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161 Cards in this Set

  • Front
  • Back
Signs of respiratory distress (RD)

pursed lip breathing (PLB)
early sign
-compensatory mechanism. keeps airways open longer.

it facilitates maximal expiration for clients with obstructive lung disease.
-it allows better expiration by increasing airway pressure that keeps air pasages open during exhalation
Signs of respiratory distress (RD)

Pursed Lip Breathing - what is the primary purpose?
-the primary purpose is to promote CO2 elimination
Signs of respiratory distress (RD)

Tripoding
early

sitting forward
it is the easiest/best way to get air in
Signs of respiratory distress (RD)

increased RR (3-4 breaths above their normal baseline)
early
Signs of respiratory distress (RD)

what is the earliest sign of ARDS:
increased RR
Signs of respiratory distress (RD)

SOB
early
Signs of respiratory distress (RD)

diaphoretic (lip and forhead)
early
Signs of respiratory distress (RD)

restlessness
early

caused by lack of o2 to the brain
Signs of respiratory distress (RD)

1 word responses
early
Signs of respiratory distress (RD)

confusion and distraction
early
Signs of respiratory distress (RD)

skin is pallor and cool
early

blood is going to the core
Signs of respiratory distress (RD)

pulse ox is low (less than 90)
early
Signs of respiratory distress (RD)

HR and BP increase
early
Signs of respiratory distress (RD)

wheezing on inspiration
early
Signs of respiratory distress (RD)

hypercapnia
early
Signs of respiratory distress (RD)

skin is pallor and cool
early

blood is going to the core
Signs of respiratory distress (RD)

pulse ox is low (less than 90)
early
Signs of respiratory distress (RD)

HR and BP increase
early
Signs of respiratory distress (RD)

wheezing on inspiration
early
Signs of respiratory distress (RD)

hypercapnia
early
Signs of respiratory distress (RD)

nasal flaring in an adult
late
Signs of respiratory distress (RD)

cyanosis (blue lips)
late
Signs of respiratory distress (RD)

use of accessory muscles
late

sternocleidomastoid muscle
Signs of respiratory distress (RD)

depth of breathing icnreases as distress increases leading to irregularity and apnea
late
A late signs of respiratory distress (RD)

Respiratory rate?
greater than 24
Late signs of respiratory distress (RD)

Heart rate?
greater than 120
Late signs of respiratory distress (RD)

blood pressure?
decraesed.. less than 90/50
Signs of respiratory distress (RD)

skin is cold and clammy
late
Signs of respiratory distress (RD)

dysrhythmias
late
Signs of respiratory distress (RD)

panic
late
Signs of respiratory distress (RD)


LOC decreases. their reponses is slower with increasing agitation
late
Signs of respiratory distress (RD)

lethargy
late
Signs of respiratory distress (RD)

stupor/coma
late
Signs of respiratory distress (RD)

intercostal retractions
late
Signs of respiratory distress (RD)

respiratory alkalosis or acidosis
--what do you see inititally?

--what do you see as a late sign?
alkalosis because they are blowing off CO2 (breathing faster)


resp. acidosis ..shallow and rapid breaths
Signs of respiratory distress (RD)

first early sign in children?
nasal flaring
Signs of respiratory distress (RD)

late sign in children?
intercostal retractions (children dont have an O2 reserve)
Assessment of Chronic Hypoxemia (low oxygen in blood)/ Chronic dyspnea:

4 things
•clubbing
• polycythemia
•mental changes
• cor pulmonale
Assessment of Chronic Hypoxemia (low oxygen in blood)/ Chronic dyspnea:

clubbing
(normal 160 degrees)
-late: swollen, springy, floating..angle is greater than 186
Assessment of Chronic Hypoxemia (low oxygen in blood)/ Chronic dyspnea:

polycythemia
(compensatory mechanism in which the CV produces more erythrocytes to deliver more O2),
Assessment of Chronic Hypoxemia (low oxygen in blood)/ Chronic dyspnea:

cor pulmonale
o blood has a hard time going to the lungs because the pulmonary artery becomes stiff and inelastic due to hypoxemia.
o blood starts to back up in the right atrium and less oxygenated blood is going to the body.


you will have pulmonary hypertension, edema in periphery, neck vein distention, enlargement of organs
VS
newborn HR
100-170
VS
newborn RR
30-60
VS
infant BP
60-90 / 45-65
VS
infant to 2 years HR
80-130
VS
1 year old RR
20-40
VS
Toddler BP
70-100 / 45-65
VS
2-6 year old HR
70-120
VS
6 year old RR
16-22
VS
School age BP
90-100 / 50-70
VS
adolescent HR
60-100
VS
adolescent RR
10-20
VS
adolescent BP
95-130 / 60-80
Assessment of oxygenation

•POX- beware of inaccurate readings, such as:
nail polish, being cold, bright lights, peripheral vascular disease, hypothermia, pharmacological vasoconstrictors, hypotension, peripheral edema. if cap refill is more than 3 seconds, select another site
Assessment of oxygenation

•POX- in peds where should you attach the probe?
great toe
Assessment of oxygenation

Skin
what are early vs late signs?
Skin: cyanosis and diaphoresis (late) & pallor (early)
Assessment of oxygenation

•Breath sounds:
wheezes (narrowing of airways)
Assessment of oxygenation


Peak flow meter:
starts at 50-60 and goes up. this measures how much air you can get out in 1 sec. normal is 480
Assessment of oxygenation
-work of breathing (may be subjective) so what may you use to assess this?
Borg Scale “How much shortness of breath do you have right now” it is subjective
0-nothing
10- vey very severe
now that you have assessed breathing, what do you do next?
-raise the HOB to ease breathing, never have the bed flat
Interventions for respiratory distress / Oxygen – Low flow systems

•Nasal cannula:
___L/min %
1-6 L/min (24%-44%)
Interventions for respiratory distress / Oxygen – Low flow systems

Nasal cannula
-what would you start someone on?
2L
Interventions for respiratory distress / Oxygen – Low flow systems

Nasal cannula: what do you do if a pt is complaining of a dry irriated nose
use humidification and a water based lubricant (KY)
Interventions for respiratory distress / Oxygen – Low flow systems

nasal cannula: is used for what kind of patient
a pt who is hypoxemic and has chronic hypercapnia requires low O2 delivery 1-2 L/min because a low arterial oxygen level is the clients primary drive for breathing
Interventions for respiratory distress / Oxygen

Would a COPD pt require a low or high flow system of oxygen
low flow - so they dont lose their drive to breath
Interventions for respiratory distress / Oxygen – Low flow systems

Oxygen-conserving cannula:
increase concentration of oxygen at a lower flow rate

-not as drying in the nose
-higher % at a lower rate
Interventions for respiratory distress / Oxygen – Low flow systems

Simple face mask:

____L/min and %
5-10 L/min (40%-60%)
Interventions for respiratory distress / Oxygen – Low flow systems

Simple face mask:
what can't they do
talk or eat
Interventions for respiratory distress / Oxygen – Low flow systems

Partial rebreather mask:

___L/min & %
6-10 L/min (60%-95%)
Interventions for respiratory distress / Oxygen – Low flow systems



Partial rebreather mask:
-what must they have to use this mask?
-must have flow rate high enough to keep bag inflated

1 flap is covered
Interventions for respiratory distress / Oxygen – Low flow systems
Non-rebreather mask:

_____L/min and %
6-15 L/min (60%-100%)
Interventions for respiratory distress / Oxygen – Low flow systems

Non-rebreather mask:
--how many flaps are covered and why?
-both sides have flap covered so no oxygen from outside source (flaps prevent room air from entering)
Interventions for respiratory distress / Oxygen – Low flow systems

Non-rebreather mask:

what do you do if the bag deflates when inhaling?
increase the flow rate

-do not want the bag to deflate when inhaling
Interventions for respiratory distress / Oxygen – Low flow systems

Non-rebreather mask:

-when would someone use this mask
someone with deteriorating respiratory status, needing ventilation
Oxygen – low or high flow systems (giving exact amount of oxygen – used for acute respiratory distress when all else fails)
high
Hyperbaric Oxygenation Therapy – HBO

-what is it?
100% oxygen delivered at 1.5-3 times the normal atmospheric pressure
Hyperbaric Oxygenation Therapy –

HBO purpose:
super saturates blood and tissue with oxygen. systemic oxygen enhance the ability of WBC to kill bacteria and reduce swelling
Hyperbaric Oxygenation Therapy – HBO

-used when?
-burns
-CO2 posioning (high levels of CO2 cause cerebral edema)
-air or gas embolism
-wounds
-CVA, cerebral edema
-sickle cell anemia
HBO therapy
-is the dr required

-how long does the dive last
yes

2-3 hours
Hyperbaric Oxygenation Therapy – HBO

-treatment can last up to how many dives
40
Hyperbaric Oxygenation Therapy – HBO

if the pt is diabetic, what do you instruct them to do and why
eat beacuse BS drops. make sure their BS is checking and is above 120
Hyperbaric Oxygenation Therapy – HBO

what does diving do to metabolism
increases it
Hyperbaric Oxygenation Therapy – HBO

what does diving do to BS and BP
lowers BS and increases BP
Hyperbaric Oxygenation Therapy – HBO

what kind of clothing can they wear
cotton
no glasses
no newspaper

dr must be present
Hyperbaric Oxygenation Therapy – HBO

Complications of HBO
-what happens to hearing
ears popping during dive – if continues after or problematic during dive, afrin or tubes in ears
Hyperbaric Oxygenation Therapy – HBO

Complications of HBO
-what happens to their sight
visual changes (blurred vision) can last 3-4 months after HBO therapy is completed
Hyperbaric Oxygenation Therapy – HBO

Complication
-sweating and anxiety during dive, what can you do
give meds for anxiety
Hyperbaric Oxygenation Therapy – HBO


Complications: hot and cold during compression and decompression
.........
Hyperbaric Oxygenation Therapy – HBO

Complication
-oxygen toxicity with deep dives.

Nurses intervention?
give air breaks (break for 5 minutes to breath air)
Hyperbaric Oxygenation Therapy – HBO

Complication
-seziures happen. how?
because of the compression of the brain - fastest they can bring the pt up is 10 min
Hyperbaric Oxygenation Therapy – HBO

when can you NOT dive (3 ex)
low BS

cold symptoms

sinuses conguestion or draining b/c of too much pressure
Extracorporeal Membrane Oxygenation (ECMO) is what?
cannulate vein/artery, remove blood, add oxygen to it and then add it back on the oppsoite side of the heart
Extracorporeal Membrane Oxygenation (ECMO)

candidates are:
lung or heart disease pts that prevents oxygen from getting to the organs

adults with respiratory and cardiac failure who have not responded to treatment and have a resonable chance of surival
Extracorporeal Membrane Oxygenation (ECMO)

when can it not be used
if less than 2 kg
Extracorporeal Membrane Oxygenation (ECMO

-how long are they on this
7-10 days
Complications of oxygen
-carbon dioxide narcosis:
o normally chemoreceptors monitor CO2 levels. in a person with healthy lungs, the chemoreceptors are sensitive to small changes in CO2 levels and regulate ventilation. when the CO2 levels rise to a certain level, the person inhales air.


. in pts with COPD who retain CO2, the chemoreceptors are not sensitive to small changes in CO2 and regulate ventilate poorly. in these pts it is the change in O2 level that stimulates changes in ventilation. when you administer high levels of O2, this extinguishes the stimulus to breath.
Complications of oxygen

•oxygen toxicity: exposure to high levels of PaO2 inactivates
pulmonary surfactant, cause interstitial and alveolar edema, and decrease compliance --> ARDS
endotracheal tube
-a tueb is inserted through the nares or the mouth past the epiglottis and vocal cords into the trachea.
-who would be cuffed and why
adult
-the cuff prevents aspiration of oral secretions or gastric contents into the lung and obstruct the escape of air from mechanical ventilator breaths through the upper airway
endotracheal tube

-who would be uncuffed?
a child because of the narrow trachea
Tracheostomy
-is inserted directly into the trachea through a small incision made in the patients neck
-the inner cannula can be temporarily withdrawn for clean (true or false)
true
Tracheostomy
-who would require the cuff to be inflated?
if they need to provide ventilation (someone with an ET tube)
Tracheostomy
-who would require an uncuffed
a person without a breathing problem, ex: someone without laryngeal cancer
The ET tube is always cuffed on adults, but not on children

True or False
true
ET tube insertion
(place in the correct order)

A) assess breath and epigastric sounds
B) secure the ET Tube
C) inflate the cuff with 10 mL of air
D) measure the ET tube at the gum line
E) connect the bag valve mask and oxygenate the client
A- 3
B- 4
C-1
D-5
E-2
ET tube insertion

-how many breath sounds do you assess and why do you?
5 (1, 2, 3, 4 and epigastric)

because if you are not in the lungs, the oxygen is going to the stomach.
ET tube insertion

-when assess breath sounds, what do you do if you hear sounds on the right side but not the left?
pull back on the ET tube beacuse the right lung is higher and the tube may only be in that lung
ET tube insertion

if the ET tube is needed 5 days or longer, what happens
a trachea is put in to prevent acquired pneumonia
Cuffs: the purpose of inflated a cuff is to help hold in place and seal off the air so it goes into the lungs

true or false
true
Trachea
-2 examples of why someone might have this?
-someone is intubated with an ET tube for 5 days


-can be used for laryngeal cancer (doesn't have to be cuffed because they don't have a breathing problem)
The nurse is caring for a patient that has an endotracheal tube. The nurse has received the order to remove the tube. Place the following steps for ET tube removal in the correct order.


A) deflate the cuff
B) explain the procedure to the patient
C) connect the suction tubing and turn on the suction
D) apply oxygen
E) gather gloves, suction, and oxygen tubing
F) have the patient take a deep breath and pull out the tube when exhaling
G) measure the pulse and POX
5 A) deflate the cuff
2 B) explain the procedure to the patient
3 C) connect the suction tubing and turn on the suction
4 D) apply oxygen
1 E) gather gloves, suction, and oxygen tubing
6 F) have the patient take a deep breath and pull out the tube when exhaling
7 G) measure the pulse and POX

C & D might be switched
ET tube removal

-what do you make sure they have before you give them something to eat or drink
gag reflex
ET tube removal

-what do you tell them regarding their throat and voice
it may be hoarse and my have a sore throat for several days
Suctioning through the trachea
-preoxygenate for how long?
3-5 ventilations
Suctioning through the trachea
-suction infants at ___ to ___ mm Hg?
40-80
Suctioning through the trachea
-suction adults at ___ to ___ mm Hg?
80-120
Suctioning through the trachea
-postoxygenate for how long
3-5 ventilations
Suctioning through the trachea
-suction no more than how many seconds in an adult
10
Suctioning through the trachea
-suction no more than how many seconds in an infant

-should suctioning be intermittent or continuous?
take no more than 5-8 seconds

it should never be continuous suction because it causes damage to the mucosa
Suctioning through the trachea

-what should you monitor while suctioning?
heart rate 40 beats above baseline or 20 beats below baseline or if POX drops (if that occurs you need to do a better job of preoxygenation)
Suctioning through the trachea

-what should you do if a patients heart rate decreases when suctioning
stop the procedure and reoxygenate
The nurse is about to suction a patient that needs tracheal suctioning. The nurse explains the procedure to the patient and washes hands. Which steps should be taken by the nurse when performing tracheal suctioning? Place the steps in the correct order.


A) prepare the suction equipment
B) place finger over suction control port of catheter and suction intermittently while withdrawing the catheter
C) test suction by sucking up water
D) insert catheter into trach and advance to just above the carina
E) pick up suction catheter with dominant hand and attach it to connection tubing
F) place tip into sterile container while applying suction to clear secretions from the tubing
G) open sterile package, put on sterile glove
1 A) prepare the suction equipment
6 B) place finger over suction control port of catheter and suction intermittently while withdrawing the catheter
4 C) test suction by sucking up water
5 D) insert catheter into trach and advance to just above the carina
3 E) pick up suction catheter with dominant hand and attach it to connection tubing
7 F) place tip into sterile container while applying suction to clear secretions from the tubing
2 G) open sterile package, put on sterile glove
The nurse is caring for a patient in the emergency department. The patient is complaining of chest pain. The nurse is applying oxygen by nasal cannula. An appropriate amount of oxygen is:

A) 24% - 28%
B) 32% - 36%
C) 40% - 44%
D) 46% - 50%
A
The nurse will be suctioning an adult patient through an endotracheal tube.

allow at least 60 seconds between passes

true or false
true
The nurse will be suctioning an adult patient through an endotracheal tube.

how many suction passes should you have per suctioning episodes?
2-3
The nurse will be suctioning an adult patient through an endotracheal tube.

what protective equipment should you wear
wear a face shield or goggles and a mask when suctioning
The nurse is assisting with an ET tube insertion. The nurse knows that after the ET tube is inserted the correct placement can be verified by:

A) assessing for epigastric sounds
B) assessing the breath sounds in the apex of the lungs
C) assessing the breath sounds in the right lobe
D) assessing breath sounds in 4 lung fields and in the epigastric area
D
The nurse is assisting with the insertion of an ET intubation. When the tube is inserted the nurse should carry out the following steps: Place the steps in the correct order

A) assess breath and epigastric sounds
B) secure the ET tube
C) inflate the cuff with 10 ml of air
D) measure the ET tube at the gum line
E) connect the bag valve mask and oxygenate the client
3 A) assess breath and epigastric sounds
4 B) secure the ET tube
1 C) inflate the cuff with 10 ml of air
5 D) measure the ET tube at the gum line
2 E) connect the bag valve mask and oxygenate the client
Chest physiotherapy (CPT)
-what is the purpose of this?
• purpose is to get secretions to move into the larger central airways, secretions are removed through coughing or suctioning
Chest physiotherapy (CPT)

the hands should be flat when striking the chest (true or false)
false-
hand should be cupped
Chest physiotherapy (CPT)

this should be done over a shirt or blanket (true or false)
true
Chest physiotherapy (CPT)

perform this when regarding meals?
1 hr before meal

or

1-3 hours after meals
Chest physiotherapy (CPT)

should you administer a bronchodilate?

when?
yes, 15 min before the procedure
Chest physiotherapy (CPT)

how long should you keep the pt in position for
5-15 min as tolerated
Chest physiotherapy (CPT)

percuss for how long?
1-2 min

percussion is using a cupped hand to assist in loosening retained secretions from the airway
Chest physiotherapy (CPT)

when do you use vibration?
while the pt exhales 4-5 deep breaths

tensing hand and arm muscles repeatedly and pressing with the flat area on the hand to the affected area
(moves sections from small distal airways into larger central airways)

done only on exhalation
Chest physiotherapy (CPT)

when you finish this procedure, what should you do
mouth care
Chest physiotherapy (CPT)

should the patient be encouraged to cough after?
yes
Chest physiotherapy (CPT)

who do you not perform this on
hip replacement
back and neck surgeries
spinal issues
cardiac patients (you'd increase the preload)
COPD patients (cause bronchospasm)
stroke or breain injury pts (you'd increase ICP)
-unstable VS
-history of fractures
what is the purpose of a chest tube
to maintain negative intrathoracic pressure so the lungs can expand
chest tube - where is it going into in the body?
go in the plural space to rid drainage
Hemothorax:
-what is it?

-is the chest tube placed low or high? why?
collapse of lung caused by accumulation of blood in pleural space






(tube is placed low because blood pools)
Pneumothorax:
-what is it?


-is the chest tueb placed low or high? why?
collapse of a lung caused by air in pleural space






(tube is placed high)
Chest tubes
-the dr determines the size of chest tube, the location, and inserts the tube.

The nurse is assisting with a chest tube insertion on a patient that has a pneumothorax. Once the physician has the chest tube inserted the nurse should:

A) assess the breath sounds
B) assess for crepitus
C) turn the suction on
D) connect the chest tube to the tubing from the collection device
D
The nurse is assisting with the chest tube insertion on a patient with a hemothorax. The physician has ordered 15 cm of suction. The nurse should:


A) turn the wall suction to 15 cm of suction
B) turn the wall suction to 120 cm of suction and on the chest tube collection device turn the suction to 15 cm
C) turn the suction on the chest tube collection device to 15 cm and leave the suction open to air
D) adjust the water seal chamber to 15 cm of suction
B
Chest tube Collection Device
-you should see bubbling in the suction chamber (true or false)
true

there should be constant bubbling
Chest tube Collection Device

you should see fluctuations in the water seal chamber (true or false)
true
-that is a good thing.
it maintains intrathoracic pressure. if you don't have intrathoracic pressure, the lung will collapse
Chest tube Collection Device

there should be an occlusive dressing around the chest tube insertion site (true or false)
true
Chest tube Collection Device

you should have dependent loops hanging below the level of the chest collection device (true or false)
false - have the tube between the collection device and the chest.
Chest tube Collection Device

the collection device should be ___cm below the chest
21
Chest tube Collection Device

if there is continuous bubbling in the water seal chamber, what does that indicate
an air leak. (711) PP
Chest tube Collection Device

there should be no dependent loops in the tubing (true or false)
true
Chest tube Collection Device

Dependent loops in the tubing can cause what
a tension pneumothorax
Chest tube Collection Device

if there is no movement in teh water seal chamber that indicates
obstruction
Lung expansion / Chest tube

occurs in how many hours

is it painful
12-24 hours


yes
Lung expansion / Chest tube

what should you encourage the pt to do
ambulate
Chest Tube – Problem solving

chset tube and tubing become disconnected
reconnect & stick chest tube in liquid to keep pressure otherwise you'd suck in air and the lung would collapse due to positive intrathoracic pressure (we want negative to expand the lung)
Chest Tube – Problem solving

chest tube becomes dislodged
apply occlusive dressing
Chest Tube – Problem solving

collection chamber becomes full
change entire collection device
Chest Tube – Problem solving

collection tube
-how do you transport the patient
disconnect from wall suction and the maintain position of the chest tube
Chest tube removal
-medicate for pain if possible and make sure lungs are expanded (how can you do that)
-chest xray can show reexpansion
-a halt in the fluctuation in the water seal chamber for 24 hrs indicates lung expansion (bubbling indicates that the lung is not fully expanded)
-percuss for resonance
-ausculate for normal breath sounds
Chest tube removal
-remove securing device
-cover with occlsuive dressing

-what do you instruct the patient to do and why?
take a deep breath and hold it until the tube is removed

this prevents air from being suckd into the chest as the tube is pulled out