO 4- Asthma
Asthma patho? Chronic inflammatory disease that causes
1. airway hyper responsiveness which causes bronchoconstriction that leads
to obstruction of airways
2. inflammation and edema
3. Mucus production
4. REVERSIBLE
Manifestations Cough, wheezing, dyspnea
Generalized wheezing first on expiration
Tripod position, diaphoresis, tachypnea
Choking sensation during exercise
Inflammatory response initiated by release of Histamine secreted by mast cells
mediators Increase BF, vasoconstrict fluid leak, attraction of WBC, mucous secretion,
and bronchoconstriction
What is status asthmaticus Severe and persistent asthma that doesn’t respond with conventional
therapy
Severe bronchospasm with mucus plugging leading to asphyxia
Status asthmaticus manifestations As obstruction worsens wheezing disappears; no air moving on inspiration or
expiration is a sign of impending resp failure
- asphyxia, hypoxemia
ABG Alkalotic because of hyperventilation; increase in eosinophils
Triggers of asthma Dust, dust mites, roaches, cloth, pets, horses, detergents, soap, mold,
pollens
Diagnostic Peak Flow Monitoring
- measure highest airflow during forced expiration
- repeat 1-5 times, record personal best
Volume measurement of PFM Green: 80-100%
Yellow: 60-80%
Red: < 60%

LO 4- Diagnostic Tests
Obstructive Sleep Apnea Airway obstruction and reduction in ventilation
Breathing cessation for 10 sec or longer followed by loud gasp
OSA results in Hypoxia and hypercapnia
Pulmonary Function Test Ax resp function and extent of dysfx response to therapy
Arterial Blood Gases To ax adequacy of alveolar ventilation and the ability of the lungs to provide
O2 and remove CO2
Pulse Oximeter To monitor O2 sat of the blood
C PAP vs Bi PAP C: provides positive pressure to the airways throughout the resp cycle
B: ventilation offers independent control of inspiratory and expiratory
pressure while providing support ventilation
Expected Outcomes in Chest X-Ray Normal AP and lateral chest radiograph, pulmonary markings, cardiac size,
pleura, and soft tissue structures
Abnormal findings in CXR Mass, abscesses within lungs, pneumonia, cardiac enlargement
 LO 4- pH Acid Base Imbalance
 Respiratory acidosis
o Inadequate Ventilation
o Low pH, High CO2, normal HCO3
o Caused by:
 Asthma
 Chronic COPD
 Chronic OSA
 narcotics, traumatic brain injury, anxiety, resp distress
o SxS
 Tachycardia, HA, confusion
 Respiratory Alkalosis
o Hyperventilation
o High pH, low CO2, normal HCO3
o Caused by:
 Hypoxia
 ASA toxicity
 Chronic asthma
o SxS
 Cardiac dysrhythmias
 Tingling of hands and feet
 Shallow breathing
 Metabolic Acidosis
o Low pH, < CO2, < HCO3
o Hyperventilation
o Caused by:
 Diabetic ketoacidosis
o SxS
 Hyperventilation
 Metabolic Alkalosis
o High pH, normal CO2, high HCO3
o < resp rate and depth to retain CO2
o Caused by
 Aspirin overdose
 Prolonged vomiting
o SxS
 Tetany, dizziness, seizures
 Compensation
o Respiratory and metabolic system work together to correct acid-base imbalance
 Occurs when pH is normal, CO2 and HCO3 are both elevated

LO 6 Rehabilitation
What are the 5 levels of HC available to pts and Health Promotion
families Disease and Injury Prevention
Diagnosis and Tx
Rehabilitation
Supportive Care
What are the 5 main goals of Rehab Improve and maintain function
Promote and maintain independence
Preserve self esteem
Prevent complications
Encourage adaptation to live with disability
Common Health Problems requiring Rehab Heart disease
Pulmonary disease
Neurological and Vascular disease
Assessment of Functional Ability Observe the pt perform specific activities
Self- care deficit - assistive devices
- loose fitting, comfortable shoes
- Occupational therapists are involved
Pt with Impaired Mobility Interventions - Maintain supportive positioning and body alignment when sitting and lying
Dx down
Impaired skin integrity - ROM
- Assist ADLs
- Pressure Reduction
- Physiotherapists are involved
Trochanter roll To prevent external rotation of the hip
Towel folded in 3rds lengthwise and rolled toward pt
From crest of ilium to midthigh preventing deformity
Preventing Foot drop Foot is plantar flexed
Damage to loss of flexibility of Achilles tendon result in footdrop
Can be caused by prolonged bedrest, lack of exercise, incorrect positioning
in bed
Nursing Interventions involved in Using assistive - push off chair or bed to come to sitting position
devices
Pt with Impaired Skin Integrity Initial sign of pressure is erythema
Risk for impaired skin integrity
Impaired skin integrity r/t immobility
Etiology: < tissue perfusion, altered nutritional stat, friction, and shear, >
moisture
Risk for Pressure Ulcers - Immobility
- Malnutrition
- Prolonged pressure on tissue
- Bowel or urine incontinence
Assessment of risk - Ax total skin condition at least 2x day
- Inspect pressure site for erythema
- Inspect for dry, moist, breaks in skin
Nursing Interventions - relieve pressure by frequent positioning
- shift weight. Every 15-20 mins, pillows under bony prominences
- reduce friction and shear, HOB < 30 degrees
Pt with Altered Elimination patterns Urinary Incontinence, fecal incontinence, constipation, for SCI above T6
Assessment - ability to get to bathroom
- cognitive functioning
- episodes of activity and incontinence
Nursing Intervention Bladder Retraining: interval between voiding is 90-120 mins
Improving Mobility and Joint Deformities- for Pt with hemiplegia, voluntary muscle is lost, arms adduct and rotate
Ischemic Stroke internally
Correct positioning
Prevent adduction: pillow
Hip flexion: prone
Exercise: passively
Communicating with the pt with aphasia - face the pt and establish eye contact
- impairs ability to express and understand what is - use gestures, pictures, objects
being said - use short phrases
- left stroke with right sided paralysis
Pt with tetraplegia Promote maximal ability to perform self-care
- no voluntary ability to upper and lower body
Grieving process Denial
Anger
Bargaining
Depression
acceptance
Pt with Impaired Respiratory Function Sitting position when eating
Interventions Double swallowing
Sit upright 30 min after meals
Protein to prevent muscle wasting

LO 5- Anemia
What are common findings of Iron deficiency Pallor, cheilosis, brittle ridged nails
anemia - clinical manifestations are the body’s response to tissue hypoxia
How to treat Iron deficiency Increase dietary iron, Blood Transfusion
- iron absorption is < with food, especially with dairy products-50%
- increase intake of Vit C (strawberries, tomatoes, juices)
- stools will become dark in color; dark green or black
Foods high in iron Meats, beans, green leafy vegs, raisins
Pernicious anemia common findings Abd pain, paresthesia hand/feet, dementia
What is pernicious anemia When intestine doesn’t absorb Vit B12 bc Intrinsic factor is not present
Diagnostic sign Smooth, sore, red tongue
Megaloblastic anemia Vit b12 and folic acid deficiency
Folic acid can be found in vegetables and liver
Vit b12 found in fresh fruits and vegs; vegetarians are at risk for
Process of RBC production Begins with immature myeloid cell
Erythropoietin goes to marrow and helps in maturation of myeloid cell
Erythropoietin released more if O2 levels are low, or if anemia exists
Requires iron, vit b12, folic acid, protein, vit b6
- < in any of requirements; < in RBC production
What is the Schilling Test Used for perniscous anemia
First stage
- pt receives oral dose of radioactive vit b12, then non-radioactive parenteral
dose.
- If more than 8% is excreted in the urine within 24 hrs; no radioactive is
present- the cause is GI malabsorption
- if radioactivity is present, the prob is NOT pernicious anemia
Second stage
- IF is added to the oral vit b12
- if radioactivity is seen in urine, pernicious anemia is present bc of the
presence of IF
Folic acid deficiency anemia Caused by poor nutrition, anorexia, OH abuse
Findings are the same for pernicious anemia but have NO neurological probs

LO5- Peptic Ulcer

What are some causes of peptic ulcer? NSAIDs, corticosteroids, genetics, smoking, caffeine
Describe it Pain; gnawing, burning, aching, hunger-like; experienced in epigastric region,
radiating to the back; occurs when the stomach is empty; pain relieved by
eating
4 major complications of Peptic Ulcer Hemorrhage: most common
Perforation: most lethal
 Penetration
Pyloric obstruction
Pathophysiology Damage to gastroduodenal mucosa results in decrease resistance to bacteria
so H.pylori occurs
Sxs- ax Tachycardia, HTN, tachypnea
Usual diet and last 72-hour period
Diagnosis Acute pain
Anxiety
Imbalanced nutrition
Deficient knowledge
Goals Tx with antibiotic- to eradicate H. pylori
Acid reduction: proton pump inhibitor (block acid secretion) and h2 receptor
antagonist (< acid secretion)
Antacid to neutralize acid
Intervention Reduce anxiety
Develop a routine in lifestyle and eating
Help identify stressors
Dietary restriction: regular meals to neutralize acid
Most common complication Hemorrhage
Large loss: 2-3 L- mostly vomited out
Dark coffee ground appearance
Management of hemorrhage Ax for sxs of hypovolemic shock
Treatment
- IV fluids
Signs of perforation Severe upper abd pain, vomiting, collapse, tender board like abd, signs of
shock
Pyloric Obstruction - area distal is stenosed bc of spasm, edema, scar tissue
- sx: N + V + C + A, later weight loss
- NG tube to decompress stomach, IV fluids and electrolytes
Theory about diet modification for peptic ulcer Avoid extreme temperatures
Eat 3 regular meals a day
Avoid diets rich in milk and cream

LO5- Diagnostic Tests

 Stool will be white or light colored for 2-3 days
 Gastroscopy
o 20-30 mins to complete
o After procedure, pt allowed to drink first then eat as soon as gag reflex returns
 Barium swallow
o Ct NPO 6-8 hours prior
o Increase fluids to excrete barium

Ischemic Stroke
 Neurological Ax
o PERRLA
o Orientation and LOC
o Response to stimuli
 Nursing Dx
o Impaired physical mobility r/t musculoskeletal impairment
o Risk for injury r/t loss of balance and coordination
o Risk for injury r/t decreased field of vision
  Problem that may develop r/t hemiplegia or unilateral paralysis
o Contractures
 Bc abnormal flexion and adduction of muscle and joints

Hemorrhagic Shock
 Negative outcome of peptic ulcer
 Causes
o GI bleed, vaginal bleed, pregnancy, gunshot wounds, amputation
 SxS
o Anxiety
o Blue lips and fingernails
o Low or no urine output
o Shallow breathing
o LOC, low BP
o Rapid HR, weak pulse
 SxS of internal hemorrhaging
o Abd pain
o Blood in stool and urine
o Vomiting blood
o Chest pain

Phases of rehab
 Indisciplinary
 Inpatient
 outpatient