Chapter 39 Nursing

adventitous

abnormal breath sound heard over lungs

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

an infant with a resp rate of 16 bpm -infant normal range is 20-40 bpm -child normal range is 20-32 bpm -child 6-12 is 18-26 bpm

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

arterial blood gas -include levels of oxygen, CO2, bicarbomate, and pH -they determune the adequacy of alveolar gas exchange and the ability of the ungs and kidneys to maintain the acid ase balance of body fluids

tracheosotomy

artifial opening made in trachea through which a tracheostomy tube is inserted

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take?

assess oxygen tubing connection

wheezes

continuous high pitched squeak or muscial sound made as air moves through narrowed or partially obstructed airwway

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

corticosterdoids -open airways and ease breathing and releive inflammattion

hypoxemia

deficient oxygenation of blood

surfactant

detergent like phospholipid that reduces surface tension pf fluid in alveoli

dyspnea

difficult or labored breathing

nasal cannula

disposable plastic devie taht delivers oxygen via two protruding prongs for insertion into the nostrils

crackles

fine crakling sounds made as air moves throuhg the wet secretions in the lungs

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?

fluid in lungs

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high fowlers position -postural drainage makes use of gravity to drain sectetion from lungs from smally pulmonary branches into larger ones where they can be removed by coughing

bronchial sounds

high pitches harsh blowing sounds -sound on expiration is longer than inspiration -heard over larynx and trachea

nursing diagnoses

identofy problems related to alteration in cardiopulmonary function and problems for which alterations in cardiopulmonary function are the etiology

hypoxia

inadequate amounf os oxygen available to cells

atelectasis

incomplete expansion or collapse of part of the lungs

spirometer

instrument used to measure lung capacities and volumes, one type is used to encourage deep breathing

oxygen analyzer

measures the percentage of delivered oxygen to determine whether the client is recieving the prescribed amount

brondodilator

medication that relaxes contractions of smooth muscles of the bronchioles

canography

method to monitor ventilation and indirectly, blood flow through lungs

brionchiovesicular sounds

moderate blowing sounds -inspiration = expiration - heard over mainstem bronchus

Factors that can interfere with accurate pulse oximetry

nail polish, thickness of nails, acrylic nails, peripheral vascular disease

vesicular sounds

normal sound of respiration heart on auscultation over peripheral lung areas

nursing assessment

nursing history, physcial assessment, and review of medical info including pertinent diagnostic tests

face tents

open and loose around the face, should be used on patients with facial burns or trauma -simple mask or nasal canua\la would irritae the facial skin

Which statement accurately describes a general consideration when performing CPR on a client?

perform cpr the same as you would on both obese and non obese clients -cpr should be initaited even if nurse is unsure if client has a pulse, if available, use a one way valve mask over childs nose and mouth

factors effecting oxygenation

persons level of health, developmental stage, use of medications, lifestyle, environment, and psychological health

endotracheal tube

polyvinyl-chloride airway that is inserted through nose or mought into the trachea, uses laryngoscope as a guide

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

poor tissue perfusion -chronically poor perfsion may result in hair loss in affected aea, discolored skin, thickend nails, shiny dry skin indicative of inadequare tissue nutrition

Hypoxia can result from

problems with ventilation, respiration, or perfusion

perfusion

process by which oxygenated blood passes through the body tissues

nursing interventions

promote optimal functioning of the cardiopulmonary systems, promote comfort, promote and control coughing, meet resp needs with meds, provide oxygen, manage chest tubes, use artifical airways, suction airway, clear obstructed airway, administer cardiopulmonary resuscitation

tachypnea

rapid rate of breathing

sputum

respiratory secretion expelled by coughing or clearing the throat

dysrythmia/arrhythmia

result of problems with electrical impulse generation or abnormal conduction of electrical impulses through the heart

bradypnea

slow rate of breathing

cardiac output

stroke volume x heart rate

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

suction the trach tube using sterile technique -area around new tracheostomy may need to be assessed and cleaned every 1-2 hrs -

angina

temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

trauma to tracheal mucosa -occluding the y port is what creates the suction

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

vesicular -described as low pitched, soft sounds over the lungs peripheral fields -

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?

when holding airway on side of face it should reach from tragus of ear to tip of nostril