210- Exam 3
Nasal Cannula
-Administer only 1-6 liters -1-2 L/min: FIO2 is 23-30% -3-5 L/min: FIO2 is 30-40% -6 L/min: FIO2 is 42% -Potential for skin breakdown -Check pt frequently to ensure both prongs are in pt nares
Venturi Mask
4-10 L/min: FIO2 is 24-40% Potential for skin breakdown Delivers the most precise amount of O2 Dial on mask to change for FIO2 rate Large tube with an O2 inlet
cancer pain
70-90% relief to patients
Chylothorax
Accumulation of lymphatic fluid
If chest tube comes out
Address the patient Valsalva maneuver Cover the site Dip Chest tube into sterile water or saline Call provider Place pt on oxygen Prepare set-up for a insertion of a new chest tube
The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems?
Air leak
Water seal
Drains fluid away from patient into a large chamber. One way valve allows air to exit the chest and prevents it from going back in. Should see intermittent bubbling in the water seal Continuously bubbling means an air leak Clamp the tube and call the doctor if this occurs As the pressures change you will see fluctuation in the water levels. Indication that the patient is getting better. The lower the water content, the lower the imposed suction The higher the water content, the higher the imposed suction
S/Sx why you might get a chest tube
Flu like symptoms SOB crackles or wheezing may only hear lung sounds on one side muffled heart tones cyanosis, possible cardiac arrest, short, shallow, increased respirations
FIO2
Fraction of inspired oxygen
Management of chest tube
Gently strip or milk the tube (controversial because it can damage delicate lung tissue) Tubing should never be dangled or have a dependent loop in the tubing as it obstructs the drainage. Tubing should be coiled at the bedside. Only two times to clamp the tubing: do not clamp for more than 1 minute If you have to change the drainage system Physician order
Venturi Mask- flow
High Flow
A client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use?
Intermittent suction while withdrawing the catheter
Non-rebreather Mask- flow
Low Flow
Metal Tracheostomy Tube
Not used frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes -Patients cannot get a MRI. -One needs to notify the security personnel at the airport prior to metal detection screening.
When suctioning a client's tracheostomy tube, what should the nurse do?
Oxygenate the client before suctioning.
Education for trach
Patient needs to know risks How long they will have it Cares and assessments that will be done Why they have it What to expect: how it feels being inserted Pain Level How to move Encourage to ambulate and get out of bed
PAP/ CPAP:
Positive airway pressure (PAP) Mild pressure to keep airways open Helps maintain CO2 and O2 Sleep apnea & apnea CPAP- Continuous positive airway pressure
Lock-out
Prohibits any tampering with the device and limits possibility of possible overmedication. *Always have a lock out on a PCA
Documentation of trach
Respiratory Communication Neurologic
severe pain
The 10%-30% of patients with severe pain who do not obtain satisfactory pain relief with this guideline may require alternative routes of drug administration such as a nerve block or other invasive procedure
The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?
To clear secretions from the tubing
Cuffed Tube with Reusable Inner Cannula
Used to obtain a closed circuit for ventilation. -Cuff should be inflated when using with ventilators. -Cuff should be inflated just enough to allow minimal air leak. -Cuff should be deflated if patient uses a speaking valve. -Cuff pressure should be checked twice a day. -Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Loading Dose
administered to raise blood levels to a therapeutic level and control the pain
Epidural Analgesia
used to provide pain relief during the postoperative phase and for chronic pain situations. Also can be used for children with terminal cancer and for children undergoing hip, spinal, or lower extremity surgery. Used during labor as well.
When increasing levels of O2
you will need to add humidity
Most common post-op Surgeries using Epidural Analgesia
-Thoracic -Abdominal -Orthopedic -Vascular
Disadvantages of PCA
-Can be confusing for older adults/ children (not recommended for this population) -Pain medication could get off schedule resulting in the higher pain level -Easy for the user to program the pump wrong and it is the most common human error involving this therapy
Simple Mask
-Can switch to nasal cannula while eating (need provider order to do this) -6-8 L/min: FIO2 is 40-60% (5L is minimum flow) -Potential for skin breakdown -Monitor pt frequently to check placement of mask -Support pt if claustrophobia is a concern
PCA Population (should NOT be used for these pts)
-Cognitive impairment -Physical impairment -Infants and young children -Patient with conditions for which other sedation proposes a significant risk i.e. sleep apnea -Patients taking contraindicated medications
Nurses responsibility related to PCA administration
-Ensuring it is functioning properly -Know the signs and symptoms of opioid toxicity and withdrawal -Set up PCA system -Carefully monitor pt. response to therapy -2nd nurse check prior to start of PCA
World Health Organization (WHO) Three- Step Analgesic Ladder
-Guides treatment for cancer or chronic pain. -Used to manage chronic pain effectively, emphasis on individualizing treatment and provide alternative aggressive pain relief
Nurse responsibility w/ epidurals
-Monitor patients vital signs, including pain -Monitor for adverse side effects: Hypotension Pruritus Urinary Retention N/V Infection or Contamination
Sources for oxygen therapy
-Nasal Cannula -Non- Rebreather -Face Tent -Partial rebreather -02 tent (pediatric) -Venturi -Simple face mask
Indications for Oxygen need
-Oxygen saturation below 90% -Low respirations -Short of breath
Advantages of PCA
-Patient gets to control the administration of pain med -Promotes patient participation in care -Eliminates delayed administration of analgesic medication -Maintains therapeutic drug level -Enables patient to effectively use respiratory system with less pain
PCA Population (should be used for these pts)
-Physically able to use equipment -Cognitively able to use equipment -Understand relationship with pain and pushing PCA pump to administer analgesic agent -Children age 4 and older are eligible
Epidural time
-Rapid onset of action- 5 minutes -Short duration of action- approximately 2 hours
Narcotics monitor for
-Respiratory depression (most important) -Blood pressure change -Tachycardia
Non-rebreather Mask
12 L/min: FIO2 is 80-100% Potential for skin breakdown Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. Check the valves and rubber flaps are functioning properly (open & expiration and closed during inhalation) Monitor SaO2 with pulse ox. Delivers highest level of concentration to a spontaneously breathing patient Has 2 way valves As pt inspires the bag is filled with oxygen and the exhaled air goes out through vents If the mask malfunctions carbon dioxide will increase and potentially cause suffocation Oxygen is not mixed with room air
Partial Rebreather Mask
8-11 L/min: FIO2 is 50-75% Potential for skin breakdown Set flow rate so that the mask remains ⅔ full during inspiration Keep the reservoir bag free of twists and kinks.
Subcutaneous emphysema
Air below the tissue, feels like crepitis, which feels like rice krispies Caused by air that got into the cavity and must reabsorb it, usually moves up to neck or face Does not cause pain
Simple Mask- flow
Low Flow
Size of Trach to be used
Based on the patient's condition, neck size and reason for having the trach.
Which of the following assessment factors would indicate a need for oropharyngeal suctioning?
Breathing rate of 36 breaths/min and noisy, gurgling respirations
Demand Dose
Button that activates the PCA device to deliver a small preset bolus dose to analgesic *Always have a demand dose on a PCA
Nasal Cannula- flow
Low Flow (Most Common Long Term Device)
Forms of naloxone
Can get naloxone at a drugstore (walgreens, CVS, Hyvee, etc.), pharmacy First responders carry naloxone - police, emt, paramedic, ambulances are equipped Available in: Injection or nasal spray
Which would the nurse most likely expect as treatment for a pneumothorax?
Chest tube insertion
Chest tube purpose
Chest tube is used where pressure is positive where it should be negative. Chest tube is used to relieve the pressure and drain the fluid and re-expand the lung
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the drainage in the collection chamber
Frequently Prescribed analgesics
Morphine Fentanyl Hydromorphone
Hemothorax
Collection of blood in the space between the chest wall and the lung (pleural space)
Empyema
Collection of purulent material
Hemopneumothorax
Combination of two conditions (pneumothorax and hemothorax)
Dry system
Considered safer Provide other advantages: Quieter If tips over, won't spill Mechanical one way valve: does not provide the same assessment data Not as easy to see the changes in pressure of the chest. Does not have a measurement of water, uses suction pressure mechanically instead of the column of water.
Pleural effusion
Excessive fluid in the pleural cavity
Partial Rebreather Mask- flow
Low Flow
What medication is given to reverse the effects of morphine, fentanyl, and hydromorphone?
Naloxone - patient begins withdrawing immediately (produces side effects - combative, hypotension, hypertension, tachycardia, etc.)
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?
Nasal cannula
Elderly Considerations
Shortness of breath Confusion Nasal flaring Changes in mental status Ability to ventilate decreases Ability to cough decreases
Three-step ladder
Step 1: Pain persisting or increasing, use a non-opioid. Step 2: Pain persisting or increasing, use opioid for mild or moderate pain. Step 3: Freedom from pain, use opioid for moderate to severe pain.
Cuffed Tube with Reusable Inner Cannula
Used for patients with tracheal problems. Used for patients who are ready for decannulation -Save the decannulation plug if the patient is close to decannulation. -Patient may be able to eat and may be able to speak without a speaking valve. -Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Which of the following demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion?
Use sterile gloves during the procedure.
Fenestrated Cuffed Tracheostomy Tube
Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak -There is a high risk for granuloma formation at the site of the fenestration (hole). -There is a higher risk for aspirating secretions. -It may be difficult to ventilate the patient adequately.
Fenestrated Cuffless Tracheostomy Tube
Used for patients who have difficulty using a speaking valve -There is a high risk for granuloma formation at the site of the fenestration (hole).
Cuffless Tube with Disposable Inner Cannula
Used for patients with tracheal problems. Used for patients who are ready for decannulation. -Save the decannulation plug if the patient is close to getting decannulated. -Patient may be able to eat and may be able to talk without a speaking valve. -Inner cannula is disposable.
Cuffed Tube with Disposable Inner Cannula
Used to obtain a closed circuit for ventilation. -Cuff should be inflated when using ventilators. -Cuff should be inflated just enough to allow minimal air leak. -Cuff should be deflated if patient uses a speak valve. -Cuff pressure should be checked twice a day. -Inner cannula is disposable.
Oxygen Face Tent:
Used with pediatric or claustrophobic patients
Before chest tube
Want it to maintain air tight seal. Use chest x-ray to confirm reexpansion of the lung.
Bronchopleural Fistula
abnormal passageway the develops between large airways in the lungs (the bronchi) and the space between the membranes that line the lungs (pleural cavity)
Pneumothorax
air collection in the pleural space (lung collapse) most common reason that we insert a chest tube. -Can spontaneously occur -Can happen from forceful coughing
Patient- Controlled Analgesia (PCA)
allows patient to self administer doses of pain relieving medication within physician prescribed time and dose limits
Basal Dose
continuous infusion and patient has no control over the delivery of a continuous infusion
An order is required for administration of O2 unless
in an emergent situation want to wean patient off of oxygen as soon as you're able
Oxygen therapy is used to
increase the effectiveness & ability to breathe
A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?
inner cannula
Epidural analgesia acts directly
on the opiate receptors in the spinal cord
Effective treatment of pain in patients with
phantom limb pain and end-stage renal disease
Tension pneumothorax
shift in organs to unaffected side
PCA by proxy
someone else activates the pump- is controversial
