NUR 265 Exam 2 Study Guide
Lungs Physiology
2 Pleural, 1 attached to outside of lungs and 1 attached to inside of ribs.
Space between the 2 pleural is negative to atmosphere
When inhale becomes more positive and atmosphere more negative. Exhaling is passive
Most of lower lobes are posterior, must listen to lungs posteriorly
Breath sounds
Bronchial: High pitched & loud, normal in tracheal & larynx
Bronchovesicular: Moderate pitched & amplitude, normal over major bronchi
Vesicular: Low pitched & soft, like wind through trees, normal in lower lung fields
where smaller bronchioles & alveoli are.
Pulmonary Emboli (P 603)
Occlusion of portion of pulmonary artery by a blood clot – from venous circulation – lower
extremities or heart.
Causes ventilation-perfusion mismatch (V/Q) – Ventilated alveoli no longer perfused due to
clotted artery.
Risk Factors
Venous stasis (w/prolonged immobility); Central venous catheters; Surgery (NPO,
dehydrated, immobilized pts); Obesity; Advanced age; Hypercoagulability
(Platelets >400K and not enough fluids; sticky blood); Hx of thromboembolism.
Greatest r/f in the young is the combo of smoking and hormone based contraceptives.
Nursing Assessment Findings
Respiratory Classic Manifestations (Hypoxia drives all s/s)
Dyspnea (sudden onset); Chest pain (sharp & stabbing); Apprehension,
restlessness; Feeling of impending doom; Cough; Hemoptysis (blood in
sputum).
Respiratory Signs
Pleural friction rub (scratching sounds from pleura rubbing together &
pain on deep inspiration); Tachypnea; Crackles (or normal); S3 or S4;
Diaphoresis; Low grade fever; Petechiae over chest and axillae; Decreased
arterial oxygen saturation (SaO2)
Many pts w/ a PE do not have “classic” sx (i.e. hypoxia), but instead have vague sx
resembling the flu (n/v & general malaise)
Cardiac Manifestations
Decreased tissue perfusion: tachycardia, JVD, Syncope (loss of
consciousness), Cyanosis, & Hypotension.
In patients with r/f for PE, JVD (RSHF), syncope (decreased blood flow to brain),
cyanosis (severe hypoxia) and hypotension together, NEED RAPID RESPONSE
TEAM CALLED. HAVE HELP ON WAY B4 O2 APPLIED
When pt has sudden onset of dyspnea, chest pain, and/or hypotension, immediately
notify Rapid Response Team. Reassure pt. and elevate HOB. Prepare for O2
, therapy and ABG analysis
Saddle Emboli – Embolism at split of pulmonary artery that blocks both branches to the
lungs
Medical Dx
Chest X-ray – May show PE if large but will help r/o other things
CT scan – Most often used to dx PE
TEE (Transesophageal Echocardiography) – See if there are clots in the atria
Ventilation Perfusion scan (V/Q)
Considered if pt is allergic to contrast dye done w/CT scan
Radioactive substance to see if air is getting into the alveoli; injected into
blood to look at clot and can also detect pneumothorax. Done 2x
ABGs
Respiratory Alkalosis FIRST from hyperventilation
THEN Respiratory Acidosis from shunting
• Shunting of blood from the right side of the heart to the left side w/o
picking up O2 from lungs
– causes PaCO2 level to rise resulting in respiratory acidosis.
LATER Metabolic Acidosis & lactic acid buildup from tissue hypoxia
, Even if ABGs & Pulse Ox shows hypoxemia it is not enough to dx PE alone as
PE is not the only cause of hypoxemia.
Medical Management
GIVE O2, IV FLUIDS, INOTROPES (DOBUTAMINE/MILRINONE)
Oxygen therapy to maintain O2 sat at 95% or patient baseline
Hypotension - Tx w/ IV fluids (isotonic) & Inotropes (Dobutamine/Milrinone,
make heart contract more forcefully); vasopressors (norepi, epi, dopamine)
when hypotension persists after fluids.
Anticoagulation w/ Heparin drip – Goal is PTT 1.5-2.5 x normal (60-70 sec) = 90-175
sec
Minimize growth of existing clots and prevent new ones
Antidote Protamine Sulfate
Do not use w/salicylates (Aspirin)
Convert to Warfarin when stable – On 3rd day of Heparin use, overlap – INR target 2-3
(0.9-1.2 normal)
Antidote – Vit K – phytonadione (Mephyton)
Teach pts to avoid foods high in K (leafy dark green vegis, herbs, spring
onions, Brussel sprouts, broccoli, cabbage, asparagus, potatoes, &
winter squash).
Enoxaparin or dalteparin
Fibrinolytic (tPA) to tx massive PE or hemodynamic instability
Antidotes – clotting factors, FFP, & aminocaproic acid (Amicar)
Dissolve the clot itself
Embolectomy – surgical removal of the embolus – When tPA can’t be used or for
massive PE w/shock
Inferior Vena Cava Filter – to prevent DVTs from moving to the lungs
**Bleeding precautions with all blood thinners
Prevent injury to pt on anticoagulation therapy
Use lift sheet; firm pressure on needle stick for 10 minutes; Apply ice to
trauma areas; Avoid trauma to rectal tissues; no razor (electric only); soft-
bristled toothbrush; NO floss; Not blow nose forcefully; shoes with firm soles;
Assess IV sites q4 hrs for bleeding, measure abd girth q8 hrs – internal
bleeding
Nursing Management
Monitor for hypoxemia & respiratory compromise every 1-2 hrs.
VS, lung sounds, cardiac & respiratory status, & urine output (bc hypotensive
can cause AKI)
Elevate HOB to high fowlers if BP tolerates.
Obtain venous access and monitor heparin drip/LMWH/Coumadin
Pain and anxiety management w/morphine (vasodilator) – O2 1st then other things b4
morphine.
Communication is critical in allaying anxiety. Acknowledge the anxiety
& pt perception of a life- threatening situation. Stay with them, speak
calmly, and clearly, providing assurances.
Bleeding precautions, oral care – especially if mouth breather.
Prevention Measures
,
Measures that prevent venous stasis and VTE
Passive and active ROM for postop & immobilized pts
Post-op ambulation ASAP
SCDs or Plexipulse compression – for prevention, not for active DVT
Pt repositioning q2 hrs
Low dose anticoagulant & antiplatelet meds
Smoking cessation (especially females on hormone based contraceptives) bc increases
risk for DVTs
Traveling – drink plenty of H2O, change positions, avoid crossing legs, get up and move
every 1hr for 5 min.
NANDA Diagnoses
Impaired Gas Exchange; Acute Pain, Anxiety; Risk for Bleeding (when on treatment)
Pleural Effusion (P 504-505)
Collection of fluid (too much) in the pleural space – clear transudative, or exudative (outside the
lungs)
Cleat transudative – similar to fluid normally present in pleura space
Exudative – Excess protein, blood, or evidence of inflammation or infection (white,
green, cloudy is bad)
Can cause pleurisy sx
Pleural friction rub, scratching sounds caused by inflamed pleura rubbing together, pain
on deep inspiration.
Lungs Physiology
2 Pleural, 1 attached to outside of lungs and 1 attached to inside of ribs.
Space between the 2 pleural is negative to atmosphere
When inhale becomes more positive and atmosphere more negative. Exhaling is passive
Most of lower lobes are posterior, must listen to lungs posteriorly
Breath sounds
Bronchial: High pitched & loud, normal in tracheal & larynx
Bronchovesicular: Moderate pitched & amplitude, normal over major bronchi
Vesicular: Low pitched & soft, like wind through trees, normal in lower lung fields
where smaller bronchioles & alveoli are.
Pulmonary Emboli (P 603)
Occlusion of portion of pulmonary artery by a blood clot – from venous circulation – lower
extremities or heart.
Causes ventilation-perfusion mismatch (V/Q) – Ventilated alveoli no longer perfused due to
clotted artery.
Risk Factors
Venous stasis (w/prolonged immobility); Central venous catheters; Surgery (NPO,
dehydrated, immobilized pts); Obesity; Advanced age; Hypercoagulability
(Platelets >400K and not enough fluids; sticky blood); Hx of thromboembolism.
Greatest r/f in the young is the combo of smoking and hormone based contraceptives.
Nursing Assessment Findings
Respiratory Classic Manifestations (Hypoxia drives all s/s)
Dyspnea (sudden onset); Chest pain (sharp & stabbing); Apprehension,
restlessness; Feeling of impending doom; Cough; Hemoptysis (blood in
sputum).
Respiratory Signs
Pleural friction rub (scratching sounds from pleura rubbing together &
pain on deep inspiration); Tachypnea; Crackles (or normal); S3 or S4;
Diaphoresis; Low grade fever; Petechiae over chest and axillae; Decreased
arterial oxygen saturation (SaO2)
Many pts w/ a PE do not have “classic” sx (i.e. hypoxia), but instead have vague sx
resembling the flu (n/v & general malaise)
Cardiac Manifestations
Decreased tissue perfusion: tachycardia, JVD, Syncope (loss of
consciousness), Cyanosis, & Hypotension.
In patients with r/f for PE, JVD (RSHF), syncope (decreased blood flow to brain),
cyanosis (severe hypoxia) and hypotension together, NEED RAPID RESPONSE
TEAM CALLED. HAVE HELP ON WAY B4 O2 APPLIED
When pt has sudden onset of dyspnea, chest pain, and/or hypotension, immediately
notify Rapid Response Team. Reassure pt. and elevate HOB. Prepare for O2
, therapy and ABG analysis
Saddle Emboli – Embolism at split of pulmonary artery that blocks both branches to the
lungs
Medical Dx
Chest X-ray – May show PE if large but will help r/o other things
CT scan – Most often used to dx PE
TEE (Transesophageal Echocardiography) – See if there are clots in the atria
Ventilation Perfusion scan (V/Q)
Considered if pt is allergic to contrast dye done w/CT scan
Radioactive substance to see if air is getting into the alveoli; injected into
blood to look at clot and can also detect pneumothorax. Done 2x
ABGs
Respiratory Alkalosis FIRST from hyperventilation
THEN Respiratory Acidosis from shunting
• Shunting of blood from the right side of the heart to the left side w/o
picking up O2 from lungs
– causes PaCO2 level to rise resulting in respiratory acidosis.
LATER Metabolic Acidosis & lactic acid buildup from tissue hypoxia
, Even if ABGs & Pulse Ox shows hypoxemia it is not enough to dx PE alone as
PE is not the only cause of hypoxemia.
Medical Management
GIVE O2, IV FLUIDS, INOTROPES (DOBUTAMINE/MILRINONE)
Oxygen therapy to maintain O2 sat at 95% or patient baseline
Hypotension - Tx w/ IV fluids (isotonic) & Inotropes (Dobutamine/Milrinone,
make heart contract more forcefully); vasopressors (norepi, epi, dopamine)
when hypotension persists after fluids.
Anticoagulation w/ Heparin drip – Goal is PTT 1.5-2.5 x normal (60-70 sec) = 90-175
sec
Minimize growth of existing clots and prevent new ones
Antidote Protamine Sulfate
Do not use w/salicylates (Aspirin)
Convert to Warfarin when stable – On 3rd day of Heparin use, overlap – INR target 2-3
(0.9-1.2 normal)
Antidote – Vit K – phytonadione (Mephyton)
Teach pts to avoid foods high in K (leafy dark green vegis, herbs, spring
onions, Brussel sprouts, broccoli, cabbage, asparagus, potatoes, &
winter squash).
Enoxaparin or dalteparin
Fibrinolytic (tPA) to tx massive PE or hemodynamic instability
Antidotes – clotting factors, FFP, & aminocaproic acid (Amicar)
Dissolve the clot itself
Embolectomy – surgical removal of the embolus – When tPA can’t be used or for
massive PE w/shock
Inferior Vena Cava Filter – to prevent DVTs from moving to the lungs
**Bleeding precautions with all blood thinners
Prevent injury to pt on anticoagulation therapy
Use lift sheet; firm pressure on needle stick for 10 minutes; Apply ice to
trauma areas; Avoid trauma to rectal tissues; no razor (electric only); soft-
bristled toothbrush; NO floss; Not blow nose forcefully; shoes with firm soles;
Assess IV sites q4 hrs for bleeding, measure abd girth q8 hrs – internal
bleeding
Nursing Management
Monitor for hypoxemia & respiratory compromise every 1-2 hrs.
VS, lung sounds, cardiac & respiratory status, & urine output (bc hypotensive
can cause AKI)
Elevate HOB to high fowlers if BP tolerates.
Obtain venous access and monitor heparin drip/LMWH/Coumadin
Pain and anxiety management w/morphine (vasodilator) – O2 1st then other things b4
morphine.
Communication is critical in allaying anxiety. Acknowledge the anxiety
& pt perception of a life- threatening situation. Stay with them, speak
calmly, and clearly, providing assurances.
Bleeding precautions, oral care – especially if mouth breather.
Prevention Measures
,
Measures that prevent venous stasis and VTE
Passive and active ROM for postop & immobilized pts
Post-op ambulation ASAP
SCDs or Plexipulse compression – for prevention, not for active DVT
Pt repositioning q2 hrs
Low dose anticoagulant & antiplatelet meds
Smoking cessation (especially females on hormone based contraceptives) bc increases
risk for DVTs
Traveling – drink plenty of H2O, change positions, avoid crossing legs, get up and move
every 1hr for 5 min.
NANDA Diagnoses
Impaired Gas Exchange; Acute Pain, Anxiety; Risk for Bleeding (when on treatment)
Pleural Effusion (P 504-505)
Collection of fluid (too much) in the pleural space – clear transudative, or exudative (outside the
lungs)
Cleat transudative – similar to fluid normally present in pleura space
Exudative – Excess protein, blood, or evidence of inflammation or infection (white,
green, cloudy is bad)
Can cause pleurisy sx
Pleural friction rub, scratching sounds caused by inflamed pleura rubbing together, pain
on deep inspiration.
