NR324 EXAM 1 KEY CONCEPTS(PERFECT FOR QUICK EXAM STUDY) 2021/22 UPDATE

NR324 EXAM #1 CONCEPT REVIEW


*Remember, this is a supplemental tool to to remove pleural fluid, or instill medication.
help in your studies!!!!! OBTAIN CHEST X-RAY AFTER
PROCEDURE TO R/O
Assess for Allergies/use of anticoagulants PNEUMOTHORAX. - can happen up to
with All procedures and obtain Consent. 24hr afterwards.
Remove dentures if applicable prior to Measure fluid after procedure, label
specimens at bedside.
procedure. Maintain NPO status
AMOUNTOF FLUID IS LIMITED TO 1L
according to order. Admin pre-procedure AT A TIME TO PREVENT RE-
medications. EXPANSION PULMONARY EDEMA.
Indications:
Procedures (define & know nurse’s role)  HF
Bronchoscopy- visualization of the bronchi  Cirrhosis
with the aid of a fiberoptic scope for  Nephritic syndrome
diagnostic or treatment purposes. Mild fever  Hypoproteinemia
for less than 24hr is expected as is small  Exudates
amount of blood tinged sputum. Oral  Empyema
hygiene.  Pneumonia
Client EducationGargle with salt water or  Trauma- crushing, penetrating
lozenges can help sore throat. Presentation: s/s
 Fluid in pleural space compressing lung
tissue- SOB
PRE-OP- Obtain Consent and NPO 6-12hr  Dull percussion
before.  Decreased chest wall expansion
Give sedative as ordered.  Pain- other abnormal breath sounds
POST OP- Keep NPO until gag reflex
returns. PRE-OP- Explain procedure and obtain
Monitor for recovery from sedation consent.
Blood tinged mucus can be expected. If DURING- typically in patients room so
biopsy was performed monitor for provide privacy. Position patient upright
hemorrhage and pneumothorax with elbows on an overbed table and feet
supported. Tell patient not to talk or cough
CT scan- Diagnosis of suspicious lesions during procedure.
difficult to assess by conventional x-ray. POST-OP- Observe for s/s of hypoxia and
PRE-OP- Evaluate renal function. Assess for pneumothorax. Auscultate all lung fields and
allergy to shellfish because of iodine in encourage deep breaths to expand lungs.
contrast. Possibly NPO 4h before, check Send labeled specimen to lab for analysis.
order. Sputum studies-
DURING- Communicate to patient that Types: Acid Fast= tests for acid fast bacilli
media may cause a feeling of warmth and such as Mycobacterium tuberculosis. In a
flushing. Caution about importance of rapid test sputum is spread thinly on a slide
staying still. and treated with fluorochrome stain to be
POST-OP- Encourage fluids to avoid renal examined under a microscope for AFB.
problems with contrast Culture for AFB may take up to 6 weeks.
Thoracentesis- (Sterile) Obtaining
specimen of pleural fluids for diagnosis, or

, NR324 EXAM #1 CONCEPT REVIEW


C&S= Diagnose bacterial infection and  Continuous VS monitoring- at least Q4
select appropriate antibiotic or evaluate post op
treatment. Specimen is collected sterilely  Check water seal Q2h
and results typically take 48-72 hours.  Document hourly for first 24hr.
Afterwards Q8 marking container
Cytology= Determines the presence of  Report >70mL/h
abnormal cells that may indicate cancer. A  Assess regulator dial and ensure at
single sputum specimen is collected in a prescribed level
special container with a fixed solution.  Ensure tidaling in in the water chamber
 Continuous bubbling in SUCTION
Chest Tube chamber ONLY
First Chamber- Drainage collection  Have two hemostats, sterile water,
Second chamber- Water seal (psi/ -20cm occlusive dressing at bedside
H2O; level of water determines suction If chest tube comes out, is disconnected
psi.)– created by adding sterile fluid to 2cm accidently, or breaks, instruct patient to
line. Allows air to exit on exhalation and exhale as much as possible and cough to
stops air from entering the lungs with remove air from pleural space. If tube is
inhalation. compromised, immerse in sterile water. If
Third chamber- suction control (wet or dry) removed, apply sterile gauze.
INDICATIONS:
 Pneumothorax Gram Stain=Allows for classification of
 Post-op chest drainage – i.e. Open heart bacteria as ither gram positive or gram
 Hemothorax negative to be used as therapy guide until
 Pleural Effusion culture and sensitivity results are complete.
 Pulmonary Empyema- pus in pleural DURING- Obtain specimen early in the
cavity morning after mouth care because secretions
Client presentation: collect during the night. Have patient
 Dyspnea expectorate sputum into a container after
 Distended neck veins deep breathing and coughing deeply. If
 Hemodynamic instability unsuccessful, try increasing oral fluid intake
 Pleuritic pain unless restricted. Sputum can be collected in
 Cough sterile container by using trap via ET tube or
 Absent/reduced breath sounds aspirating from trachea. If patient cannot
 Dullness/ flat percussion on affected produce specimen, a bronchoscopy may be
side needed.
 Asymmetrical chest mvmt.
Nurse Management: Central venous access devices (CVAD):
 Consent Catheters placed in subclavian or jugular
 Assure client breathing will improve vein for people who need frequent access to
 Assist to semi-fowlers/ supine the vascular system.
 Prepare drainage system (fill water Indications for use include:
chamber)  Plasmapheresis- Autoimmune Disorders
 Administer pain medication per order  multiple blood draws for diagnostic
 Prep insertion site tests, infusion of blood
 Place below patient’s chest and ensure  Ultrafiltration- Heart Failure
no coiling measuring of central venous pressure