Other

I am looking at a q right now that asks you to distinguish between chronic and acute changes in a
patient, and potential vs actual problems. Wow, be sure to use that kind of thinking, in addition to
other question-strategies we have talked about

Remember safe delegation to and scope of practice for LPN, UAP

Remember to use the nursing process FIRST when looking at choices of things to do

Remember ABCs

Significance of elevated C reactive protein, erythrocyte sedimentation rate (sed rate/ESR)

● C reactive protein
o Measures inflammation
▪ May be done with or instead of ESR
▪ More sensitive to inflammatory changes than ESR
▪ Can also detect infection anywhere in the body
o An inflammatory marker associated with increased risk for cardiovascular inflammation
and death
o Raised in patients with DM
● ESR
o Also called “sed rate”
o Measure how blood cells fall through plasma
▪ Measure acute phase reactants that occur with inflammation
o Indicator of inflammation
▪ Confirms inflammation or infection anywhere in the body
▪ The more severe the disease gets the higher it goes
o Normal
▪ Male- up to 15
▪ Female- up to 20
o Elevated in
▪ Inflammatory disease
● RA, SLE, PMR, temporal arteritis
▪ Bacterial infections
▪ Severe anemias
o Effectiveness of therapy is often associated with a decrease in this value
o From class notes
▪ If bacterial pericarditis then will have increased sed rate

Hepatic and biliary disorders

Lab changes associated with pancreatitis, cirrhosis, hepatic encephalopathy, heart failure

● Pancreatitis
o Acute
▪ Labs
 ● Amylase, Lipase
o Amylase earlier
o Lipase more specific
o ‘the aces are high’
▪ massive fluid shifts
● crystalloid and colloids
▪ electrolytes
● *-low Ca++
● - potentially low K+, Mg++
▪ Glucose may be high
● may or may not be making insulin gtt?
▪ May have elevated liver enzymes
▪ May have elevated leukocytes
● Elevated ESR
● Elevated C reactive protein
▪ Increased bilirubin
o Chronic
▪ Fat in stool
▪ Normal to moderate lipase/amylase
▪ May have elevate bilirubin and liver enzymes
▪ May have DM increased BG
● Cirrhosis

Normal liver functions Result of liver dysfunction

Filters toxins, bacteria from blood Body exposure to bacteria, toxins

Produces bile salts Can’t absorb fats, fat soluble vitamins

May lose weight

Eliminates bilirubin (from dead RBCs) Jaundice and itching

Metabolism of hormones Alterations in sex characteristics, adrenal

hormone excesses

Stores, breaks down glycogen Hypoglycemia

Fat metabolism Too low cholesterol

Protein metabolism Low albumin, elevated ammonia

Clotting factor synthesis Bleeding

Vitamin and mineral storage Deficiencies

Lab Cirrhosis Notes:

Aspartate aminotransferase (AST) ‘liver enzymes’ Indicate liver stress

Alanine aminotransferase (ALT) ELEVATED As liver deteriorates, ALT/AST will

decline- not enough tissue to make
them

Alkaline phosphatase (Alk Phos) Elevated (but lots of things can cause that)

Indirect bilirubin (product of broken ELEVATED Liver can’t process and excrete it
down RBC)

Serum protein/Albumin LOW Liver can’t produce albumin, and

protein lost in ascites fluid

Coags (PT, INR) ELEVATED Coagulopathatic

Also Thrombocytopenic

Liver is not making precursors

NH4 (ammonia) (from protein ELEVATED Can’t detoxify

metabolism)

● Hepatic encephalopathy
o Increased NH4 levels
o One of the jobs of the liver is to handle the ammonia (NH4) that is a breakdown product
of protein metabolism. IF the liver is not working, ammonia may build up in the brain
and cause confusion -> coma.
o Normal NH4 level is 15-110 but there is some variation by lab.
o Hepatic encephalopathy
● Heart failure
o Risks
▪ Blood pressure equal to or higher than 130/85 mmHg
▪ Fasting blood sugar (glucose) equal to or higher than 100 mg/dL
▪ Large waist circumference (length around the waist):
● Men - 40 inches or more
● Women - 35 inches or more
 ▪ Low HDL (good) cholesterol:
● Men - under 40 mg/dL
● Women - under 50 mg/dL
▪ Triglycerides equal to or higher than 150 mg/dL
o Labs
▪ No test for HF
▪ B-type natriuretic peptide (BNP)
● Elevated when the ventricles are stretched
● Normal <100 pg/ml
▪ Lipid panel
▪ CBC, electrolytes
What is Cullen’s and Grey Turner signs and what do they mean

● S/S of acute pancreatitis

o I don’t think chronic
● From leaking of pancreatic enzymes
● Grey Turner
o Can be seen in ectopic pregnancy also
o Red ecchymosis on flanks

o
● Cullen’s signs
o Ecchymosis around belly button in shape of C

o
Care for acute pancreatitis

● Inflammation of pancreas
o Pancreatic enzymes get activated inside pancreas
▪ Autodigestion
 ▪ Release of inflammatory mediators
● SIRS, MODS, remote organ injury
● Endo/exocrine dysfunction
● 2 main causes
o Gallstone
o Alcohol
● Severity
o 80% mild
▪ Self limiting
o 20% necrotizing
▪ Organ failure, sepsis, death
● S/S
o Main symptom is pain
▪ mid epigastric or LUQ
▪ Intense and continuous
▪ Worse when lying supine
o Hypocalcemia when acute
o Hypoactive bowel sounds
o Belly pain/guarding/distention
o Grey Turner
▪ Can be seen in ectopic pregnancy also
▪ Red ecchymosis on flanks
o Cullen’s signs
▪ Ecchymosis around belly button in shape of C
● Dx
o S/S
o Labs
▪ Amylase, Lipase
● Amylase earlier
● Lipase more specific
● ‘the aces are high’
o Ultrasound
o ERCP*
▪ Scope from mouth that goes down GI
▪ Informed consent
▪ Visualize the liver, gall bladder, bile ducts
▪ Conscious sedation
▪ NPO 6 hrs
▪ Dentures out!
▪ NPO until gag returns
● Risk of aspiration
● Position up and on side
▪ Risk of perforation
● Monitor for
o CT
▪ *gold standard
o Hypocalcemia?
● Medical priorities
o Fluids
▪ massive fluid shifts
● crystalloid and colloids
▪ electrolytes
● *-low Ca++
● - potentially low K+, Mg++
▪ glucose
● may or may not be making insulin gtt?
▪
o Nutritional support
▪ There are now new recommendations- still not updated on NCLEX though
▪ Old
● NPO, NG suction
● Rest pancreas
● TPN
● Feed when enzymes normalize
▪ New
● Gastric or jejunal feeds
o Less sepsis, metabolic complications
● No NG suction unless vomiting, distention
● Do this now because without anything in mucosal barrier starts to break
down a little
o Do trickle feeds (10ml/hr)
o Keeps gut healthy but does not trigger pancreas
o See if pt can tolerate it
o Systemic complications
▪ Shock
● Nursing care
o Prevent and treat shock
o Reduce pancreatic stimulation and maintain nutrition
o Control pain; promote comfort
o Prevent or minimize complications
o Pancreatic rest
▪ NPO if ordered
▪ NG suction
▪ TPN or enteral feed if tolerated
▪ Monitor Blood Glucose
▪ When tolerated (as inflammation begins to go down)
● High protein, high calorie, low fat
● Bland
● Avoid bowel stimulants
● (no caffeine)
o Comfort/pain
▪ Opioids
● Very painful, will most likely start with this
▪ Positioning
 ● Knee chest
● Side lying
▪ Relaxation techniques
● In addition, not instead of meds
● anxiolysis
Reason for doing paracentesis, possible complications after

● Often done when so much ascites from cirrhosis

● Paracentesis
o Drainage for ascites
o Not curative
▪ Fluid will reaccumulate
o Removal of fluid for diagnostic or therapeutic purposes
o To allow patient to breathe easier
o Ascites, evaluate abdominal injury, prevent peritoneal rupture, diagnostic purposes
o Nursing care
▪ Informed consent
▪ Have patient PEE!
▪ Weight before and after
▪ Position patient at 45-60 degrees
● Lets fluid settle
▪ Ultrasound maybe
● Looking for big pocket
▪ Assess for
● Do not worry about bleeding
● Worry about fluid shifts
● Monitor for hypotension

Cardio

Signs of pulmonary edema and what it is

● Left sided Heart failure

o impaired pumping ability of left side of heart
▪ inability of the heart to push blood forward
o blood backs up into pulmonary circulation
▪ L side of heart cant push blood to body🡪backs up to pulmonary circulation
o elevated pressure & congestion in pulmonary veins/capillaries
▪ backs up to pulmonary circulation🡪 blood in vasculature in lungs🡪 elevated
pressure/increased hydrostatic pressure in lungs🡪 fluid goes into lungs🡪
pulmonary edema🡪 fine crackles in bases (end of inspiration) 🡪 as worse higher
in lungs
● note ronchi is not hear in HF it is heard with mucus and is on inspiratory
and expiratory
● S/S of pulmonary edema
o Crackles upon auscultation of lungs
 ▪ End of inspiration
o Cough
o Pink frothy sputum
o Dyspnea on rest
o Disorientation or acute confusion
o Tachycardia
o Hyper or hypotension
o Reduced UOP
o PVC ir other arrythmias
o Anxiety, restlessness, lethargy

Distinguish between right and left heart failure

● Cardiac remodeling
o When heart cannot do its job
▪ Cannot push blood to body
o Walls get stressed, stiff/occluded blood vessels, stiff from longterm inflammation
▪ Heart has to squeeze harder and use more O2
● imbalance in amount of O2 available and O2 needed
o causes ischemia of heart, inflammation, less blood going to
body
▪ Less blood to Kidneys so RAAS-
● hold onto sodium- hold into water- more blood- more work for heart-
raises BP- more stress cant do what its supposed to do
● Why do symptoms appear
o Chronic inflammation from the heart being over stressed
▪ Ventricles are much smaller
o Downward spiral that will end in death if not stopped
o Heart muscle is unable to pump adequately
o Blood supply not enough to meet metabolic needs
▪ Loss or dysfunction of cardiac muscle
▪ Congestion of tissues, dilation of chambers
▪ Inability of ventricle to fill or eject blood
● Left sided Heart failure
o impaired pumping ability of left side of heart
▪ inability of the heart to push blood forward
o blood backs up into pulmonary circulation
▪ L side of heart cant push blood to body🡪backs up to pulmonary circulation
o elevated pressure & congestion in pulmonary veins/capillaries
▪ backs up to pulmonary circulation🡪 blood in vasculature in lungs🡪 elevated
pressure/increased hydrostatic pressure in lungs🡪 fluid goes into lungs🡪
pulmonary edema🡪 fine crackles in bases (end of inspiration) 🡪 as worse higher
in lungs
● note ronchi is not hear in HF it is heard with mucus and is on inspiratory
and expiratory
o S/S
▪ Fatigue, activity intolerance,
 ▪ shortness of breath, cough,
▪ orthopnea
● cannot lay flight without SOB
● need pillows
▪ Pulmonary Congestion
● Right sided heart failure
o impairment of pumping ability on right side of heart
▪ in ability of the heart to push blood forward
o Backup of blood followed by congestion and elevated pressure in systemic veins and
capillaries
▪ Blood cannot be pushed into pulmonary circulation 🡪 systemic congestion
o Could be from
▪ Damage in R side of heart
▪ Corpulmonale
● COPD
▪ Most common cause:
● left-sided dysfunction
o S/S
▪ Symptoms result from volume overload leading to ascites and edema
▪ bloating and discomfort, with poor appetite and sometimes nausea/ vomiting
▪ JVD, pedal edema
▪ paroxysmal nocturnal dyspnea (PND)
● waking up in acute pulmonary congestion
● but happens because when systemic fluid goes into blood when laying
down because of gravity then into lung
● can lay down flat but then wake up with pulmonary congestion
▪ Systemic congestion
● Dx
o No single test to establish diagnosis of heart failure
o Full history
▪ Onset, severity, and symptoms
▪ Presenting symptoms typically volume overload and low cardiac output
▪ Dyspnea is most common presenting symptom
▪ DOE is dyspnea on exertion
● Activity that should not cause person to be SOB is making them SOB
▪ Thorough family history
▪ Functional assessment:
● What can you do now?
● What could you do before?
● Baseline ability to complete ADLs
● NYHA class
o Used in HF to describe how bad it Is for pt
o How much activity it takes to make you symptomatic (chest pain
or SOB)
 o
o Physical examination
▪ Assess for signs of volume overload, decreased cardiac output
● Overload-
o auscultate lungs, edema, ascites, JVD, hepatomegaly (should
not feel liver passed ribs)
● Low CO-
o Weak pulses, cool extremities
o hypertension
●
▪ As cardiac output deteriorates:
● Confused/disoriented patient
● Forgetfulness and loss of concentration
● Extreme wt loss possible
▪ Crackles upon auscultation of lungs
● End of inspiration
● Cough
● Pink frothy sputum
o Show pulmonary edema
▪ Cloudiness on x-ray
▪ Dull breath sounds
▪ Tachypnea
▪ Apical pulse displaced laterally
▪ S3, S4,
● Extra heart sounds
o Laboratory and diagnostic testing
▪ Labs
● No test for HF
● B-type natriuretic peptide (BNP)
o Elevated when the ventricles are stretched
o Normal <100 pg/ml
● Lipid panel
● CBC, electrolytes
▪ Echocardiogram
▪ Ejection fraction
● How much blood is squeezed out of ventricle compared to how much
was in it
 ● Never 100%
● 60-70% is normal
o Stress testing
▪ Pt walks on treadmill. Cardiac fxn monitored
● Oxygenation, EKG, BP
● Stopped when maximal HR achieved
o More in shape the higher it will be
o Usually around like 160
▪ NPO 2-4 hrs
● Person gets exhausted don’t want them to throw up
● But also warn them to drink water before NPO- don’t want them to get
dehydrated
▪ No tobacco, alcohol, caffeine before
● Don’t want stimulants
▪ If not tolerated, may have chemical stress test instead
● For people in wheel chair
● Inotropic agent
▪ May use Thallium
● Radionucleotide for imaging cardiac perfusion
● To see which part of heart is getting perfused

Signs of reduced cardiac output

● Low cardiac output

o Can have RHF/LHF and low cardiac output- or may have one- 3 separate things, often
happen together but can have any of these alone
o One way or another not getting blood to body
▪ Could be
● Not enough fluid
● Heart is weak
● Blood vessels are very vasoconstricted
▪ Body says it is ischemic due to lack of flow
● Get shunting of blood
o No blood to fingers, toes, kidneys
o Just like with anemia
o S/S
▪ Cold extremities
● vasoconstriction
▪ Low BP
▪ Weak pulses
▪ Cerebral hypoxia?
● May see confusion if not enough blood to brain
▪ Slow cap refil?????
● don’t really have with HF
o Tells more about perfusion the oxygenation
Review TTE (transesophageal echocardiogram) and nursing care
 ● Examines cardiac function and structure
o Ultrasound placed behind the heart either in esophagus or stomach
● Preparation is similar to GI endoscopic examination

MAWDS teaching: weights

● Teaching how to manage HF at home

o MAWDS
o Medications
▪ Patients need to understand:
● Names of meds
● Time of day to take them
● Purpose
● What to do in case of missed doses and/or adverse reactions
▪ Work on this for compliance
● Plan strategies to increase long-term adherence and access to
medications
● Try to partner with patient, not dictate to them
● Give them written tool and ask to see it- or now there are apps
● Maybe bring meds in and ill fill, get fam to do, put next to tooth brush,
put near breakfast, ect
o Activity
▪ Needs to be responsible exercise program
● too much can cause heart ischemia, under not much benefit
● Have patient consult w/MD before starting
● Exercise prescriptions:
o Type, frequency, duration, intensity
▪ Optimal activity has significant benefits
● Want to increase myocardial oxygenation by creating more vessels
▪ Encourage responsible exercise program
● Cardiac rehab programs
o Underused, very good
▪ Assess and increase motivation
● Talk to them about benefits
▪ Laps in mall are great
 ▪
o Weight
▪ Important for patients to understand why they should weigh themselves daily
● Tell pt part of it is monitoring fluid status- to see if holding on to too
much or getting dehydrated
o Weight change = fluid change
o
● Weigh at same time, same clothes same scale
● Document
▪ Dry weight-
● weight for size they are when fluid is optimized-
● doctor will say this is dry weight-
● weight you should be if not gaining or losing fat- may change if losing or
gaining weight
▪ what to do if deviation from dry weight
● Instruct patients to call healthcare provider
o Weight increase 2 or more pounds overnight
o Weight increase more than 5 pounds in a week
o Weight decrease 5 or more pounds below goal weight
● Losing weight could be a good thing but still need to tell doctor
o It could also mean dehydration
▪ goal: to maintain euvolemia
● Mean you are keeping optimal fluid
o Diet
▪ Diuretics work best with low Na+ diet
● ingest <2 g of sodium daily
● don’t add salt to food
● calculate with labels on food
▪ If fluid status very unstable, fluid may be restricted
▪ Caution:Salt substitutes have potassium
 ● SOME patients need to watch this- who?
o People on potassium sparing diuretics (spirlactalom) and ACE-
inhibitors
o Or kidney failure
▪

▪ Diet for heathy weight loss

● There are approximately 3,500 calories in 1 pound of fat.
● To lose two pounds is deleting 7,000 calories.
● Healthy weight loss is a maximum of 2 pounds per week. (that’s 100 lbs
in a year)
● Thus a loss of 7,000 calories/wk would be deleting 1,000 calories per
day OR deleting 500 calories/d and adding exercise equivalent to 500
calories daily.
o Symptoms
▪ Patients should know how to track symptoms and when to call if symptoms
worsen
▪ What signs are expected?
● How can the patient handle them at home?
● Expect orthostatic hypotension, teach to change positions slowly
● Track- weight daily, how feeling in general
o Self care diary trackers
o You as nurse must check- if not they wont do it
▪ What signs are dangerous?
● Better call the MD
● Passing out
● SOB
 ● Angina
● Reduced exercise tolerance
● Coughing
● Weight gain/loss
● Weakness/GI changes
o Could be electrolyte issues (hypokalemia, hypercalcemia both
make you weak)
● Altered LOC

Signs of cardiac tamponade. How do you measure pulsus paradoxus

● Tamponade
o When fluid builds up inside pericaridum
o Squeezes heart
▪ Not letting blood in or out
o Symptoms
▪ reduced CO
● based on how reduced CO is
▪ Becks Triad
● No blood movement so congestion
● Muffled heart sounds
● hypotension
● JVD
▪ Narrowing blood pressure
● Narrowing pulse pressure until basically the same
● Shows cardiac stand still when the same- no blood going out
▪ Pulsus paradoxous
● Change in systolic based on inspiring or expiring
● Normally there is not much change
● This the difference is about 10 or more
● Hard to take exactly when breathing
● Easier to see with A line

What to assess for when valves on the left side of the heart are impaired vs those on the right side of
the heart

● 4 valves
o Remember their locations
 o
● Pressure is higher on L so more valve problems on left usually
● Causes
o Rheumatic disease
o Infective endocarditis
o HTN
● How a valve can be faulty
o Valvular Stenosis
▪ Inability of valve to close completely during systole
▪ Impedes FORWARD movement of blood
▪ hardening and thickening, not opening much, blood fitting through small
opening and heart has to work harder- chamber behind valve has to worker
harder- hypoxic and hypertrophy and less blood gets through and previous
chamber is more dilated- impedes forward movement
o Valvular regurgitation
▪ Results in backflow of blood through incompetent valve orifice into previous
chamber
▪ Increases BACKWARD movement of blood
▪ valve sags open- goes through but then comes back- backward motion- so
chamber before also has to work harder because more blood
o Both
▪ A chamber has to work harder, uses more O2, may become hypertrophic and/or
dilated
▪ Can lead to HF
▪ Basically both are different ways but lead to the same issue
● S/S depend on which valve and which disorder
o Mitral disease often associated with rheumatic heart disease
▪ Mitral stenosis
● L side of heart
● L atrium and ventricle
 ● blood from lungs cannot get to ventricle well- L atria has to work
harder- atrium gets full and backs up to the lungs- expect L heart
symptoms
▪ Mitral regurgitation
● L side of heart
● L atrium and ventricle
● blood from L ventricle moves backwards and into atria- L atria has to
work harder- atrium gets full and backs up to the lungs- expect L heart
symptoms
● Mitral valve prolapse!
▪ Most common complaint is dyspnea (pulmonary involvement)
o Aortic valve disease from aging/congenital or rheumatic disease
▪ Aortic valve stenosis
● L side of heart
● Aorta and ventricle
● Blood cannot get into aorta well- L ventricle has to work harder-
ventricle gets full and doesn’t work well
▪ Aortic valve regurgitation
● L side of heart
● Aorta and ventricle
● Blood moves back into ventricle from aorta- L ventricle has to work
harder- ventricle gets full and doesn’t work well
▪ Results in L heart dysfunction
o Tricuspid valve disease- stenosis is rare, regurg r/t pulmonary HTN
▪ Tricuspid stenosis
● R side of heart
● Atrium and ventricle
● blood from body cannot get to ventricle well- R atria has to work
harder- atrium gets full and backs up to the body- expect R heart
symptoms
▪ Tricuspid regurgitation
● R side of heart
● Atrium and ventricle
● blood from ventricle goes back into atrium- R atria has to work harder-
atrium gets full and backs up to the body- expect R heart symptoms
▪ Results in R heart failure
o Pulmonic valve disease rare
▪ Pulmonic stenosis
● R side of heart
● R ventricle and pulmonary artery
● Blood cannot get into lungs- R ventricle working harder and building up
then build up in R atrium then get R HF symptoms
▪ Pulmonic regurgitation
● R side of heart
● R ventricle and pulmonary artery
● Blood goes back into R ventricle- R ventricle working harder and
building up then build up in R atrium then get R HF symptoms
▪ R sided failure
 ▪ Decreases cardiac output
o So basically, know which side of the heart it is causes that sided HF s/s
o Already have to know S/S of R vs L
o

Recognize signs of cerebral hypoxia wherever you find it

● Confusion

Blood cells

Know normal values for platelets, WBCs, hemoglobin, hematocrit

Study Normals Why abnormal?

PT 10-13 seconds High- warfarin(Coumadin), cold

 Therapeutic is 1.5-2 times that Low ->excess Vit K

(15-20seconds)

PTT 30-40 sec High-> heparin, DIC, liver disease

Therapeutic is 1.5-2 times that

(~60-80seconds)

INR ~1 High->warfarin (Coumadin)

Therapeutic 2-3

What does it mean if there are a lot of band cells or blast cells or reticulocytes

● Reticulocytes
o Immature RBC
o In anemia
▪ Maybe be increased/decreased reticulocytes
● Very anemic with high reticulocytes
o Bone marrow responding to erythropoietin
o See high in sickle cell anemia
● Very anemic with low reticulocytes
o Something is broken- bone marrow or kidneys
● Band cells
o Immature neutrophils
o Also called segmented cells
o Look at shift to left
● Blast cells
o Immature leukocytes
o Seen in leukemia
● All of these immature cells not doing job well

Cause of polycythemia vera

● Polycythemia vera
o excess RBCs
o Assoc w/chronic hypoxia
▪ Familial or acquired
▪ COPD
● Low O2= erythropoietin- make more RBC- get too many
o Red skin, itching
o Blood clots
▪ Blood is thicker
o Tx:
 ▪ Wear O2
▪ Phlebotomy
● May take out blood and trash it

Symptoms of iron deficiency anemia, Care for anemia, and know what is different for different kinds of
anemia as well as what is the same

● Anemia
o Unifying feature of all anemia:
▪ CELL HYPOXIA
● Origin of symptoms
● Driver of nursing care
▪ Decreased hemoglobin, hematocrit, RBC count
▪ Triggered by
● Loss of blood
● Inadequate production of RBCs
● Increased destruction of RBCs
o Nursing care goals
▪ 1. prevent complications due to inadequate oxygenation
▪ 2. ID cause(s)
o Nursing assessment
▪ Past medical history
▪ Medications?
▪ Feeling tired? SOB?
▪ Black/bloody stool? Brown/red emesis?
▪ Surgery? Injury?
● Chronic wound?
o Inflammatory response not making RBC
▪ Family history?
▪ Risk factors
● Poor health maintenance behaviors
● Dietary assessment
o S/S
▪ Tissue hypoxia!
▪ Tachycardia
● Heart tries to help
▪ Shortness of breath
● Lungs try to get more O2
▪ Some tissues are more important so there is shunting of blood
● Vasodilation to
o Brain, spinal cord, heart
● Vasoconstriction to non-essential parts
o Extremities, kidneys, gut
● Pale skin, mucous membranes
● Cold extremities
● Pale nails- shows shunting
o Cap refill not effected shows perfusion?
 ▪ Fatigue
▪ Cyanosis? Angina?
▪ Confusion?
▪ Kidneys
● Not getting enough O2
● Will make erythropoietin to tell bone marrow to make more RBC
● Different then when not enough volume (cardiac)- this triggers renin
▪ Labs
● (H&H)
o Hematocrit (Hct)
▪ % if total blood volume that is RBCs
o Hemoglobin (Hgb)
o Reflect amount of RBCs in blood
▪ Too few -> anemia
● Decreased RBC count
● Decreased oxygen levels on arterial blood gas
● Maybe be increased/decreased reticulocytes
o Very anemic with high reticulocytes
▪ Bone marrow responding to erythropoietin
o Very anemic with low reticulocytes
▪ Something is broken- bone marrow or kidneys
o Nursing diagnosis
▪ Activity deficit
▪ Impaired gas exchange
▪ Self care deficit
▪ Deficient knowledge (maybe)
▪ Risk for falls!
● Iron deficiency
o Inadequate iron to make RBCs
▪ Not enough iron to make RBC so make tiny pale cells instead
o Cells are little and pale
▪ ‘Microcytic’
o Can happen for a few reasons
▪ Starvation,
▪ prolonged bleeding,
● cant recycle iron if bleeding out
▪ poor diet
▪ at risk groups
● Premenopausal women
● Pregnant women
● Persons from low socioeconomic backgrounds
● Older adults
● Individuals experiencing blood loss
o S/S
▪ Fatigue
▪ Swollen tongue
● May or may not
 ▪ pica/ice eating
● specific to iron
▪ Cold intolerance
▪ Spoon shaped nails
● Koilonychia
● In advanced not mild
▪ Telitis
● Small cracks near mouth
o Tx-
▪ Better foods, iron replacements
▪ Treat underlying cause
● Transfuse
● Improve diet
● Stop blood loss
▪ Treat symptoms
● Rest, warmth, oxygen
▪ Replace Iron
● Oral, parenteral supplements
o Z-track
● Dietary (meats, eggs, legumes, green leafy vegetables, etc)
o Chicken/white fish not a lot of iron
o Red meats have a lot
o Yok in eggs
o Raisins
▪ Activity intolerance
● Do not want someone to get really tired- big o2 deficit- bad things
happen to organs- periods of rest and activity
● Plan care to alternate periods of rest and activity to provide activity
without tiring the patient.
● Strive for a 1:3 rest/activity ratio;
o Do not do all activities in the morning then rest in afternoon-
spread things out
● Help them with ADLs
o Give them O2 and make them use less O2
● Allow rest times- sign on door
o Limit visitors, phone calls, noise, and interruptions by hospital
staff to reduce demands placed on patient.
● Monitor VS to evaluate activity tolerance.
● Monitor H&H as a guide to planning activities.
● Also don’t want them in bed 24/7
o Can make worse by losing muscle- need more energy for activity
● Megaloblastic anemia
o Big floppy RBC
o Pernicious anemia
▪ B12 deficiency
▪ Takes 2 years to exhaust stores
● Vegan diet
 ● Gut surgery/ileostomy/celiac disease
▪ Neurologic sx
● Parasthesias, ataxia, confusion
▪ Teaching:
● supplements, food sources
o Folic acid deficiency anemia
▪ Common causes
● Poor nutrition
● Malabsorption syndromes
● Drugs (anticonvulsants, anti TB)
o Methotrexate blocks folic acid
● Alcohol abuse and anorexia
● Loss during hemodialysis
▪ Teaching
● Nutritional education
o Green leafy vegetables
o Legumes/soybeans
o Liver
o Sunflower seeds
o Oranges
● Important during pregnancy
● Protects against neural defects
o Spina bifida
o Anacephaly
o S/S
▪ Sx of anemia plus
▪ beefy red, smooth tongue
▪ Anorexia, nausea
▪ Hyperpigmentation (color) on hands
▪ How to tell if pernicious or folate?
● Pernicious
o Neurological sx
● Folate
o Birth defects of offspring
● Distinguish with schilling test
● Anemia in chronic disease
o Can be from
▪ Infection
▪ Acute and chronic
▪ Chronic inflammation
▪ Cancer
▪ Protein/calorie malnutrition
▪ Renal insufficiency
o Basically using nutrition/products for other things
o Sx
▪ Often attributed to underlying disease Or psychological reaction
 ▪ Can get missed because often tired with chronic illness- attribute anemia s/s to
disease
▪ Important to do regular checking of H/H
o Tx
▪
Only give Iron if their ferritin levels are low
● Too much iron can be toxic
o Nursing care
▪ Monitor for sx of anemia in sick people
● Activity tolerance
● Skin, mucous membranes
● Breathing, cognition
▪ Monitor labs
▪ Keep patient safe!
● Hemoglobinopathies
o Genetic diseases
o Thalassemia- error in production of RBCs
▪ Alpha form- more mild
▪ Beta form- may be extremely severe/fatal
o Sickle Cell Disease
▪ Genetic disorder
▪ Any ethnicity, but primarily AA
▪ Both parents must be carriers
▪ Make defective hemoglobin
● Hemoglobin S
● RBCs die quicker (10-20 days)
o Higher levels of bilirubin
▪ Hopefully liver gets rid of but some probably gets
through
● RBCs are inflexible, can’t carry O2 efficiently, get stuck in vessels and
block blood flow to organs.
o Arteries- ischemia
o Veins- congestion
● Have higher number of reticulocytes, always making more
▪ Crisis
● Sickle cell crisis (vaso-occlusive) crisis is an emergency
o Pain, tissue hypoxia, splenic sequestration of blood
o s/p infection
● Causes
o Low temp
o Alcohol ingestion
o Hypoxia
o Infection
o Pregnancy
o High altitude
● Medical emergency
o Remember ABCs
o Oxygen
 o Rest
o Fluids/start IV
▪ 200mL/hr
o Treat PAIN
▪ Usually morphine because also vasodilator
o Monitor CONTINUALLY for infection
▪ Leg ulcers
▪ Lungs, urine
▪ worry of trigger of crisis
● Discharge teaching
o Avoid infections
▪ Wash hands, don’t go in crowds or sick people, get
vaccines, wear mask
o Drink 3-4 L daily
o Keep warm!
o Avoid strenuous activity
o Genetic counseling
▪ Will not help them but can help with family planning
o Call MD EARLY for illness
▪ Prophylactic Antibiotics for children
o Folic acid supplements
▪ Making cells faster so need more folate
▪ Nursing care
● Don’t want anything that can trigger
o Keep vasodilated, avoid hypoxia
▪ keep them warm (environment), increase fluids (keep
well hydrates, not too much), stop them from doing
things of vasoconstriction- stress, fever, being sick,
exercising and not replacing fluids, no smoking
(vasoconstriction and reduced O2) no stramineous
exercise
● Hemolytic anemia
o From
▪ early destruction of RBC
▪ From fragile cell membrane
▪ Unfavorable physiologic environment
● infection, certain meds, autoimmune disease, pregnancy, cancers,
toxins, septic
o Sickle cell anemia also this type
o S/S
▪ Jaundice
▪ hemoglobinuria (red-brown urine)
▪ spleen/liver enlargement
● spleen double time due to recycling
● liver working harder for precursors
▪ May result in acute renal failure if damaged RBCs occlude kidney tubules
o Nursing care
 ▪ Anemia care
▪ Risk for renal failure
● Monitor I&O
● Monitor fluid status
● Keep good flow through kidneys
▪ Itching (bilirubin)
● Prevent skin breakdown
● No hot water
▪ Pain interventions

Expected cell counts w/aplastic anemia

● Aplastic anemia
o Pancytopenia
▪ RBC, WBC and platelets low
o Cause
▪ Idiopathic/autoimmune
▪ Drugs/toxin
▪ Radiation

What kind of anemia results in jaundice

● Hemolytic anemias
o Sickle cell

What does losing your spleen put you at extra risk for?

● Recycles blood cells

o May not be getting iron??

Expected signs of DIC

● Disseminated intravascular coagulopathy

● Causes:
o Part of inflammatory response early system is coagulation/inflammation automatically
triggers clotting
▪ Too much inflammation= too much clotting
▪ A ton of micro clots
▪ Run out of clotting factors then bleed too much
o persistent activation of the clotting cascade
o Response to widespread triggers
o Infection, trauma, obstetric emergency, cancer
o Depletion of clotting factors
o Activation of the fibrinolytic system
● Stages
o 1.Excessive clotting
▪ Vague symptoms
▪ Microvasculature thrombosis
 ▪ Thrombi spread to affect the organs:
● Decreased consciousness
● Abdominal pain: GI tract occlusion
● Decreased urinary output
● Chest pain, respiratory difficulty
o 2.Excessive bleeding
▪ Bleeding: mucocutaneous and puncture sites
▪ As DIC progresses, bleeding in:
● GI tract → melena
● CNS → hemorrhagic stroke
● Heart → chest pain, shortness of breath
● Genitourinary tract → hematuria
● Hemodynamic shock from blood loss
● See blood coming from spots that were clotted like IV sites
● Lots of evidence of bleeding and low platelets
▪ Often not diagnosed until these symptoms
● Therapeutic management complex
o Really cannot do a lot, very sick
o Must treat underlying condition
▪ It will take like a week for platelets to go back to normal
o Priorities of care
▪ Implement bleeding precautions
▪ Maintain fluid balance
▪ Protect from injury
▪ Implement psychosocial support
● Warn family about bruising
o Administer, monitor
▪ Transfusion therapy
● Will need to replace platelets and clotting factors
● Oxygen therapy
Think about what you might see if someone had ‘occult bleeding’ =use your imagination

● Not visible
● Monitor for in thrombocytopenia

Keep neutropenia and thrombocytopenia straight in your head

● Neutropenia is low WBC

● Thrombocytopenia is low platelets
● Thrombocytopenia
o Protect from injury
o Handle patient carefully
▪ Lift sheets
▪ Avoid sheer in skin
▪ Watch elbows and ankles
o Avoid invasive things
o Bleeding precautions
▪ Not giving shots
 o Avoid all trauma
o Monitor for occult bleeding
● Neutropenia
o Low bacteria diet
▪ Nothing raw
● Raw or under cooked- 160* for meat- cant always tell from color (beef
oxidized looks brown)- measure temp
● Agricultural products- only eat stuff with peel but even better if not raw
o Avoid germ growth in environment
▪ Decrease bacteria in environment- don’t have them be cleaning, pick up dog
poop, cleaning out cat box, don’t work in garden
▪ Pets- mammals good still wash hands - some can add fungus to environment-
bad pets= reptiles and amphibians, fish, birds
o Hand hygiene
o Frequent bathing
▪ Axilla, groin 2x/day
▪ If too tired someone needs to do it for them
▪ Can become infected from own normal flora
o Check temp 2x/day
▪ (0.5 degree elevation significant)

Care for multiple myeloma, possible complications to anticipate and plan for

● Multiple myeloma
o Cancer of the marrow (B-cells)
▪ B lymphocytes
● Overproduce antibodies, cytokines
o ‘Bence Jones proteins’ is marker
o Monoclonal Ab, useless
▪ Not specific
▪ Not helping fight infection
o Inflammation in bone
▪ Can cause lessions
o S/S
▪ Destruction of bone
● ‘Swiss cheese bones’
● Areas of very thin bones due to lessions
● Tons of antibodies being formed in that area of the bone
▪ Hypercalcemia
● Calcium from the destroyed bone goes into blood
▪ Pain, pathologic fractures
● Pathologic fracture- fracture from very little stress
▪ Renal failure
● Immunoglobulins excreted through the kidneys and can cause kidney
failute
● Similarities
o Over production of a cell but not good-
 o normal function impaired-
o good cells get invaded by abnormal
o All interfere with normal production of blood cells
▪ -> bleeding, infection, fatigue
● Nursing care
o Fatigue
▪ Monitor H&H
▪ Use vs as marker of exercise tolerance
▪ Energy conservation strategies
● Prioritize activities
● Limit visitors prn
● Promote sleep
● Promote nutrition
▪ transfusions
● don’t give iron unless low iron
o Thrombocytopenia
▪ Protect from injury
▪ Handle patient carefully
● Lift sheets
● Avoid sheer in skin
● Watch elbows and ankles
▪ Avoid invasive things
▪ Bleeding precautions
● Not giving shots
▪ Avoid all trauma
▪ Monitor for occult bleeding
o Neutropenia
▪ Low bacteria diet
● Nothing raw
o Raw or under cooked- 160* for meat- cant always tell from
color (beef oxidized looks brown)- measure temp
o Agricultural products- only eat stuff with peel but even better if
not raw
▪ Avoid germ growth in environment
● Decrease bacteria in environment- don’t have them be cleaning, pick up
dog poop, cleaning out cat box, don’t work in garden
● Pets- mammals good still wash hands - some can add fungus to
environment- bad pets= reptiles and amphibians, fish, birds
▪ Hand hygiene
▪ Frequent bathing
● Axilla, groin 2x/day
● If too tired someone needs to do it for them
● Can become infected from own normal flora
▪ Check temp 2x/day
● (0.5 degree elevation significant)
o Monitor renal function
▪ ONLY FOR MM
 ▪ Acute to chronic
▪ BUN and creatinine
▪ Fluid retention
▪ E lytes
▪ Reduce Calcium
● Worry about kidney stones
● Hypercalcemia lso makes you weak and constipated
o Worry about falls
● Fluids, loop diuretics
o Want to pee it out
o Don’t give thiazide diuretic

Look up methotrexate and know what supplement the patient needs to take with it

● Folic acid deficiency anemia

o Folate= B9
o Common causes
▪ Poor nutrition
▪ Malabsorption syndromes
▪ Drugs (anticonvulsants, anti TB)
● Methotrexate blocks folic acid
▪ Alcohol abuse and anorexia
▪ Loss during hemodialysis
o Teaching
▪ Nutritional education
● Green leafy vegetables
● Legumes/soybeans
● Liver
● Sunflower seeds
● Oranges
▪ Important during pregnancy
▪ Protects against neural defects
● Spina bifida
● Anacephaly

What does a shift to the left tell you and what should you do if a patient has one

● Shift to the left

o Unusually large number of band cells
▪ Actual band cell cant do too much
▪ Those band cells will turn into neutrophils
▪ This is early indication of infection
● Before S/S
o Bone marrow stimulation
▪ Neutrophils are 1st responders
▪ Releases relatively immature, juvenile cells
▪ → WBC count goes up, reflecting juvenile cells
 ▪ Early indicator of infection in healthy person
o If they never had shift to the left
▪ WBC count remains normal or is lower
▪ Insufficient host defense, as in:
● Bone marrow disease
● Immune system insufficiencies
● Immunosuppressive therapies (e.g., chemotherapy)
o Nursing implications
▪ Assessment
● Check lab values, cell counts
● Monitoring for sx of infection
▪ Planning
● Keep patients who are immunosupressed (neutropenic) separate from
those infected
● Protective isolation if neutropenic
o ‘reverse isolation’

Presentation findings for Hodgkin’s lymphoma

● Lymphoma
o Cancer of lymph tissue
▪ Overgrowth of lymphocytes
▪ Growth in lymph tissue, nodes, spleen
▪ Must check young people when they have large lymph nodes
o Associated w/viral infections (epstein-barr, HIV eg), chemical agents, genetics
▪ This is one of HIV opportunistic cancers
o Hodgkin’s lymphoma
▪ Reed-Sternberg cell
● Marker
▪ Orderly progression, node group to node group
▪ Painless enlarged nodes
▪ “B” symptoms
● Recurring fevers (week on week off)
● Night sweats, wt loss
● Alcohol induced node pain
● May look like HIV, TB or a few other things
o Non-Hodgkin’s lymphoma
▪ Multiple subtypes
● Group of like 20 lymphomas
▪ Spreads through lymph system more randomly
▪ Extranodal sites
● (GI, skin, marrow, CNS etc)
▪ Poorer prognosis
▪ Older generally

Care and positioning after bone marrow bx

 ● Bone marrow biopsy
o Confirm diagnosis
o Examine cell proteins
▪ Look for markers on cells
o Local anesthesia
o Bedside
▪ Sterile procedure
o Usually iliac crest or sternum
▪ Usually iliac crest
● May be positioned on side or stomach
o Education
▪ They will get local anesthesia
▪ Will feel pressure, some discomfort
● ‘crunching, scraping’
▪ Lasts ~15 min
▪ Pressure dressing after
▪ Take analgesic
▪ Ice to site
o Big risk after is bleeding
▪ Monitor
▪ Prevent
● Lay flat on site
● Ice
Pulmonary

Post bronchoscopy care. Be able to distinguish between expected symptoms and worrisome symptoms
afterwards and prioritize

● Bronchoscopy
o Visualized, treat trachea, larynx, bronchi
▪ May suction, may take sample
o Usually done at bedside
o Risk for bleeding, perforation
o Consent
o Dentures out
o NPO 8-12 hrs
o Oral anesthetics?
▪ Usually numb gag reflex
o Nursing care
▪ Monitor patient response during
▪ After:
● Positioning for airway
o Want to promote expansion and prevent aspiration
o Lay on side with head up
▪ Once alert can be on back but no food until gag retuens
● VS, LOC, airway
● Cough, deep breathe
● Must have GAG and SWALLOW before drinking
 ● Have trach tray, O2, suction in room
● Probably staying in room for about an hour
▪ Gargle with salt water, lozenges
▪ Expected
● A little hemoptysis
● Low grade fever
● Client is groggy but recovers
● Sore throat
● No gag reflex initially
● Have slight dehydration and inflammation
▪ Not expected
● Respiratory distress
● Hoarseness, stridor, wheezing
● Lots of hemoptysis
● SOB
● Fever after 24 hrs

Prep and teaching for PFTs

● Pulmonary function tests

o To evaluate lung volumes and capacities, flow rates, gas exchange etc.
o Patient preparation:
▪ No smoking prior
▪ No big meal prior
▪ ? No inhalers (ask MD)
● Depends on what theyre testing
▪ education.
● No needles, no driver needed
o Forces exhaled vlume in one second
▪ Force of whats the most you can blow out
o Peal expiratory flow rate
▪ How fast they can blow airout
▪ Tells how open airways are

Home care for laryngectomy

● Tracheostomy
o Tracheostomy is the stoma, or opening, that results from the procedure of a
tracheotomy.
o Procedure may be temporary or permanent.
o Nursing care
▪ Preoperative care
● NPO
● Education
o On what to consent
● consent
● usually done in OR sometimes done at bedside
 ▪ Post-op
● Ensure patent airway
▪ Must be able to put 2 fingers into collar
▪ Always use precut gauze
o Tracheostomy tubes
▪ Disposable or reusable
▪ Cuffed tube or tube without a cuff for airway maintenance
● Cuff has a balloon
▪ Inner cannula disposable or reusable
▪ Fenestrated tube
● Holes in it
● Allows them to talk
o Hygiene
▪ Bronchial Hygiene
● Turn and reposition every 1 to 2 hr, get OOB
● Coughing and deep breathing
● keep well hydrated
o helps thin mucus
● Sterile suction as needed
o Going into airway so need to be sterile
▪ Oral hygiene
● Brush teeth, rinse mouth
● Oral suctioning if needed
o If deepest is mouth then just clean
● avoid glycerin swabs or mouthwash that contains alcohol
● assess mouth for ulcers, bacterial or fungal growth, or infections.
▪ Air warming and humidification
● To mobilize secretions:
● Air must be humidified.
● Maintain proper temperature.
● Ensure adequate hydration.
● *DON’T instill saline into tube!
▪ Suctioning
● Maintains a patent airway and promotes gas exchange.
o Get rid of CO2
● Never schedule it
o Better if the patient coughs by self
● Suctioning
o Through airway- STERILE
o Through mouth- nonsterile
▪ Gets nasty secretions in throat
o Can go from clean to dirty but not dirty to clean
● Preventing hypoxia
o Preoxygenate with oxygenation
▪ Give 100% O2 prior!
o Don’t suction longer than you can hold your breath comfortably
▪ 10 sec or so
 o Keep suction pressure at 80-120 mm Hg
o Don’t suction too often
▪ Just when patient needs it
▪ Its better if they cough
o Speech and communication
▪ Patient can speak with a cuffless tube, fenestrated tube, or cuffed fenestrated
tube that is capped or covered.
▪ Patient can write.
▪ Yes-no questions
▪ Finger occlusion
▪ Passy Muir
▪ Usually done when permanent
● Laryngectomy
o Risk for head and neck cancer
▪ Smoking
▪ Alcohol
o If radical neck dissection, cut cranial nerve 11
▪ Shoulder drop
o May be partial, total
▪ Total
● Lose voice
● Permanent trach (may not need appliance)
o Appliance at first then can move to none
▪ Partial
● Temporary trach
● Speech, swallow difficulties
o Nursing management
▪ Priorities are airway maintenance, pain management, and nutrition
▪ Body image, social discomfort, grief
● Voice
● Job?
● Cant reattach when you remove so you will have trach opening
o Anything from mouth goes to stomach
o Anything that goes to lungs comes from trach opening
▪ Preop teaching
● Introduce alternative communication
o Bring laptop?
● Teach self suctioning
● Discuss pain control
● Discuss voice options
o Get speech involved from very beginning
o Esophageal speech
▪ Lower pitch
▪ Sounds like burping
▪ Takes intensive practice
o Artificial larynx
▪ Immediate
 ▪ Harsh, electronic
o Tracheoesophageal puncture (TEP)
▪ Hole, device between trachea and esophageus
▪ Manually compress or hands free
▪ More natural
▪ Postop
● Laryngectomy tube inserted
o Prevent contracture
o Replaced with button
● ABCs
o Humidified air
o Suction PRN
● Clean/dress
o Breakdown common
o Clean and dry
● No trying to speak few days
● Nutrition
o Tube feeds
o Well hydrated
● Speech therapy
● Swallowing
o Esophagus not altered but may be narrowed
o Nerve, muscle resection/weak
o Aspiration risk (ONLY partial laryngectomy!)
▪ No risk if total because mouth doesn’t go to lungs
▪ Small bites
▪ Dry swallows in between bites
▪ Sit upright
▪ Tuck chin in to swallow
● Never tell pt to hyperextend and swallow- very
hard (only with acathesia)
▪ Thicken liquids
▪ Avoid watery fruits
o Sxn prn
▪ Stoma care
● Permanent change in their airway
● Breathe only from their stoma
● Clean stoma at least every 8 hours, p.r.n. to prevent buildup of
secretions, scarring
● Position patient’s head so as not to occlude the airway
● Should have humidity in the home
● Could aspirate if some thing goes into that hole
▪ Home care
● Humidification after discharge until the airway becomes used to room
air
o Teach self suction
▪ (Clean not sterile)
 ● Must protect stoma from
o Shower water
o Dust
o Gnats
o Powdered or aerosolized material

Care for nose bleeds

● Epistaxis
o Nose bleed
o Can be from
▪ dry/picking,
▪ Tumors, abnormal clotting
▪ Trauma, HTN
▪ Cocaine, surgery
● Cocaine is vasoconstrictor but it reduces blood flow and makes tissues
more fragile
o Anterior vs posterior
▪ Assess how, when, why, how much
o Anterior
▪ Sit up and lean forward
● To avoid aspiration
▪ Keep pt calm, quiet
▪ Squeeze nose for 5 min
▪ Ice, cool clothes to nose and face
● Best way to stop is direct pressure
● Ice may help but more superficial so not penetrating as much as
pressure
▪ Pack w/gauze and leave it in for several hours
● If it is packed to not remove it before told to
▪ Don’t blow nose
o Posterior
▪ Medical emergency
▪ Not bleeding visibly
▪ Difficult to access
● Lose lots of blood
● Risk for aspiration
o Blood directly to airway
▪ Sedation
● May need sedation/intubation
▪ Monitor H&H, coags
● Especially in older people with anticoagulation and hypertension
▪ Look for frequent swallowing, coughing
● Coughing up blood
▪ Shove balloon up there
Proper PPE for TB
 ● Precautions
o Airborne
▪ N-95
▪ Negative pressure room
▪ until three consecutive sputum cultures have tested (-)
o Room has to sit for 2 hours
o Give tissues, bag for disposal
o Pt wears mask if transported
▪ Can be surgical mask
o Wear barrier if client spits

What amount of induration is a (+) PPE ; and for who?

● Screening
o You might have the disease
o Tuberculin skin test (PPD)
▪ 15mm (+)
▪ 10mm (+) if risk factors
● live with someone, come with area, poor health
▪ 5mm (+) if immunosupressed/HIV
▪ (+) read in 48-72 hrs
▪ Measure induration (bump) not redness
▪ Shows exposure but not necessarily disease, BCG
▪ Two step
▪ Come up positive if vaccination
o X-ray
▪ If nothing there then you don’t have it
▪ If there are signs then you need to get diagnostic test

Complications from thoracentesis and care afterwards

● Thoracentesis
o Put needle in to remove something
o Reason
▪ For diagnosis
▪ For removing fluid
● 1 L max
▪ For removal of air
▪ For instillation of medication
● To scar pleura
● ‘pleuradesis’
o Nursing care
▪ Before
● Consent
● X-ray or U/S or percussion to locate fluid
● Position
o Upright, lean forward, shoulders up
 ● Don’t talk! Don’t move! Don’t cough!
o Don’t want needle to go into lungs
▪ During
● Monitor patient response
● Document fluid removed
● Send specimens
▪ After
● Dressing over puncture
● Lie on OTHER side for 1 hr
o do not want to smoosh that lung allow it to expand (opposite of
liver biopsy)
● Monitor VS
● Encourage deep breathing
o Remember: what is your therapeutic goal for patient after the
procedure??
o Deep breathing especially first hour because wont to re-expand
lungs
● Not worrying about bleeding
o Needle not going into organ so a band aid should be enough
● Worry about pneumothorax after

Indications of pneumothorax/tension pneumothorax

● Pneumothorax
o Can be from
▪ Chest trauma
● Rib fracture
● Bullet/knife wound
▪ s/p central line placement
▪ Spontaneous
● Young male smokers
● COPD
o Blebs
▪ Weak spots that can burst
o S/S
▪ Gradual SOB
▪ decreased SaO2
▪ Hypoxia
▪ agitation, chest pain
▪ subcutaneous emphysema (crepitus)
▪ tachycardia, fatigue.
o Tension pneumothorax
▪ pressure is so much it starts also pushing on other side of the chest and heart
▪ Much more emergegnt and severe
▪ S/S
● DRAMATIC SOB, hypoxia
● tachycardia, hypotension
 ● loss of breath sounds unilaterally
● tracheal deviation (sometimes), altered mental status
● increasing resistance to manual ventilation
o Tx
▪ Chest tube insertion
● Drain air, blood
▪ Nursing
● Monitor breathing
● Pain
● Keep device to suction
▪ Thoracentesis?

Recognize normal from abnormal findings for a chest tube

●
● Collection chamber
o Right 3 rows
o Collects fluid
o Monitor amount, color, character
▪ Bloody? Pus? Serous?
▪ Mark level each shift
● As output
o (doesn’t ever do anything)
▪ No bubbling
● Suction chamber
o On far left
o Fill to 20 cm of water
o Attached to wall suction
▪ Makes the water bubble
● (gentle bubble fine)
o More bubble more evaporation more often to fill
▪ There is NEVER a reason to turn up the suction
● It won’t help anything!!
● Do not manipulate suction to manipulate patient
● Basically one level and that is on
● Water Seal chamber
o Middle
o Fill to 2 cm water
o Looking in this chamber is like looking into the patient’s chest
o If air is entering the chest, it will get pulled into the water seal chamber and make it
bubble
o ‘Tidaling’
▪ Gentle rise and fall of level w/breathing
o 2 reasons for bubbling in the water seal chamber
▪ Good
● Patient just got chest tube and the pneumothorax air is being drained
out
● System is working!
▪ Bad
● The tube is disconnected or there is a hole somewhere
● Air is entering the Pleurovac, but not because of the patient
● Uh oh!
▪ Trouble shoot
● If you see bubbles check the connection
● To assess for a leak in the system
o Check all connections
o Check if chest tube is stil in patient
o Did it get pulled out a little?
o Squeeze tube close to patient
▪ Did bubbling stop?
▪ Move down a few inches and try again
o If bubbling- is it patient- squueze tube close to patient to
occlude- if it stopped then from pt chest
▪ If it keeps on then hole in tube- try to find hole- move
clamp down- replace system
● Assess and know baseline
o 2 reasons for no bubbling in water seal chamber
▪ Good reason
● There is no more air in the pleural space
● The lung has healed!
▪ Bad reason
 ● There is an occlusion in the chest tube tubing
● Maybe there is a kink, or the patient is lying on the tubing
▪ Trouble shooting
● Check entire tube for kinks
● Reposition patient
● Blood clots?
o Gently squeeze
o Don’t MILK tube
▪ Too much traction on lungs
o 2 reasons that there is no tidaling
▪ Ok
● The lung is REEXPANDED
● Yeah!!
● Or the patient is just not breathing deeply enough to make the water
level move
● It happens sometimes
o No big deal
▪ Not ok
● There is an occlusion or kink in the tubing
● That means there is not really an open connection between the chest
and the Pleur evac
▪ Trouble shooting
● Same as no bubbling in water seal chamber

Proper dressing for sucking chest wound

● Nursing care
o Assess respiratory status
▪ Has lung re-expanded?
▪ Is breathing adequate?
o Assess whether drainage system is working
▪ Water levels?
● If low refill it
▪ Drainage?
▪ Suction? Leaks? Tidaling?
o Assess pain
o Encourage deep breathing
o Equipment that must be at bedside
▪ Keep padded clamps
● ONLY for brief, temporary!!
▪ Keep liter of sterile water
● In case of accidental disconnection of system
▪ Keep an occlusive dressing
o What to do if disconnected
▪ If tubing separates
● have patient exhale/cough
● Reconnect tubes
 ▪ If Pleurovac gets destroyed, stick chest tube into water bottle
● Basically making own water seal
● Cannot leave them
o Must hold water there and have someone else grab new system
o What to do if it comes out
▪ Cover hole with occlusive dressing
▪ Taped on 3 sides
● 3 sided occlusive dressing
▪ Why?
● So that air can EXIT chest with expiration, but can’t come back in hole
during inspiration
o One way valve
● *avoids creating a SUCKING chest wound
o Important points
▪ Do not ‘strip’ or ‘milk’ tubes
● Creates too much negative pressure
▪ Tape connections
▪ Sit patient up to re-expand lungs if possible
▪ Keep Pleurovac below chest level
● Things to monitor and document
o Amount, type and color of drainage
o Is there a leak?
o Are all connections tight?
o Is the wall suction on so that the suction chamber is bubbling softly (too
much=evaporation) Check water levels.
o Any dependent loops or pinched tubing?
o Patient comfort/condition?

Complications of chest tubes.

Recognize sub q emphysema and what it represents

● Palpation
o Sub q emphysema
▪ Crepitus
● S/S of pneumothorax

Immune

Nursing care for allergy teaching (intradermal vs RAST)

● Allergy testing
o radioallergosorbent Test (RAST)
▪ Done on sample of blood
● Blood put in contact with allergen
 ● Measures IgE levels
▪ No risk to patient
▪ Cons
● Very expensive
● limited allergens
o will not do on a bunch of allergens but if there was a reaction to
something then will do this
▪ safer
▪ Results on scale 1-5
o Skin testing
▪ Intradermal injection
● Scratch/prick
▪ More risky
▪ Look for localized rxn
● But must be on alert for anaphylaxis
▪ Nursing:
● clean skin, alcohol to remove oil
▪ No steroids, antihistamines for 5 days- 2 weeks
▪ Be ready for anaphylaxis
▪ Can do a version topically
● Very uncomfortable but less risk of anaphylaxis
● Walk around for 48 hours with it