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60 Cards in this Set
- Front
- Back
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What is hypoxia
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A lack of oxygen at a cellular level.
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What causes hypoxia
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low oxygen carrying capacity
decreased diffusion poor tissue perfusion impaired venilation |
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Clinical manifestations of Hypoxia
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restlessness
irritability anxiety tachycardia tachypnea confusion + BP |
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What is HYPERventilation
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abnormal pulmonary ventilation with increased air exchange (decreased CO2 levels)
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What causes HYPERventilation
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anxiety
fever infection pulmonary embolism metabolic acidosis |
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Clinical manifestations of HYPERventilation
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disorientation
SOB dizziness tachycardia blurred vision numbness |
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What is HYPOventilation
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abnormal pulmonary ventilation with increased air exchange (decreased O2 levels)
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What causes HYPOventilation
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atelectasis
COPD |
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Clinical manifestations of HYPOventilation
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lethargy
headache confusion coma convulsions dysrhythmias |
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Nursing interventions for airway management that are non invasive
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deep breathing
coughing exercises humidification medications (decongestants, bronchodilators, antihistamines) percussion (orders) vibration (orders) |
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How often are patients encourage to practice coughing exercises
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every 2 hours while awake
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What is the Huff cough
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coughing that stimulates natural cough reflex and patient says "huff" on expiration
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When is Oropharyngeal and Nasopharyngeal suctioning done
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when patients HAVE the ability to cough but can't always clear their airways
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When is Orotracheal and Nasotracheal suctioning done
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when patients can't cough
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When is Endotracheal and Tracheostomy suctioning done
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when patients have artificial airways they are unable to manage due to illness or injury
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What is the purpose of nasopharyngeal suctioning
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Removes secretions from posterior oral cavity; clean technique is used
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What is the purpose of nasotracheal suctioning
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Removes secretions from the lower airways; aseptic technique is used
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What are complications of nasotracheal suctioning
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hypoxemia
cardiac dysrhythmias bronchospasms trauma (nasal, pharyngeal, tracheal) |
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What are some of the contraindications to nasotracheal suctioning
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facial/neck trauma
bleeding disorders nasal bleeding irritable airway |
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How should a patient be positioned for suctioning
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Face foward
Facing to right-facilitate passage into left bronchus Facing to left-facilitate passage into the right bronchus |
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What is a fenestration and what is it's purpose
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A fenestration is a small hole in the tubing
It allows the patient to speak |
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When do tubes have an inflatable cuff
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Adult tracheostomy tubes have an inflatable cuff
Pediatric tubes are cuffless |
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What is the purpose of the inflatable cuff
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It is inflated during manual ventilation or eating to prevent air leakage and food aspiration.
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How often should a tracheostomy tube be cared for
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Every 8-12 hours
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hat are some indications for tracheostomy care
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excess secretions
soiled/damp ties diminished airflow through tracheostomy signs of airway obstruction unstable tube |
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What are indications for whole blood
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massive hemorrhage
active bleeding with loss of 25% blood volume hypovolemic shock/oxygen carrying deficiency cardiopulmonary surgery |
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autologous
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transfusion of patients own blood through prior prep or collection during surgery
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When is autologous blood used
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Replace red cell volume in NON hemorrhaging adult
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Indications for RBC transfusion
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chronic anemia
CHF Hgb less than 8 g/dL blood loss from surgery, birth, trauma, chemo |
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When are PRBC used
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Raise Hgb/Nct levels to the same as whole blood
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When is FFP used
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Replace plasma without RBC's or platelets
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When are platelets used
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For immunoligically refractory
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Who is considered a universal donor
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Someone with type O negative blood
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Who is considered a universal recipient
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Someone with AB blood type
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What is cryoprecipitate
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The fraction of plasma that separates out of FFP when it is slowly thawed in the refrigerator
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What reaction will occur if the wrong blood type is administered to a patient
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RBC's will clump when an antibody is present that reacts with the antigens on the RBC membrane.
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What are the most common symptoms of a hemolytic reaction
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fever
lower back/chest pain chills nasuea/vomiting headache |
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When does an acute febrile transaction usually occur
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Within 15 minutes of transfusion
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What is the most common sign of acute febrile reaction
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pain the in kidneys and chest
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How long will it take for a febrile non hemolytic reaction to take place
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30 minutes to 6 hours
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When should blood be used when removed from the refridgerator
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Within 30 minutes; otherwise send to blood bank
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What are some advantages of autologous transfusion
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lower risk of infection
normal pH more viable RBC's quickly available |
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What are three methods of auto transfusion
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pre operative
peri operative hemodilution |
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What are necessary nursing assessments for a blood transfusion
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chest assessment
vitals |
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How long must you stay with a patient during infusion
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For the first 15 minutes; then check in every 30 minutes
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peripheral vascular disease
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narrowing of occlusion by atherosclerotic plaques of arteries outside the heart or brain
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Characteristics of arterial disease
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decreased, absent pulse
cool temperature, pallor no edema loss of hair on legs/feet located at tips of the toes, foot or lateral malleolus thick, brittle toenails |
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Characteristics of venous disease
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pulse present
warm to touch lower leg edema hair on legs/feet present dull ache normal OR thickened toenails |
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What is intermittent claudication
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Ischemic muscle ache or pain precipitated by a constant level of exercise that resolves itself within 10 minutes of rest
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What is pneumothorax
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Collapse of lung tissue caused by collection of air in the pleural space
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What is hemothorax
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The presence of blood in pleural space resulting from partial or complete lung collapse
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What is empyema
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Collection of pus and fluid from infection tissue
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When are clamps indicated with chest tubes
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To assess air leak
Quickly to empty/change disposable systems Disconnection of drainage tubing Assess whether patient is ready to have tubes removed |
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What can clamping chest tubes cause
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Tension pneumothorax
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How do clamps cause tension pneumothorax
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air pressure builds in pleural space causing the lung to collapse
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What is equipment is best kept at the bedside
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padded clamps
sterile water vasoline soaked gauze sterile 4x4 tape dressing |
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what is the required nursing intervention is the chest tube is dislodged
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apply pressure over the insertion site, apply occlusive gauze dressing and contact physican
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What do fluctuations in the water seal column indicate
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system is functioning efficiently
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What would no fluctuations indicate
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obstruction
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What does bubbling indicate
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air leak
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