NUR 265
EXAM 2 REVIEW
Medical-Surgical Nursing
Galen College of Nursing
, Review
1. S/S of PE (Pulmonary Embolism) p 587
● Sudden onset of dyspnea
● Sharp, stabbing chest pain
● Restlessness, feeling of impending doom
● Cough
● Increased respiratory rate
● Crackles, wheezes
● Pleural friction rub
● Tachycardia
● Low grade fever
● Petechiae over chest
● Decreased arterial oxygen saturation
● D-dimer levels rise with fibrinolysis. When the value is normal or low, it can rule out PE.
Even if the value is high, other diagnostic testing is done to determine whether a PE has
occurred
2. Treatment for PE
● Heparin
○ If someone is on lifelong heparin therapy for a PE, and they are bleeding around
an IV catheter, foley site: Patient is going to be a priority, the first one you go and
see
● Lovenox
● Coumadin- INR needs to be monitored–INR needs to be 2-3
● Oxygen therapy is critical for a pt with PE
3. ABG for PE
-Respiratory alkalosis
-PH is going to be high
4. ABG for ARDS and acute respiratory failure
-Respiratory acidosis
PH is going to be low
5. Teaching for a patient on coumadin with a PE
-Monitor for bleeding, consume more vitamin K (green leafy vegetables)
-Soft bristle toothbrush, electric razors
6. S/S chest tube issues
-Management of chest tube drainage system p 561
Patient
● Ensure that the dressing on the chest around the tube is tight and intact
● Assess for difficulty breathing
● Assess breathing effectiveness by pulse ox
● Listen to breath sounds on each lung
● Check alignment of trachea
● Check tube insertion site for condition of the skin. Palpate area for puffiness or crackling
that may indicate subcutaneous emphysema
EXAM 2 REVIEW
Medical-Surgical Nursing
Galen College of Nursing
, Review
1. S/S of PE (Pulmonary Embolism) p 587
● Sudden onset of dyspnea
● Sharp, stabbing chest pain
● Restlessness, feeling of impending doom
● Cough
● Increased respiratory rate
● Crackles, wheezes
● Pleural friction rub
● Tachycardia
● Low grade fever
● Petechiae over chest
● Decreased arterial oxygen saturation
● D-dimer levels rise with fibrinolysis. When the value is normal or low, it can rule out PE.
Even if the value is high, other diagnostic testing is done to determine whether a PE has
occurred
2. Treatment for PE
● Heparin
○ If someone is on lifelong heparin therapy for a PE, and they are bleeding around
an IV catheter, foley site: Patient is going to be a priority, the first one you go and
see
● Lovenox
● Coumadin- INR needs to be monitored–INR needs to be 2-3
● Oxygen therapy is critical for a pt with PE
3. ABG for PE
-Respiratory alkalosis
-PH is going to be high
4. ABG for ARDS and acute respiratory failure
-Respiratory acidosis
PH is going to be low
5. Teaching for a patient on coumadin with a PE
-Monitor for bleeding, consume more vitamin K (green leafy vegetables)
-Soft bristle toothbrush, electric razors
6. S/S chest tube issues
-Management of chest tube drainage system p 561
Patient
● Ensure that the dressing on the chest around the tube is tight and intact
● Assess for difficulty breathing
● Assess breathing effectiveness by pulse ox
● Listen to breath sounds on each lung
● Check alignment of trachea
● Check tube insertion site for condition of the skin. Palpate area for puffiness or crackling
that may indicate subcutaneous emphysema
