Midterm Exam: NR571/ NR 571 Complete Review (Latest 2023/ 2024 Update) Complex Diagnosis & Management in Acute Care |Questions and Verified Answers|100% Correct – Chamberlain
Midterm Exam: NUR571/ NUR 571
Complete Review (Latest 2023/ 2024 Update)
Complex Diagnosis & Management in Acute
Care |Questions and Verified Answers|100%
Correct – Chamberlain
Q: pulmonary diagnosis
Answer:
PFTs, arterial blood gases and radiography are for
Q: PTFs
Answer:
for intraoperative or postoperative respiratory complications. for bron- chodilator therapy, risk
evaluation for patients before thoracic or upper abdominal surgery.
Q: PFTs Evaluating
Answer:
lung volumes or the ability to fully expand
flow rates, rate of inflow and outflow of air maximal voluntary ventilation or airflow through the
major airways by completing rapid inspiration expiration maneuvers evaluation of diffusing
capacity or the ability of the oxygen to get into the blood
Q: PFTs Measures
Answer:
Spirometry evaluates the amount of air exhaled and inhaled during forced maneuvers
Lung volume refers to the total amount of air in the lungs with maximal inspiration. diffusing
capacity measures gas exchange and is often done in conjunction with a pulse oximetry reading.
Q: Normal PFTs
Answer:
FEV1 (80% to 120%), FVC (80% to 120%), Absolute FEV1/FVC Ratio (Within 5% of the
predicted ratio), TLC
(80% to 120%), FRC (75% to 120%), RV (75% to 120%), DLCO (>60% to <120%),
Q: Restrictive Lung Disease=
Answer:
decrease in the total volume of air that the lungs can hold. decrease in the elasticity, inability of
the chest wall to expand during inhalation
Q: associated with restrictive lung function
Answer:
interstitial lung disease such as idiopathic pulmonary fibrosis, sarcoidosis, obesity, including
obesity hypoventilation syndrome, scoliosis, neuromuscular diseases such as muscular dystrophy
or ama- teur amyotrophic lateral sclerosis (ALS) associated
Q: Obstructive Lung Disease
Answer:
impede exhaled air from the lungs due to the narrowing of the airways or actual damage to the
lung parenchyma.
Q: associated with obstructive lung function
Answer:
asthma, chronic (COPD), cystic fibrosis, bronchiectasis are associated
Q: PTs Diagnostic Approach
Answer:
Determine if the FEV1/FVC ratio is low. (obstructive defect present)
Determine if the FVC is low. (restrictive pattern indicating restrictive lung disease, a mixed
pattern, or pure obstructive lung disease with air trapping).
Grade the severity of the abnormality.
Determined the reversibility of the obstructive defect..
Bronchoprovocation is done when a provider suspects exercise or allergen-induced
Q: Bronchodilator Response
Answer:
FEV1 or the FEV increases by at least 12% the obstructive pattern is considered reversible, with
Q: Bronchoprovocation
Answer:
for exercise, or allergen-induced asthma, involves a methacholine challenge or a mannitol
inhalation challenge.
Q: Restrictive and obstructive disorders
Answer:
Severity according to the American
Thoracic Society’s (ATS) based on FEV1 abnormality for
Q: restrictive processes
Answer:
The pattern of reduced FEV1 and FVC with preserves
FEV1/FVC ratio is often seen with
Q: airflow obstruction
Answer:
low FEV1 and low FEV1/FVC ratio, and low FEV1 and FVC
with a decreased FEV1/FVC ratio equals
Q: Complications with asthma
Answer:
sleep disturbance, limitation of physical activity, increased weight gain due to inactivity,
increased sick days from work, and perma- nent narrowing of the airways resulting in decreased
reserves are complications of
Q: acute asthma exacerbation S/S
Answer:
chest tightness, expiratory wheezing, dysp- nea, and non-productive cough, escalation at night,
anxiety s/s
Q: Physical Exam acute asthma exacerbation
Answer:
tachypnea, tachycardia, de- creased oxygen saturation, expiratory wheezing, and a prolonged
expiratory phase use of accessory muscles, hypercapnia develops, hypoxemia impaired ventilation/perfusion results in acidosis are present exam for
Q: acute asthma exacerbation impending death!
Answer:
The absence of breath sounds and a pCO2 > 70 mmHg are signs of
Q: Differential Diagnosis for asthma
Answer:
airway obstruction related to a mechanical or foreign body, airway obstruction related to a
structural abnormality such as a tumor, aspiration or severe gastroesophageal reflux disease,
paradoxical vocal cord motion disorder, heart failure, COPD, vasculitis, bronchiectasis,
pulmonary emboli interstitial lung disease are differential
Q: Diagnostic Testing for asthma
Answer:
physical exam findings, lung function, and oxygen saturation, peak expiratory flow (PEF),
spirometry, Chest x-ray, Labs are test
Q: Asthma Exacerbations-Mild or Moderate
Answer:
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the total volume of gas within the lungs after a maximal inspiration
the volume of gas expired after a maximal inspiration followed by a maximal expiration.
FRC (functional residual capacity)
the volume of gas within the lungs at the end of expiration during normal tidal breathing at rest
PFTs measure three distinct parameters which include
spirometry, lung volume, and diffusing capacity.
PFT’s are useful in evaluating:
-lung volumes or the ability to fully expand
-flow rates or the rate of inflow and outflow of air
-maximal voluntary ventilation or airflow through the major airways by completing rapid inspiration expiration maneuvers
-evaluation of diffusing capacity or the ability of the oxygen to get into the blood
total volume a patient exhales for the total duration of the test
forced expiratory volume (FEV1)
the percentage of the FVC expired and 1 second
Normal: Within 5% of the predicted ratio
the maximal volume of air exhaled from end-expiration
the maximal volume of air held from end-inspiration
the volume of air remaining in the lungs after a maximal exhalation
the volume of air inhaled or XL during each respiratory cycle
Functional Residual Capacity (FRC)
the volume of air in the lungs at resting end-expiration
the volume of air in the lungs at maximal inflation
the largest volume measured on complete exhalation after full inspiration
the diffusing capacity of the lung for carbon monoxide
Classification of Pulmonary Disorders Based On PFT:
Restrictive Lung Disease
Classification of Pulmonary Disorders Based On PFT:
Obstructive Lung Disease
A systematic approach is helpful to accurately interpret PFTs and includes the following steps:
1. Determine if the FEV1/FVC ratio is low. This finding will indicate that there is an obstructive defect present.
2. Determine if the FVC is low. This finding will indicate a restrictive pattern indicating restrictive lung disease, a mixed pattern, or pure obstructive lung disease with air trapping.
3. Grade the severity of the abnormality. If there is an obstructive defect, restrictive pattern, or mix pattern you should grade the severity of the abnormality based on the FEV1 percentage predicted based on the American Thoracic Society’s (ATS) system for grading PFT abnormalities.
4. Determined the reversibility of the obstructive defect. If the patient does have an obstructive defect, the determination should be made if it is reversible based on the increase in FEV1 or FVC after bronchodilator treatment.
5. Bronchoprovocation is done when a provider suspects exercise or allergen-induced asthma may be causing the abnormality.
-If the FEV 1 is 70% or less predicted on standard spirometry, bronchoprovocation should be used to make the final diagnosis. This involves a methacholine challenge or a mannitol inhalation challenge.
What is a Bronchodilator Response used for
Determined the reversibility of disease when an obstructive pattern is present
Allergen exposure in those with a predisposition to atopy
Infections (viral and Mycoplasma)
Fungi in allergic airway mycoses
Acute irritants and reactive airway dysfunction syndrome (RADS)
High-intensity exercise in elite athletes
Inpatient vs. Outpatient for asthma exacerbation
-Most mild exacerbations can be managed in the primary or urgent care setting.
-initiated with bronchodilators, systemic corticosteroids, and oxygen if able
1.Was the patient’s asthma controlled before this exacerbation? -If not, inpatient management may be indicated with close monitoring and medication adjustment.
2. Has the patient achieved symptom relief and improved peak flow readings with treatment that was administered?
-If so, a period of observation should be done to assure a rebound attack does not occur.
Standard treatment for acute asthma exacerbation (5)
Supplemental Oxygen for acute asthma exacerbation
Delivered by nasal cannula or mask to keep O2 saturation 93-95%. Can correct hypoxemia
Inhaled SABA Therapy for acute asthma exacerbation
repetitive or continuous (MDI) or nebulizer can quickly reverse airflow obstruction.
Inhaled Short Acting B2-antagonist(SABA):
what are the names of 2 inhaled SABA?
albuterol
Levalbuterol (R-albuterol)
albuterol doses for acute asthma
Inhaled Short Acting B2-antagonist(SABA): albuterol nebulizer -2.5-5 mg q 20 min for 3 doses
Levalbuterol (R-albuterol) dose for acute asthma
-1.25-2.5mg q 20min x3; 1.5-5mg q 1-4hr PRN
Systemic Corticosteroids for acute asthma exacerbation
Administer within 1 hour of presentation.
dosage for systemic corticosteroids
40-80mg/d in 1 or 2 divided doses until PEF reaches 70% of predicted or personal best.
Anticholinergics for acute asthma exacerbation
Ipratropium bromide Nebulizer
Ipratropium with albuterol nebulizer
Ipratropium bromide Nebulizer dosing
0.25mg/mL
0.5mg every 20 min for 3 doses, then as needed.
Ipratropium with albuterol nebulizer dosing
Differential Dx for pneumonia of noninfectious origin
Which of the following is TRUE regarding the development of pneumonia?
1. pneumonia is an acute inflammatory condition within the parenchyma of the lung
2. immunocompromised individuals are at an increased risk of developing pneumonia
3. pneumonia often develops as a consequence of bacterial colonization and micro aspiration of upper airway track secretions
4. all of the above
All of the following are common symptoms of community-acquired pneumonia in adults except:
Mr. C is a 75-year-old male with a recent history of an ischemic stroke. He is being cared for at home and has home health assistance. Residual effects of his stroke include dysphasia and right-sided weakness. He presents today for evaluation secondary to fever, chills, and productive cough. His CXR demonstrates the following:
What is the most likely cause of this finding?
-COPD
-bacterial pneumonia
-viral pneumonia
-aspiration pneumonia
Differential Dx for COPD exacerbations?
ER room Tx of COPD exacerbations
Oxygen
Oxygen therapy in the hospital setting is a key treatment in managing COPD exacerbations. Supplemental oxygen delivered via a high-flow mask (venti-mask), should be initiated and titrated to a target oxygen saturation of 88-92%.
SABA
SABAs, with or without short-acting anticholinergics, are recommended as the initial bronchodilator to treat an exacerbation; however, maintenance therapy with LABA should be administered as soon as possible and before discharge
Systemic Corticosteroids
improve FEV1 and oxygenation as well as shortens recovery time and length of stay but should not be given more than 7 days
Antibiotics
when indicated, have been shown to improve outcomes
Arterial Blood Gas (ABG)
Arterial blood gases should be drawn after starting oxygen and then frequently throughout the patient’s stay to monitor oxygenation, CO2 retention, and acidosis.
mild to moderate COPD exacerbation Tx in outpatient/PC
post-bronchodilator FEV1/FVC < 0.70
A 70-year-old patient with a history of COPD presents to the emergency room for cough and increasing exertional dyspnea with newly reported symptoms at rest. Sputum production is clear to white, but an increase in the amount is reported. The patient’s last hospitalization for COPD was 4 years ago. She is currently taking a LABA as monotherapy but is using her rescue inhaler 3-4 times per day since her symptoms started. She is alert and oriented, breath sounds are scattered with inspiratory and expiratory wheezing throughout all lung fields, and there are no signs of respiratory distress. Vital signs are T 98.0 F, BP 120/80, HR 85, RR 20, SaO2 90 % on room air. EKG and labs including CBC, CMP, BNP, troponin are normal. Chest x-ray reveals hyperinflation and flattened diaphragm without infiltrates or cardiomegaly. ABG is normal except for a mildly decreased pO2. Which of the following is the most appropriate treatment for this patient at this time?
1. administer supplemental oxygen, albuterol nebulizers, and oral corticosteroids
2.administer antibiotics, supplemental oxygen, and albuterol nebulizers
3. initiate noninvasive ventilation and administer IC corticosteroids
4. intubate and transfer the patient to the ICU
administer supplemental oxygen, albuterol nebulizers, and oral corticosteroids
Rationale
The initial management of COPD exacerbation includes supplemental oxygen, SABA, and corticosteroids. Her exam findings show mild hypoxia and tachypnea, but other results show her to be medically stable. She is not exhibiting any signs of infection; therefore, antibiotics are not indicated at this time. There are no signs of respiratory distress therefore noninvasive ventilation or mechanical ventilation is not appropriate.
arterial blood gas (ABG) analysis
A 16-year-old patient with a history of mild, intermittent asthma is seen in the emergency room complaining of shortness of breath. She normally only needs her albuterol inhaler before exercise, but she is using it now 2-3 times per day for 3 days. Upon examination, the AGACNP notes the patient’s appearance as calm but tachypneic. HR is 108, O2 saturation on room air is 91 %. A bedside peak expiratory flow measurement reveals FEV1 at 58 % of her personal best. The AGACNP should classify this patient’s asthma as which of the following?
1. mild/moderate
2. severe
3. life-threatening
4. the severity cannot be determined with the information given
subjective symptoms of COPD exacerbation
patients experiencing an exacerbation include:
air hunger
increased cough;
a change in color, viscosity, or amount of mucus;
more noticeable wheezing than normal;
dizziness or lightheadedness (due to hyperventilation and hypercapnia);
worsened fatigue;
trouble sleeping;
headaches;
severe anxiety, fear, or sense of impending doom;
chest tightness;
fever may be present.
Considerations for Discharge Home versus Hospital Admission in COPD exacerbation
The decision to discharge the patient from the ER and provide home management is informed by the following questions:
-Is the patient in respiratory distress after treatment?
-Does the patient require continued supplemental oxygen?
-Is the patient hypercapnic despite treatment?
If the answer to any of these three questions is yes, the patient requires inpatient admission for further management stabilization.
secondary prevention strategies in COPD
Which of the following is TRUE regarding the development of pneumonia?
-pneumonia is an acute inflammatory condition within the parenchyma of the lung
-immunocompromised individuals are at an increased risk of developing pneumonia
-pneumonia often develops as a consequence of bacterial colonization and microaspiration of upper airway track secretions
-all of the above
All of the following are common symptoms of community-acquired pneumonia in adults except:
Mr. C is a 75-year-old male with a recent history of an ischemic stroke. He is being cared for at home and has home health assistance. Residual effects of his stroke include dysphasia and right-sided weakness. He presents today for evaluation secondary to fever, chills, and productive cough. His CXR demonstrates the following:
What is the most likely cause of this finding?
1.COPD
2. bacterial pneumonia
3. viral pneumonia
4. aspiration pneumonia
causes of hypoxemia: hypoventilation
causes of hypoxemia: V/Q mismatch
causes of hypoxemia: Right to left shunt
causes of hypoxemia: Diffusion limited
pattern of PFT abnormalities: The obstructive pattern
pattern of PFT abnormalities: The restrictive pattern
low TLC
decreased FEV1 and FVC
normal FEV1/FVC
a normal or super-normal FEF 25-75%
a low DLCO