Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
59 Cards in this Set
- Front
- Back
|
An __________ airway is a semicircular, minimally flexible, curved piece of hard plastic that extends from just outside the ___, over the tongue, & to the ____. Purpose is to ________ hold the airway open & prevent ____ from obstructing the ____. May NOT be delegated. Device vary in length & width & inserted with a ___ _____ technique.
|
Oropharyngeal
lips pharynx mechanically tongue pharynx non sterile |
|
|
DO NOT insert oropharyngeal airway into a _____ or _____ patient because it can cause vomiting & ___. An airway that is too ___ can dislodge, stimulate _____, or obstruct breathing by depressing the _____into laryngeal opening. **Size is CORRECT if, flange is parallel to front ____ w/ airway ____ cheek & end of curve reaches angle of ___ or ear.
|
conscious or semi-conscious
laryngospasm long gagging epiglottis teeth against jaw |
|
|
DO NOT _____ oropharyngeal airway device in place because when patient becomes ____ he wouldnt be able to ____ device which increases risk of gagging & ______.
|
tape
alert expel aspiration |
|
|
Insertion of an oropharyngeal airway is a ___ ___. Size is determined by measuring from corner of patients ____ to the angle of his jaw below the ___. Explain procedure to _______ though not alert. Wash ___, wear ___, mask & ______ or shield. Remove dentures. Place patient on ____ with head ________
|
non sterile technique
mouth ear hands gloves goggles back hyperextended |
|
|
Oropharyngeal airway should be inserted ___ ___ to avoid pushing tongue towards ____. Slide over tongue to back of mouth & ____ 180 degrees as it passes the ____. ______ lungs to ensure _____ & position patient on ____ to facilitate secretion drainage & prevent ____. Remove q ___ to provide mouth care & assess for _____. Before reinsertion _____ .
|
upside down
pharynx rotate uvula Auculate ventilation side aspiration 4hrs irritation secretions |
|
|
Need for insertion of oral airway: ____ airway gurgling, no __ __, increased oral secretions/excretions, excessive ____, grinding or clenching teeth, ____ oral tracheal or gastric tube, labored ____, _____ respiratory rate.
|
upper
gag reflex drooling teeth biting respirations increased increased |
|
|
ONLY use an oropharyngeal airway when patient doesnt have a ___ ___. When sizing, device should be ____ one that fits.
Premi's & neonates 000 newborns 00 newborn - 1yr 0 1-2 yrs 1 2-6 yrs 2 6-18 yrs 3 18 + 4-10 |
gag reflex
smallest |
|
|
Use of _______ airways in pediatric patients are ____ often used because their airways are so _______ that the device may be more _____ than helpful.
Premi's & neonates 000 newborns ? newborn - 1yr ? 1-2 yrs ? 2-6 yrs ? 6-18 yrs ? |
oropharyngeal
NOT Premi's & neonates 000 newborns 00 newborn - 1yr 0 1-2 yrs 1 2-6 yrs 2 6-18 yrs 3 narrow obstructive |
|
|
Documentation for oropharyngeal airway includes assessment findings for inserting airway, size, placement, tolerance, presence of ____ distress, vomiting, quality of ____, & pain.
|
respiratory
secretions |
|
|
If continual coughing & ____ occurs during oro airway insertion, ___ b/c patient may begin to vomit & risk ____. Try using a ____ airway, or reassess if patient really needs it. If airway obstruction is not relieved w/device obtain ____ ___, attempt other methods of _____ airway.
|
gagging
stop aspiration smaller immediate assistance clearing |
|
|
Nasal pharyngeal airways
aka "nasal trumpets" are preferred in ____ patients because it is better tolerated & less likely to ___ ___. |
responsive
induce vomiting |
|
|
These airways are preferred in the responsive patient b/c it is better tolerated & less likely to induce vomiting. This airway is also known as called “nasal trumpets”. because of their shape
|
Nasal pharyngeal airways
|
|
|
Indications for Nasal Pharyngeal Airways: ____ Pt's & preferred for infants & ___ due to small mouths & ____ tongues. Nasal Airways are usually tolerated better than oral airways. Indications for use are ____ surgery's, wired ___, ___ breathing, excessive ____, & airway ___. Tape ____ used to hold device in place, & tubing can be lubricated w/____ for insertion. ____ technique is appropriate, & Pt is placed in ____ position for insertion. Nasal airways should be cleaned every __hrs.
|
responsive
pediatrics large oral jaws irregular drooling maintenance can be sterile jelly CLEAN semi fowlers q4h |
|
|
Assessing Pt for insertion of Nasal pharyngeal airway is inspecting nasal ___ for ____ such as polyps, fractures, or _____. Rn then selects ____ possible tube measured from external ___ to ___. RN should always _____ procedure to Pt.
|
passages
obstructions hemorrhage largest nares to ear EXPLAIN |
|
|
Nursing implementation of Nasal Pharyngeal Airway: ____ use & procedure to Pt. Measure tube from external ___ to ___& use ____ possible tubing diameter. Place Pt in ____ position & lubricate tubing w/____. Using ___ technique, insert tube in nostril & direct it ____ & toward ___ passing nasal pharyngeal airway into ____ w/ slight _____ motion, until flange rests against ____. Use ___ to hold in place.
|
EXPLAIN
nares to the ear largest semi-fowlers sterile jelly CLEAN posteriorly ear oropharynx rotating nostril tape |
|
|
Nasal Pharyngeal Airway can be used in conjunction w/ ______, & nasal tubing can be inserted into ______.
|
oropharyngeal airways
both nares |
|
|
If insertion of oral or nasal airway does not improve _____ status, assist ventilations w/a ___-___-___ unit, also known as an ____. This procedure is most effective w/__ __ of which 1 person obtains an ____ mask seal after inserting an ___ or ___ airway & the other person squeezes the bag w/___ __ for ventilations, & watching for chest ____.
|
ventilatory
bag-valve-mask (BVM) Ambu bag two people airtight oral or nasopharyngeal both hands rise |
|
|
When using a bag-valve-mask (BVM) unit (Ambu bag), apply the APEX of mask over bridge of the ___ & lower mask over face & mouth. Apply pressure behind ____ with fingers & seal mask against the face w/ ____. If cervical injury is possible, maintain head & neck in a ____ position
|
nose
mandible thumbs neutral |
|
|
When 2 people are assisting ventilations using a Ambu bag, while 1 person obtains airtight ___ ___ the other person ____ bag w/___ ___ for ventilations & watches ____ rise. When squeezing Ambu bag remember it should be fully ____ & allowed to fully ____. Rate of ventilations should be equivalent to rate used in ____.
|
mask seal
squeezes both hands chest deflated inflate CPR |
|
|
When only 1 person is providing ventilations with n Ambo bag, form a ____ around the ventilation port w/the thumb & index finger & then use the middle figer, ring finger, & little fingers to ____& form a seal w/the mask. Use the other hand to _____ the bag
|
“C”
lift jaw squeeze |
|
|
Asisting ventilations is indicated if patient is breathing, but not w/ sufficient ____ to maintain adequate ___ ____. Give assisted breaths with ___ oxygen at the same time the patient _____
|
depth
gas exchange 100% breaths |
|
|
What is a semicircular shaped flexible hard plastic curve that when inserted, extends from just outside the lips, over the tongue and to the pharynx?
|
oropharyngeal airway
|
|
|
What is a flexible piece of curved plastic with a wide or trumpet like end flange that when inserted, extends from the nares past the sinus to the pharynx?
|
Nasal pharyngeal airway
|
|
|
What other term is given to a is a Air Mask Bag Unit
|
Ambu Bag
|
|
|
The amount of oxygen entering the lungs is?
|
ventilation
|
|
|
The blood flow to the lungs and the body tissues?
|
perfusion
|
|
|
Suctioning is using ____ pressure to remove secretions such as ____ & ____. Suctioning is done in surgery, oral procedures & often performed at bedside in ICU, ER.
|
negative
pulmonary gastric secretions |
|
|
Indications for Pulmonary suctioning are patients who are ____ ventilated, tracheostomy, anyone unable to maintain a patent ___ &/or ____ airway independently, sedated patients, post-operative, post-ictal, drug ___, inability to cough ____, & Pt's w/chronic ____ illness.
|
mechanically
upper lower overdose effectively respiratory |
|
|
Types of suction for Endotracheal intubation are:
1- ________ suctioning mouth & pharynx 2- ________ suctioning through nose into naso-pharynx & trachea 3- _________ suctioning Endotracheal tubes (ET tube) & Tracheostomy tubes |
oropharyngeal suctioning
Nasotracheal suctioning Artificial Airway suctioning |
|
|
Oral Pharyngeal Suctioning uses _____ suction catheter (tonsil tip), ____ technique w/______ precautions & ____ delegated. It is effective on copious, ____ , upper airway secretions, for Pt's w/oral & ____ surgery, impaired ___ or for performing oral ___.
|
Yankauer
CLEAN universal may be thick facial swallowing hygiene |
|
|
Nasopharyngeal/Nasotracheal Suctioning uses ____ plastic or rubber suction catheter, requires ____ technique, is invasive & ____ tolerated by the awake patient but necessary when ____ airway requires suctioning, & patient is ___ mechanically ventilated. Also used to obtain ____ specimens.
|
flexible
STERILE poorly lower NOT sputum |
|
|
When patient is not mechanically ventilated & lower airway requires suctioning _________ is indicated.
|
Nasopharyngeal/Nasotracheal
|
|
|
Nasopharyngeal/Nasotracheal is used to collect ____ _____.
|
sputum specimens
|
|
|
Endotracheal (ET) tubes are used on Pt's to provide _____ ventilation, protect airway from ___ & are a ___ solution used only for __-__. They are placed by trained professnl. Adult ET tubes have a ___ molded around tube at distal end. ET tubes prevent ____ of oral/gastric contents into lung & “seals” ____ so air does not ____ during mechanical ventilation. Pediatric ET tubes are ___ cuffed due to delicate tissues of trachea & trauma/pressure from the cuff.
|
mechanical
aspiration temporary 2-4 weeks cuff aspiration airway escape NOT |
|
|
A temporary solution solution used only for 2-4 weeks to provide for mechanical ventilation & to protect airway from aspiration are ________.
|
Endotracheal (ET) tubes
|
|
|
Tubes used on clients to provide for mechanical ventilation, protect airway from aspiration that have a cuff molded around the distal end to prevent aspiration & seal airway to prevent escape during mechanical ventilation are ________.
• ET tubes are a temporary solution (usually 2-4 weeks) • Placed by trained professional • Adult ET tubes have a cuff molded around the tube at the distal end (adults) – Prevents aspiration of oral/gastric contents into lung – Obstructs or “seals” airway so that air does not escape during mechanical ventilation – Pediatric ET tubes are not cuffed due to delicate tissues of the pediatric trachea and the trauma/pressure from the cuff |
Endotracheal (ET) tubes
|
|
|
Suctioning ET Tubes are ___ delegated to AP's & only performed __ ____ depending on Pt's status rather than on a routine schedule. ET suctioning is ______ to perform than nasotracheal because there is direct ____. A flexible plastic or rubber suction catheter is used. The intubated patient is probably sicker & at ____ risk of complications
|
NOT
as needed easier access increased |
|
|
Two methods for performing ET suctioning are ____ & ____ (in-line). Both methods are considered equally effective in removing secretions.
|
Open suctioning
Closed suctioning |
|
|
Closed ET suctioning allows ____ circuit to stay closed ____ chances of contamination for both Pt/nurse, & chances of splashing & spraying are minimized. Closed suctioning is more easily performed by one person & is performed using ____ technique.
|
respiratory
decreasing CLEAN |
|
|
Tracheostomy tubes may be ____ or ____ & are used for ___-__ mechanical venilation, ____ neck surgery, &___ upper airway. Trachs are placed ____ & tubes may be ____ or ____, plastic, silicone, or ____. Suctioning methods are ___ or ___. Closed method is used if Pt is ________.
|
temporary or permanent
long-term radical obstructed surgically cuffed or uncuffed metal Open & Closed on ventilator. |
|
|
With Tracheostomy Suctioning it is necessary to ____ the amount of ____ pressure to prevent ____ damage. Therefore, always use the least amount of suction necessary.
|
adjust
negative mucosal |
|
|
With , if _____ is felt after inserting catheter the recommended amount, you have probably hit the ____. This stimulates severe ____ & usually causes discomfort. In this event, pull back ____ then apply ____.
|
resistance
carina coughing 1-2 cm suction |
|
|
To determine suction catheter size for Tracheostomy Suctioning, – ____ the ET tube ____ X __, then use the next size ____ suction catheter
French sizes are only even numbers! |
multiply
diameter 2 smaller Example: 8.0 ET tube X 2= 16 Use 14 Fr suction catheter French sizes are only even numbers! |
|
|
Guidelines for Trach Suction are: always assess Pt __ & __ suctioning & only apply suction when ____ cath, NOT on ____. Recommendations are to ____ Pt & give additional 02 ____ & ____procedure. If mouth & throat contain lrg amounts of secretions, suction this area ____ w/a ____ tip, then proceed to ____ airway w/____ flexible catheter. Otherwise, ____ is suctioned last. Do not suction longer than ____.
|
before & after
WITHDRAWING insertion hyperventilate before & after first yankauer lower STERILE mouth 10 seconds |
|
|
Complications of Tracheostomy Suctioning are: irritation & bleeding of ____ ____, stimulation of gag reflex, Cardiac ___, Hypoxia & hypoxemia, caregiver exp., ______ infectn, ____ of secretions, bronchospasm or ____, elevated ____ pressure.
DISCONTINUE suctioning if pulse drops ___, increases ___, 02 sats below ___ or 5% below baseline, ___ coughing, pallor, ____. |
mucous membranes
dysrhythmias nosocomial aspiration bronchoconstriction intracranial 20bpm 40bpm 90% paraxysmal cyanosis |
|
|
After Trach Suctioning, ____ Pt & dispose of equip by wrapping ____ around gloved hand & rolling glove off & over it to decrease contamination. _____ your findings, Pre & post ____ c___, a___, & consis___ of sputum, & Pt's tolerance of procedure
REMEMBER… Respiratory Therapy is your friend! ALWAYS document ___, ___, & ___ |
reassess
catheter Document assess color, amount & consistency before, during, & after |
|
|
Water seal drainage – 3 Bottle System (Pleur-evac Water Seal system - fxns same as three bottle system)
Intermittent ____ in water seal chamber is seen during ____ or when Pt ____ sneezes. Tidaling in water seal chamber occurs w/___ & ___. Lack of tidaling or occasional bubbling is a sign the lung has ____ or ____tube is ____ |
bubbling
exhalation coughs inspiration & expiration re-expanded or chest obstructed |
|
|
Nursing Management of Chest Tubes is keep chest drainage tubing ____ from bed to container & coiled loosely ____ chest level. Instruct Pt not to lay on or compress tube & tape/secure all ____ between chest tube, drainage tubing & drainage collector.
Maintain ____ & ____ seal levels & mark ____ & ____of drainage depending on orders, Pt's condition & amount of drainage (Q 1 - 8 hrs) & report any change in ____ of chest drainage & observe for intermittent ____ in water-seal chamber & ____ w/ respiration in fluid of tubing in water – seal clamber. Rising w/ ______ & falling w/ ____ are normal but the opposite occurs w/ ____ ____. Assess Pt frequently for signs of _____ _______ & encourage Pt to ____ breathe frequently. Be familiar w/ the institutions policy r/t _____ of chest tubes. |
straight
below connections suction & water time & level color bubbling fluctuations inspiration expiration opposite mechanical ventilation respiratory distress deep stripping |
|
|
ONLY Clamp chest tubes for short periods of time & ONLY when accidentally ____, changing ____ bottles, checking for ____ in drainage system, checking for resolution of ____ (sometimes)
Clamping for even short periods can create _____ pressures sufficient to induce ____ pneumothorax. Be sure to know facility policy |
disconnected
drainage leaks pneumothorax intrathoracic tension |
|
|
Nursing Intervention & Eval of Chest tubes is maintain ____, patent, functioning, chest drainage system & ____ all connections & chest tube ____ as needed. Keep tubing unobstructed & place a rolled towel ____ chest tube to prevent compression when Pt is lying on that side. Encourage Pt to ____, ___ ___, & change ____ & ___ ___ frequently & implement approved interventions for suspected chest tube ____. ONLY ___ tube if it becomes disconnected & immediately replace ___ system. Only clamp the tube for a very short period.
Intervention & Evaluation – Con’t Watch patient closely for signs of tension pneumothorax Cover the chest opening immediately with a gloved hand or an occlusive dressing if the chest tube is accidentally dislodged or removed - secure the dressing on three sides only & prepare for reinsertion of the tube Mark and measure chest drainage at 1 - 4 hour intervals Notify the physician of constant bubbling, increase in color and amount of drainage |
airtight
re-tape dressings under cough deep breathe change positions obstruction clamp drainage |
|
|
NDX:
chest tubes Anxiety r/t ____risk of chest tube ____, system ____ & inability to breathe Breathing pattern ____ r/t ____ lung expansion, pain Risk for ____ r/t ____ of chest tube Pain r/t ____ injury |
perceived
dislodgment disruption ineffective asymmetrical injury presence tissue |
|
|
Chest Tube Nursing Interventions & Eval include providing Pt w/inf about chest tube & ____ ____ & stress ____ of avoiding chest tube compression as well as maintaining tubing ____ level of ___. Explain ___ & ___ of drainage expected & explain ____ & ____fluctuation in the system. Provide time for ___ & provide needed explanations
& place call ___ within reach |
drainage system
importance below bed type and amount bubbling and fluid questions bell |
|
|
Chest Tube Removal are removed when the lungs are ___ & fluid drainage has ___, tidaling w/______ decreased or absent, ____confirmation, decreasing amount of ____ applied, chest tube may be placed to ____ drainage or ____ per physicians orders w/ close assessment of Pt response prior to chest tube ____
|
re-expanded
ceased respiration Chest x-ray suction gravity clamped removal |
|
|
With Chest Tube Removal you ____ supplies, ____ procedure to Pt & medicate if ordered. You will assist physician, Advanced Practice Nurse or PA to ____ chest tube. They will prepare a sterile dsg., clip ___, place occlusive dsg. over site; ask Pt to take ___ ___ & ___ ___ (valsalva), remove tube & secure suture & dsg. You assess Pt for signs of ___ distress, assess ___ for drainage, ___, ___, & ___, remove equipment & monitor Pt ___. Pt Outcomes should be Normal ___ ___ w/ resp unlabored at ___, ABG’s are approaching normal & Lung expansion evidenced on ____x
|
prepare
explain remove sutures deep breath bear down respiratory dressing color, amount, & odor pulse ox breath sounds 16 - 20/minute -ray |
|
|
Suction tubes are typically ____ for adults & ____re-used for a 2nd pass if not contaminated.
|
12-14fr
can be |
|
|
The problem w/ cuffs is they can ___ & ___ the trachea. Suctioning an ET tube is ___ delegated.
|
erode
irritate NOT |
|
|
Mini ____ State Exam Gauges mental state w/a maximum score of ___. Score of 24-30 may indicate ____, less than 20 may indicate ____/____. MMSE is important assessment every ____ for persons ___ & up.
|
Mental
30 depression dementia/delirium 6 months 65 years |
|
|
MMSE - Areas assessed are Orientation, ____, Attention & ____, Recall, Language & Level of ____ Continuum
|
Registration
Calculation Consciousness |
|
|
A Neuro asessment includes Cranial Nerve ___, ___, ___, & ____ strength such as hands strength & the ____ drift, as well as ____ strength, &
Vital Signs ____ ____. The Romberg test assess balance |
III, IV, VI
Motor palmar Lower Cushing’s triad |
