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112 Cards in this Set

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  • Back
ambu bag is capable of delivering what size inspiratory volume?
things to remember about the AMBU bag.
additional O2 can be added to the reservoir bag.
remove client from additional O2 source
compress bag one breathe q 3-5 seconds or 20 breaths a minute.
Oropharyngeal airway
to keep upper airway passage open when obstructed by tongue or secretions.
stimulates gag reflex.
Advantages of an oropharyngeal airway.
easy to insert
low risk of complications
insertion specifics for an oropharyngeal airway.
size appropriate to size and age of client.
lubricate w/ water soluble gel prior to insertion
Nursing management for a client with a oropharyngeal airway.
mouth care 2-4 hours
assist client to a side lying position
suction PRN
Indications for suctioning. list 6
respiratory distress
client unable to expectorate
bubbling or rattling breath sounds
poor skin color=cyanosis
decreased Sa02 levels (O2sats)
How long should one pass with the suctioning catheter last?
10 seconds with a 2 minute break between passes.
Suctioning reminders
10 seconds for each pass
do not apply suction until in place
allow client to breath and cough between.
suctioning done too often can increase secretions
What is the wall suction set at when suctioning a tracheostomy?

portable suction is set at?
100-120 for wall suction


10-15 for portable unit
What asepsis technique should the nurse use when suctioning.
What happens when the sterile hand touches the suctioning tubing?
becomes unsterile and cannot be used to touch anything sterile
How long should the nurse hyperoxygenate the client before suctioning the tracheostomy?
Give three to five breathes and wait 3 minutes in between each catheter pass
nasopharyngeal airway nursing management.
frequent oral care
reposition airway in other nares q. 8 hours or as ordered to prevent necrosis of mucosa
To insert an oropharyngeal airway the nurse should remember?
rotate 180 degree when you reach the soft palate.
place client in side lying position with head turned.
suction PRN by inserting catheter along the side airway.
when client gags or coughs= REMOVE TUBE
When should a nasopharyngeal not be used?
nasal obstructions
predisposition to epitaxis
When are endotracheal tubes used?
with general anesthesia
emergency situations
Who can insert an endotracheal tube?
a doctor


specialty trained nurse.
What is used to guide an endotracheal tube?
Where does the endotracheal tube end when inserted?
before the bifurcation of the trachea into the bronchi
What is the purpose of the air filled tracheal tubes?
prevent air leakage.
Is the client able to speak with an endotracheal tube in place?
NO because it passes through the epiglottis and glottis.
What are some nursing interventions for a client with an endotracheal tube?
secure the tube with tape.
How is a nasopharyngeal tube inserted?
close to midline of nostril floor into posterior pharynx behind tongue. Rotate tube slightly if resistance is encountered.
Endotracheal cuff is maintained at what pressure?
20-25 mm/Hg
What can be used to prevent a client from biting down on a endotracheal tube?
oropharyngeal airway
endotracheal tube assessment and interventions
client in side lying or semi-prone position.
provide humidified air or oxygen
if on mechanical ventilation; make sure alarms are set.
provide note pad for communication
oral endotracheal tube
larger diameter= makes easier insertion
difficult if head or neck has limited ROM.
swallowing is difficult
laryngeal trauma & subglottic stenosis
nasal endotracheal tube
more stable than oral
more difficult to dislodge
can be placed blindly
indicated when head and neck manipulation is risky
no need for bite block, oral care is easier
more difficult to suction
When would a tracheostomy be performed?
need for long term airway support
ET tube in place for 10 + days
permits oral intake and speech
bypasses upper airway obstruction
facilitates removal of secretions
What are advantages of tracheostomy ?
list 5
less risk for long term damage to airway
increased client comfort
client can eat
cuff can be deflated or speaking tube used
mobility increased
outer tracheosomy cannula
inserted into trachea
rest against the neck
allows tube to be secure
used to insert the outer cannula
inner cannula
may be removed for periodic cleaning
Low pressure cuffs
commonly used for low, even pressure against trachea.
DO NOT NEED TO BE DEFLATED to reduce pressure
Foam cuff does not require air to be injected.
What type of catheter is more effective at removing thick mucous plugs?
open tipped
A whistle tipped suctioning catheter is used because it is ?
less irritating to respiratory tissues
If it is time to suction a client who is showing no signs of distress, what does the nurse do?
do not suction unless it is necessary
Complications when suctioning
trauma to airway
nosocomial infection
cardiac dysrhythmia r/t hypoxemia
done manually with resuscitation bag or thru ventlator and performed by increasing the oxygen flow ( usually 100%) before suctioning and between attempts
What size catheter is needed to suction the endotracheal or tracheostomy?
the suction catheter should be 1/2 the diameter of the inside diameter of the tracheostomy or ET tube to prevent hypoxia.
Hyperoxygenation is used when
there is copious amounts of secretions
but could cause secretions to go deeper which increases the risk of infection. use 100% oxygen for several breaths.
The overall goals for a client with oxygenation problems are to ?
maintain a patent airway
improve comfort and ease of breathing
maintain or improve pulmonary ventilation and oxygenation.
improve ability to participate in physical activities.
prevent risk assc. with oxygenation problems
Cuffed tracheostomy tubes are surrounded by an inflatable cuff that produces an airtight seal to prevent?
aspiration of oropharyngeal sectreions and air leakage between the tube and the trachea
Where should the client's obturator be kept at all times while the client is hospitalized?
at the bedside in case of accidental removal of the tubes.
Cuffed tubes used immediately after surgery are essential for the client needing?
mechanical ventilation
What would the nurse document after doing tracheostomy care?
suctioning, tracheostomy care, dressing change, noting your asessment
What should the nurse document after suctioning of the oropharyngeal and nasopharyngeal airway? list 5
amount, consistency, color, odor of sputum, client's breathing status before and after the procedure.
Advantages of a closed airway tracheal suction system AKA in-line suctioning??
client does not need to be disconnected from the ventilator
term used to describe inhaling and exhaling air.
Breathing is controlled by the
medulla oblongata in the Brain Stem which is sensitive to increased concentrations of CO2 & hydrogen. Also controlled by chemoreceptors sensitive to decreased O2 & pH changes.
separates the right and left bronchi
External - exchange of gases (inspiration and expiration)
Internal - O2 exchanged at the cell level
-Difficulty breathing in a reclining position
Arterial Blood Gases (ABG)-
Definitive information on resp status and metabolic balance. Determines pH (acid base balance) O2, CO2,02 sat
Sputum Analysis
Best time to collect sputum is first thing am. Have pt drink extra fluids. Rinse mouth prior - no mouthwash
Acid FastTest
-determines the presence of tubercle bacillus (TB) bacteria
Inspection of larynx, trachea and bronchi with an endoscope, looking for any abnormalities, obtaining tissue for biopsy and secretions collection. NPO until gag reflex returns, semi-fowler and on either side to facilitate removal of secretions, assess for bronchospasms or laryngospasm (wheezes/SOB). If bx is done monitor sputum for signs of hemorrhage. (Blood streaked sputum can be expected for a few days after biopsy).
Pulse Oximeter
non-invasive monitoring of arterial 02 saturation using infrared finger clip.
? history of colds, ? pneumonia, ? COPD, ? sinus problems
? smoking ? environmental or occupational exposure
Physical exam
vital signs, normal resp rate- quality of respirations
? nail clubbing, ? cyanosis ?Hypoxia-decreased O2 sat
Dyspnea/ orthopnea -onset, duration
C/O chest Pain – poss causes-pulmonary emboli, pneumonia, pleurisy, CA
assess characteristics- level, type(sharp,dull etc)
? cough-productive ?sputum - color, amount, consistency
Pink frothy-pulmonary edema, yellow/green infection
delivers up to 6L,COPD must never have more than 3 L
simple mask
pt cannot tolerate cannula or needs have O2 concentration
venturi mask
dial on bottom for adjustment. Delivers precise amt of O2, set 5L-10L
Partial rebreather
has bag on bottom, must always be full ; delivers 40-60% O2
has a reservoir bag -60-100% of O2, 6L -15
Oxygen Safety Reminders
* Oxygen is a medication therefore a physician’s order is needed to start or change it
* Oxygen is flammable
* Place a “NO SMOKING” SIGN wherever oxygen is in use
* It is a nursing responsibility to enforce safety rules against no smoking, matches or
anything that may cause a spark while oxygen is in the room
* Oxygen should always be turned on and running before it is attached to the patient
* Oxygen masks should be taken off periodically and wiped of perspiration and dirt
* Use extreme caution with large bore nebulizer tubing, it collects condensation
* Always use sterile distilled water in oxygen therapy
Chest physiotherapy
cupping and clapping

postural drainage
cupping and clapping - loosens secretion in chest

postural drainage - pt in different positions to facilitate drainage

How do you assess proper funcition?
constant bubbling in the suction chamber- indicates proper fx
bubbling in the water seal chamber indicates?
air leak
note change in
color, amt, consistency
Why is vasiline and guaze kept in the room at all times for a patient with chest tubes?
to plug wound immediately after they are removed
Four most common bacteria that cause pneumonia are:
Streptococcus pneumoniae (pneumococcal)
Hemolytic streptococcus type A
Staphylococcus aureus
Haemophilus influenzae type B
Bacterial pneumonia is marked by an alveolar exudate(pus) with consolidation
collapse of a lung
Atelectasis -cause
Post op complication
S&S anxious increase temp dyspnea Decrease B/P
wheezes increase HR tachypnea Pain on affected side
Decrease or absence of breath sounds
Atelectasis- treatment
Chest tube
Prevention (ISP)
Normal blood gas values
pH:7.35 TO 7.45
pCO2:35 TO 45 MM hG
HCO3:22 TO 27 mEg/L
Po2:80 to 100 mmHg
Look at pH and determine if it is high or low (alkalosis or acidosis)
If pH is low it is some type of
So to sum it all up.

Look at pH and determine if it is high or low (alkalosis or acidosis)
If pH is low it is some type of acidosis
If CO2 is high, it’s respiratory acidosis
If CO2 is high
it’s respiratory acidosis
If HCO3 is low
it’s metabolic acidosis
If pH is high
it is some type of alkalosis
If CO2 is low,
its respiratory alkalosis
If HCO3 is high
its metabolic alkalosis
Anytime CO2 and HCO3 are going the same direction (either both high or both low).
it is a compensated process - such as partially compensated respiratory acidosis (both CO2 and HCO3 are high)
CO2 aka PCO2 is what component of the arterial blood ?
HCO2 are what component of the blood gas
How is the respiratory component measured?
on a scale of 0-100

Normal vales = <35 = alkalotic
> 45 = acidosis
How is the metabolic component measured?
22-26 mEg/l

<22 = acidosis
>26 = alkolotic
Disease process associated with metabolic acidosis.

think about 6 processes
diabetic ketoacidosis
renal failure
salicylate overdose
Name some processes associated with metabolic alkalosis.
Loss of gastric secretions
Overuse of antacid
Potassium wasting diuretics
List some processes associated with Respiratory acidosis = Hypoventilation

think about 6 items
drug overdose
chest trauma
pulmonary edema
airway obstruction
Neuromuscular disease
List some processes associaed with Respiratory alkalosis= hyperventalation

think 7 items
high altitude
excessive tidal volume
initial stages of pulmonary embolus
What is done to determine the removal of chest tubes?
chest x-ray.
Subcutaneous emphysema
common with chest tubes
bubble beneath the skin when chest tube enters the body
resolves in 2-3 days after removal of the chest tubes
Postural draining
use of gravity to drain secretions form segments of the lungs.
Implementation of postural drainage
lung to be drained is uppermost
best done in the A.M., one hour before meals, 2-3 hours after meals.
STOP is cyanosis or exhaustion occurs
maintain position for 5-20 min
dispose of sputum
provide mouthcare
Incentive spirometry instructions
use lips to form seal around mouthpiece
inspire deeply
hold inspiration for a few seconds
forcefully exhale
AVOID at mealtime d/t may cause nausea
What causes TB ?
Myobacterium tubercuosis
What type of bacteria is TB?
acid fast,
what segments of the lungs is most affected by TB?
upper levels d/t high oxygen concentrations.
What other organs an TB affect?
What are the goals of treatment for TB?
prevent transmission
control symptoms
prevent progression
Risk factors for TB?
IV drug use
crowded living conditions
healthcare workers
How is TB transmitted?
airborne route by droplet infection
When TB has been identified in an individual, when will the risk of speading the disease be decreased once they begin medications?
2-3 weeks
Symptoms that may indicate TB?
persistent cough and the production of muscoid sputum, occasionally streaked with blood.
night sweats
low grade fever
chest tightness, aching chest pain, when coughing
What test is used to determine a postive result of TB
sputum cultures
What is a reliable determinate of TB exposure ?
Mantoux test
a positive response does not indicate active disease.
a positive result indicated exposure.
once the mantoux test is positive it will be positive in future test.
x-ray done to rule out active disease.
What foods shoudl a client with TB increase in their diet?
Protein and vitamin C
When can a client with TB be considered not infectious to others and resume work?
after 2 negative sputum results