Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 2 Respiratory System
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During the test:
•
The injection needs to be given intradermally on the forearm. If it is given
at the wrong depth, the reading will not be accurate and there may be irri-
tation or damage to the tissue.
•
After the test:
•
Patients need to return in 48 to 72 hours to have the injection area evalu-
ated for induration.
•
Teach the patient:
•
That a positive test result means they have been exposed to the disease.
•
Further testing may need to be done depending on the outcome of this test.
•
There may be slight redness at the injection site later on the day of injec-
tion. This does not mean that the test is positive or that the patient has TB.
The result is read at 48 to 72 hours.
Lung Biopsy
WHY IS IT DONE?
Removal of a tissue sample to be examined by the histology lab for abnormalities.
HOW DOES THE TEST WORK?
A tissue sample can be extracted by inserting a needle through the chest and into
the lung or by using a bronchoscope. A biopsy can also be performed as an open
procedure through the chest wall, opening the lung to remove tissue samples.
WHAT TO DO?
•
Before the test:
•
The patient must sign an informed consent. This is required for an inva-
sive procedure which will remove something from the body.
•
NPO for 8 hours to decrease the chance of aspiration if done as an open
procedure.
•
During the test:
•
Monitor vital signs, skin color, and respiratory effort; cardiac monitor.
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Medical-Surgical Nursing Demystified
•
After the test:
•
Examine the incision site for bleeding.
•
Monitor respiration for changes, potential for pneumothorax development
after a piece of the lung has been removed.
Quiz
1. Following an asthmatic attack, a mother asks you how to prevent another
asthmatic attack. You should:
(a) Tell her that asthmatic attacks cannot be prevented.
(b) Help the mother identify triggers that cause asthmatic attacks and show
her how to avoid them.
(c) Ask her physician to change her medication.
(d) Immediately move her family to a dry climate.
2. The patient presents with difficulty breathing and a barrel chest. He is diag-
nosed with emphysema. The patient asks why increasing oxygen therapy
doesn’t relieve his difficulty breathing. The best response is:
(a) Difficulty breathing is due to air trapped in your lungs, reducing the
lungs’ ability to exchange oxygen and carbon dioxide. Increasing oxy-
gen does not resolve the trapped air.
(b) You must lie on your right side for oxygen therapy to work properly.
(c) Your barrel chest has decreased, causing your lungs to over-expand.
(d) You must take deeper breaths when receiving oxygen therapy.
3. The physician has scheduled a thoracentesis. The patient asks why there is
so much fluid in the pleural space. The best response is:
(a) An error occurred and you were administered too much IV medication.
(b) Your body is unable to remove fluid, resulting in a build-up of fluid in
the pleural space around your lungs.
(c) This is the result of oxygen therapy.
(d) This is a normal side effect of bumetanide, which is the medication
ordered by your physician.
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CHAPTER 2 Respiratory System
4. Your patient is apprehensive about undergoing bronchoscopy. He cannot
imagine having anything inserted into his throat. What is the best response?
(a) Your physician performs this procedure hundreds of times a week.
(b) I had it performed three years ago and I was fine.
(c) The thought of this procedure seems to be disturbing you. You will
be asleep during this procedure. I will ask your physician to visit
you again and answer any questions that you have regarding the
procedure.
(d) You won’t feel a thing. You’ll be fine.
5. A 25-year-old nonsmoker who is normally in good health reports having
a bad cough for the past three weeks. He has crackles and rhonchi and
shows you a small clear plastic container that has discolored, blood-
tinged sputum that he produced this morning. What would his physician
want to rule out?
(a) Lung cancer.
(b) The flu.
(c) Pneumonia.
(d) Asthma.
6. Your patient returns from the operating room. Why would you monitor the
patient for atelectasis?
(a) All postoperative patients are at risk for infection.
(b) Postoperative patients might have received too much oxygen during
surgery.
(c) Immobility, anesthesia, and lack of deep breathing places the patient at
risk for atelectasis.
(d) Postoperative patients do not receive enough oxygen during surgery.
7. A patient reports sudden difficulty breathing with tachypnea and tachycar-
dia and localized chest pain. The physician suspects a pulmonary embolism.
What test would you expect the physician to order?
(a) Helical CT scan.
(b) EKG.
(c) ECC.
(d) Vital capacity.
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Medical-Surgical Nursing Demystified
8. The patient hospitalized with bronchitis is concerned that she might have
chronic bronchitis. She asks you to explain the difference between acute
and chronic bronchitis. What is the best response?
(a) Acute bronchitis lasts for three consecutive months and is reversible.
(b) Acute bronchitis lasts seven to ten days.
(c) Chronic bronchitis lasts three consecutive months in two consecutive
years, resulting in blockage of the airways and cannot be reversed.
Acute bronchitis is caused by a viral or bacterial infection and lasts
about ten days. Blockage of the airways is reversible in acute bronchitis.
(d) I will ask your physician to explain the differences during his rounds.
9. A patient who has successfully been treated for a pulmonary embolism is
about to be discharged. How can he lower the risk of experiencing another
pulmonary embolism?
(a) Avoid sitting and standing for too long and do not cross legs.
(b) Take vitamin K with heparin.
(c) Avoid confined spaces.
(d) Jog five miles each day.
10. The physician orders a pulmonary function test. The patient asks you how
the test is performed. The best response is:
(a) A tube is inserted into your lungs while you are asleep to expand your
lungs to their full capacity.
(b) You breathe through a mouthpiece into a spirometer until all air in your
lungs is expelled. Then you will take a deep breath through the mouth-
piece. This is done three times and a computer calculates the capacity
of your lungs.
(c) You breathe into a spirometer to measure your lung capacity.
(d) A computer is used to measure your volume and vital capacity.
Immune System
CHAPTER 3
Thymus
Mucosal associated
lymphoid tissue
Lymph
vascula
system
Lymph node
Thoractic
duct
Bone
marrow
Left subclavian
vein
Spleen
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Medical-Surgical Nursing Demystified
Learning Objectives
Key Terms
Allergies
Anaphylaxis
Antigen
Autoimmune disorders
B-cells
Exudation
Histamines
Human immunodeficiency virus
(HIV)
Hypersensitivity reactions
Immunodeficiency disorders
Lymphocytes
Reed-Sternberg cells
T-cells
Tryptase
Urticaria
Western blot
Acquired immunodeficiency
syndrome (AIDS)
Anaphylaxis
Ankylosing spondylitis
Kaposi’s sarcoma (KS)
Lymphoma
Rheumatoid arthritis
Scleroderma
Mononucleosis
Epstein-Barr virus/
Chronic fatigue syndrome
Lyme disease
Septic shock
Systemic lupus erythematosus
(SLE)
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2
3
4
5
6
7
8
9
10
11
12
How the Immune System Works
Normal functioning of the immune system protects the body against the invasion
of outside organisms. A variety of organisms are capable of this; however, not all
are harmful. The cells of the immune system recognize organisms that invade the
body, then isolate and destroy them. At times, the immune system is not able to
adequately function in this capacity. This results in infection, immunodeficiency
disorders, autoimmune disorders, allergies, and hypersensitivity reactions.
Lymphocytes are the primary cells of the immune system. Lymphocytes are
divided into B-cells and T-cells. B-cells provide a humoral immune response,
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CHAPTER 3 Immune System
since they produce an antigen-specific antibody. T-cells provide a cellular immune
response. Mature T-cells are composed of CD4 and CD8 cells. CD8 cells are re-
sponsible for destroying foreign and viral inhabited cells, and suppress immuno-
logical functions. CD4 cells, also known as helper T-cells, stimulate immune
functions, such as B-cells and macrophages. A macrophage is a cell whose func-
tions include ingesting foreign or invading cells.
Just the Facts
Acquired Immunodeficiency Syndrome
(AIDS)
WHAT WENT WRONG?
The human immunodeficiency virus (HIV) causes malfunction of T-cells which
protect the body from invading microorganisms. When it enters a cell, HIV repli-
cates, causing the cell to reproduce more infected cells. It also frequently causes
cell death. The CD4 lymphocyte is most often affected, followed by B-lymphocytes
and macrophages. Immunodeficiency results.
PROGNOSIS
Prognosis has improved since HIV was discovered in 1981. Fewer patients are
progressing from HIV to AIDS, and both classes are living longer. New drugs and
therapies are decreasing the number of deaths. Patients are living with fewer dis-
abilities and comorbidities.
HALLMARK SIGNS AND SYMPTOMS
•
Anorexia—secondary to GI manifestations, oral disease, and side effects of
medications.
•
Fatigue—cells dying at an abnormal rate; opportunistic infections due to a
poorly functioning immune system.
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Medical-Surgical Nursing Demystified
•
Night sweats—immune system triggered response.
•
Fever—may be due to a concurrent infection related to a low WBC count.
•
Malnutrition—due to poor appetite, poor nutrition, nausea and vomiting, and
most often from a secondary infection; decreased protein synthesis.
INTERPRETING TEST RESULTS
•
Less than 200 T-cells per microliter—the CD4 lymphocyte is the most com-
monly used count; <200 cells/μl signals the process from HIV to AIDS, and
thus, increases the risk for malignancies and advancing infection.
•
Positive HIV antibody titer—95 percent positive 6 weeks after contact. Often
used with the Western blot to confirm diagnosis.
•
Positive Western blot—confirms positive HIV test.
TREATMENT
•
High-calorie and high-protein diet to combat wasting and weight loss.
•
Administer antibiotics to combat opportunistic infections:
•
trimethoprim/sulfamethoxazole
•
Administer antiviral medication to suppress HIV replication, causing support
of the immune system and fewer opportunistic infections.
•
Nucleoside analogs (have antiviral activity):
•
didanosine
•
zidovudine
•
stavudine
•
zalcitabine
•
Nucleotide analog:
•
tenofovir
•
Protease inhibitors (suppress HIV replication):
•
fortovase
•
ritonavir
•
indinavir
•
nelfinavir
•
Nonnucleoside reverse transcriptase inhibitors (stop reverse transcriptase
at a different site):
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CHAPTER 3 Immune System
•
nevirapine
•
delavirdine
•
efavirenz
•
Administer antiemetic to combat nausea:
•
prochlorperazine
•
Administer antifungal medication to combat fungal infections, which are often
opportunistic:
•
fluconazole
NURSING DIAGNOSES
•
Hopelessness
•
Social isolation
•
Ineffective protection
NURSING INTERVENTION
•
Maintain activity as tolerated and schedule rest periods to maintain physical
functioning.
•
Avoid exposure to blood to prevent the spread of the virus.
•
Explain to the patient:
•
Use of condoms to prevent the spread of the virus.
Anaphylaxis
WHAT WENT WRONG?
An allergen, usually food or medication, enters the body causing the release of his-
tamines, which result in capillaries dilating and smooth muscle contracting. This
results in edema, respiratory distress, hypotension, and skin changes, leading to an
allergic reaction. Lesser degrees of extreme allergy are urticaria (hives) and angio-
edema (swelling caused by exudation).
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Medical-Surgical Nursing Demystified
PROGNOSIS
Prognosis may be guarded, depending on how severe the reaction is and how quickly
treatment is rendered. Patients need to be monitored for 1 to 2 days after treatment
and cautioned about reexposure to the offending item.
HALLMARK SIGNS AND SYMPTOMS
•
Shortness of breath due to swelling of the larynx
•
Hypotension and shock due to generalized vasodilation
•
Sneezing—a common occurrence to an allergan
•
Anxiety secondary to difficulty in breathing
•
Rales (crackles) heard in the lungs—due to fluid in the lungs
•
Wheezing (rhonchi) due to bronchospasm
INTERPRETING TEST RESULTS
Tryptase levels are from mast cells which increase in anaphylaxis. After the acute
episode is over, allergy skin testing is recommended.
TREATMENT
•
Administer emergency medications:
•
epinephrine to open airways and to reduce bronchospasm
•
corticosteroids to reduce symptoms
•
antihistamines to mitigate symptoms
•
Administer circulatory volume expanders to treat hypotension caused by
vasodilation:
•
saline
•
plasma
•
IV fluids
•
Administer vasopressors to counteract vasodilation and to increase blood
pressure:
•
norepinephrine
•
dopamine