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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 |
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Signs of respiratory distress (RD)
Pursed Lip Breathing - what is the primary purpose? |
-the primary purpose is to promote CO2 elimination
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Signs of respiratory distress (RD)
Tripoding |
early
sitting forward it is the easiest/best way to get air in |
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Signs of respiratory distress (RD)
increased RR (3-4 breaths above their normal baseline) |
early
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Signs of respiratory distress (RD)
what is the earliest sign of ARDS: |
increased RR
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Signs of respiratory distress (RD)
SOB |
early
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Signs of respiratory distress (RD)
diaphoretic (lip and forhead) |
early
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Signs of respiratory distress (RD)
restlessness |
early
caused by lack of o2 to the brain |
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Signs of respiratory distress (RD)
1 word responses |
early
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Signs of respiratory distress (RD)
confusion and distraction |
early
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Signs of respiratory distress (RD)
skin is pallor and cool |
early
blood is going to the core |
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Signs of respiratory distress (RD)
pulse ox is low (less than 90) |
early
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Signs of respiratory distress (RD)
HR and BP increase |
early
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Signs of respiratory distress (RD)
wheezing on inspiration |
early
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Signs of respiratory distress (RD)
hypercapnia |
early
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Signs of respiratory distress (RD)
skin is pallor and cool |
early
blood is going to the core |
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Signs of respiratory distress (RD)
pulse ox is low (less than 90) |
early
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Signs of respiratory distress (RD)
HR and BP increase |
early
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Signs of respiratory distress (RD)
wheezing on inspiration |
early
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Signs of respiratory distress (RD)
hypercapnia |
early
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Signs of respiratory distress (RD)
nasal flaring in an adult |
late
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Signs of respiratory distress (RD)
cyanosis (blue lips) |
late
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Signs of respiratory distress (RD)
use of accessory muscles |
late
sternocleidomastoid muscle |
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Signs of respiratory distress (RD)
depth of breathing icnreases as distress increases leading to irregularity and apnea |
late
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A late signs of respiratory distress (RD)
Respiratory rate? |
greater than 24
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Late signs of respiratory distress (RD)
Heart rate? |
greater than 120
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Late signs of respiratory distress (RD)
blood pressure? |
decraesed.. less than 90/50
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Signs of respiratory distress (RD)
skin is cold and clammy |
late
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Signs of respiratory distress (RD)
dysrhythmias |
late
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Signs of respiratory distress (RD)
panic |
late
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Signs of respiratory distress (RD)
LOC decreases. their reponses is slower with increasing agitation |
late
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Signs of respiratory distress (RD)
lethargy |
late
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Signs of respiratory distress (RD)
stupor/coma |
late
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Signs of respiratory distress (RD)
intercostal retractions |
late
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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 |
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Signs of respiratory distress (RD)
first early sign in children? |
nasal flaring
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Signs of respiratory distress (RD)
late sign in children? |
intercostal retractions (children dont have an O2 reserve)
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Assessment of Chronic Hypoxemia (low oxygen in blood)/ Chronic dyspnea:
4 things |
•clubbing
• polycythemia •mental changes • cor pulmonale |
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Assessment of Chronic Hypoxemia (low oxygen in blood)/ Chronic dyspnea:
clubbing |
(normal 160 degrees)
-late: swollen, springy, floating..angle is greater than 186 |
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Assessment of Chronic Hypoxemia (low oxygen in blood)/ Chronic dyspnea:
polycythemia |
(compensatory mechanism in which the CV produces more erythrocytes to deliver more O2),
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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 |
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VS
newborn HR |
100-170
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VS
newborn RR |
30-60
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VS
infant BP |
60-90 / 45-65
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VS
infant to 2 years HR |
80-130
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VS
1 year old RR |
20-40
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VS
Toddler BP |
70-100 / 45-65
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VS
2-6 year old HR |
70-120
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VS
6 year old RR |
16-22
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VS
School age BP |
90-100 / 50-70
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VS
adolescent HR |
60-100
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VS
adolescent RR |
10-20
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VS
adolescent BP |
95-130 / 60-80
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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
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Assessment of oxygenation
•POX- in peds where should you attach the probe? |
great toe
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Assessment of oxygenation
Skin what are early vs late signs? |
Skin: cyanosis and diaphoresis (late) & pallor (early)
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Assessment of oxygenation
•Breath sounds: |
wheezes (narrowing of airways)
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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
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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 |
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now that you have assessed breathing, what do you do next?
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-raise the HOB to ease breathing, never have the bed flat
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Interventions for respiratory distress / Oxygen – Low flow systems
•Nasal cannula: ___L/min % |
1-6 L/min (24%-44%)
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Interventions for respiratory distress / Oxygen – Low flow systems
Nasal cannula -what would you start someone on? |
2L
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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)
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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
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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
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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 |
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Interventions for respiratory distress / Oxygen – Low flow systems
Simple face mask: ____L/min and % |
5-10 L/min (40%-60%)
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Interventions for respiratory distress / Oxygen – Low flow systems
Simple face mask: what can't they do |
talk or eat
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Interventions for respiratory distress / Oxygen – Low flow systems
Partial rebreather mask: ___L/min & % |
6-10 L/min (60%-95%)
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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 |
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Interventions for respiratory distress / Oxygen – Low flow systems
Non-rebreather mask: _____L/min and % |
6-15 L/min (60%-100%)
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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)
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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 |
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Interventions for respiratory distress / Oxygen – Low flow systems
Non-rebreather mask: -when would someone use this mask |
someone with deteriorating respiratory status, needing ventilation
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Oxygen – low or high flow systems (giving exact amount of oxygen – used for acute respiratory distress when all else fails)
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high
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Hyperbaric Oxygenation Therapy – HBO
-what is it? |
100% oxygen delivered at 1.5-3 times the normal atmospheric pressure
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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
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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 |
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HBO therapy
-is the dr required -how long does the dive last |
yes
2-3 hours |
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Hyperbaric Oxygenation Therapy – HBO
-treatment can last up to how many dives |
40
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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
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Hyperbaric Oxygenation Therapy – HBO
what does diving do to metabolism |
increases it
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Hyperbaric Oxygenation Therapy – HBO
what does diving do to BS and BP |
lowers BS and increases BP
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Hyperbaric Oxygenation Therapy – HBO
what kind of clothing can they wear |
cotton
no glasses no newspaper dr must be present |
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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
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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
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Hyperbaric Oxygenation Therapy – HBO
Complication -sweating and anxiety during dive, what can you do |
give meds for anxiety
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Hyperbaric Oxygenation Therapy – HBO
Complications: hot and cold during compression and decompression |
.........
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Hyperbaric Oxygenation Therapy – HBO
Complication -oxygen toxicity with deep dives. Nurses intervention? |
give air breaks (break for 5 minutes to breath air)
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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
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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 |
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Extracorporeal Membrane Oxygenation (ECMO) is what?
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cannulate vein/artery, remove blood, add oxygen to it and then add it back on the oppsoite side of the heart
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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 |
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Extracorporeal Membrane Oxygenation (ECMO)
when can it not be used |
if less than 2 kg
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Extracorporeal Membrane Oxygenation (ECMO
-how long are they on this |
7-10 days
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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. |
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Complications of oxygen
•oxygen toxicity: exposure to high levels of PaO2 inactivates |
pulmonary surfactant, cause interstitial and alveolar edema, and decrease compliance --> ARDS
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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 |
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endotracheal tube
-who would be uncuffed? |
a child because of the narrow trachea
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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
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Tracheostomy
-who would require the cuff to be inflated? |
if they need to provide ventilation (someone with an ET tube)
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Tracheostomy
-who would require an uncuffed |
a person without a breathing problem, ex: someone without laryngeal cancer
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The ET tube is always cuffed on adults, but not on children
True or False |
true
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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 |
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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. |
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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
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ET tube insertion
if the ET tube is needed 5 days or longer, what happens |
a trachea is put in to prevent acquired pneumonia
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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
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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) |
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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 |
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ET tube removal
-what do you make sure they have before you give them something to eat or drink |
gag reflex
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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
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Suctioning through the trachea
-preoxygenate for how long? |
3-5 ventilations
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Suctioning through the trachea
-suction infants at ___ to ___ mm Hg? |
40-80
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Suctioning through the trachea
-suction adults at ___ to ___ mm Hg? |
80-120
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Suctioning through the trachea
-postoxygenate for how long |
3-5 ventilations
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Suctioning through the trachea
-suction no more than how many seconds in an adult |
10
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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 |
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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)
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Suctioning through the trachea
-what should you do if a patients heart rate decreases when suctioning |
stop the procedure and reoxygenate
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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 |
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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
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The nurse will be suctioning an adult patient through an endotracheal tube.
allow at least 60 seconds between passes true or false |
true
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The nurse will be suctioning an adult patient through an endotracheal tube.
how many suction passes should you have per suctioning episodes? |
2-3
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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
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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
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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 |
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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
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Chest physiotherapy (CPT)
the hands should be flat when striking the chest (true or false) |
false-
hand should be cupped |
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Chest physiotherapy (CPT)
this should be done over a shirt or blanket (true or false) |
true
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Chest physiotherapy (CPT)
perform this when regarding meals? |
1 hr before meal
or 1-3 hours after meals |
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Chest physiotherapy (CPT)
should you administer a bronchodilate? when? |
yes, 15 min before the procedure
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Chest physiotherapy (CPT)
how long should you keep the pt in position for |
5-15 min as tolerated
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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 |
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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 |
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Chest physiotherapy (CPT)
when you finish this procedure, what should you do |
mouth care
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Chest physiotherapy (CPT)
should the patient be encouraged to cough after? |
yes
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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 |
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what is the purpose of a chest tube
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to maintain negative intrathoracic pressure so the lungs can expand
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chest tube - where is it going into in the body?
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go in the plural space to rid drainage
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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) |
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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) |
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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
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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
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Chest tube Collection Device
-you should see bubbling in the suction chamber (true or false) |
true
there should be constant bubbling |
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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 |
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Chest tube Collection Device
there should be an occlusive dressing around the chest tube insertion site (true or false) |
true
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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.
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Chest tube Collection Device
the collection device should be ___cm below the chest |
21
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Chest tube Collection Device
if there is continuous bubbling in the water seal chamber, what does that indicate |
an air leak. (711) PP
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Chest tube Collection Device
there should be no dependent loops in the tubing (true or false) |
true
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Chest tube Collection Device
Dependent loops in the tubing can cause what |
a tension pneumothorax
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Chest tube Collection Device
if there is no movement in teh water seal chamber that indicates |
obstruction
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Lung expansion / Chest tube
occurs in how many hours is it painful |
12-24 hours
yes |
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Lung expansion / Chest tube
what should you encourage the pt to do |
ambulate
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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)
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Chest Tube – Problem solving
chest tube becomes dislodged |
apply occlusive dressing
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Chest Tube – Problem solving
collection chamber becomes full |
change entire collection device
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Chest Tube – Problem solving
collection tube -how do you transport the patient |
disconnect from wall suction and the maintain position of the chest tube
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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 |
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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 |