Medical Surgical Nursing

Location

Btw mouth &

cranium

Function
Remove foreign
bodies
Warm
Moisten
Olfactory

Contains

Cilia
Hair-like

Sensitive nerve
endings:
Sneeze

Description
4 pairs
Facial area
Continuous w/
nasal cavity

Function:

Speech

Passageway

Food & liquids

Digestive tract

Air
Respiratory tract

Lowest portion

Opens into 2
space

Location

Behind nasal cavity

Contains

Adenoids

Tonsils
Lymph system

Eustachian tubes

Location

Btw pharynx &

trachea

Function
Vocalization
Facilitates
cough/sneeze

Epiglottis
Gateway / trap
door
Flap of elastic
cartilage

Thyroid cartilage

Adams apple

Vocal cords

Speech

Location

Btw larynx & bronchi

Description
4-5 inches long
Palpate

Above sternal notch

C-shaped rings of
cartilage

Function

Conduct air

Location
Below trachea
Center of chest
Behind the heart
Branches into 2
tubes

Rt
diameter
More vertical
Shorter in length

Mr. Henderson had a CVA 5 days ago and is

having some difficulty swallowing. There
is some question that he may have
aspirated some food and developed
pneumonia. What side pneumonia would
you except him to have?
A. Right sided
B. Left sided

Location

Thoracic cage

Description

Airtight
Mult. Air sacs

3 lobes

Rt
Lf
2 lobes

Bronchi

Bronchial tree

Bronchioles

No cilia
No cartilage
Patency d/t
elastic recoil of the

smooth muscles
alveolar pressure

Alveolar ducts

Smallest tubes

Alveoli
Functional unit
Air sacs
Gas exchange
Surrounded by
pulm. Capillaries

Alveoli
Thin membrane
Tendency to
collapse

Alveolar Pressure
surfactant

Location

Surrounds surface
of lung & interior
wall of thorax

Function
Protects
Neg. pressure
Allows movement
( friction)

Pleural
space/cavity

Contains fluid

Location

Space btw lungs

Contains
Heart
Large blood
vessels
Esophagus
Trachea
Bronchi

Location

Muscle btw lungs &

abd. Cavity

Aids in resp

Ribs
12 pairs
Thoracic cage

Sternum

Main function of resp. system is to

deviler O2 to the blood & remove
CO2 from it.
Pulm. Art.

CO2 / deoxygenated

Pulm vein

O2 / oxygenated

Inf/sup vena cave

Rt atrium

Rt ventricle

Pulm

Pulm art
Pulm cap
Pulm vein
Lt atrium

Tricuspid

Bicuspid / mitral

Left venticle
Aorta

Ventilation

Movement of air in & out of the the

tracheobronchial tree. Delivering O2 to the
alveoli & removing CO2
Perfusion

Blood flow in the capillary bed in the lungs

Diffusion

Movement of gases (O2 & CO2) across the

alveoli membrane

Flows from area of greater concentration to

lesser concentration

Cartilage hardens
Muscles weaker
cough reflex

elasticity

Nasal Congestion
Sore throat
Change in voice
Difficulty breathing
Orthopnea
Pain

Cough
Sputum
Affect on ADLs

Physical problems
Function problems
Life style
Smoking
Family Hx
Occupation hx
Allergens /
environment
Anxiety

Normal chest
2x as wide as
deep
Anterior/posterior
diameter

1:2

Barrel chest
D/t over inflation of
lungs
anterior-posterior
diameter

2:2

Kyphosis

AKA
Hunchback

Abnormal
curvature of the
thoracic spine

Lordosis

AKA
Sway-back

Abnormal
curvature of the
lumbar spine

Uniform
expansion of the
chest
Intercostal
spaces

Shoulder rise
Accessory
muscles
Posture

Trachea

midline

Color
LOC
Emotional state

Rate
Eupnea
Normal
12-20 / min

Tachypnea

rate

Bradypnea

rate

Depth
Hyperventilation

depth & rate

Hypoventilation

depth & rate

Purpose
Asses air flow through bronchial
tree
Procedure
Diaphragm of stethoscope
Superior inferior
Compare rt to lf

Normal

Vesicular

Lung field
Soft and low

Bronchial

Trachea & bronchi

Hollow

Adventitious

Crackles

Fine crackles

air bronchi with

secretions

Air suddenly
reinflated

Course Crackles

Moist

Wheezes

Sonorous wheezes
Deep low pitched
Snoring
Caused by air

narrowed passages
D/t secretions

Sibilant Wheezes
High pitched
Whistle-like
Caused by air

narrowed passages
D/t constriction
Asthma

Anxiety
Bradycardia
Cyanosis
Depressed
respirations
Diaphoresis
Disorientation
Dyspnea

Restlessness
Headache
Agitation
Poor judgment
Retraction
Tachycardia
Tachypnea

Definition

SOB

Significance

Common with cardiac & resp. disease

Orthopnea

Sit up to breath
COPD
CHF

Right ventricle
If chronic airway resistance
pressure
Rt ventricle work
Rt. Vent damage

Nrs Management
Find cause
Give O2
HOB
Communication

KISS

Definition

To expel air from the lungs suddenly

Irritation of mucous membrane

Significance
Infection
Irritants
Protective mechanism

Nrs management
Assess
Describe
Directed
Pain control

Splinting

Infection control
Suppressants / Anti-tussives

Definition
Matter discharged from resp. track
that contains mucus and pus, blood,
fibrin, or bacteria

Significance
Purulent
Thick,
yellow/green
Bacteria

Nrs Management
Thick

Hydrate
water
Nebulizer
Humidifier

TCDB
No smoking
Oral care
Appetite

What breath sound would you expect to hear

on a patient with increased sputum
production?
A.
Vesicular
B.
Crackles
C.
Sonorous wheezes
D.
Sibilant wheezes

Explain

From lungs

Sterile cup
Deep breath x 3

Cough deeply
Expectorate
Best time for
specimen
collection?

AM

Significance
Cardiac or
pulmonary

Nrs Management
Assess
Analgesics OK,
but
Position for pain
Affected side
Splint

Definition
Expectoration of blood from
the respiratory tract

Significance
Pulm or cardiac

Hemoptysis

Definition?

Hematemesis

Coughed up blood

From?

Vomited blood

Pulm hemorrhage

Description
Pink, red, mixed with

sputum

Definition?
From?
Stomach / GI

Description
Coffee ground

Nrs Management
Determine
source
Serious

Definition
Bluish coloring of
skin

Purpose
Noninvasive O2
Sat
Normal
95-100%
<85%

Tissue is not
receiving enough
O2

Not reliable in
Cardiac arrest
Anemia

Chest x-ray
CT scan
Angiography
Bronchoscopy
Thoracoscopy
Thoracentesis

Description
2-d image
Purpose
Fluid
Tumor
Foreign bodies

Description

Computerize
Tomography

With or without
contrast medium
Purpose

Tissue

Tumor

Foreign bodies

Fluid

Nrs management

Without contrast
medium

No prep

With contrast
medium
NPO 6 hrs
Assess for allergies

Purpose
Visualize Pulm.
Circulation
Description
Dye
Femoral vein
Heart

Pulm Arteries

Nrs. Management

Pre-op

NPO
Check Allergies
Shellfish/iodine

Post-op

Lie flat 8 hrs

Sandbag
Check pedal pulses
Assess hemorrhaging
Push fluids

Description
Direct inspection
of larynx, trachea
& bronchi via
flexible tube
(fiberoptic)
Purpose
Examine
Tissue sample

Nrs Management
Pre-op
NPO 6-8 hrs
Sedation

Nrs management

Post-op
Side-ling until gag
back
NPO till gag back
Check gag
Check bleeding

Purpose
Remove fluid

Nrs Management

Position patient

Support

Post-op

Vital signs q 15

Check for

Pathogens

C&S

Normal

5,000 10,000
cell/mm3

Elevated

Bacterial
infection

Decreased

Viral infection

Normal

Female: 12-16 g/dl

Male:14-18 g/dl
Elevated

COPD

Dehydration
Decreased

Anemia

Hemorrhaging

Normal

Female: 37-47%

Male: 42-52%
Elevated

Dehydration

Burns

COPD
Decreased

Anemia

Leukemia

Airway clearance

Nrs Dx
Ineffective airway

clearance

fluids
Splinting
Infection Control

Goal
Provide adequate
transport of O2
work
stress to
myocardium

Need for O2
based on
ABGs
Clinical
assessment

Cautions on O2 tx
Med!

Except in an emergency situation is

administered only with Dr. order

Give O2 only to bring the pt back to
baseline
***COPD
WHY?

COPD & O2
Normal - CO2 indicator to breath
COPD O2 indicator to breath

d/t CO2 levels burned medulla sensor for CO2

Medulla uses O2 to initiate breath

COPD + O2
Resp

Precautions
Catalyst for
combustion
No smoking sign
Tanks missiles
No friction toys

The nurse is to teach a client with Chronic

Obstructed Pulmonary Disease safety
precautions for using oxygen at home. The
nurse knows that the client understands the
safety principles discussed when he says the
following:
A. "Smoking is permitted when oxygen is in use."
B. "Fire extinguishers do not need to be stored."
C. "Acetone, oil, and alcohol are appropriate
substances to use with clients who are using
oxygen."
D. "Avoid materials that generate static
electricity."

A client is being discharged and will receive

oxygen therapy at home. The nurse is
teaching the client and family oxygen safety
measures. Which of the following
statements by the cleint indicated the need
for further teaching?
A. I realize that I should check the oxygen level
of the portable tank on a consistent basis
B. I will keep my scented candles within 5 feet
of my oxygen tank
C. I will not sit in front of my wood-burning
fireplace with my oxygen on.
D. I will call the physician if I experience any
shortness of breath

A cyanotic client with an unknown

diagnosis is admitted to the emergency
room. In relation to oxygen, the first
nursing action would be to
A. Wait until the clients lab work is done
(ABGs)
B. Not administer oxygen unless ordered
by the physician
C. Administer oxygen at 2 Liters flow per
minute
D. Administer oxygen at 10 Liters flow per
minute and check the clients nail beds
frequently

Side effects
O2
Hyper or hypo
ventilation?

Hypoventilation

Nasal Cannula
Flow rate

FiO2

1-6 L/min
20-40%

Nrs
Talk & eat
Comfort
Nose breather

Simple Mask
Flow rate

FiO2

6-10 L/min
40-60%

Nrs

Higher flow rate

Partial Re-breather
Mask (Reservoir)

Flow rate

FiO2

6-10 L/min
60-100%

Nrs

Uses reservoir to
capture some
exhaled gas for
rebreathing
Vents allow room air
to mix with O2

Non-rebreather
Mask
Flow rate

6-10 L/min

FiO2

70-100%

Nrs
Side vents closed
Reservoir vent
closed for I, open
for E
Reservoir bag
stores O2 for I but
does not allow E air
in
Reservoir never
collapse to <

Venturi
Flow rate

FiO2

4-8 %
20-40%

Nrs.
Precise % of O2
i.e. COPD

Which one of the following conditions

could lead to an inaccurate pulse
oximetry reading if the sensor is
attached to the clients ear?
A.
B.
C.
D.

Artificial nails
Vasodilation
Hypothermia
Movement of the head

A nurse is having difficulty setting up

humidified oxygen at 40% per
Venturi mask and does not know
how many liters of flow she should
use. Which of the following actions
is most appropriate to ensure safe
oxygen administration?
A. Consult with a respiratory therapist.
B. Look at the package directions and try
to figure it out.
C. Ask the nursing assistant how to set it
up.
D. Use a regular oxygen mask.

A.

B.

C.

D.

Post an oxygen in use sign on the door

to the room
Adjust the oxygen level before applying
the cannula
Explain the rules of fire safety and oxygen
use
Lubricate the nares with water-soluble
jelly

Time

7am

9am

11am

1am

3am

Reading

95%

90%

90%

85%

80%

The pulse oximetry reading at 3:30 PM is

75%. What should the nurse do first?
A.
B.

C.

D.

Administer oxygen via mask

Swaddle the neonate in heated
blankets
Reassess the oximetry reading in 30
minutes
Draw blood gases for oxygen and
carbon dioxide levels.

Deliver Moisture
OR medication
directly into the
lungs
Topical
systemic S/E
Indications:

Must be able to
deep breath

Meds:
Bronchodilators

Corticosteroids
Mucolytic agents

Albuteral
(ventolin)

Acetylcysteine

Antibiotics

Admin. Topical
meds directly
into the lungs
systemic S/E

Meds:

Corticosteroids
Bronchodilators
Mast cell
inhibitors

Procedure
Canister into unit
correctly
Shake gently
Hold inhaler
breath out slowly
(not into inhaler)

Place mouthpiece
into your mouth
Close lips around it
Tilt head back
Keep tongue out of
way
Press top of the
canister firmly &
breath in through
your mouth

Remove inhaler
from mouth
Hold breath for
several seconds
Breath out
slowly

Rinse your mouth afterward to help reduce

unwanted side effects

The nurse is teaching a client with asthma

about the proper use of a metered-dose
inhaler. Which statement by the client
indicates that the teaching was
effective?
A. "I'll flex my head forward and breathe
out forcefully before inhaling the drug."
B. "As I press down on the canister, I'll
inhale slowly over 10 seconds."
C. "I'll hold my breath for 5 seconds after
inhaling the drug to allow the drug to
reach my lungs."
D. "I'll wait one minute between puffs."

Device enc.
Deep breath
Prevent & tx
Atelectasis
Procedure

Inhale!

Airway Clearance, ineffective

Aspiration, risk for
Breathing Pattern, ineffective
Gas Exchange, impaired

Characterized by
airflow limitation
Irreversible
Dyspnea on exertion
Progressive
Abn. inflammatory response of the lungs to
noxious particles or gases

Includes
Emphysema
Chronic bronchitis

Does not include

Asthma

COPD 4th leading cause of death in the

US
12th leading cause of disability
Death from COPD is on the rise while
death from heart disease is going down

Risk Factors for COPD

Exposure to tobacco smoke

80-90% of COPD

Passive smoking
Occupational exposure
Air pollution

#1

Smoking

Why is smoking so bad??

phagocytes
cilia function
mucus production

Disease of the airway

Definition:

cough + sputum production

> 3 months

Pathophysiology
Pollutant irritates airway
Inflammation
secretion of mucus

Plugs become areas for bacteria to grow

and chronic infections which increases
mucus secretions and eventually, areas
of focal necrosis and fibrosis

Bronchial walls thicken

Bronchial Lumen narrows
Mucus plugs airway

Alveoli/bronchioles become damaged

susceptibility to LRI

Exacerbation of Chronic bronchitis is most

likely to occur during?
A. Fall
B. Spring
C. Summer
D. Winter

Pathophysiology
Affects alveolar membrane
Destruction of alveolar wall
Loss of elastic recoil
Over distended alveoli

Pathophysiology
Over distended alveoli
Damage to adjacent pulmonary capillaries
dead space
Impaired passive expiration

Impaired gas exchange

Impaired gas exchange

impaired expiration
Hypoxemia
CO2

Damaged pulmonary capillary bed

pulmonary pressure
work load for right ventricle
Right side heart failure

Risk factors, S&S, treatment, Dx, Rx

- same for Chronic Bronchitis &
Emphysema

Clinical Manifestation (primary)

1.
Cough
2.
Sputum production
3.
Dyspnea on exertion
(Secondary)

Wt. loss
Resp. infections
Barrel chest

Risk factors
Past Hx / Family Hx
Pattern of development
Presence of comobidities
Current Tx
Impact

ABGs

Baseline PaO2

Rule out other diseases

CT scan
X-ray

Risk reduction

Smoking cessation!
(The only thing that slows down the progression

of the disease!)

Primary
Bronchodilators
Corticosteriods
Secondary

Antibiotics
Mucolytic agents
Anti-tussive agents

Action:
Relieve bronchospasms
Reduce airway obstruction
ventilation

Examples
Albuterol (Proventil, Ventolin, Volmax)
Metaproterenol (Alupent)
Ipratropium bromide (Atrovent)
Theophylline (Theo-Dur)*

* Oral

Action

Potent anti-inflammatory agent

S/E

Cushing
Moon face
Na+ & H20 retention

Never discontinue abruptly

Examples
Prednisone
Methyprednisone
Beclovent

Treatment

O2
When PaO2 < 60 mm Hg

Pulmonary rehab
Breathing exercises
Pulmonary hygiene

Impaired gas exchange

Ineffective airway clearance
Ineffective breathing patterns
Activity intolerance
Deficient knowledge about self-care
Ineffective coping

A.
B.

C.
D.

It enhances cardiovascular fitness

It improves respiratory muscle
strength
It reduces the number of acute attacks
It worsens respiratory function and is
discouraged