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118 Cards in this Set
- Front
- Back
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What does depression of the respiratory center result in? |
Reduced the rate of respiration
Reduced depth of respiration Reduced amount of inhaled O2 |
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Where is central cyanosis observed?
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Observed in the tongue, soft palate, and conjunctiva of the eye.
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What does central cyanosis indicate?
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Central cyanosis indicates hypoxemia.
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Where are the indicators of peripheral cyanosis observed?
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Peripheral cyanosis is observed in the palms of the hands, soles of the feet, nail beds, and/or earlobes. It is often a result of vasoconstriction and stagnant blood flow.
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What would you do if you find a client on O2 with a worsening respiratory status? Prioritze actions.
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Check for O2 patentcy. (Make sure tubing isn't kinked, and that it is attached to the O2 flowmeter.)
Check O2 level set on flowmeter; determine if delivered amount is consistent with physician's order. If not using wall oxygen, determine if the oxygen source contains enough oxygen to deliver the prescribed oxygen amount. Notify physician. |
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When a patient on O2 experiences dry nares and a dried upper airway mucosa, what interventions can you take? |
O2 flow rate greater than 4 L/min, determine need for humidification.
Assess the client's fluid status, and increase fluids if appropriate. Provide frequent oral care. Obtain physician's order for intermittent use of sterile nasal saline . |
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If pt experiences skin breakdown over the ears from elastic band, what interventions can you do?
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Adjust tightness of elastic strap.
Provide good hygiene and skin care around the ears. Create a barrier pad with 4 × 4s between elastic and ears. Reposition strap frequently. |
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What must be remembered regarding initiating or adjusting O2?
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Oxygen is a medication and adjusted only with a health care provider's order. (Can initiate or adjust if emergent or indicated - obtain order after.)
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What is the flow rate range for a nasal cannula?
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Oxygen is delivered via the cannulas with a flow rate of up to 6 L/min. Flow rates greater than 4 L/min are not often used due to drying effects.
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Approximate FIO2 with Nasal Cannula @ ___ L/min = __%
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1 L/min: 24%
2 L/min: 28% 3 L/min: 32% 4 L/min: 36% 5 L/min: 40% 6 L/min: 44% |
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Approximate FIO2 with Face Mask @ ___ L/min = __%
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5-6 L/min: 40%
6-7 L/min: 50% 7-8 L/min: 60% >8 L/min: 60% |
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Approximate FIO2 with Venturi Mask @ ___ L/min = __%
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4 L/min: 24%-28%
8 L/min: 35%-40% 12 L/min: 50%-60% |
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What type of mask is used for short term O2 therapy? (At which concentration)
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The simple face mask is used for short-term O2 therapy. It fits loosely and delivers O2 concentrations from 30% to 60%.
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When is the O2 mask contraindicated?
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The mask is contraindicated for clients with carbon dioxide retention because retention can be worsened. (COPD) With COPD use low flow rates and a nasal cannula.
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What type of masks are used for higher concentration O2 therapy? (At which concentrations)
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When used as a nonrebreather, the plastic face mask with a reservoir bag delivers from 60% to 95% oxygen with a flow rate of 6 to 10 L/min. The Venturi mask delivers oxygen concentrations of 24% to 60% with oxygen flow rates of 4 to 12 L/min.
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How often should the nurse check the patency of the nasal cannula?
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Check cannula at least every 8 hours or with changes in client's cardiopulmonary status.
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How often should a nurse assess the skin and nares of the patient with a nasal cannula?
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The nurse should assess the client’s nares and ears for skin breakdown every 6 hours.
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What do sudden changes of LOC, vital signs and behavior potentially indicate with a patient receiving supplemental O2?
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Patients with sudden changes in their vital signs, level of consciousness, or behavior are often experiencing profound hypoxia.
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Patients using supplemental O2 who demonstrate SUBTLE behavioral, mental and physiological changes over a long period of time indicate what?
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Patients with sudden changes in their vital signs, level of consciousness, or behavior are often experiencing profound hypoxia. Clients who demonstrate subtle changes over time have worsening of a chronic or existing condition or a new medical condition.
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How often should O2 flow be checked?
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Oxygen flow should be checked every 8 hours.
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Left untreated, what can hypoxia cause?
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Hypoxia can cause cardiac dysrhythmias and death.
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What are the clinical signs of the blood's inadequate ability to transport O2 (ex. anemia.)
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Clients with severe anemia have fatigue, decreased activity tolerance, and increased breathlessness, as well as pallor (especially seen in the conjunctiva of the eye) and an increased heart rate.
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What does FIO2 stand for?
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Fraction of inspired oxygen concentration.
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True or False: Shock and severe dehydration can lead to reduced circulating blood volume (hypovolemia.)
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True
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What happens in regards to O2 during a fever and the consequences of long term fever?
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Fever increases the tissues' need for oxygen, and as a result, carbon dioxide production increases. When fever persists, the metabolic rate remains high and the body begins to break down protein stores, resulting in muscle wasting and decreased muscle mass. Respiratory muscles such as the diaphragm and intercostal muscles are also wasted.
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How does the body attempt to compensate during times of increased carbon dioxide levels?
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The body attempts to adapt to the increased carbon dioxide levels by increasing the rate and depth of respiration.
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What should be done during nasotracheal suctioning catheter removal?
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Intermittent suction for up to 10 to 15 seconds should be applied to prevent injury to the mucosa.
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Identify the group at greatest risk for hypoxemia.
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Clients with pulmonary diseases are at greater risk for hypoxemia.
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Identify initial assessment findings for a patient with early stage left sided heart failure.
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Assessment findings include fatigue, breathlessness, dizziness, and confusion as a result of tissue hypoxia from the diminished cardiac output.
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What additional assessment findings occur as left sided heart failure continues to persist.
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Blood begins to pool in the pulmonary circulation, causing pulmonary congestion. Clinical findings include crackles on auscultation, hypoxia, shortness of breath on exertion and often at rest, cough, and paroxysmal nocturnal dyspnea.
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Describe the primary cause and progression of right sided heart failure.
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Right-sided heart failure more commonly results from pulmonary disease or as a result of long-term left-sided failure. The primary pathological factor in right-sided failure is elevated pulmonary vascular resistance (PVR). As the PVR continues to rise, the right ventricle generates more work, and the oxygen demand of the heart increases. As the failure continues, the amount of blood ejected from the right ventricle declines, and blood begins to “back up” in the systemic circulation.
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Describe the clinical signs of right sided heart failure.
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Clinically the client has weight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema.
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What does the respiratory system attempt to do during metabolic acidosis?
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The respiratory system attempts to correct metabolic acidosis by increasing ventilation to reduce the amount of carbon dioxide and thereby raise the pH. The respiratory system would compensate for metabolic acidosis with increased respirations, the respiratory system compensates by exhaling a greater amount of carbon dioxide.
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What is normal arterial carbon dioxide tension (PaCO2)?
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Between 35 and 45 mm Hg
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What is normal arterial oxygen tension (PaO2)?
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Between 95 and 100 mm Hg.
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True or False. The terms hyperventilation and hypoventilation refer to the client's respiratory rate.
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False. Hyperventilation and hypoventilation refer to alveolar ventilation and not to the client's respiratory rate.
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What are normal arterial saturation levels on room air?
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Between 95% and 100%
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What conditions or factors can induce hyperventilation?
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Anxiety, infections, fever, drugs (Salicylate (aspirin) poisoning, Amphetamines), or an acid-base imbalance (diabetic ketoacidosis) induce hyperventilation. Hypoxia associated with pulmonary embolus or shock can also induce hyperventilation.
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What is the body trying to accomplish when it goes into hyperventilation?
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Reduce the amount of carbon dioxide available to form carbonic acid.
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What is hyperventilation?
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Hyperventilation is a state of increased ventilation in excess of that which is actually required to eliminate the carbon dioxide produced by cellular metabolism.
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What is hypoventilation?
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Hypoventilation occurs when (alveolar) ventilation is inadequate to meet the body's oxygen demand or to eliminate sufficient amounts of carbon dioxide. (Retention of CO2) Can be caused by atelectasis.
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What is atelectasis?
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"Atelectasis" is a collapse of the alveoli in the lung. It prevents normal exchange of oxygen and carbon dioxide. As alveoli collapse, less of the lung is able to be ventilated and hypoventilation occurs.
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What occurs when a client with COPD is given "excessive" O2?
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In clients with COPD, the administration of excessive oxygen results in hypoventilation.
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What can excessive CO2 retention lead to?
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Respiratory arrest
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What clinical signs present with hypoventilation?
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Signs and symptoms of hypoventilation include mental status changes, dysrhythmias, and potential cardiac arrest. If untreated, the client's status will rapidly decline, leading to convulsions, unconsciousness, and death.
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What is treatment and goal of treatment for hypoventilation?
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O2 admin. Treatment requires improving tissue oxygenation, restoring ventilatory function, treating the underlying cause of the hypoventilation, and achieving acid-base balance.
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What signs/symptoms are exhibited with patients experiecing a pneumothorax (collapsed lung)?
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Patients with a pneumothorax will exhibit dyspnea and pain.
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What are the signs/symptoms of hypoxia?
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Hypoxia signs and symptoms: apprehension, restlessness, inability to concentrate, declining level of consciousness, dizziness, and behavioral changes. The client with hypoxia is unable to lie down and appears fatigued and agitated. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock. As the hypoxia worsens, the respiratory rate declines as a result of respiratory muscle fatigue.
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What is the goal of O2 therapy?
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Prevent or relieve hypoxia.
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What action is taken if a client develops respiratory distress during the suction procedure?
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Immediately withdraw catheter and supply additional oxygen and breaths as needed.
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True or False? During an emergency O2 can be directly administerd through the suctioning catheter.
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True. During an emergency, disconnect suction and attach oxygen at prescribed flow rate then administer through the catheter.
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Which vital signs are monitored and of concern indicating the need to discontinue suctioning of the client's respiratory system?
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A change of 20 beats per minute (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline.
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Is cyanosis and early or late sign of hypoxia.
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Cyanosis is a late sign of hypoxia.
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What is the difference between hypoxia and hypoxemia.
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Hypoxia is inadequate tissue oxygenation at the cellular level. Hypoxemia is low O2 levels in the blood.
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Identify what is included during the assessment phase of the nursing process for a cardiopulmonary focus.
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Assessment
• In-depth history of the client's normal and present cardiopulmonary function • Past impairments in circulatory or respiratory functioning • Patient history including a review of drug, food, and other allergies • Physical examination of the client's cardiopulmonary status reveals the extent of existing signs and symptoms. • Use PQRST for pain / HPI for other symptoms • Review of laboratory and diagnostic test results |
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How should chest pain be addressed during a cardiopulmonary assessment?
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The presence of chest pain needs an immediate thorough evaluation, including location, duration, radiation, and frequency. Determine if it appears to be cardiac, pleuritic or musculoskeletal pain. If indicated, take immediate nursing intervention action.
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How does cardiac pain usually present?
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Cardiac pain does not occur with respiratory variations and is most often on the left side of the chest and radiates to the left arm in men. Chest pain in women is much less definitive and is often a sensation of breathlessness, jaw or back pain, nausea, and fatigue.
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How does pericardial pain present?
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Pericardial pain results from inflammation of the pericardial sac, occurs on inspiration, and does not usually radiate.
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How does pleuric pain present?
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Pleuritic chest pain is peripheral and radiates to the scapular regions. Inspiratory maneuvers, such as coughing, yawning, and sighing worsen pleuritic chest pain. An inflammation or infection in the pleural space often causes this, and clients usually describe it as knifelike, lasting from a minute to hours and always in association with inspiration.
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How does musculoskeletal pain usually present?
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Musculoskeletal pain is often present following exercise, rib trauma, and prolonged coughing episodes. Inspiration worsens this pain, and clients often confuse it with pleuritic chest pain.
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Is sterile or clean techinique used for suctioning?
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Within a medical facility use sterile technique for suctioning. (The oropharynx and trachea are considered sterile.) Clean technique is used in the patients home.
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Would you suction the mouth before or after suctioning of the oropharynx and trachea? (Or can it be either?)
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The mouth is considered clean, whereas the oropharynx and trachea are considered sterile, therefore you would suction oral secretions after you suction the oropharynx and trachea.
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When should suctioning secretions from the oropharynx and trachea be initiated and how often should it be done?
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Client assessment determines the frequency of suctioning. When you auscultate secretions, and other methods to remove airway secretions have failed, suctioning is indicated.
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What can occur if suctioning is done too frequently?
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Too-frequent suctioning puts the client at risk for development of hypoxemia, hypotension, arrhythmias, and possible trauma to the mucosa of the lungs.
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When is oropharyngeal or nasopharyngeal suctioning indicated?
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Oropharyngeal or nasopharyngeal suctioning is used when the client is able to cough effectively but is unable to clear secretions by expectorating or swallowing. Apply suction after the client has coughed.
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When is orotracheal or nasotracheal suctioning indicated?
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Orotracheal or nasotracheal suctioning is necessary when the client with pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway present.
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Which method of suctioning is preffered, the oro- or naso- route?
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The nose is the preferred route because stimulation of the gag reflex is minimal.
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What must be remembered when suctioning?
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The entire procedure from catheter passage to its removal is done quickly, lasting no longer than 15 seconds. Unless in respiratory distress, allow the client to rest between passes of the catheter. If the client is using supplemental oxygen, replace the oxygen cannula or mask during rest periods.
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Where should suctioning begin and via what route anatomically?
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Use nasal approach before oral, and tracheal before pharyngeal whenever possible. The nasal approach does not initiate the gag response and the mouth and pharynx contain more bacteria than the trachea does. Work from the most sterile area backwards starting with the trachea. However, if copious oral secretions are present before beginning the procedure, suction mouth with oral suction device.
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Is inspiration / expiration active or passive responses?
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Inspiration is an active process, stimulated by chemical receptors in the aorta. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work.
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Name some factors that affect chest wall expansion and respiration.
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Factors affecting chest wall movement and respiration:
Pregnancy Obesity Musculoskeletal Abnormalities Trauma Neuromuscular Diseases Alterations of the CNS Influences of Chronic Disease |
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What is pursed lip breathing and what does it accomplish?
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Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, instruct the client to take a deep breath and to exhale slowly through pursed lips, as if blowing through a straw.
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What is incentive spirometry?
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Incentive spirometry is a device used for encouragement of voluntary deep breathing by providing visual feedback to clients regarding inspiratory volume. Incentive spirometry promotes deep breathing and prevents or treats atelectasis in the postoperative client. There is solid evidence to support the use of lung expansion with incentive spirometry in preventing postoperative pulmonary complications following abdominal surgery.
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How should the client be instructed to use and incentive spirometer?
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Flow-oriented incentive spirometers consist of one or more plastic chambers that contain freely moving colored balls. The client inhales slowly and with an even flow to elevate the balls and to keep them floating as long as possible to ensure a maximally sustained inhalation. Again, the patient is inhaling on the device to activate the visual feedback on the spirometer.
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What positioning is most effective in reducing stasis of pulmonary secretions and aiding chest wall expansion limitations?
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The 45-degree semi-Fowler's position is the most effective position. This position uses gravity to assist in lung expansion and reduces pressure from the abdomen on the diaphragm.
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How should a patient with the presence of pulmonary abscess or hemorrhage be positioned?
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Position the client with the affected lung down to prevent drainage toward the healthy lung.
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How should a client with unilateral lung disease, such as a pneumothorax, atelectasis, unilateral pneumonia, a thoracotomy, or trauma affecting one lung be positioned?
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A client with unilateral lung disease, such as pneumothorax, atelectasis, pneumonia, thoracotomy, and multiple trauma affecting one lung, should be positioned in a manner to promote perfusion of the healthy lung and improve oxygenation. In most cases the client is positioned with the “good lung” down.
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How often should clients with chronic pulmonary diseases, upper respiratory tract infections, and lower respiratory tract infections be encouraged to deep breathe and cough?
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Encourage clients with chronic pulmonary diseases, upper respiratory tract infections, and lower respiratory tract infections to deep breathe and cough at least every 2 hours while awake.
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How often should clients with a large amount of sputum be encouraged to cough?
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Encourage clients with a large amount of sputum to cough EVERY hour while awake and every 2 to 3 hours while asleep until the acute phase of mucus production has ended.
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What is cyanosis?
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Cyanosis, blue discoloration of the skin and mucous membranes. It is a result of desaturated hemoglobin in the capillaries.
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Name four factors that influence adequate circulation, ventilation, perfusion, and transport of respiratory gases to the tissues.
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(1) Physiological
(2) developmental (3) lifestyle (4) environment |
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What physiological conditions can affect oxygenation?
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Any condition affecting cardiopulmonary functioning directly affects the body's ability to meet oxygen demands.
*Cardiac disorders *Respiratory disorders(hyperventilation, hypoventilation, and hypoxia.) *Anemia *Increases in the body's metabolic demands (pregnancy, obesity, fever or infection)*Alterations affecting chest wall movement *Hypovolemia *Musculoskeletal impairments of the thoracic area *Trauma to chest wall *Opiod use *Neuromuscular disorders *CNS damage or impairment (Cervical trauma) *Chronic disease |
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Discuss the developmental factors affecting oxygenation/respiration of infants and toddlers.
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Toddlers and infants are at risk for bacterial URI’s. as a result of frequent exposure to other children and exposure to secondhand smoke. In addition, during the teething process some infants develop nasal congestion, which encourages bacterial growth and increases the potential for respiratory tract infection.
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What risks do school age children and teens face in regards to O2 and respiration issues.
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Respiratory infections and 2nd hand smoke. increased risk for cardiopulmonary disease and lung cancer for teens who start smoking and continue into adulthood.
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What are the contributory factors for young and middle-age adults oxygenation / respiration risks.
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Young and middle-age adults - multiple cardiopulmonary risk factors: unhealthy diet, lack of exercise, stress, OTC and prescription drugs not used as intended, illegal substances, and smoking.
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Oxygen precautions to teach clients for home use of O2.
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Oxygen is a highly combustible substance. Smoke only outside or in a room provided for smoking, away from O2. Acetone, oil, and alcohol are appropriate substances to use with clients who are using oxygen . Fire extinguishers should be readily available, and there should be an individual/family member with knowledge of its use
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The initial priority in assessing the cardiopulmonary system.
(From modules) |
According to the American Heart Association, the first assessment to complete for each client is the "ABCs" (Airway, Breathing, and Circulation).
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Decribe Eupnea (Eupnic breathing)
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16 to 20 breaths
Normal No adventitious sounds |
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Describe Tachypnea
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Respirations greater than 35
Clincal significance/contributing factors: Respiratory failure Response to fever Anemia Pain Respiratory infection Anxiety |
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Describe Bradypnea
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Respirations less than 10
Clinical significance/contributing factors: Sleep Respiratory depression Drug overdose Central nervous system lesion |
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Describe Apnea
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Lack of respiration for greater than 15 seconds
Clinical significance/contributing factors: Intermittent, usually occurs during sleep (sleep apnea) Respiratory Arrest |
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Discuss the developmental factors affecting oxygenation/respiration of the older adult.
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Older Adult – Aging affects on system: Calcification of the heart valves, SA node, and costal cartilages. The arterial system develops atherosclerotic plaques. Osteoporosis leads to changes in the size and shape of the thorax. The trachea and large bronchi become enlarged from calcification of the airways. The alveoli enlarge, decreasing the surface area available for gas exchange. The number of functional cilia is reduced, causing a decrease in the effectiveness of the cough mechanism, putting the older adult at increased risk for respiratory infections.
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Discuss the nutrition lifestyle factor that obesity/malnourishment play in oxygenation/respiration.
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Severe obesity decreases lung expansion, increased body weight increases tissue oxygen demands. Malnourished client experiences respiratory muscle wasting, resulting in decreased muscle strength and respiratory excursion. Cough efficiency is reduced secondary to respiratory muscle weakness, putting the client at risk for retention of pulmonary secretions.
Morbidly obese and/or malnourished are at risk for anemia. |
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How do high carbohydrates affect oxygenation/respiration?
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High carbohydrates increase the carbon dioxide load for clients with carbon dioxide retention.
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What types of foods does cardioprotective nutrition include?
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diets rich in fiber; whole grains; fresh fruits and vegetables; nuts; antioxidants; lean meats, fish, and chicken; and omega-3 fatty acids. In addition, potatoes and citrus fruit juices are cardioprotective in women, but not men.
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What dietary restrictions are cardioprotective?
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Dietary restriction of sodium and high potassium prevents hypertension and help improve control of hypertension.
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What affect does 30 to 60 minutes of excercise daily play in cardiopulmonary health?
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Lower pulse rate and lower blood pressure, decreased cholesterol level, increased blood flow, and greater oxygen extraction by working muscles.
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Discuss cigarette smoking on cardiopulmonary health.
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Cigarette smoking worsens peripheral vascular and coronary artery diseases. Produces injury to the lung endothelium. Inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood pressure and decreasing blood flow to peripheral vessels. Women who take birth control pills and smoke cigarettes have an increased risk for thrombophlebitis and pulmonary emboli.
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Which occupational group is at risk for coccidioidomycosis, a fungal disease caused by inhalation of spores of the airborne bacterium Coccidioides immitis.
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Farm workers in dry regions of the southwestern United States are at risk for coccidioidomycosis, a fungal disease caused by inhalation of spores of the airborne bacterium Coccidioides immitis.
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Name three or four nursing dx's appropriate for clients with an alteration in oxygenation.
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Impaired gas exchange
Risk for infection Ineffective airway clearance Risk for imbalanced fluid volume Impaired spontaneous ventilation Impaired verbal communication Ineffective breathing pattern Activity intolerance Decreased cardiac output Fatigue Ineffective health maintenance Anxiety |
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Describe the cough of a client with chronic bronchitis.
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Clients with chronic bronchitis generally cough and produce sputum all day, although greater amounts are produced after rising from a semirecumbent or flat position. This is a result of the dependent accumulation of sputum in the airways and is associated with reduced mobility.
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Describe the cough of a client with chronic sinusitis.
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Clients with chronic sinusitis usually cough only in the early morning or immediately after rising from sleep. This clears the airway of mucus resulting from sinus drainage.
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"Wheezing"
Describe the sound, what pathologies it is associated with and if it occurs during inspiration, expiration or both. |
49. Wheezing is a high-pitched musical sound caused by high-velocity movement of air through a narrowed airway. Wheezing is associated with asthma, acute bronchitis, or pneumonia. Wheezing occurs during inspiration, expiration, or both.
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Name four nursing interventions that promote the removal of pulmonary secretions, assist in achieving and maintaining a clear airway and help promote lung expansion and gas exchange.
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Nursing interventions: Humidification, Nebulization, Chest Physiotherapy (CPT), Postural drainage.
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Cascade coughing: What is the technique and when is it indicated?
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cascade cough, the client takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then the client opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in clients with large volumes of sputum.
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Huff coughing: What is the technique and when is it indicated?
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The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the client opens the glottis by saying the word huff. With practice the client inhales more air and is able to progress to the cascade cough.
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Quad coughing: What is the technique and when is it indicated?
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The quad cough technique is for clients without abdominal muscle control, such as those with spinal cord injuries. While the client breathes out with a maximal expiratory effort, the client or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough.
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Explain pursed-lip breathing.
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Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, instruct the client to take a deep breath and to exhale slowly through pursed lips, as if blowing through a straw. Emphysema patients especially benefit from this technique.
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Explain diaphragmatic breathing.
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Diaphragmatic breathing is more difficult and requires the client to relax intercostal and accessory respiratory muscles while taking deep inspirations. The client concentrates on expanding the diaphragm during controlled inspiration and learns to place one hand flat below the breastbone above the waist and the other hand 2 to 3 cm below the first hand. Ask the client to inhale while the lower hand moves outward during inspiration. The client observes for inward movement as the diaphragm ascends. The client practices these exercises initially in the supine position and then while sitting and standing. The exercise is often used with the pursed-lip breathing technique.
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What do conditions such as shock and severe dehydration (resulting from extracellular fluid loss) and reduced circulating blood volume cause?
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Hypovolemia
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Carbon monoxide is a toxic inhalant that decreases the oxygen-carrying capacity of blood by:
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Forming a strong bond with hemoglobin
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Anemia leads to increased _______ and decreased _______.
(Choose from: Blood flow, breathlessness, activity tolerance, WBC's.) |
Symptoms associated with anemia include:
Increased breathlessness Decreased activity tolerance |
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A simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion is:
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Frequent change of position
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Thick sputum,
decreased coughing ability and abnormal lung sounds in the left lower lobe indicate the need for what nursing intervention? |
Suctioning
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True or False: A client with thin, watery secretions indicates a need for immediate intervention/suctioning.
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False. Thin, watery secretions are mobile and can be exporated by client.
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Identify after each symptom whether it is a sign of a tension pneumothorax:
Increased heart rate. T or F Decreased heart rate. T or F Increased respiratory rate. T or F Increased blood pressure. T or F Decreased blood pressure. T or F Asymmetrical chest wall movement. T or F |
Increased heart rate. F
Decreased heart rate. T Increased respiratory rate. T Increased blood pressure. F Decreased blood pressure. T Asymmetrical chest wall movement. T |
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Air humidity in oxygen hoods and oxygen tents require what nursing intervention?
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Air in the humidity hoods/tents sometimes becomes cool and falls below 20° C (68° F), causing the child to become chilled leading to hypothermia. Children in humidity tents require frequent changes of clothing and bed linen to remain warm and dry.
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Chest physiotherapy is especially useful in treating symptoms of which condition:
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Cystic Fibrosis
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