NUR1 oxygenation

the steps for performing upper airway suctioning (nasopharyngeal)

1. Position the patient in a semi-Fowler's position with the neck hyperextended. 2. Adjust the suction regulator according to agency policy. 3. Don procedure gloves. 4. Using your dominant hand, attach the suction catheter to the connection tubing. 5. Approximate the depth that the suction catheter should be inserted. 6. Lubricate and insert the suction catheter. 7. Gently advance the catheter the premeasured distance into the pharynx. 8. Engage the suction and apply it while you withdraw the catheter, using a continuous rotating motion.

The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patient's care? 1) Supine 2) Head of bed elevated 80° 3) Head of bed elevated 30° 4) Lying on left side

2. head of bed elevated 80

A 45-year-old woman arrives at the emergency department with complaints of shortness of breath, anxiety, dizziness, and numbness and tingling around her mouth. Her respirations are deep, at a rate of 28 breaths/min. Her lungs are clear with good aeration throughout. Oxygen saturation is 100%. An arterial blood gas shows a PO2 of 110 and PCO2 of 29 mm Hg. Based on this assessment, an appropriate nursing diagnosis would be: 1) Ineffective Airway Clearance 2) Decreased Cardiac Output 3) Impaired Gas Exchange 4) Hypocarbia

3) impaired gas exchange

While caring for a young adult being mechanically ventilated, the ventilator alarms sound. On entering the patient's room, the nurse notes that he is agitated and his skin is ashen and diaphoretic. His pulse oximetry shows an oxygen saturation of 78%. The nurse is unable to identify any obvious mechanical problems with the ventilator. The first step the nurse should take is to: 1) assess his breath sounds. 2) call the respiratory therapist to troubleshoot the problem. 3) manually ventilate him with an Ambu bag. 4) contact the physician.

3) manually ventilate him with an Ambu bag.

Which of the following goals is appropriate for a client without underlying cardiopulmonary disease who is being monitored with continuous pulse oximetry? 1) Patient will refrain from movement while monitored in order to ensure accurate readings. 2) Oxygen saturation will remain at 80% to 90% during hospitalization. 3) Patient will report pain as less than 3 on a scale of 1 to 10 during monitoring. 4) Oxygen saturation will remain at 95% to 100% while monitored.

4) Oxygen saturation will remain at 95% to 100% while monitored.

You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? 1) Nonrebreather mask 2) Nasal cannula 3) Partial rebreather mask 4) Venturi mask

4) Venturi mask Rationale: The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise level of FIO2 to be delivered. This is very useful for patients with chronic lung disease. Rebreather masks are used when high concentrations of oxygen are required. A nasal cannula administers oxygen in liters per minute and does not allow administration of a precise level of FIO2

why is a chest tube inserted

A chest tube is inserted to remove air or fluid from the pleural space so that the lungs can fully expand.

The nurse is performing a morning assessment. The patient is curled on her side with the bed flat, and the nurse notes breath sounds are absent at the lung bases. Which of the following would be an appropriate nursing action? A. Assist the patient to sitting positionand reassess the lungs.. B. Start oxygen at 4 L per nasal cannula C. Call the physician and notify him of the findings immediately. D. Call for a STAT respiratory treatment.

A. Assist the patient to sitting positionand reassess the lungs..

In what structure of the pulmonary system does inhaled air come in contact with the blood of the pulmonary circulation? 1) Apex of the lungs 2) Alveolar-capillary membrane 3) Cilia in the bronchi 4) Right and left main-stem bronchi

Alveolar-capillary membrane

The structure(s) of the respiratory system most associated with the function of respiration is/are the: A. trachea. B. alveoli. C. bronchi. D. nose.

B. Alveoli

Which of the following provides the most reliable data about the effectiveness of airway suctioning? 1) The amount, color, consistency and odor of secretions 2) The patient's tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry noted before and after suctioning 4) The number of suctioning passes required to clear secretions

Breath sounds, vital signs, and pulse oximetry noted before and after suctioning

The nurse is caring for Mrs. Plank, who had abdominal surgery yesterday. Today, the nurse has Mrs. Plank splint her incision to enable a strong cough that will move respiratory secretions. This intervention is meeting the outcomes for which nursing diagnosis? A. Impaired Gas Exchange B. Ineffective Breathing Pattern C. Ineffective Airway Clearance D. Impaired Spontaneous Ventilation

C. Ineffective Airway Clearance Rationale: There is no evidence given that oxygen is not diffusing across the alveolar membrane, nor that there is an alteration in the patient's ventilation. The purpose of coughing is to clear the airway of secretions.

Which of the following explains why high-flow oxygen therapy is contraindicated in patients with chronic obstructive pulmonary disease (COPD)? High levels of oxygen: A. take away the carbon dioxide drive to breathe. B. burn out the oxygen receptors in the lungs. C. prevent hypoxemia. D. prevent hypercarbia.

C. prevent hypoxemia. Rationale: Patients with COPD are no longer sensitive to high levels of carbon dioxide; therefore, their primary drive to breathe becomes hypoxia. High-flow oxygen therapy "fixes" hypoxemia, thereby taking away the secondary drive to breathe in the client with COPD.

Assessing Oxygenation Status: CV

Cardiovascular effort; look for and respond to: • Pain • Fatigue • Dyspnea Tissue and Organ Perfusion

major risks to oxygenation related to developmental factors in children?

Children. Incomplete development of the lungs and immune system places infants and young children at increased risk for problems with oxygenation. Increasing motor skills that are not accompanied by knowledge of risks also place young children at risk for aspiration and drowning.

You are caring for a client who is receiving morphine for pain relief. After the latest dose, you notice that the client's respiratory rate has declined to 10 breaths per minute. Which of the following nursing diagnoses would be most appropriate for this client?

Ineffective Breathing Pattern (hypoventilation) related to overdose of morphine

What is the purpose of mechanical ventilation?

Mechanical ventilation assists a patient to breathe. It can merely assist breathing or breathe entirely for the patient

promoting peripheral circulation

Promoting circulation - Improving venous return - Preventing clot formation

Lung elasticity

ability to recoil; tendency of the elastin fibers to return to their original position after being stretched (like a rubber band) Loss of elasticity allows the lungs to inflate easily but inhibits deflation, leaving stale air trapped in the alveoli

The level of which gas (oxygen or carbon dioxide) is the primary stimulant for breathing?

carbon dioxide

what is pharyngeal suctioning?

clears secretions that have collected in the back of the throat.

tracheal suctioning

clears secretions that have entered the lower airways.

Hypoventilation

decreased rate or shallow breathing that moves only a small amount of air in/out of lungs

chemoreceptors

detect changes in blood pH, O2, CO2; regulate ventilation; send messages back to the central respiratory center in the brain in response to lack of oxygen

A patient who complains of being claustrophobic and requires low-flow humidified oxygen

face tent

Hyperventilation

fast and deep breathing to move a large amount of air through the lungs; causes too much CO2 to be removed Mild hyperventilation can occur in response to hypoxemia

Which oxygen delivery method is appropriate for the following patients? A patient ordered to receive 2 L/min of oxygen

nasal cannula

A patient who wants to avoid intubation but requires an FIO2 of 100%

nonrebreather mask

Mrs. Jones becomes short of breath when the head of her bed is lower than 15° of elevation. Mrs. Jones is experiencing _________________________

orthopnea

You are caring for a patient who has a chest tube and a water-seal drainage system. The end of the chest tube is inserted into which of the following? pleural space or trachea

pleural space

Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumonia 4) Pulmonary embolus

pneumonia

Baroreceptors

sensitive to pressure changes; regulate heart rate and vascular tone; stimulate the sympathetic nervous system to increase heart rate and induce vasoconstriction

A patient has a respiratory rate of 30 breaths/min that is rhythmic and moderate in depth. What term would you use to describe this breathing pattern

tachypnea

A patient with air in the pleural space whose chest tube becomes kinked or clamped is at risk for a _________________________ _________________________.

tension pneumothorax

A patient with chronic obstructive pulmonary disease (COPD) with an order for oxygen at an FIO2 of 24%

venturi mask

You are teaching a client how to use a peak flow meter at home. Which of the following instructions is accurate?

The client should take a deep breath and forcefully exhale

*Factors that affect the adequacy of ventilation:

-respiratory rate and depth -lung compliance -lung elasticity -airway resistance

What assessment findings might the nurse expect to see in a patient experiencing hypoxia? Select all that apply. 1) Altered level of consciousness 2) Peripheral pitting edema 3) Cyanosis of skin and mucous membranes 4) Weak or absent peripheral pulses 5) Jaundiced sclera

1) Altered level of consciousness 3) Cyanosis of skin and mucous membranes Rationale: Hypoxia leads to decreased oxygenation of organs and tissues. To determine adequacy of tissue oxygenation, you must assess both circulation and tissue/organ function. An altered level of consciousness may result from hypoxic central nervous system tissue. Poor peripheral circulation is characterized by weak or absent pulses; pale, ashen, or cyanotic skin and mucous membranes; and cool skin temperature. Peripheral edema does not result from hypoxia.

The nurse is caring for an older adult woman who was admitted 3 days ago following a cerebrovascular accident. She has had trouble swallowing and has been placed on aspiration precautions. Care of this patient will include the following. Select all that apply. 1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink. 2) Break or crush her pills (if appropriate) before administration. 3) Provide only thin, clear liquids. 4) Keep suction setup available at all times.

1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink. 2) Break or crush her pills (if appropriate) before administration. 4) Keep suction setup available at all times.

Respiratory function involves, in addition to the respiratory system, which three body systems? Select all that apply. 1) Neurological 2) Endocrine 3) Cardiovascular 4) Musculoskeletal

1) Neurological 3) Cardiovascular 4) Musculoskeletal

What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged

1) Prevents air from leaking around the site

The nurse is caring for an adolescent with a history of asthma. The patient is currently being treated for acute bronchitis. A thorough nursing assessment of the patient's pulmonary status will include. Select all that apply. 1) Skin color 2) Temperature 3) Auscultation of breath sounds 4) Testing of cough reflex 5) Chest x-ray

1) Skin color 2) Temperature 3) Auscultation of breath sounds

You are caring for a client who is on mechanical ventilation. Which of the following interventions should you perform? SELECT ALL THAT APPLY. 1) Check arterial blood gases and assess respiratory status about 30 minutes after setup. 2) Maintain the patient in a recumbent position (head of the bed all the way down). 3) Drain the condensate from the ventilator tubing into the humidifier. 4) Give sedatives or anti-anxiety drugs as needed. 5) Reposition the patient every 1 to 2 hours. 6) Moisten the lips with a cool, damp cloth and water-based lubricant.

1,4,5,6

Identify at least three nursing interventions to promote optimal respiratory function in a hospitalized patient with chronic lung disease

Annual influenza vaccination Annual pneumonia vaccination Frequent position changes to keep all areas of lungs well ventilated Incentive spirometry 10 to 20 times per hour Positioning upright for meals

You are caring for a client with chronic obstructive pulmonary disease (COPD) who is short of breath. Which of the following positions would be best for this client?

If the patient is short of breath, provide an overbed table so that the client may lean forward on it. Patients with impaired respiratory function adopt a tripod position to allow maximum expansion.

Pulse oximetry is the most accurate way to assess blood oxygen levels. T/F

False Rationale: Arterial blood gases directly measure blood oxygen levels. Although reliable, a pulse oximetry reading is an indirectly calculated estimate.

In which structures of the lung does gas exchange take place?

Gas exchange takes place in the type I alveolar cells.

How does hypoventilation affect risk for hypoxemia and hypoxia?

Hypoventilation occurs when a small amount of air is moved into and out of the lungs, which is caused by a decreased rate and/or depth of breathing. Hypoventilation increases the risk for problems with oxygenation (hypoxemia) and perfusion (hypoxia).

normal levels of PO2 SaO2 PCO2

Normal levels are as follows: PO2, 80 to 100 mm Hg SaO2, 95% to 100% PCO2, 35 to 45 mm Hg

what are the major risks to oxygenation related to developmental factors in older adults?

Older adults. The effects of aging also influence oxygenation. Costal cartilage begins to calcify, making the chest wall gradually less mobile and more rigid, reducing chest wall movement during breathing. The lungs have less recoil ability, and the alveoli lose elasticity. These changes result in reduced lung expansion and less alveolar inflation, especially in the bases of the lungs. The cough reflex is less effective, and the number of cilia in the airways decline with aging, making it more difficult to expel mucus or foreign material. Exhalation becomes less efficient, causing progressive air trapping, which decreases the ability to increase ventilation when oxygenation demands increase (as with exercise). The immune response declines with aging, especially cell-mediated immunity, T-cell activity, and the inflammatory response. All of these changes put elders at risk for respiratory infections.

What does a pulse oximetry reading tell you?

Pulse oximetry is a noninvasive estimate of arterial blood oxygen saturation (SaO2). SaO2 reflects the percentage of hemoglobin molecules carrying oxygen. The normal value is 95% to 100%.

A client coughs up some rust-colored sputum. Which of the following conditions should you most suspect based on this finding?

Rust-colored sputum is associated with pneumococcal pneumonia, tuberculosis, and possibly the presence of blood.

What environmental and lifestyle factors that influence ventilation can be avoided or minimized?

The following environmental and lifestyle factors that influence ventilation can be avoided: Poor nutrition Obesity Sedentary lifestyle Smoking Substance abuse To a lesser extent, exposure to poor air quality, high altitude, temperature extremes, and stress can be minimized.

You are caring for a client who has had an opening surgically made directly into the trachea to bypass an airway obstruction and permit an open airway. Which of the following airway types is this?

Tracheostomy tubes are pliable tubes inserted directly into an opening in the trachea.

Asthma would be a greater threat to oxygenation than hay fever. T/F

True Rationale: Asthma causes edema and spasms of the lower airway, causing breathing to become ineffective in terms of gas exchange. In contrast, hay fever is associated with a runny nose and some edema in the upper airways.

A person with a PCO2 of 28 mm Hg may experience facial numbness, tingling, or both. T/F

True Rationale: Decreased carbon dioxide (an acid) or increased bicarbonate (a base) level makes the body too alkaline, a condition called alkalosis. Alkalosis is usually accompanied with low blood potassium level, causing, numbness, tingling, and muscle cramps (from disturbed function of the skeletal muscles), and muscle spasms (from disturbed function of smooth muscles).

Enhancing Pulmonary Circulation with Meds

• Bronchodilators • Respiratory anti-inflammatory • Nasal decongestants • Antihistamines • Cough and Cold preps ▫ Do not: give children adult cold preps ▫ Do not: give children under 4 years an OTC ▫ Do read the label. Efficacy is now questioned for 2-11 year olds ▫ Do carefully follow the directions ▫ Do measure carefully

Oxygenation Nursing Diagnosis

• Ineffective Airway Clearance • Ineffective Breathing Pattern • Impaired Gas Exchange • Impaired Spontaneous Ventilation • Dysfunctional Ventilatory Weaning Response • Risk for Aspiration

suctioning airways

• Upper airway suctioning - Oropharyngeal suction probably more comfortable • Lowerairwaysuctioning - Nasopharyngeal suctioning done by advancing cath into the pharynx, and advance with an inspiration to avoid coughing or vomiting.

Enhancing CV Circulation with Meds

• Vasodilators • Beta adrenergic blockers • Diuretics • Positiveinotropes