HESI COMPLETE STUDY GUIDE. LATEST 2021

RESPIRATORY  Pneumonia – Inflammation of the lower respiratory tact o Types:  Bacterial (gram positive / negative)  Viral  Fungal (rare)  Chemical o Reach lungs by:  Aspiration  Inhalation  Hematogenous ...

RESPIRATORY  Pneumonia – Inflammation of the lower respiratory tact o Types:  Bacterial (gram positive / negative)  Viral  Fungal (rare)  Chemical o Reach lungs by:  Aspiration  Inhalation  Hematogenous Spread o High Risk Groups  Altered Level of Consciousness  Depressed/absent gag and cough reflexes  Susceptible to aspirating -> Oropharyngeal secretions  Alcoholic, anesthetized individuals  Drug Overdose  Stroke Victims  Immunocompromised o Nursing Assessment  Tachypnea – shallow, often accessory muscles  Sudden onset of fever/shaking/chills  Productive Cough with pleuritic (lung) pain  Rapid/bounding pulse  Breath sounds - crackles o OLDER ADULTS: confusion, lethargy/malaise, anorexia, tachypnea, tachycardia o Interventions:  Assess sputum – COCA  Turn and deep breath q2hrs  Humidify room/oxygen  Chest physiotherapy  3L/day of fluids (liquefies secretions)  Monitor ABG’s  PO2 >80, PCO2 <45  Encourage at risk groups to get annual pneumonia and flu shots  Promote rest and conserve energy o Hydration – thins out mucus, essential for client w/ fever, 300-400mL of fluid is lost daily by lungs through evaporation o Cerebral Hypoxia – irritability and restlessness are early signs o Pneumonia Preventives  Older adults & Asplenia: flu/pneumonia shots  Comatose/immobile: elevation of HOB and for 1 hr after feeding, frequent turning.  Anti-Infectives o Penicillin  AR – Anaphylaxis, diarrhea, GI distress, superinfection (sore mouth, vaginal discharge, cough), phlebitis @ IV site  NI – Observe for 30 mins following parenteral admin, Orals = empty stomach, alters birth control effectiveness o Tetracycline (-cycline)  AR- Hypersensitivity and Photosensitivity  NI- alters birth control effectiveness, NO ANTACIDS OR MILK PRODUCTS, inspect IV frequently, no <8yrs – yellow/brown teeth discoloration and growth retardation o Aminoglycosides – xxxx sulfate, Vancomycin, Metronidazole (Flagyl)  AR- Neuromuscular blockade, Nephro/Ototoxicity  NI- Renal Function Test, BUN, creatinine, I&O  Ototoxicity – headache, dizziness, hearing loss, tinnitus  Peak and Trough levels required. o Cephalosporin – (cef/ceph)  AR – Thrombophlebitis, GI distress  NI – caution if allergic to penicillin o Macrolides – Clarithromycin (Biaxin), Erythromycin, Azithromycin (Zithromax)  AR – Pseudomembranous colitis, phlebitis, dizziness, dyspnea  NI – Biaxin with food, Zithromax without food  Liver and Renal Labs  Space MAOI’s 14 days before and after Biaxin o Fluoroquinolones  CNS disturbances, Cataracts, blistering  NI- Prompt onset, Category D, Lowers seizure threshold, LIVER/RENAL/CBC, many drug-drug interactions  Chronic Bronchitis: Sputum with daily cough production for 3mo-2yr consecutive, hypoxemia, cor pulmonale (enlarged R side heart -> result of lung or pulmonary blood vessel disease), increased bronchial wall thickness o Factors: Higher incidence in smokers o Generalized cyanosis, BLUE BLOATERS, Right sided HF, distended neck veins, crackles, expiratory wheezes. o NI – Lowest FiO2 possible to prevent CO2 retention, S/s fluid overload, PaO2 between 55-60, teach pursed lip breathing and diaphragmating breathing, Tripod position  Emphysema: Reduced gas exchange, decreased capillary network, increased air trapping o Factors: smoking, genetic, environmental/occupational exposure o PINK PUFFERS, pursed lip breathers, barrel chest, distant/quiet breath sounds, wheezes, pulmonary blebs on radiograph. o NI- Same as Bronchitis  Asthma: Narrowing/closure of airway due to a stimulant o Factors: Mucosal edema, Increased work of breathing, beta blockers, respiratory infection, allergic reaction, emotional stress, exercise, environmental/occupational exposure, reflux esophagitis o Dyspnea, wheezing, chest tightness o NI- Administer bronchodilators, fluids and humidification, ABG’s, ventilatory patterns  In advanced emphysema, due to the alveoli being affected, hypercarbia is a problem, rather than in bronchitis, where the airways are affected.  Compensation occurs over time in clients with chronic lung diseases, and ABGs are altered.  Productive cough and comfort can be facilitated by semi-Fowler (30-45) or high-fowler (90), which lessens pressure on the diaphragm by abdominal organs. o Gastric distention becomes a priority -> it elevates the diaphragm and inhibits full lung expansion  Pink Puffer -> barrel chest, client works harder to breathe, but O2 taken in is adequate to oxygenate the tissues  Blue Bloater -> Insufficient oxygenation and leads to generalized cyanosis and often Right Sided Heart Failure.  COPD / Asthma Interventions o Tripod position o Small frequent meals, increase calories and protein, Mg and Ca -> muscle contraction and relaxation, Mg and Phosphorus -> related to bone mineral density o 3L+/day -> between meals rather than with  Adrenergic and Sympathomimetic o Bronchodilator o AR – anxiety, increase HR, N&V, urinary retention o Monitor HR, urinary retention, may cause sleep disturbance o BRONCHODILATOR BEFORE STEROID!!!  Corticosteroids o Anti-inflammatory o AR- cardiac dysrhythmias with long term use o ORAL CARE after use  Anticholinergics o Bronchodilator & control of rhinorrhea o AR- dry mouth, blurred vision, cough, essentially can’t do shit  Combination products o Fluticansone + salmeterol o Ipratromium + Albuterol  Eating = less energy needed for breathing -> soft diets  ABC -> Airway first, breathing, circulation CAB-> CPR  O2 Delivery -> in adult, O2 must bubble through some type of water solution so it can be humidified in >4L/min or delivered directly to trachea. If 1-4L/min or by mask/nasal prongs, mucus membranes provide adequate humidification  Cancer of the Larynx