Respiratory Level 2 EAQ

Chest Tube Drainage

A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly: Increased negative intrapleural pressure on inspiration causes the fluid to rise; a decrease in negative intrapleural pressure on expiration causes the fluid to fall. Remaining constant in the chest drainage chamber indicates that an obstruction is present in the drainage tubing or that the suction is too low; a slight increase in fluid should be evident in this chamber postoperatively. Bubbling gently in the chest drainage chamber indicates an air leak. If the water is bubbling vigorously in the suction control chamber, the suction is too high; bubbling should be gentle.

PICC line pt states that it got tangled and broken off

the nurse should do a quick respiratory assessment, inspect the catheter to determine how much may have embolized, clamp the remaining device if possible, and then notify the health care provider.

ABGs (Metabollic Acidosis)

A client is diagnosed with metabolic acidosis. The nurse recalls that the changes that occur during metabolic acidosis include: Excess amounts of hydrogen ions are being excreted The body fights acidosis by hydrogen exchange, which results in excretion of excess hydrogen in the urine, a compensatory mechanism to increase the serum pH level. With acidosis the pH level of the blood is decreased. Plasma bicarbonates will be decreased with metabolic acidosis. With acidosis the respiratory center in the medulla is stimulated to increase respirations and blow off carbon dioxide, which is carried to the lung as carbonic acid. Lowering carbonic acid increases the serum pH level.

Stab Wound

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's first action? Apply a wound dressing. The wound must be covered to prevent atmospheric air from entering the pleural cavity until closed chest drainage can be instituted. While some sources specify an airtight dressing, others suggest that a side or corner of the dressing be left unsecured to prevent tension pneumothorax. Administering oxygen and obtaining baseline vital signs will be done eventually; they are not the priority. Suctioning fluid from the wound is traumatic to lung tissue and is contraindicated.

Proper position for Ventilation Post Surgery (General)

An important nursing intervention that ensures adequate ventilatory exchange after surgery is: Positioning the client laterally with the neck extended When positioning the client laterally with the neck extended the tongue does not obstruct the airway so that drainage of secretions, and oxygen and carbon dioxide exchange, can occur.

Proper Utilizaiton of Nebulizer (breathing technique)

AVOID: Inhaling with the lips tightly sealed around the mouthpiece of the nebulizer results in nasal breathing, which negates the effects of aerosol medication. The mouthpiece should be gently held in the mouth just past the lips. The nebulizer tip should be past the lips to deliver the medication. Holding the inspired breath for at least three seconds promotes contact of the medication with the bronchial mucosa. Exhaling slowly through the mouth with lips pursed slightly prolongs and improves delivery of the medication to the respiratory mucosa.

Interventions for a leak in thoracic duct post radical neck surgery.

Bed rest is recommended because lymphatic flow increases with activity. A chest tube drains the leaking chyle from the thoracic area. TPN boosts immune defenses, provides nutrition, and decreases thoracic duct flow

thoracentesis for a pleural effusion.

Can cause vascular collapse if fluid is removed to quickly.

Differentiate The Disease

Chest pain, fever, productive cough, and rust-colored sputum are cardinal signs of pneumonia. Chest pain results from excessive coughing; fever, increased sputum, and rust-colored sputum result from the infectious process. Chest pain, high fever, productive cough, and rust-colored sputum are not present with pulmonary edema. Dependent edema, respiratory distress, and crackles on auscultation of the lungs are associated with pulmonary edema. Chest pain, high fever, productive cough, and rust-colored sputum are not the signs of TB. Pulmonary TB is associated with a low-grade fever, nonproductive or mucopurulent blood-tinged sputum, night sweats, and fatigue. Although chest pain is expected with a pulmonary embolus, rust-colored sputum and a high fever are not.

Emphysema Alveolar Sacs?

Clients with emphysema experience changes in the alveolar sacs when they lose elasticity. Trapped air causes the sacs to become distended and can cause them to rupture. This in turn impairs gas exchange. Teach them rhythmic breathing, NOT O2 Even if it is in the PT's history, never administer more than 2L O2, they may go back into resp. Failure.

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, the nurse should: 1 Notify a respiratory therapist 2 Drain the fluid from the tubing 3 Decrease the amount of humidity 4 Record the amount of fluid removed from the tubing

Emptying the fluid from the tubing is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid and others have to be temporarily disconnected while emptying the fluid.

symptomatic of heart failure.

Engorged neck veins

TB

Erosion of lung tissue causes blood in the sputum, a classic sign of tuberculosis. Increased body temperature causes profuse diaphoresis, a classic sign of tuberculosis.

pulmonary edema

Frothy sputum

Position for Chest Tube (Hemopneumothorax)

On the side where injury or placement is. Lying on the affected right side increases drainage from the pleural space and allows the unaffected lung to expand to the fullest extent.

Fat Embolism S/S

Oxygen reduces surface tension of the fat globules and reduces hypoxia. Oxygen should be administered before the health care provider is called. "fractured femur is being prepared for surgery" the client exhibits cyanosis, tachycardia, dyspnea, and restlessness, peticheae

Position Post Right Side Pneumonectomy

Supine or right side-lying position permit ventilation of the remaining lung and prevent fluid from draining into the sutured bronchial stump. Lying on the nonoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump. Although the high-Fowler position promotes ventilation, it is tiring.

Stridor is heard over what part of the respiratory airway.

The sound is a stridor, which is a high pitched crowing sound that is often heard after traumatic intubations, and is usually heard at the larynx. Heard on inspiration, the sound often is audible without a stethoscope. A stridor is not heard at the nasal cavity, trachea, or pharynx.

pulmonary tuberculosis S/S for Dx

Tuberculosis is an infectious disease in which recurrent fevers are present, usually in the late afternoon. Profuse diaphoresis at night (night sweats) is a classical sign of tuberculosis. Blood-tinged sputum (hemoptysis) results from pathophysiological trauma to mucous membranes. The cough is productive, because the inflammatory process causes purulent mucus.

Metered Dose Inhaler

When using an MDI, the medication should be shaken for 30 seconds to ensure that the medication is mixed. Exhaling completely maximizes emptying the lungs. The inhaler should be held upright in the mouth past the teeth with the lips closed around the mouthpiece (closed mouth method) or held upright 1 to 2 cm in front of the open mouth (open mouth method). Inhalation is begun at the same time that the device is compressed to ensure that maximum medication reaches the lungs.

Suction As Needed

hemiglossectomy and right radical neck dissection. After a hemiglossectomy a client will have difficulty swallowing and expectorating oral secretions because of the trauma of surgery. The client may not be reactive or have energy to cough or expectorate; the priority is to prevent secretions from entering the respiratory tract.

Venturi Mask

i.e severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when 'caring for this client'? 1 Assess frequently for nasal drying. (*nasal canula*) 2 Keep the mask tight against the face. (*snug not too tight*) Correct3 Monitor oxygen saturation levels when eating. (*change pt to a nasal canula and monitor them*) 4 Set the oxygen flow at the highest setting possible. (*not necessary*)