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N444: Test 6 by Mind Map: N444: Test 6
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N444: Test 6

Respiratory Assessment

A&P Review

Functions, UR: Warms, filters air, LR: Gas exchange, Oxygen to tissues, Carbon dioxide out to air, (works with circulatory)

Structures, Lungs, Pleura, Mediastinum, Lobes, 2 on left, 3 on right, Bronchi/bronchioles, Alveoli, Site of gas exchange, Alveolar-capillary membrane, Numerous and grouped, Round and open, Collapsed = atelectasis, Lubricated by surfactant, Three types, 1) Alveolar walls, 2) Secrete surfactant, 3) Macrophages for immunity

Ventilation, Inspiration, 1/3 of cycle, Contraction, Diaphragm, Intercostal muscles, Increases space of diaphragmatic chamber, Lowers ITP, Air enters lungs, inflates them, Expiration, 2/3 of cycle, (requires elastic recoil of lungs), Relaxation of diaphragm >>, UPWARD movement >>, Increases ITP, Pushes air out of lungs, Inadequate ventilation, Decreased compliance, Low surfactant, Atelectasis, Impaired chest wall fxn, Obesity, MSKT alterations, Multiple sclerosis, Restrictive dx, Fibrosis, Lung cancer/disease, Increased resistence, Bronchoconstriction, Obstructions, Asthma, Emphysema, COPD, Sleep apnea, Pneumonia

Perfusion, R/T to ventilation, Oxygen to hemoglobin, Delivery of oxygen to tissues, Cellular respiration, Signs of hypoxemia, Cyanotic or darker nail beds or sclera, Pale and clammy skin

V/Q ratio, V = Ventilation, Movement of air into/out of lungs, Q = Perfusion, Filling pulmonary capillaries w/blood, Entire output of RV, Gas exchange @ alveoli, Adequate V/Q ratio, Matched ventilation + perfusion, If not, shunting occurs, >> HYPOXIA

Gerontological Differences

Decreased secretions

Weaker lungs

Weaker chest muscles that calcify

Decreased airway diameter

Increased immunosuppression


History, Dyspnea, Clubbing, Cyanosis, Accessory muscle use, Cough, Sputum production, Chest pain, RR rate per minute, WOB, Lung sounds, Normal, Vesicular, Soft, Lower pitched, Bronchovesicular, Intermediate, Bronchial, Very loud, Relatively high, Adventitious, Wheezing, Can't get air out, COPD/asthma, Exp > Insp, Low rumbling or "whistle-like", Musical sounds, Crackles, Friction rubs, Harsh, crackling sounds, Like 2 pieces of leather rubbing together

Lung volumes & capacities, TV = Air of each breath, Use spirometer, Measure several breaths, IRV = Max volume inhaled during normal INH, ERV = Max volume exhaled during normal EXHL, VC: TV + IRV + ERV, FEV: Volume exhaled forcefully / sec

Pulse oximetry, Non-invasive, Oxygen saturation of HgB in blood, Normal is 95%+, May be unreliable (so still check ABGs), Check machine if running unusually low**


Pulmonary function tests


Sputum tests


Fluroscopic stuies

Radioisotope procedures

Bronchoscopy, Scope test, Conscious sedation, May cough up blood, No red juice or soda, Interferes w/interpretation


Thoracentesis, Pleural effusion, Monitor site for excess bleeding or fluid, Pain management needed




Airflow limitation that isn't fully reversible, Progressive decrease of oxygen flow to all tissues, R/T abnormal inflammation caused by toxins, Airways, lungs, pulmonary vasculature, Scar tissue forms, Airway obstruction, Lung tissue damage r/t damaging substances, Altered vasculature >> vessel damage

Fourth leading COD (12th leading CO disability)

Made of disease(s) that cause airflow obstruction, Chronic bronchitis, Emphysema, (either or)

No longer includes asthma (but may be comorbid)

Risk Factors

Tobacco smoke, 80%+ of ALL cases, Damages alveoli, R/T protease elactase release, Destroys cilia (defenses), Most important risk factor, 8 years of smoking or more (especially), May also include passive smoking (second-hand), Smoking cessation, Ask about pack-year history, Confined areas = increased damage

Non-modifiable, Ambient air pollution, Occupational hazards, Genetics, Alpha-antitrypsin, Needed for protection, Can be replaced by IV (but it's $$$)


COPD, Defining characteristics, At least 3 mo over 2 consecutive years, Aggravating, persistent cough, Irritation of airways, Inflammation, hypersecretion of mucus, Proliferation of mucus-secreting glands & goblet cells, >> Clogs the airway, Structural changes, Reduced ciliary fxn, Thickened bronchial walls, Narrowed bronchial airways, Mucus plugging, Damaged, fibrosed alveoli, Diminished alveolar macrophage fxn

Emphysema, Distension of air spaces beyond terminal bronchioles, Destruction of alveolar walls, Decreased alveolar surface area, Over-stretched, Non-elastic, Clumped, Increased "dead space", Impaired oxygen diffusion, [NO GAS EXCHANGE IS HAPPENING!], Pulmonary capillary bed reduced, Increased vascular resistence, Increased pulmonary artery pressure, Ultimately causes hypoxemia, cor pulmonale**, Other manifestations, 2:1 AP ratio instead of 1:2, R/T compensation of chest, Start out with thinner chest, then barrel-chest, May not report problems w/breathing b/c feels normal, Tripod position helps SOB (or Semi-Fowler's position)

Clinical Manifestations

Appearance, Pink puffer, Severe COPD, Thin with low muscle mass, Puffing r/t "air hunger", Troubling removing CO2, Pursed lip breathing, Close mouth, Nose, Purse lips like whistling, Breathe out mouth w/o puffing cheeks, Notes, Strengthens abdominal muscles, Like breathing during labor, Blue bloater, Appear blue-tinged, dusky, Bronchitis, Mucus blocks airway, Hypoxemia

Slumped over appearance, Energy conservation, Tripod position for gas exchange

Will appear to be in distress, WILL NOT COMPLAIN, It feels normal, Monitor frequently, r/t increased CO2, low oxygen

Chronic cough w/sputum

Dyspnea, Exertion, Rest, Orthopnea

Weight loss

Large neck muscles

Slow moving

Shallow respiration

Easily tired

Cor pulmonale


Prolonged expiration



Bronchodilators, e.g. Mucomyst, Opens vessels

Corticosteroids, Treats inflammation, May cause increased blood glucose*, Monitor diabetics


Oxygen, Promote oxygenation w/o hypercapnia, Oxygen is still a medication

Nursing care, Shake MDI before admin, Mouth care after MDI

Nursing Process

Assessment, H&P, Diagnostics, Pulmonary function, Especially FEV >>, If really low, indicates COPD, ABGs (precise), CXR, Hyperinflation, Flat diaphragm, Alpha-antitrypsin screen

Diagnoses, Ineffective gas exchange, Impaired airway clearance, Ineffective breathing pattern, Activity intolerance, Deficient knowledge, Ineffective coping

Collaboration, RR failure, Acidosis, Hypercapnia, Atelectasis, Pulmonary infection, Pneumonia, Pneumothorax, Pulmonary HTN, Cor pulmonale**, "R-sided heart failure", R/T pulmonary disease, Airway collapses, Pressure on lung tissues, Impairs easy blood flow, Changes that occur, Increased workload, Hypoxemia, Vasoconstriction, R. chamber hypertrophy, Dysrhythmias

Planning, Smoking cessation, Activity tolerance, Self-care, Coping, Adherence, Absence of complications

Interventions, Gas exchange, Medications, Reduce irritants, Directed coughing or "huff" coughing, CPT, Breathing exercises, Supplemental O2, Activity tolerance, Rehabilitation, ADLs, Independence, Pacing activities, Exercises, Walking aids to conserve energy, Collaborate approach, Nutrition, Weights, PO intake & supplements, Avoid foods that cause bloating, Don't drink before/during meals, Mouth care, Give bronchodilator 30 min before meal, Others, Realistic goals, Avoid extreme temps, Coping strategies, Complications, Education, Patho, Meds, Procedures, When/how to seek help, Asepsis, Avoid irritants, Lifestyle changes*, Health promotion, NO smoking!, Vaccinations, Avoid high-exposure areas, Medication compliance, Orders, Medications

Evaluation, WOB easier?, Voice need for meds?, Compliant?, No complications?, Acidosis, Cor pulmonale, Pneumonia, Pneumothorax, Increase in FEV?, Usually decreased w/COPD, R/T fact they can't get rid of air

LRT Disorders


Classifications, CAP, Late fall and winter, Influenza, HAP, Preventible, Costly, PCP, HIV-associated, Immunosuppression, Aspiration

Pathophysiology, Microbes enter lungs, From URT, From bloodstream, Inflammation of lung tissue, Automatic response to invader, Creates exudate, increased WBCs, Bronchi, Alveoli, Impaires adequate V and diffusion of gases, V/Q mismatch occurs, Poorly oxygenated blood returns to heart, Moves systemically >> hypoxemia

Risk factors, Lifestyle, Smoking, Alcohol, Unsterile equipment, HCPs, Age, Immobility (supine), Post-op, Immunosuppression, Cough reflex, MV/trachs

Clinical manifestations, Mucopurulent sputum, Congestion, Sore throat, Orthopnea/SOB, Fatigue, Poor appetite, Cyanosis, Cough, Diaphoretic, "Wet" lung sounds, Corse, Rhonchi

Alternative presentations, Bacterial, Chills, Fever, Pleuritic pain, Tachypnea, Accessory muscles, Rapid, bounding pulse, Compensation, Viral, Relative bradycardia, >> Given elevated temperature

Medical management, Antibiotics, Determined by Gram stain, If not identified, empiric treatment, Not indicated for viral, Primary or secondary infection, Supportive care, RR, S/S hypoxia, Oxygen, I/S, Pulse ox, Bronchodilators, TCDB, Dehydration, IVFs, Inflammation, Decongestants, Antihistamines, Anti-pyretics, O2 + IVF, then antibiotic

Nursing process, Assessment, Findings, T, HR, CXR, Mental status, Auscultation, Crackles, Rhonchi, *Assess all lung fields, Secretions, UO, Fluid in lungs/around heart, Dehydration, Cough, Tachypnea, SOB, Concomitant Heart failure*, Risk for shock, Diagnoses, Ineffective airway clearance, Activity intolerance, Risk for FVD, Imbalanced nutrition, Deficient knowledge, Collaborative, Continuing symptoms after therapy, Shock, RR failure, Atelectasis, Pleural effusion, Confusion, Superinfection, Planning, Airway clearance, Energy conservation, Fluid volume, Nutrition, Patient understanding, No complications, Interventions, 2-3L per day*, Humidified oxygen, Coughing, CPT, Semi-Fowler's, Rest, Nutrition, Fruits, veggies, Vitamin C, "Sick day" foods


Overview, M. tuberculosis (acid-fast bacillus), Affects 1/3 of world, Leading COD r/t infection, On the rise in USA, Immigration, HIV, Drug resistance*, Decreased detection by HCPs, Lack of funding

Pathophysiology, Inhale microbe via droplet, Travels to lungs, and may enter bloodstream (miliary), Inflammatory response, Latent TB (infection), Macrophages "wall off" granules, Dead bacteria, Lung tissue, Calcification, then inactivation, Active TB (disease, Granulomas don't form or are compromised, Person then becomes infectious

Transmission, Person-to-person via droplet, 1 cough = 3000 droplets, Longer life in darker places, Killed via direct sunlight, Can remain in air for hours!

Risk factors, Close contact, Immunocompromised, Inadequate health care, Comorbidities, Immigration, Institutionalization, Substandard housing, HCPs!

Manifestations, Low-grade fever, Dry cough, Night sweats, Fatigue, Weight loss, Anorexia, MP sputum or hemoptysis

Diagnostics, TB skin test/Mantoux, Indicator, Unreliable*, 0.01cc, By certified RN, Create a wheal, 5 mm = infection, >5 mm = +, Variable for immunocompromised, Read w/i 72 hrs, Infected if:, TB skin test +, CXR = massive consolidation, Mycobacterium +, Symptoms +

Medications, INH*, Rifampin, Pyrazinamide, Ethambutol, Nursing care, Monitor liver fxn!!, INH only for infection, Daily, 6-12 mo, Prophylaxis, All 4 meds, daily for four weeks, Non-infectious after 2 weeks, Must be compliant!!, Then, INH + R for 4-7 months

Nursing Process, Assessment, H&P, S/S, Flu-like, Junky lung sounds, Breath sounds, Fremitus, Egophony, Percussion, Diagnoses, Ineffective airway clearance, Deficient knowledge, Activity intolerance, Isolation r/t droplet precautions, Collaborative, Malnutrition, ADRs, Multidrug resistance, Spread of infection, Planning/Goals, Patent airway, Knowledge, Adherence, Activity tolerance, No complications




Progressive neuron loss

Slow, progressive onset

Mostly home-health


Decreased dopamine, Substantia nigra in basal ganglia, Rigidity, bradykinesia, tremors, Postural instability

Risk factors, Onset @ age 50, Males > females, Family trend, Head trauma, Environmental, Smoking, Metals, Herbicides, Radiation, Viral infxn, Encephalitis, AIDS, Caucasian

Nursing care, Assessment, Degree of disability & function, Emotional response/coping, Depression, Education, Vital, Overwhelming, Home health, Hazards, Family dynamics, Coping, Fall risk assessment, Complications, Falls, Fractures, RI, UTI, Manifestations, 2+ cardinal manifestations, Tremors, Rigidity, Bradykinesia, Postural instability, Medications, Antipsychotics, Drowsiness, Increased risk for falls, Care plan, Mobility, Exercises, Walking techniques, PT, Shoes, Energy conservation, Self-care, Independence, Modifications, Bowel elimination, Constipation >> obstruction, Hydration, fiber, Avoid straining, Lowers BP, Fall risk, Swallowing/nutrition, Semi-solid diet, Thickened liquids, No plain water, Aspiration, Pulmonary issues, Restrict coffee, Weekly weights, Dietary consult PRN, Assistive devices, Communication, Low, soft voice, Face patients, Pay attention, Amplifier, ST consult, Coping, Realistic goals, Socialize, Be active, "Mask-like" facial expressions, Diagnoses, Impaired verbal communication, Constipation r/t muscle weakness, Adult FTT r/t depression, Imbalanced nutrition : <TBR, Tiredness, Tremors, Problems feeding, Chronic sorrow, Impaired mobility, Self-care deficit

Manifestations, 4 cardinal signs, Tremor, At rest, Worsens w/walking, Rigidity, Involuntary, Arms, legs, Face, Postural, Bradykinesia, Postural instability, ANS symptoms, Psych changes, Hypokinesia, Micrographia, Dysphonia, Shoulder pain*

Complications, RTIs, UTIs, Skin rbeakdown, MSKT injuries r/t falls, Dyskinesia, Orthostatic hTN

Diagnostics, H&P (at least 2 signs), PET & SPECT, Labs, imaging = not useful

Medical care, Control symptoms and promote function, Cannot prevent progression, Individualized care, Medications, Levadopa*, Effective, Mainstay of treatment, Anti-cholinergics, Antivirals (Symmetrel), Dopamine agents (Requip), MAOIs, COMI (Comtan), Antidepressants, Tricyclic, SRIs, Antihistamines, Surgery, Stereotactic procedures, Thalatomy, Pallidotomy, Neural transplant, Deep brain stimulation


Pathophysiology, Neuropathological/biochemical changes, Tangles: Non-fxn neurons, Plaques of amyloid protein, Shrinkage of cerebral cortex r/t neuronal damage, Cells that use ACH (deficiency)

Senile dementia

Confirmed via brain biopsy


"Lou Gehrig's disease", Unknown cause, May be caused by excess glutamate (MSG), Amyotrophic, Atrophy of muscle fibers, Sclerosis, Hardening, Anterior and lateral columns

Risk factors, Autosomal dominant in 5-10%, 40-60 years old, Males > females before age 60, Environmental toxins, UV rays, Carbon monoxide

Nursing process, Assessment, Muscle weakness, Skin status, Nutritional status, Small, frequent meals, Parkinson diet, Hydration, Dysphagia, Swallow reflex, RR status, Chest expansion, SOB, Lung sounds, Accessory muscles, Nasally voice, Hard time articulating message, Support system, Urinary/bowel status, No incontinence, Constipation, No UTIs, Plan of care, Support, Independence, Communication, ROM, Repositioning, Skin care, ADLs, Medications, Spasticity >>, Drowsiness, fall risk, Diagnoses, Anxiety, RR-related, Communication, Decisional conflict r/t vent, Impaired resilience, Risk for aspiration

Manifestations, Variable, Fatigue, Progressive weakness, Cramps, twitching, Atrophy, Spasticity, Regurgitation, Problems laughing, talking, etc


Diagnosed by S/S, EMG, muscle biopsy, MRI

Nursing care, Focused at function & QOL, One medication: RIlutek, Baclofen, Dantrium, Valium, (anti-spasmodic), Active & passive ROM


Incurable, inherited

Pathologic features, Degeneration, loss of muscle, Variation in muscle fiber size (contractures), Phagocytosis, regeneration, Muscle replaced by CT, Will also have elevated muscle enzymes

Nursing process, Assessment, MSKT, Joint mobility, CV, RR status, Plan of care, Promote function, Enhance QOL, Diagnoses, Constipation, Fatigue, Nutrition, Skin integrity

Diagnostics, Blood or urine, Exercise tests, EMG, ECG, PFT

Medications, Supportive only, Muscle relaxants, Baclofen, Flexaril

Medical care, Supportive, Promote activity & QOL, Supportive devices, Spinal fusion sx


Premature death of basal ganglia cells, Also affects cerebellum, cortex, Unknown etiology, R/T abnormal glutamine in nucleus >>, Cell death



Two forms, Septic/bacterial, Viral (less common), HIV, Mono, Immunosuppression

Inflammation with IICP, Infected CSF, Edema, Brain compression, IICP

Clinical manifestations, Headache & fever (1st), Nuchal rigidity, Positive K and B signs, Photophobia, Rash, Change in LOC, Acute fulminant infection, Only 10%, Death w/i few hours, High temp w/lesions, Dehydration, shock, seizures

A&D, CT (brain stem herniation), MRI, Lumbar puncture, Cloudy, Low glucose, High protein, High WBC, Bacterial culture, Gram stain*

Risk factors, Lack of vaccination, Close settings, Tobacco use, URI, Otitis media/mastoiditis, Immunosuppression

Prevented by vaccination!

Treatment, Medications, IV Vanc + Cephalosporin, Can cross BBB, Decadron r/t inflammation, IV fluids, Hydration, Shock, Phenytoin r/t seizures, Antimicrobial prophlaxis, Rifampin, Cipro, Rocephin

Nursing care, Frequent neuro checks, Injury, Daily weights, Labs, Electrolytes, Urine labs r/t SIADH, Immobility, Isolation, Support

Brain abscess

Collection of pus and brain parenchyma

Purulent, usually bacterial

Higher risk w/poor immunity, Otitus media, Rhinosinusitis

Manifestations, Headache esp. in AM, Fever, Vomiting r/t pressure, Neuro efects base on area, S/S IICP, DLOC, seizures

A&D, Neuroimaging, MRI or CT aspiration, Blood cultures, CXR if lung infection, EEG for brain activity, blood loss

Risk factors, Immunosuppressed, Cranial surgery, Head injury, Tongue piercing

Prevention, Prompt treatment of risk factors

Treatment, C&S >> antibiotics, Corticosteroids for inflammation, edema, Antiseizure meds

Nursing care, Frequent, ongoing neuro checks, Response to treatment, Client safety, Support


HSV, Local necrotizing hemorrhage, Edema >>, Nerve body degeneration, Most common cause of acute encephalitis, HSV-1, Cold-sores, Rarely travels, Children/adults, HSV-2, Perinatal transmission, Neonates, Clinical manifestations, Based on location, HA, Fever, Confusion, Changes in LOC, A&D, EEG shows temporal lobe alteration*, LP, CSF cloudy, High pressure, Low glucose, High protein, MRI, Viral cultures, PCR for HSV-1 bands, 1st and 10th days, Treatment, ASAP, for up to 3 weeks, Antiviral agents, Acyclovir*, Renal dosage, Ganclcovir, BBW, Hematological alterations, Carcinogenic, Decreased sperm count, Valtrex, PO for HSV-1?

Arthropod-borne, Transmission, Primary (birds), Vector (mosquito), Secondary (human), Blood tests are slow, Manifestations, Early, flu-like, Seizures for SL >> WN, St. Louis, SIADH w/low Na, Parkinson-like movements, West Nile, Maculopapular or morbilliform rash, Enlarged LNs, Flaccid paralysis, Parkinson-like movements, A&D, MRI, SL: Basal ganglia, WN: Periventricular area, LP, IgM antibody, Positive, Blood or CSF, Viral RNA in PCR, Treatment, Manage symptoms, Siezures, IICP, Interferon w/SL, Experimental for WN, Ribavirin, Interferon alpha 2b

Fungal, Immunocompromised usually, Certain areas, professions, Respiratory risk, Manifestations, F/HA/M**, Meningeal signs, Cranial nerve dysfunction, Skin lesions, Seizures, Associated w/stroke, A&D, H/O immunosuppression, LP, High WBC, Elevated protein, Decreased glucose, Serologic test w/antibody, Blood cultures, Lung biopsy r/t inhalation, MRI for secondary, Treatment, Amphotericin B, D5W only!!, 2-4 hrs, Many CSEs, Antiemetic, Benadryl, Acetaminophen, Glucose, Maintenance, Fluconazole, N/V, Increasedl iver enzymes, Flucytosin, BMS >>, Watch platelets

CJD, Very rare, incurable, Caused by prions, TSE, Manifestations, Onset around age 50, Late psych symptoms, Deterioration, Ataxia, Vision changes, Paralysis, 6-month survival, A&D, CSF has proteinase inhibitor, EEG w/specific pattern, MRI of basal ganglia, Confirmed only through biopsy/autopsy

VCJD, Human variation of BSE, Manifestations, Early psych symptoms, Lays dormant for ~10yrs, Onset at age 27, Affective changes, S/C impairment, Limb pain, muscle spasms/rigidity, Incoordination, Sleep disturbance, 22 month survival, A&D, MRI: bilat hyperintensity of posterior thalamus, Tonsillar biopsy*** shows prions, Treatment, Progressive, fatal, Opiates for pain, Meds for myoclonus


MS, Immune-mediated, Progressive, Demyelinating CNS, Genetic, Manifestation, Relapses, exacerbations, Parasthesias, Coordination problems, LOB, Pain, Vision changes, A&D, MRI, LP, Urodynamic studies, Neuropsych testing, Treatment, Interferon, B-1a, B-1b, Glatiramer acetate (Copaxone), Methylprednisone IV, Symptom treatment, Nursing care, Memory aids, Structured environment, Relaxation, Temperature, Assistive devices

Myasthenia gravis, Autoimmune, Impaired muscle transmission, Voluntary muscle weakness, Ocular muscles, Facial, Vocal, Manifestations, Diplopia, ptosis, Facial muscle weakness, Swallowing impairment, Speech, General weakness, A&D, ACHI test, IV Tinselon for 30 min, Visual changes resolve for few min, then return, MRI scan for enlarged thymus, SEMG for delay in transmission, Treatment, Cholinesterase inhibitor, Pyrostigmine (Mestinon), 1st line of treatment, Inhibits ACH breakdown, increases availability, Corticosteroids, Cytotoxic meds, Immunomodulating therapy, Plasmapharesis, Exacerbations, Timing on patient response, Thymectomy, Complications, MG, RR illness, Too much or too little treatment, RR distress, failure, CG, Too much ACH r/t overmedication, Bradycardia, resp. distress, Treat w/atropine to dry up secretions, Nursing care, Meds with food, on time, Ocular strategies, Maintain temp, Aspiration

GBS, Autoimmune, Acute PN myelin attack, AA mimics PNS protein, Body attacks!, Rapid, Usually after virus, Recovery phase*, Manifestations, Ascending weakness, Bulbar weakness, Tachy or brady, Meds, Pacemaker, HTN or htn, Medications, Unaltered LOC, A&D, Symmetric weakness w/upward progression, History of VI, Changes in VC, NIF, LP shows only elevated protein, Nerve conduction, Nursing care, ICU observation, High risk for RR distress, Plasmapheresis, IVIG**, Tx of choice, Fewer SEs, RT or vent, Immobility, Cardiac dysrhythmias