NR 325 Med Surg ATI HESI Review
, HESI Review
OXYGEN THERAPY
Oxygen Toxicity – Signs and symptoms include a non-productive cough, substernal pain, nasal stuffiness, nausea and
vomiting, fatigue, headache, sore throat, and hypoventilation.
Hypoxemia – Early Signs – Tachypnea, Tachycardia, Restlessness, Pallor, Elevated BP, Accessory muscles, nasal flaring,
adventitious lung sounds.
Hypoxemia – Late Signs - Confusion & stupor, cyanosis, bradypnea, bradycardia, hypotension, dysrhythmias
Nasal Cannula – Most appropriate flow rate is 2 to 4 L/min
Face Mask – 5 to 8 L/min is appropriate flow rate (minimum of 5 to flush CO2 out of mask)
Non-rebreather Mask – 10/12 L/min
RESPIRATORY SUCTIONING
Should not be performed for more than 15 seconds at a time. Suctioning for periods longer than 15 seconds may
cause hypoxemia and trigger a vagal response (results in hypotension & bradycardia).
If suctioning is indicated, it is best to begin with oropharyngeal suctioning since it is better tolerated.
Set pressure on wall canister to 80-120 mm Hg
BRONCHOSCOPY
NPO status prior to the procedure, usually 8-12 hours.
Complications – laryngospasm & aspiration due to lack of gag reflex
After the procedure, the nurse should report bronchospasms to the MD because they pose an airway concern.
After the bronchoscopy, the nurse should monitor the vital signs every 15 minutes.
CHEST TUBES
Water seals are created by adding sterile fluid to a chamber up to the 2 cm line. The water seal allows air to exit the
pleural space on exhalation and prevents air from entering with inhalation.
To maintain the water seal, the chamber must be kept upright and below the chest tube insertion site at all times.
The nurse should add fluid to maintain the 2 cm level.
Tidaling – movement of water with respiration.
Continuous bubbling is a sign of an air leak.
Cessation of tidaling in the water seal chamber signals lung re-expansion or an obstruction in the system.
Due to the risk of causing a tension pneumothorax, chest tubes are only clamped per a MD in special circumstances
Do not strip or milk tubing routinely….only with an MD order.
Indications for chest tube draining include:
o Pneumothorax
o Hemothorax
o Postoperative chest drainage
o Pleural effusion
o Lung abscess
o Severe thrombocytopenia is a contraindication to a chest tube – excessive bleeding.
With removal of the chest tube, instruct client to deep breath, exhale and bear down (Valsalva maneuver) or to take
a deep breath and hold it (increases intrathoracic pressure and reduces risk of air emboli).
Apply sterile petroleum jelly gauze dressing
If tubing separates, patient is instructed to exhale and cough to remove as much air as possible from the pleural
space. The nurse cleanses the tips and reconnects the tubing.
If the drainage system breaks, the nurse immerses the end of the tube in sterile water to maintain the seal.
If chest tube is accidentally removed, occlusive dressing taped on 3 sides is placed.
, HESI Review
THORACENTESIS
Amount of fluid removed is limited to 1 liter at a time to prevent cardiovascular collapse.
Recurrent pleural effusions can be managed by installing an irritant into the pleural space to cause scarring.
Apply dressing over the puncture site and position the patient on the unaffected side for an hour.
MECHANICAL VENTILATION
Delivers warm humidified O2 at FiO2 levels of 21 to 100%
Ventilator alarms should never be turned off.
Monitor and document ventilator settings hourly.
Assess cuff pressure every 8 hours. Maintain cuff pressure below 20 mm Hg to reduce the risk of tracheal necrosis.
Reposition the organ endotracheal tube every 24 hours
Fluid retention – due to decreased CO, activation of rennin-angiotensin-aldosterone system
ASTHMA
Mild intermittent – symptoms occur less than twice a week
Mild persistent – Symptoms occur more than twice a week but not daily
Moderate persistent – Daily symptoms occur in conjunction with exacerbations twice a week
Severe persistent – Symptoms occur continually, along with frequent exacerbations that limit the client’s physical
activity and quality of life.
Forced vital capacity – the volume of air exhaled from full inhalation to full exhalation
Forced expiratory volume – The volume of air able to be blown out as quickly as possible during the first second of a
forceful exhalation after inhaling fully
Peak expiratory flow rate: The fastest airflow rate reached during exhalation
A decrease in FEV or PERF by 15-20% is common in clients with asthma.
Medications
Bronchodilators
o Short acting beta 2 agonists – Albuterol (proventil, ventolin) provide rapid relief of acute symptoms.
o Cholinergic antagonists – ipratropium (Atrovent), block the parasympathetic nervous system. This allows for
the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions.
o Methylxanthines – theophylline – require close monitoring of serum medication
Anti-inflammatories
Corticosteroids – fluticasone (flovent) and prednisone
Leukotriene antagonists – montelukast (Singulair)
Mast cell stabilizers – cromolyn sodium (Intal)
Monoclonal antibodies – omalizumab (Xolair)
Combination agents – bronchodilator and anti-inflammatory
Ipratropium and albuterol (Combivent)
Fluticasone and salmeterol (Advair)
Older adults have a decreased sensitivity to beta 2 agonists. More medication is needed.
COPD
Risk factors include cigarette smoking, air pollution and alpha1-anti trypsin deficiency
ABGs show increased PaCO2 and decreased PaO2
Position client to maximize ventilation (High Fowlers)
, HESI Review
Administer heated and humidified O2 therapy as prescribed.
Clients with COPD may need 2 – 4 L/min per nasal cannula or up to 40% per venturi mask.
Clients with hypercarbia usually require 1 – 2 L/min via nasal cannula
Complications of COPD
Respiratory infection from increased mucus production
Right sided heart failure (cor pulmonale). Manifestations include, hypoxemia, cyanotic lips, enlarged and tender
liver, distended neck veins, dependent edema,
Clubbed fingers and circumoral cyanosis are late signs of serious hypoxemia
Pneumonia
Pneumonia is an inflammatory process in the lungs that produces excess fluid. It is triggered by infectious
organisms or by the aspiration of an irritant.
Administer heated and humidified oxygen therapy as prescribed
Position in high fowler’s position to facilitate air exchange
Medications
o Antibiotics – penicillins and cephalosporins
o Bronchodilators – short acting beta 2 agonists, such as albuterol (Proventil, Ventolin) quickly improve
bronchodilation.
o Methylxanthines such as theophylline – narrow therapeutic range
o Corticosteroids – prednisone – decrease airway inflammation
Confusion from hypoxia is the most common manifestation of pneumonia in older adults.
TB
Induration of 10 mm or greater in diameter indicates a positive test
Induration of 5 mm is considered a positive test for immunocompromised clients.
A positive acid fast test indicates an active infection.
Diagnosis is confirmed by a positive culture
Wear an N95 hepa respirator when caring for patient
Isoniazid (INH) should be taken on an empty stomach; monitor for hepatitis and neurotoxicity. Vitamin B6
(pyridoxine) is used to prevent toxicity from isoniazid
Rifampin (RIF). Inform patient that the urine and other secretions will be orange
Ethambuton (EMB) – obtain baseline visual acuity tests; determine color discrimination ability
Streptomycin – not widely used due to resistance – can cause ototoxicity
To decrease resistance, newer drugs contain a combination of Rifampin and isoniazid OR Rifampin, isoniazid and
pyrazinamide.
Sputum samples are needed every 2 – 4 weeks.
Miliary TB – The organism invades the bloodstream and can spread to multiple organs with complications
including meningitis and pericarditis.
Laryngeal Cancer
Men are three times more likely to get this.
Tobacco and alcohol use are the primary risk factors. Their effects are synergistic when used in combination.
Superior Vena Cava Syndrome
Occurs from pressure placed on the vena cava by a tumor
, HESI Review
OXYGEN THERAPY
Oxygen Toxicity – Signs and symptoms include a non-productive cough, substernal pain, nasal stuffiness, nausea and
vomiting, fatigue, headache, sore throat, and hypoventilation.
Hypoxemia – Early Signs – Tachypnea, Tachycardia, Restlessness, Pallor, Elevated BP, Accessory muscles, nasal flaring,
adventitious lung sounds.
Hypoxemia – Late Signs - Confusion & stupor, cyanosis, bradypnea, bradycardia, hypotension, dysrhythmias
Nasal Cannula – Most appropriate flow rate is 2 to 4 L/min
Face Mask – 5 to 8 L/min is appropriate flow rate (minimum of 5 to flush CO2 out of mask)
Non-rebreather Mask – 10/12 L/min
RESPIRATORY SUCTIONING
Should not be performed for more than 15 seconds at a time. Suctioning for periods longer than 15 seconds may
cause hypoxemia and trigger a vagal response (results in hypotension & bradycardia).
If suctioning is indicated, it is best to begin with oropharyngeal suctioning since it is better tolerated.
Set pressure on wall canister to 80-120 mm Hg
BRONCHOSCOPY
NPO status prior to the procedure, usually 8-12 hours.
Complications – laryngospasm & aspiration due to lack of gag reflex
After the procedure, the nurse should report bronchospasms to the MD because they pose an airway concern.
After the bronchoscopy, the nurse should monitor the vital signs every 15 minutes.
CHEST TUBES
Water seals are created by adding sterile fluid to a chamber up to the 2 cm line. The water seal allows air to exit the
pleural space on exhalation and prevents air from entering with inhalation.
To maintain the water seal, the chamber must be kept upright and below the chest tube insertion site at all times.
The nurse should add fluid to maintain the 2 cm level.
Tidaling – movement of water with respiration.
Continuous bubbling is a sign of an air leak.
Cessation of tidaling in the water seal chamber signals lung re-expansion or an obstruction in the system.
Due to the risk of causing a tension pneumothorax, chest tubes are only clamped per a MD in special circumstances
Do not strip or milk tubing routinely….only with an MD order.
Indications for chest tube draining include:
o Pneumothorax
o Hemothorax
o Postoperative chest drainage
o Pleural effusion
o Lung abscess
o Severe thrombocytopenia is a contraindication to a chest tube – excessive bleeding.
With removal of the chest tube, instruct client to deep breath, exhale and bear down (Valsalva maneuver) or to take
a deep breath and hold it (increases intrathoracic pressure and reduces risk of air emboli).
Apply sterile petroleum jelly gauze dressing
If tubing separates, patient is instructed to exhale and cough to remove as much air as possible from the pleural
space. The nurse cleanses the tips and reconnects the tubing.
If the drainage system breaks, the nurse immerses the end of the tube in sterile water to maintain the seal.
If chest tube is accidentally removed, occlusive dressing taped on 3 sides is placed.
, HESI Review
THORACENTESIS
Amount of fluid removed is limited to 1 liter at a time to prevent cardiovascular collapse.
Recurrent pleural effusions can be managed by installing an irritant into the pleural space to cause scarring.
Apply dressing over the puncture site and position the patient on the unaffected side for an hour.
MECHANICAL VENTILATION
Delivers warm humidified O2 at FiO2 levels of 21 to 100%
Ventilator alarms should never be turned off.
Monitor and document ventilator settings hourly.
Assess cuff pressure every 8 hours. Maintain cuff pressure below 20 mm Hg to reduce the risk of tracheal necrosis.
Reposition the organ endotracheal tube every 24 hours
Fluid retention – due to decreased CO, activation of rennin-angiotensin-aldosterone system
ASTHMA
Mild intermittent – symptoms occur less than twice a week
Mild persistent – Symptoms occur more than twice a week but not daily
Moderate persistent – Daily symptoms occur in conjunction with exacerbations twice a week
Severe persistent – Symptoms occur continually, along with frequent exacerbations that limit the client’s physical
activity and quality of life.
Forced vital capacity – the volume of air exhaled from full inhalation to full exhalation
Forced expiratory volume – The volume of air able to be blown out as quickly as possible during the first second of a
forceful exhalation after inhaling fully
Peak expiratory flow rate: The fastest airflow rate reached during exhalation
A decrease in FEV or PERF by 15-20% is common in clients with asthma.
Medications
Bronchodilators
o Short acting beta 2 agonists – Albuterol (proventil, ventolin) provide rapid relief of acute symptoms.
o Cholinergic antagonists – ipratropium (Atrovent), block the parasympathetic nervous system. This allows for
the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions.
o Methylxanthines – theophylline – require close monitoring of serum medication
Anti-inflammatories
Corticosteroids – fluticasone (flovent) and prednisone
Leukotriene antagonists – montelukast (Singulair)
Mast cell stabilizers – cromolyn sodium (Intal)
Monoclonal antibodies – omalizumab (Xolair)
Combination agents – bronchodilator and anti-inflammatory
Ipratropium and albuterol (Combivent)
Fluticasone and salmeterol (Advair)
Older adults have a decreased sensitivity to beta 2 agonists. More medication is needed.
COPD
Risk factors include cigarette smoking, air pollution and alpha1-anti trypsin deficiency
ABGs show increased PaCO2 and decreased PaO2
Position client to maximize ventilation (High Fowlers)
, HESI Review
Administer heated and humidified O2 therapy as prescribed.
Clients with COPD may need 2 – 4 L/min per nasal cannula or up to 40% per venturi mask.
Clients with hypercarbia usually require 1 – 2 L/min via nasal cannula
Complications of COPD
Respiratory infection from increased mucus production
Right sided heart failure (cor pulmonale). Manifestations include, hypoxemia, cyanotic lips, enlarged and tender
liver, distended neck veins, dependent edema,
Clubbed fingers and circumoral cyanosis are late signs of serious hypoxemia
Pneumonia
Pneumonia is an inflammatory process in the lungs that produces excess fluid. It is triggered by infectious
organisms or by the aspiration of an irritant.
Administer heated and humidified oxygen therapy as prescribed
Position in high fowler’s position to facilitate air exchange
Medications
o Antibiotics – penicillins and cephalosporins
o Bronchodilators – short acting beta 2 agonists, such as albuterol (Proventil, Ventolin) quickly improve
bronchodilation.
o Methylxanthines such as theophylline – narrow therapeutic range
o Corticosteroids – prednisone – decrease airway inflammation
Confusion from hypoxia is the most common manifestation of pneumonia in older adults.
TB
Induration of 10 mm or greater in diameter indicates a positive test
Induration of 5 mm is considered a positive test for immunocompromised clients.
A positive acid fast test indicates an active infection.
Diagnosis is confirmed by a positive culture
Wear an N95 hepa respirator when caring for patient
Isoniazid (INH) should be taken on an empty stomach; monitor for hepatitis and neurotoxicity. Vitamin B6
(pyridoxine) is used to prevent toxicity from isoniazid
Rifampin (RIF). Inform patient that the urine and other secretions will be orange
Ethambuton (EMB) – obtain baseline visual acuity tests; determine color discrimination ability
Streptomycin – not widely used due to resistance – can cause ototoxicity
To decrease resistance, newer drugs contain a combination of Rifampin and isoniazid OR Rifampin, isoniazid and
pyrazinamide.
Sputum samples are needed every 2 – 4 weeks.
Miliary TB – The organism invades the bloodstream and can spread to multiple organs with complications
including meningitis and pericarditis.
Laryngeal Cancer
Men are three times more likely to get this.
Tobacco and alcohol use are the primary risk factors. Their effects are synergistic when used in combination.
Superior Vena Cava Syndrome
Occurs from pressure placed on the vena cava by a tumor
