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Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Ed., Hinkle & Cheever | Registered Nurse (RN) School Study Aid
Lung Sounds - Pleural Friction Rub
Anterior Lateral LungDry, Rubbing, or SqueakingRubbing a Balloon with FingerInflamed Pleura
Tuberculosis Skin Mantoux Test (PPD)
Delayed Hypersensitivity (Cell Mediated Response)Intradermal InjectionRead 48-72 hours≥ 5 mm IndurationImmunosuppressed≥ 10 mm IndurationHigh Risk Patients≥ 15 mm IndurationChest X-Ray
Lung Cancer Assessment
2nd Most Common CancerChronic CoughHoarsenessAbnormal Breath SoundsHemoptysisChest PainAnorexia or Weight LossSymptoms Appear Late in Disease
Acute Respiratory Distress Syndrome (ARDS) Assessment
Damaged Alveolar-Capillary MembraneRestlessness DyspneaRefractory HypoxemiaDecreased PaO2Diffuse Pulmonary InfiltratesAtelectasisPulmonary Hypertension
Acute Respiratory Distress Syndrome (ARDS) Interventions
Closely Monitor PatientABG's (Arterial Blood Gases)OxygenAssess for O2 Toxicity Mechanical VentilationPEEPAssess for PneumothoraxPermissive HypercapniaHigh Mortality Rate
Pneumonia Assessment
Older AdultImmunocompromisedLong Term CareShortness of Breath (SOB)HypoxemiaCough and Sputum ProductionWheezing or CracklesFeverPleuritic PainChest X-ray
Pneumonia Intervention
Humidified OxygenDeep Breathing ExercisesPosition of ComfortIncrease Fluid IntakeManage FeverAntibioticsMucolyticsExpectorantsPneumococcal VaccineSepsisAcute Respiratory Failure (ARF)Prevention Education
Pneumothorax
Air Enters Pleural SpaceSudden DyspneaAbsent or Restricted Movement on Affected SideDecreased or Absent Breath Sounds on Affected SideChest PainTracheal DeviationVital Sign ChangesCrepitusHigh Fowler's Position With OxygenPrepare For Chest Tube PlacementEducate High Risk Patients
Pulmonary Embolism Assessment
Shortness of Breath (SOB)Pleuritic Chest PainTachypneaHemoptysisHypoxemiaSudden Death
Tuberculosis Assessment
Airborne Droplet3 Week Productive CoughNight SweatsChest PainFeverWeight LossFatigueChest X-RayBlood TestsMantoux Skin Test3 Positive Sputum Tests
Tuberculosis Intervention
Airborne IsolationCombination Drug Therapy (RIPE)6-12 MonthsDOTBCG VaccinationMedication Education3 Negative Sputum SpecimensInfection Control
Ethambutol (Myambutol)
Inhibits RNA SynthesisBacteriostaticTuberculosis (TB)Optic NeuritisRed/Green Color BlindnessGouty ArthritisMonitor Vision Acuity
Isoniazid (INH)
Interferes with DNA MetabolismTuberculosis (TB)Optic NeuritisNausea and VomitingHepatotoxicityPeripheral NeuropathyVitamin B6 ProphylaxisMonitor AST/ALT
Cardiac Tamponade
Fluid in the Pericardial SacPericarditisDecreased Cardiac OutputBeck's TriadHypotensionJugular Venous Distention (JVD)Distant Heart SoundsPulsus ParadoxusElectrical AlternansPericardiocentesis
Pulmonary Embolism Causes
FAT BAT MnemonicFatAirDeep Vein Thrombosis (DVT)BacteriaAmniotic FluidTumorHypercoagulableCentral Venous LinesImmobilized