Medical-Surgical Nursing, 11th Ed., Harding, Kwong, Roberts, Hagler & Reinisch | Registered Nurse (RN) School Study Aid
Chronic Bronchitis Assessment
- Chronic Productive Cough
- > 3 Months for 2 Years
- Increased Mucus Production
- Dyspnea
- Cyanosis
- Wheezes
- Right Side Heart Failure
- Jugular Venous Distention (JVD)
- Peripheral Edema
Chronic Bronchitis Interventions
- Tripod Position
- Humidified Oxygen
- Pursed Lip Breathing
- Increase Fluid Intake
- ABGs
- Early Detection of Exacerbation
- Lowest O2 Therapy
- Assisted Ventilation
- Increased Infection Risk
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
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
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
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
Flail Chest
- Trauma
- Shallow Respirations
- Chest Pain
- Paradoxical Chest Movement
- Mechanical Ventilation
- Analgesics
- Intercostal Nerve Blocks
- Surgical Rib Fixation
- Monitor Pulmonary Contusion
Chest Tubes: Management and Care
- Confirm suction order
- Crepitus
- Kinking
- Shortness of Breath (SOB)
- Infection
- Excessive bubbling
- If tube dislodges from patient, use petroleum gauze taped 3 ways
- If drainage system is damaged, place disconnected drainage tube in sterile water
Emphysema
- Hyperinflation and Loss of Elasticity
- Pursed Lip Breathing
- Barrel Chest
- Dyspnea on Exertion
- Clubbing
- Depression and Anxiety
- Thin Appearance
- CO2 Retention
- Low Concentration of O2
- High Fowler's Position
- High Calorie, High Protein Diet
Pulmonary Embolism Causes
- FAT BAT Mnemonic
- Fat
- Air
- Deep Vein Thrombosis (DVT)
- Bacteria
- Amniotic Fluid
- Tumor
- Hypercoagulable
- Central Venous Lines
- Immobilized
Pulmonary Embolism Assessment
- Shortness of Breath (SOB)
- Pleuritic Chest Pain
- Tachypnea
- Hemoptysis
- Hypoxemia
- Sudden Death
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