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92 Cards in this Set
- Front
- Back
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What does Cyanosis mean?
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What does Cyanosis mean?
Condition of bluish color of the fingernail beds, lips, around the mouth and mucous membranes (due to hypoxia) |
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What is the definition of diffusion?
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What is the definition of diffusion?
Exchange of oxygen and carbon dioxide in the alveoli (capillary network) |
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What do u call movement of air in and out of your lung?
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What do u call movement of air in and out of your lung?
- Ventilation |
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Diaphragm descends during inspiration or expiration?
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Diaphragm descends during inspiration or expiration?
- Inspiration |
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What is asthma?
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What is asthma?
Airway obstruction disorder in the bronchi |
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What is best position for pt who is getting asthma attack?
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What is best position for pt who is getting asthma attack?
- High fowlers (sitting up) - to allow the lungs to expand -Sitting up is always good allows for access for front and back expands the lungs |
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When assessing pt for cyanosis, where is the best place to check?
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When assessing pt for cyanosis, where is the best place to check?
- The fingernail beds, lips and mucous membranes |
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What respiratory increase takes place in the older population?
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What respiratory increase takes place in the older population?
- Anterior posterior diameter (losing muscle mass and respiratory status gets larger in diameter) |
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What do crackles sound like?
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What do crackles sound like?
Popping |
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What does auscultation mean?
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What does auscultation mean?
- listen |
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Adventitious breath sounds mean?
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Adventitious breath sounds mean?
- abnormal breath sounds |
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Describe what respiratory excursion means?
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Describe what respiratory excursion means?
- Looking at Chest movement |
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You have a pt who is changing positions (to sitting up) would it be better to assess breath sounds while they are sitting up or while they are lying down?
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You have a pt who is changing positions (to sitting up) would it be better to assess breath sounds while they are sitting up or while they are lying down?
- While they are sitting up because the lungs can expand - allows front back access |
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What does consolidation mean when found in lungs?
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What does consolidation mean when found in lungs?
- fluid build up in lungs |
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Describe what vesicular breaths sound like?
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Describe what vesicular breaths sound like?
- Rustling (like rustling in the trees) |
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After finding a pt has lung consolidation, prior to documenting and confirming what will you do 1st?
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After finding a pt has lung consolidation, prior to documenting and confirming what will you do 1st?
- Ask pt to hold breath. If pt is holding breath and you hear nothing, that means it is the lungs. If you still hear it that means it is the heart. |
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Q1. Asthmatic pt is complaining of sob, what do u hear?
Q2. Is that Adventitious? Why? |
Q1. Asthmatic pt is complaining of sob, what do u hear?
- Wheezing Q2. Is that Adventitious? Why? - Yes, because it is not normal (FYI= adventitious lung sounds include: crackles (rales), wheezing, rhonchi, and pleural friction rub) |
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If u hears fine crackles, why do you encourage pt to cough and deep breath?
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If u hears fine crackles, why do you encourage pt to cough and deep breath?
- Have pt cough, deep breath and re-assess - it might go away - clearing the airway |
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You are listening to breath sounds, you hear abnormal faint crackly sound in lung after post op, why?
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You are listening to breath sounds, you hear abnormal faint crackly sound in lung after post op, why?
- Because they have decreased respiratory (Decreased respiratory is caused because they were under anesthesia) |
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Air moves through a narrowed airway causing what sound?
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Air moves through a narrowed airway causing what sound?
- wheezing / whistling |
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What does orthopnea mean?
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What does orthopnea mean?
- Difficulty breathing while lying down (without sitting up) |
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What is the difference between dyspnea and orthopnea?
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What is the difference between dyspnea and orthopnea?
- Orthopnea = has to do with the position - Dyspnea = difficulty breathing (or it hurts when you are breathing) |
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KUSSMAUL respiratory pattern, what is it?
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KUSSMAUL respiratory pattern, what is it?
- Rapid & Deep respirations - (FYI: Rapid, deep, and regular to blow off CO2 and reduce hydrogen ion in acidosis; rapid (>20/min) gasping breaths, air hunger, panting, labored.) |
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If u have a partial airway obstruction, would u b able to talk?
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If u have a partial airway obstruction, would u b able to talk?
- no, because there is no air coming through. There is an obstruction |
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Q1. What does the finding what does ur finding bronchophony mean?
Q2. Where do u place stethoscope? |
Q1. What does the finding what does ur finding bronchophony mean?
- fluid in lungs = consolidation = pneumonia Q2. Where do u place stethoscope? - everywhere, every lobe. (FYI: Louder, clearer sounds are called bronchophony and indicates an area of consolidation (fluid build up) as in pneumonia) |
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Why does pt have to sleep sitting up?
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Why does pt have to sleep sitting up?
- So they can breathe when they have orthopnea (they cannot breath laying down) |
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What type of breath sound would u hear if pt aspirated a piece a meat?
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What type of breath sound would u hear if pt aspirated a piece a meat?
- STRIDER (its blocked) - Inspiratory & Expiratory Blockage> Both |
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Q1. What is chronic hypoxia?
Q2. What makes u hypoxia? |
Q1. What is chronic hypoxia?
Chronic= Comes and goes over 6 months Hypoxia= lack of o2 in tissues Q2. What makes u hypoxia? Anxiety= leading to restlessness= leads to anxiety |
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Q1. What does SaO2 stand for?
Q2. If your pt’s SaO2 is normal, except they have SOB when they are getting in and out of bed, what lab will be low? |
Q1. What does SaO2 stand for?
- Saturation of Oxygen Q2. If your pt’s SaO2 is normal, except they have SOB when they are getting in and out of bed, what lab will be low? - H & H = probably anemic (blood hemoglobin and hematocrit (H&H) levels Girls: 12-16 Boys: 14-18 hematocrit X3) |
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What is the Pathophisiology with anemia and o2 transport?
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What is the Pathophisiology with anemia and o2 transport?
- Not enough RBC and or Iron, unable to carry O2 |
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What is the 1st sign of a respiratory problem?
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What is the 1st sign of a respiratory problem?
- Restlessness (FYI: Apprehension, anxiety, restlessness are the earliest signs of decreased oxygenation) |
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What is hospice?
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What is hospice?
- end of life care (within 6 months) |
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What nursing diagnosis would you expect for a pt with chronic Hypoxia?
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What nursing diagnosis would you expect for a pt with chronic Hypoxia?
- Ineffective tissue perfusion - risk for falls- b/c pt is not perfusing - anxiety, at risk for (remember ABC and safety are always 1st) |
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Use of accessory muscles to breathe indicates what?
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Use of accessory muscles to breathe indicates what?
- Respiratory problems - Hypoxia: ineffective tissue perfusion |
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What s/s would pt manifest if they have Hypoxia?
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What s/s would pt manifest if they have Hypoxia?
- Blue (from not breathing) - Cyanosis - Restlessness - slow respiratory rate - wheezing - Bradycardia - Decreased LOC |
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What is the difference between Hypoxia and Hypoxemia?
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What is the difference between Hypoxia and Hypoxemia?
- Hypoxemia= decreased O2 blood levels - Hypoxia = decreased O2 in the tissue |
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If pt is pale, blue lips, blue nail beds, loc decreased, respiratory rate increase, what type of nursing diagnosis would you expect to have for tissue perfusion?
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If pt is pale, blue lips, blue nail beds, loc decreased, respiratory rate increase, what type of nursing diagnosis would you expect to have for tissue perfusion?
- Ineffective Tissue Perfusion |
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What is objective vs. subjective?
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What is objective vs. subjective?
- What you see is objective - subjective is what pt is telling you |
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What does PaO2 of 65 mean?
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What does PaO2 of 65 mean?
- hypoxia (norm is 80-100) - Give them O2 (FYI: PaO2= Partial Pressure of Oxygen in Arterial Blood) |
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What are the normal lab levels for:
pH- PaCO2- PaO2- HCO3- |
What are the normal lab levels for:
pH- 7.35 to 7.45 PaCO2- 35-45 mm Hg PaO2- 80-100 mm Hg HCO3- 21-28 mEq/L |
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What s/s would you see for a pt with COPD?
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What s/s would you see for a pt with COPD?
- Pursed Lip Breathing - barrelled chest - clubbed fingars and toes (FYI: COPD = Chronic Obstructive Pulmonary Disease) |
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How do you collect sputum specimen for culture?
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How do you collect sputum specimen for culture?
- in the morning before they eat or drink to prevent contamination |
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What can you do to help patient produce sputum, if they are having problems producing it on their own?
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What can you do to help patient produce sputum, if they are having problems producing it on their own?
- Moist warm heat (humidified air) loosens up the sputum and helps get the mucus get out. |
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Why provide mouth care after sputum spec is collected?
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Why provide mouth care after sputum spec is collected?
- Because they could have bacteria or virus. Mainly because it is gross |
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What is difference between a productive and a non-productive cough?
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What is difference between a productive and a non-productive cough?
- productive means there is sputum - non is dry irritating tickle (no sputum is coming up) |
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Q1. What is Pharyngitis?
Q2. How do you collect a throat culture? |
Q1. What is Pharyngitis?
- Pharyngitis is inflammation of the pharynx (FYI: Pharyngitis is inflammation of the pharynx, which is in the back ofthe throat, between the tonsils and the voicebox (larynx). The mainsymptom is a sore throat.) Q2. How do you collect a throat culture? - Samples are obtained with a Sterile Cotton-Tipped Applicator - When obtaining specimen, DO NOT TOUCH TONGUE, TEETH, ROOF OF MOUTH= Contamination - Use Sterile technique |
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Q1. What does ABG stand for?
Q2. What test prior to ABG, if using a radial artery? Q3. After collecting a specimen, where do you take it immediately following? Q4. What do you do with the site? |
Q1. What does ABG stand for?
- Arterial Blood Gas (ABG) Q2. What test prior to ABG, if using a radial artery? - Allen Test Q3. After collecting a specimen, where do you take it immediately following? - the lab Q4. What do you do with the site? - Apply prolonged pressure post procedure (compress for 5-10 min) - don't want uncontrolled bleeding |
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Why ABG and Pulse OX?
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Why ABG and Pulse OX?
- Measure oxygen in the blood and tissue - Efficiency of gas exchange |
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Q1. What is a pulse ox measure?
Q2. Is a pulse Ox Invasive? Q3. Where is the most common place for a pulse ox? Q4. What are the normal Pulse Ox Ranges? |
Q1. What is a pulse ox measure?
- o2 sat in the tissues Q2. Is a pulse Ox Invasive? - NO Q3. Where is the most common place for a pulse ox? - The Finger Q4. What are the normal Pulse Ox Ranges? - 95-100% |
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If your pt o2 sat read 90%, what do you do next?
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If your pt o2 sat read 90%, what do you do next?
- Look at your pt - Check to see if the Pulse ox is working & check if it is on securely - Ask your pt to "take a deep breath" - TCDB - Access Respiratory |
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What does incentive spirometer do for breathing?
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What does incentive spirometer do for breathing?
- It is a preventative thing by helping expand the lungs. |
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Why important for pt that are hypothermic to warm prior to placing the pulse ox?
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Why important for pt that are hypothermic to warm prior to placing the pulse ox?
- Inaccurate reading due to vaso constriction and there will not be any blood flow. |
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What does PFT mean?
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What does PFT mean?
- Pulmonary Function Test |
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Q1. What is Emphysema?
Q2. What does PFT have to do with Emphysema? |
Q1. What is Emphysema?
- Emphysema is chronic obstructive pulmonary disorder - fibrous lungs (brittle and check the effectiveness) tissue Q2. What does PFT have to do with Emphysema? - Trying to check how involved the COPD is - Checking the effectiveness of the lungs |
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How does the pt use the PFT?
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How does the pt use the PFT?
- Pt will breath into a mouth piece - Breathing into it. (pulmonary function test) |
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What is the Heimlich Maneuver?
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What is the Heimlich Maneuver?
- Dislodge a obstruction (residual volume) |
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Why is it important not to smoke 6-8 hours prior to a PFT?
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Why is it important not to smoke 6-8 hours prior to a PFT?
- B/C smoking causes VasoConstriction |
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If pt O2 sat are 82, respiratory 30 and shallow labored breathing, what is the priority intervention?
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If pt O2 sat are 82, respiratory 30 and shallow labored breathing, what is the priority intervention?
- Oxygen is needed! 2 - 3 liters (Anymore than 2-3 liters of o2 will need an order from the Dr.) |
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What is Tidal Volume?
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What is Tidal Volume?
- inspired air and expired out with a normal breath |
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Prior to a chest Xray, what do you advise pt to do?
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Prior to a chest Xray, what do you advise pt to do?
- Take off all metals (whatever and anything metal) |
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What does NPO mean?
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What does NPO mean?
- nothing by mouth (unless otherwise stated by dr for a sip with medication) |
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prior to pulmonary angio gram, what question do you ask your pt and why?
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prior to pulmonary angio gram, what question do you ask your pt and why?
- “Are you allergic to shellfish or iodine?” - If pt replies “YES”, ask them “what was the reaction?” - If pt replies that they “had a metallic taste”, tell em not to be a big R-tard and it’s normal. - You should only flag a crazy allergy reaction - SOB is not a normal reaction |
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Q1. What is Bronchoscopy?
Q2. Post bronchoscopy, what do you make sure the pt has? |
Q1. What is Bronchoscopy?
- Camera into the bronchia via scopy Q2. Post bronchoscopy, what do you make sure the pt has? - A Gag Reflex - Make sure the pt has been NPO prior to procedure (to prevent vomiting) |
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How do you check a gag reflex?
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How do you check a gag reflex?
- With a spoon - With a tongue depressor - Pt own finger - Place the objects at the back of the palate (tongue) without touching the uvilia b/c it will make them vomit |
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What does Vasovagal response mean?
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What does Vasovagal response mean?
- drops the heart rate |
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Why do you want to make sure the pt has a gag reflex?
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Why do you want to make sure the pt has a gag reflex?
- so the pt doesn’t aspirate food or drink |
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Post broncoscopy the pt is coughing up sputum with blood, what is the next intervention?
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Post broncoscopy the pt is coughing up sputum with blood, what is the next intervention?
1) Get pt Vitals (respiratory) 2) CALL Dr |
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How long should you suction a pt?
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How long should you suction a pt?
- suctioning kids- less than 10 sec. adults less than 15 sec |
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Pneumothorax, what is it?
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Pneumothorax, what is it?
- pneumothorax, is the collection of air in the space around the lungs (known as pleural space) |
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what is Thoracentesis?
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what is Thoracentesis?
- Thoracentesis is a procedure where you poke a hole in the pleural space to remove fluid from the space between the lungs and the chest wall called the pleural space. |
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What diagnostic testing has the highest risk for post procedure complications?
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What diagnostic testing has the highest risk for post procedure complications?
- Percutaneous biopsy in the lungs |
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What position is the pt in for Thoracentesis?
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What position is the pt in for Thoracentesis?
- Upright & Place them over the bed leaning over a pillow (sitting up) Do not lie them on the side |
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why does an active cough help maintain a patent airway?
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why does an active cough help maintain a patent airway?
b/c it expands the lungs |
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Q1. what is postural drainage?
Q2. why do we perform postural drainage? |
Q1. what is postural drainage?
- Positioning body to allow for drainage Q2. why do we perform postural drainage? - to expel fluids (sputum) |
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how does cuping work to loosen secretions?
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how does cuping work to loosen secretions?
- vibrations on the back and chest loosens it up |
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Is cupping better than coughing to remove secretions?
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Is cupping better than coughing to remove secretions?
- no, cough is better. cough deep breath then cupping |
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what is insentive speromitry is what?
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what is insentive speromitry is what?
- device used to expand lungs 8-10 x per hour |
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what is purpose of pursed lipped breathing?
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what is purpose of pursed lipped breathing?
- For a longer exhalation - to get the air that is stuck -out of there. |
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why important to wait 2 hours after meal to do postural drainage?
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why important to wait 2 hours after meal to do postural drainage?
- so they don't vomit |
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what do you encourage a pt to do every 2 hours?
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what do you encourage a pt to do every 2 hours?
- TCDB turn cough deep breath |
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when taking care pt w chest tube, what is nurse responsibility?
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when taking care pt w chest tube, what is nurse responsibility?
- make sure the fluid is paten. - check often and - document the I & O - assessing and documenting |
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what is tidleing a chest tube?
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what is tidleing a chest tube?
- Breathing in and out means you will be titleing - rise and fall with breath rise and fall with breathing |
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what chamber will have fluid rising and falling?
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what chamber will have fluid rising and falling?
- Water chamber |
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Where is the chest tube drainage placed?
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Where is the chest tube drainage placed?
- Bellow the insertion site & - bellow the heart |
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what does crepitius mean?
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what does crepitius mean?
- crackling & grading feeling and sounding. - feels like grading (scratching sounding) - it is from air leaking into the tissues |
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why place end of chest tube in sterile water?
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why place end of chest tube in sterile water?
- don't want foreign things to get sucked into the lungs - to keep posative pressure |
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how care for water seal & suction control chamber?
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how care for water seal & suction control chamber?
- add fluid as needed sterile saline as needed |
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palpating chest tube excretion site, what called?
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palpating chest tube excretion site, what called?
- creptisis. air leaking into the tissue (bulges) |
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Q1. Do you encourage cough and deep breath w chest tube?
Q2. Why? |
Q1. Do you encourage cough and deep breath w chest tube?
- yes Q2. Why? - to expand lungs and to remove the chest tube |
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How do u know how much drainage in close chest tube system?
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How do u know how much drainage in close chest tube system?
- subtract from the last date written on the chest tube system |
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Constant bubbling in the water chamber is a sign of what?
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s/s of leakage
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Tactile Febritis or Vibration
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checking for consolidation
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