Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th Ed., Hinkle & Cheever | Registered Nurse (RN) School Study Aid
Lung Sounds - Pleural Friction Rub
- Anterior Lateral Lung
- Dry, Rubbing, or Squeaking
- Rubbing a Balloon with Finger
- Inflamed Pleura
Tuberculosis Skin Mantoux Test (PPD)
- Delayed Hypersensitivity (Cell Mediated Response)
- Intradermal Injection
- Read 48-72 hours
- ≥ 5 mm Induration
- Immunosuppressed
- ≥ 10 mm Induration
- High Risk Patients
- ≥ 15 mm Induration
- Chest X-Ray
Lung Cancer Assessment
- 2nd Most Common Cancer
- Chronic Cough
- Hoarseness
- Abnormal Breath Sounds
- Hemoptysis
- Chest Pain
- Anorexia or Weight Loss
- Symptoms Appear Late in Disease
Acute Respiratory Distress Syndrome (ARDS) Assessment
- Damaged Alveolar-Capillary Membrane
- Restlessness
- Dyspnea
- Refractory Hypoxemia
- Decreased PaO2
- Diffuse Pulmonary Infiltrates
- Atelectasis
- Pulmonary Hypertension
Acute Respiratory Distress Syndrome (ARDS) Interventions
- Closely Monitor Patient
- ABG's (Arterial Blood Gases)
- Oxygen
- Assess for O2 Toxicity
- Mechanical Ventilation
- PEEP
- Assess for Pneumothorax
- Permissive Hypercapnia
- High Mortality Rate
Pneumonia Assessment
- Older Adult
- Immunocompromised
- Long Term Care
- Shortness of Breath (SOB)
- Hypoxemia
- Cough and Sputum Production
- Wheezing or Crackles
- Fever
- Pleuritic Pain
- Chest X-ray
Pneumonia Intervention
- Humidified Oxygen
- Deep Breathing Exercises
- Position of Comfort
- Increase Fluid Intake
- Manage Fever
- Antibiotics
- Mucolytics
- Expectorants
- Pneumococcal Vaccine
- Sepsis
- Acute Respiratory Failure (ARF)
- Prevention Education
Pneumothorax
- Air Enters Pleural Space
- Sudden Dyspnea
- Absent or Restricted Movement on Affected Side
- Decreased or Absent Breath Sounds on Affected Side
- Chest Pain
- Tracheal Deviation
- Vital Sign Changes
- Crepitus
- High Fowler's Position With Oxygen
- Prepare For Chest Tube Placement
- Educate High Risk Patients
Pulmonary Embolism Assessment
- Shortness of Breath (SOB)
- Pleuritic Chest Pain
- Tachypnea
- Hemoptysis
- Hypoxemia
- Sudden Death
Tuberculosis Assessment
- Airborne Droplet
- 3 Week Productive Cough
- Night Sweats
- Chest Pain
- Fever
- Weight Loss
- Fatigue
- Chest X-Ray
- Blood Tests
- Mantoux Skin Test
- 3 Positive Sputum Tests
Tuberculosis Intervention
- Airborne Isolation
- Combination Drug Therapy (RIPE)
- 6-12 Months
- DOT
- BCG Vaccination
- Medication Education
- 3 Negative Sputum Specimens
- Infection Control
Ethambutol (Myambutol)
- Inhibits RNA Synthesis
- Bacteriostatic
- Tuberculosis (TB)
- Optic Neuritis
- Red/Green Color Blindness
- Gouty Arthritis
- Monitor Vision Acuity
Isoniazid (INH)
- Interferes with DNA Metabolism
- Tuberculosis (TB)
- Optic Neuritis
- Nausea and Vomiting
- Hepatotoxicity
- Peripheral Neuropathy
- Vitamin B6 Prophylaxis
- Monitor AST/ALT
Cardiac Tamponade
- Fluid in the Pericardial Sac
- Pericarditis
- Decreased Cardiac Output
- Beck's Triad
- Hypotension
- Jugular Venous Distention (JVD)
- Distant Heart Sounds
- Pulsus Paradoxus
- Electrical Alternans
- Pericardiocentesis
Pulmonary Embolism Causes
- FAT BAT Mnemonic
- Fat
- Air
- Deep Vein Thrombosis (DVT)
- Bacteria
- Amniotic Fluid
- Tumor
- Hypercoagulable
- Central Venous Lines
- Immobilized