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91 Cards in this Set
- Front
- Back
Risk factors for pulmonary embolism
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immobility, surgery within the last 3 months (especially pelvic and lower extremity surgery), stroke, paralysis, hx of DVT, malignancy, obesity in women, heavy smoker, HTN
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What is it called when an embolus from DVT turns into a PE?
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Venous thromboembolism
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Where do most PE's arise from?
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DVT
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Where do most lethal PE's originate?
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femoral or iliac veins
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What lobe of the lungs are most frequently effected by PE?
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Lower lobes
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What commonly dislodges DVT embolisms?
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Standing or Valsalva maneuver
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What is the classic triad for PE?
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dyspnea, chest pain, hemoptysis
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S/S of PE
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cough, chest pain, crackles, fever, accentuation of the pulmonic heart sound, sudden change in mental status from hypoxemiaa
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S/S of massive PE
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hypotension, shock, pallor, severe dyspnea, hypoxemia. ECG and chest x-ray indicates rt ventricular hypertrophy due to pulmonary HTN.
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S/S of medium PE
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pleuritic chest pain, dyspnea, slight fever, productive cough with blood-streaked sputum
Tachycardia, pleural friction rub |
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S/S of small PE
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none uncless pt has cardiopulmonary disease
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Complications of PE
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pulmonary infarction, pulmonary HTN
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How long do pts live with PE?
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May die soon or live for decades
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Most frequently used test for PE
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spiral CT then D-dimer/pulmonary angiography
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Measures for PE
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O2!! Maybe endotracheal tube.
Then turn, cough, deep breathe to prevent atelectasis |
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Rx management of PE
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Clot busters like rPA in the acute, morphine for the pain
Then, start on Lovenox immediately and Coumadin for 3-6 months. |
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Surgical tx for PE
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Embolectomy in acute (50% mortality rate)
Inferior vena cava filter later. |
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Positioning of PE pt
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Semi-fowler's
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What kind of pts have the highest incidence of DVT?
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Spinal cord injury
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ABG's with PE
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hypoxemia and low PaCO2
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Activity level with PE should be
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limited
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aPTT
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25-40 sec
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INR
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Therapeutic is 2.0-3.0
Heart valve replacement 2.5-3.5 |
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What does d-Dimer test indicate?
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Amount of cross-linked fibrin fragments. Not normally in healthy people - found in stroke, DVT, acute MI, unstable angina, DIC, surgery up to post 2nd day, sickle cell crisis
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BNP
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<100
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Troponin
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<0.2-<1.0
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How is the dosage of heparin calculated?
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according to aPTT
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How is the dosage of coumadin calculated?
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INR
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Hypoxemic respiratory failure is from...
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Low blood perfusion
Ex. ARDS, PE, artery laceration, anatomic shunt, shock |
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Hypercapnic respiratory failure is from...
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Not breathing enough
Ex. Asthma, COPD, brainstem injury, sedative overdose, thoracic trauma, MS |
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PaCO2
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35-45
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Patho of hypoxemic respiratory failure
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V/Q (ventilation/perfusion) mismatch, shunt, diffusion limitation, hypoventilation
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Most common disease to have V/Q mismatch
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COPD, pneumonia, bronchospasm
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Early signs of respiratory failure
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Mental status changes (restlessness, confusion, combative)
tachycardia, tachypnea, mild HTN |
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What does a severe a.m. headache suggest?
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Hypercapnia in the night
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Later signs of respiratory failure
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acidosis, dysrhythmias, angina, impaired renal function (edema, increased Na and uremia)
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What does a change from tachypnea to bradypnea in an ARDS pt suggest?
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Extreme fatigue and impending respiratory arrest
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Inspiratory/expiratory ratio
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Normal is 1:2
ARDS - 1: 3or4 |
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What signifies moderate respiratory distress?
Severe respiratory distress? |
Accessory muscle use
paradoxic breathing |
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Augmented coughing
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For the pt to weak to effectively cough
Place hands below xiphoid process. As pt ends deep inspiration and begins expirations, move your hands forcefully downward, increasing abdominal pressure and facilitating the cough. |
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Rx for ARDS
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Bronchodialators (albuterol) given at 15-30min intervals
Corticosteroids for chronic respiratory failure IV diuretics and mitroglycerin (Lasix) to decrease pulmonary congestion. If a fib is present, Ca channel blockers and beta blockers Antibiotics for infections Sedatives for anxiety - monitor for respiratory and cardio depression |
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S/S of hypoxemic and hypercapnic breathing
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Hypoxemic - tachypnea, cyanosis, paradoxic breathing
Hypercapnic - a.m. headache, pursed-lip breathing |
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Maintainence of fluid balance with ARDS
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mild fluid restriction and diuretics as necessary
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minimal leak technique with trach
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inflate cuff until no leak is heard over trachea, then deflate 0.1mm of air
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When should minimal leak technique not be used?
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when there is risk of aspiration
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How much should trach cuff pressure be?
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<20mm Hg or <25mm H2O
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Care of pt with inflated cuff
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Monitor and record cuff pressure q8h.
Never insert decannulation tube until cuff is deflated. Monitor for increased air pressures required for cuff. When removing, have pt swallow grape juice or H2O with blue food dye and cough to assess aspiration. Wait two days after trachostomy tube is inserted to use. Deflate cuff daily to check integrity of the cuff. If it returns with air, cuff needs to be replaced. Tubing good up to 1 month in pts on home mechanical ventilation |
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How often do you do trach care?
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tid and prn
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Ideal suction pressure
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120-150mm with the tubing occluded
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How long do you suction?
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<10sec
Stop if HR decreases 20bpm, increases 40bpm, dysrhythmia, or SpO2 <90% |
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What do you instruct the pt to do before and during cuff deflation on trach?
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Cough before, exhale during
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What should the pt do during cuff inflation?
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inhale
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Trach dislodgement precautions
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1. Keep replacement tube at bedside
2. Do not change trach tapes for at least 24 hours after trach insertion. 3. Physician does first tube change no sooner than a week after insertion. |
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What do you do if a trach becomes dislodged?
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Grab retention sutures and try to put the new trach in. If you can't get it, cover ostomy with sterile saline gauze and resuscitate with Ambu bag until help arrives.
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What kind of air do trach pts receive?
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humidified
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Nursing dx for trach tube
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Ineffective airway clearance
Risk of aspiration Impaired verbal communication Ineffective self-health management Risk for infection |
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How do you evaluate a trach pt for aspiration?
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add blue food coloring to clear liquid or test tacheobronchial secretions for glucose
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Decannulation of trach
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When pt can swallow and breathe, tape the stoma closed with occlusive dressive. Pt splints stoma when coughing, swallowing, speaking. Surgical intervention is not required.
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Tx for laryngeal polyps
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Rest vocal cords and stay hydrated.
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S/s of tension pneumothorax
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tracheal deviation
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If pt has confusion/agitation. What do you do first?
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Assess VS and pulse ox FIRST!!!!
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Causes of respiratory acidosis
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Drugs, cardiac arrest, pulmonary edema, muscle weakness (MG, ALS, GB)
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Causes of respiratory alkalosis
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Hypoxemia, CNS disorder, high altitude, cirrhosis, anxiety, hyperventilation
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Causes of metabolic acidosis
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Ketoacidosis, GI loss (diarrhea), renal failure, sepsis, shock
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Causes of metabolic alkalosis
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Antacid OD, GI losses, blood transfusion, not enough K+
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What stimulates COPD pt to breathe?
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O2 level, so be careful with O2 administration b/c they lose the drive to breathe.
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What is a biot respiratory pattern?
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irregular
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Rt shift
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O2 less attracted to hemoglobin and more available to tissues. Elevated temp, acidosis
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Lft shift
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O2 more attracted to hemoglobin and less available to the tissues. Cold pt, shock, alkalosis
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What do we never give tracheostomy pts?
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STRAWS
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How often do you do trach care?
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Once a shift
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What do you do before doing trach care?
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Sterile procedure, suctioning
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What hand do you use for suctioning?
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Nondominant
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When do you lavage when suctioning?
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ONLY when there are THICK secretions
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How often do we go down with suctioning?
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As often as needed
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How do you change trach ties?
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Don't take off old ones before you put on the new ones
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What concentration do you mix the NS and H2O2 for trach care?
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50/50
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Trach care, sterile or clean procedure?
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Sterile in the hospital
Clean at home |
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How far do you insert the suction cathetar when suctioning?
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Until you meet resistance and then withdraw 0.5in
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What is a pneumothorax?
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Air in pleural space causing collapsed lung
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What is tension pneumothorax?
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caused by rapid accumulation of air in pleural space. Causes shift away from the collapsed lung.
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S/S of tension pneumothorax
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Dyspneic, tachycardic, sharp chest pain, cough from irritated pleural, absence breath sounds, tracheal shift
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Flail chest is defined as
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2 or more rib fractures on same side, paradoxical respirations
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Who sets up the suction for chest tube?
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RN
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When setting up suctioning for chest tube...
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-20 sontometers of suction.
Pour sterile water in until it goes to 20 sontometer mark. 3 sontometers in middle chamber. Clean procedure. Only adjust suction in wall. Low wall suction. GENTLE BUBBLING. Colored dye where we put the water. |
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Size of chest tube...
Small for... Large for... |
Large tube for pus drainage
Small tube for air drainage |
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Type of gauze around chest tube
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Vasoline gauze
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Positioning of pleurisy
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Lay on affected side to splint it
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Most important intervention to prevent atelectasis
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Cough, deep breathe
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Pulmonary Fibrosis
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Scar tissue in lungs from inflammation or irritant
Environmental or occupational exposure, smoking Coal mine workers Mesothelioma Poor prognosis – terminal illness Lung transplant option Exertional dyspnea, clubbing, hard to oxygenate. |
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Sarcodosis
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Granulomatous dz of unknown cause
Acute, sub-acute, or chronic Most better with symptomatic treatment 20% develop lung damage More common in African-Americans NSAID's, methotrexate |