BLUEPRINT EXAM 2 - Chapters 14, 21, 36, 37

6. Know the answers to the learning objectives on page 861.

1) give at least 3 signs of an airway obstruction, and explain why an airway obstruction is life-threatening -it interferes with ventilation and subsequently deprives the tissues of oxygen -signs of airway obstruction include grasping the throat with the hands, making aggressive efforts to cough and breathe, and producing high-pitched sound while inhaling -a complete airway obstruction require immediate action to dislodge the obstruction and restore breathing or death will occur _________________________________________________________ 2)describe appropriate actions if a client has a partial airway obstruction in cases of partial airway obstruction, appropriate actions include encouraging and supporting the victims efforts to clear the obstruction independently and preparing client to call for emergency assistance if the victims condition worsens. _____________________________________________________________ 3) explain the purpose of the heimlich maneuver and describe the circumstances for using a subdiaphragmatic and chest thrusts. the technique used to relieve a complete airway obstruction by performing a series os subdiaphragmatic thrusts or chest thrusts on conscious victims ________________________________________________________ 4)identify the recommended action for relieving an airway obstruction in an infant and in an unconscious person subdiaphragmatic thrusts are appropriate for almost all adults and children beyond infancy. chest thrusts are appropriate for infants less than 1 year old, obese adults, and women in advanced pregnancy. to dislodge an object from an infants airway, the rescuer delivers a series of back blows followed by a series of chest thrusts . when a person with an airway obstruction becomes unconscious , rescuers perform basic CPR rather than the heimlich maneuver b/c chest compressions create enough pressure in unconscious victims to eject a foreign body from the airway. _________________________________________________________ 5)list the five steps in the chain of survival 5 step intervention process 1. immediate recognition and access of emergency services 2.early CPR with a focus on compressions 3.rapid defibrillation 4.effective advanced life support 5.integrated post-cardiac arrest care ____________________________________________________________ 6)explain the cardiopulmonary resuscitation and the associated steps in CAB early CPR must proceed with C circulation A airway B breathing if the rescuer is a trained health care provider or hands--only chest compression if untrained in CPR. __________________________________________________________ 7)describe the purpose of chest compressions the CAB or resuscitation involves administering chest compressions hard and fast, opening the airway to assess for the presence of spontaneous breathing, and performing rescue breathing. __________________________________________________________ 8)name two techniques for opening the airway and list three ways a trained rescuer administers rescue breathing rescuers can safely open a victims airway under most circumstances by using the head tilt/chin lift technique or the jaw-thrust maneuver. _________________________________________________________ 9)discuss the appropriate use of an AED methods of administering rescue breathing are mouth-to-mouth, mouth-to-nose, or using a one way valve mask if available. ___________________________________________________________ 10)name at least 3 criteria used in the decision to discontinue resuscitation efforts. an AED is a portable, battery operated device that analyzes heart rhythm and can deliver a series of electrical shocks to resuscitate a person who is lifeless or experiencing a lethal dysrhythmia. ideally, an AED is used as rapidly as possible- preferably within 2 minutes oncer CPR has begun, the decision to stop resuscitation efforts are often based on the time that elapsed before resuscitation began, the length of time the resuscitation continued w/out any change in the victims condition, and the age & Dx of the victim.

5. 5 step chain of survival

5 step intervention process 1. immediate recognition and access of emergency services 2.early CPR with a focus on compressions 3.rapid defibrillation 4.effective advanced life support 5.integrated post-cardiac arrest care

12. Be sure you know how to administer oxygen safely.

ASSESSMENT perform physical assessment techniques that focus on oxygenation monitor the SpO2 level with the pulse oximeter check the medical order for the type of oxygen delivery device, liter flow or prescribed percentage, and whether the oxygen is to be administered continuously or as needed. note whether a wall outlet is available or if another type of oxygen source must be obtained determine how much the client understands about oxygen therapy PLANNING obtain equipment, which usually includes a flowmeter, delivery device, and in some cases, a humidifier. contact the respiratory therapy department for equipment, if that is agency policy "crack" the portable oxygen tank if that is the type oxygen source is being used explain the procedure to the client eliminate safety hazards that may support fire or explosion. IMPLEMENTATION wash hands assist to fowlers position or alternate position attach the flowmeter to the oxygen source fill a humidifier bottle with distilled water to the appropriate level if administering 4L/min or more. connect the humidifier bottle to the flowmeter insert the appropriate color-coded valve or dial the prescribed percentage if a venturi mask is being used attach the distal end of the tubing from the oxygen delivery device to the flowmeter or humidifier bottle turn on the oxygen by adjusting the flowmeter to the prescribed volume note that bubbles may appear in the humidifier bottle, if one is used, or that air is felt at the proximal end of the delivery device make sure that if a reservoir bag is used, it is partially filled and remains that way throughout oxygen therapy attach the delivery device to the client drain any tubing that collects condensation remove the oxygen delivery device and provide skin, oral, and nasal hygiene at least q4-8hrs reassess the clients oxygenation status q4h notify the MD if the client manifests signs of hypoxemia or hypoxia despite oxygen therapy EVALUATION RR is 12-24 breaths p/min breathing is effortless HR is less than 100 BPM client is alert and oriented skin and mucous membranes are normal in color SpO2 is greater than or = 90% FIO2 and delivery device correspond to medical order DOCUMENT assessment data % of liter flow of oxygen admin. type of delivery device length of time in use clients response to oxy. therapy

23. What is a chest x-ray for?

Chest x-ray uses a very small dose of ionizing radiation to produce pictures of the inside of the chest. It is used to evaluate the lungs, heart and chest wall and may be used to help diagnose shortness of breath, persistent cough, fever, chest pain or injury. It also may be used to help diagnose and monitor treatment for a variety of lung conditions such as pneumonia, emphysema and cancer. Because chest x-ray is fast and easy, it is particularly useful in emergency diagnosis and treatment. This exam requires little to no special preparation. Tell your doctor and the technologist if there is a possibility you are pregnant. Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown. used for: pneumonia heart failure and other heart problems emphysema lung cancer positioning of medical devices fluid or air collection around the lungs other medical conditions the chest x-ray is performed to evaluate the lungs, heart and chest wall. A chest x-ray is typically the first imaging test used to help diagnose symptoms such as: breathing difficulties a bad or persistent cough chest pain or injury fever

9. What are the various breathing techniques?

DEEP BREATHING MAXIMIZES ventilation taking in large volume of air fills alveoli to a greater capacity, thus improving gas exchange. deep breathing is therapeutic for clients who are: - inactive - in pain Encourage client to: take in as much air as possible hold the breath deeply exhale slowly in some cases it is helpful to use a spirometer, it deep breathing in itself is performed efficiently it is sufficient in its own. __________________________________________________________ INCENTIVE SPIROMETRY technique used for deep breathing using a calibrated device, encourages client to reach a goal-directed volume of inspired air. all are marked to 100 mL increments. the measurement helps the nurse evaluate the effectiveness if the clients breathing efforts. _______________________________________________________________ PURSED-LIP BREATHING form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing. or a breathing technique designed to make your breaths more effective by making them slower and more intentional. You do this after inhaling by puckering your lips and exhaling through them slowly and deliberately, often to a count. Pursed lip breathing gives you more control over your breathing, which is particularly important for people with lung conditions such as COPD (emphysema) COPD is characterized by chronic hypoxemia or hypercarbia (excessive levels of carbon dioxide in the blood) used to improve gas exchange, which if done correctly helps a client eliminate more than the usual amount of carbon dioxide from the lungs. PERFORMED AS FOLLOWS: -inhale slowly through the nose while counting to three -purse the lips as though to whistle -contract the abdominal muscles -exhale through pursed lips for a count of six or more expiration should be 2-3 xs longer than inspiration. not all can achieve initially, but with practice length of expiration can increase. ______________________________________________________ DIAPRAGMATIC BRATHING breathing that promotes the use of the diaphragm rather than the upper chest muscles. used to increase the volume of air exchanged during inspiration and expiration. with practice, reduces respiratory effort and relieves rapid, ineffective breathing. FAMILY TEACHING -lie down with knees slightly bent -place one hand on the abdomen and the other on the chest -inhale slowly and deeply through the nose while letting the abdomen rise more than the chest. -purse the lips -contract the abdominal muscles and begin to exhale -press inward and upward with the hand on the abdomen while continuing to exhale -repeat the exercise for 1 minute; rest for at least 2 minutes. -practice the breathing exercises at least 2x day for a period of 5-10 minutes -progress to doing diaphragmatic breathing while upright and active ___________________________________________________________ NASAL STRIP used to reduce airflow resistance by widening the breathing passageways of the nose. increasing the nasal diameter promotes easier breathing. common users: -people w/ ineffective airways -athletes another use is to reduce/eliminate snoring.

22. What is a cardiac catheterization for?

Done within 90 minutes of ER admission with chest pain Determines function of heart, valves, coronary circulation Abnormal blood flow through the heart and the coronary vessels can be detected Post-test Care Assess site for bleeding, neuro comparison both legs V/S q 15 min x 4, q 30 min x 2, q hour x 2-4, telemetry monitoring Keep pressure with sandbag if ordered Check femoral pulse and circulation to leg Keep leg straight Avoid flexing leg Bed rest 4-8 hours, HOB <30◦ Increase fluids to flush dye

9. Which lab values indicate infection?

During infection, the number and type of white blood cells increase

4. What instructions are given prior to EEG, Pelvic exam, MRI, Liver biopsy, Chest X-ray / radiography, pelvic exam, pelvic ultrasound, pap smear

EEG most pts are instructed to have NO stimulants, no sedatives, and no anticonvulsant drugs, such as phenytoin (Dilantin), for 48 hours before the test unless necessary to control seizures. physician will determine which meds need to be be held before the EEG try to stay awake the night before the test-gives better results instruct to eat 4 hours before the exam BUT avoid caffeinated products _____________________________________________________________ PELVIC EXAM No douching or vaginal hygiene within previous 24 hours No exam if intercourse or period with last 48 hours Empty bladder Gown on open in front Table with stirrups ______________________________________________________ MRI Remove any transdermal medication patches, such as nicotine patches, from the patient because the metal backing on the patch may cause a burn. Patient needs to know deep-breathing and relaxation techniques Instruct to lie very still Patient needs to know the duration of the test and that it requires being in a noisy environment Knocking, silence, knocking... Patient may become claustrophobic during test- open MRI metal devices MUST be removed before an MRI can now be done on pts with joint implants, but it requires a radiologist to use an adjustment called METAL ARTIFACT REDUCTION SEQUENCE (MARS) to avoid radiographic distortion of an image. ________________________________________________________ LIVER Bx Pre-Procedure avoid aspirin containing products (ASA, NSAIDS) and blood thinners for 1 WEEK prior to and after exam U/S used to outline the liver, site numbered and either small incision or needle Bx will be done ________________________________________________________ CHEST X-RAY/RADIOGRAPHY assess vitals before to provide baseline -remove any metal items (metals produces a dense image that may be confused with a tissue abnormality) -request lead apron or collar -if contrast medium is needed, ask about ALLERGIES (seafood or iodine) or previous adverse reactions such as a vasovagal response (reflex that occurs when circulating blood is diverted to the legs rather than the head, resulting in dizziness and fainting) reaction can range from mild N/V to shock and death -know location of emergency equipment incase of unexpected reaction to contrast medium. -avoid interferences with subsequent visual imaging, schedule procedures requiring iodine before those that use barium. IODINE THEN BARIUM. -encourage the client to drink a large amount of fluid after an examination involving iodine to promote its excretion, to promote urinary excretion. -check on bowel movement and stool characteristics for at least 2 DAYS after the administration of an oral barium contrast medium. barium retention can lead to constipation and bowel obstruction. report absence of bowel elimination beyond 2 days. laxative is then required _____________________________________________________ PELVIC U/S Instruct to 5-6 glasses of water 1-2 hours before exam and do not void Schedule before any barium exams Acoustic gel may be warmed or cold ______________________________________________________ Abdominal Ultrasound: Patient must drink full liter water to make sure bladder is full _________________________________________________________ PAP SMEAR Empty bladder Gown on open in front Table with stirrups

What are the nursing actions required when reviewing pre procedure checklist for ERCP?

ERCP- Endoscopic Retrograde cholangiopancreatography An endoscopic retrograde cholangiopancreatogram (ERCP) test checks the tubes (ducts) that drain the liver , gallbladder , and pancreas . A flexible, lighted scope (endoscope) and X-ray pictures are used used to identify a cause of biliary obstruction such as stricture, cyst, stones, or tumor. endoscope is inserted through the mouth and into the duodenum after an Intravenous sedation a catheter is inserted into the pancreatic duct via he endoscope and a contrast medium is injected x-ray are taken pills with due are given night before the exam- asses for seafood or iodine allergy ____________________________________________________________ withhold food +fluids or advise the client to do so for 6 hours before any procedures in which the endoscope is inserted into the upper airway or upper GI tract if conscious sedation is used monitor the clients vitals, breathing, oxygen sat. (pulse ox) and cardiac rhythm. have oxygen and resuscitation equip ready if topical anesthesia is used to facilitate the passage of an endoscope into the airway or upper GI tract, with hold food and fluids for at least 2 hours AFTER the procedure and until swallow, cough, and gag reflexes return relieve the clients sore throat with ice chips fluids or gargles when safe to do so confirm that a bowel prep using laxatives and enemas has been completed before endoscopic procedures of the lower intestine report difficulty in arousing a client, sharp pain, fever, unusual bleeding, N/S, difficulty with urination after any endoscopic exam.

35. What pre and post instructions do you ask/tell someone getting a pap smear?

Empty bladder Gown on open in front Table with stirrups

21. Communicating with tracheostomy patients

FENESTRATED TRACHEOSTOMY TUBE: one with holes in the outer cannula, which allows air to pass through the vocal cords allowing speech. SPEAKING VALVE: device that directs exhaled air through the upper airway.

17. What is the difference between fluoroscopy and computed tomography?

Fluroscopy form of radiography that display in real time image used to observe the movement of contrast media, as it is swallowed, injected, or instilled __________________________________________ Computed tomography (CT) form of X-Ray that shows planes of tissue use contrast media CT contrast medium makes it possible to identify differences in tissue density when obtaining X-Ray images from various angles and levels in the body

20. Oral airway placement steps and management in an unconscious client

For unconscious patients, keep air passages clear of obstruction and secretions Change the patient's position every 2 hours. Administer oxygen as needed. Discuss the use of an incentive spirometer and its effect on respiration. Endotracheal tubes maintain an airway in those who are unconscious or unable to ventilate on their own For unconscious patients, use an oral or nasal airway to keep the tongue from obstructing the airway, and suction as necessary

2. How do you keep mucous moist and thin?

HYDRATION, keeps mucus thin. thin consistency promotes expectoration (cough or spit out (phlegm) from the throat or lungs)

be sure you know the hand placement and electrode placement for infants, children, and adults

Hand Use: <=1 INFANT Two thumbs with the hand encircling the chest for TWO rescuers or TWO fingers on the breastbone if alone Hand Use: 1-8 y.o CHILD heel of one hand with second hand on top, or heel of one hand only. Hand use: 8 y.o + ADULT two hands; heel of one hand with the other hand on top Adult pad placement Right upper (↓ Clavicle) and on left lower chest (5th ICS) Must be placed at least 1 inch from implanted defibrillator or pacemaker If AED analyzes and says "error" check pad placement-will not stick if patient is diaphoretic Pediatric size must be used for children Placed vertically in center of chest and upper back

2. Hand position, rate and depth of chest compression and respiration during 1 and 2 responder CPR on adult, child and Infant

INFANT up to 1 Y.O COMPRESSION Location: in the midline, one finger width below the nipples. Hand Use: Two thumbs with the hand encircling the chest for TWO rescuers or TWO fingers on the breastbone if alone Rate: 100/min Depth: at least 1/3 the depth of the chest; about 1 1/2 in. RESCUE BREATHS: Compressions only when rescuer is untrained or trained, but not proficient: 1 breath q6seconds (10/min) Ratio of compressions to ventilation until advanced airway is in place 30:2 (one rescuer) 15:2 (two rescuers) Duration 1 second with visible chest rise _______________________________________________________ CHILD (1-8 y.o) COMPRESSIONS Location: center of the chest between the nipples Hand Use: heel of one hand with second hand on top, or heel of one hand only. Rate: 100-120/min Depth: at least 1/3 the depth of chest; about 2 inches RESCUE BREATHS: Compressions only when rescuer is untrained or trained, but not proficient: 1 breath q6seconds (10/min) Ratio of compressions to ventilation until advanced airway is in place: 30:2 (one/two rescuers) Duration 1 second w/ visible rise in chest ____________________________________________________ 8+ y.o COMPRESSIONS Location: center of the chest between the nipples Hand use: two hands; heel of one hand with the other hand on top Rate: 100-120/min Depth: 2-2.4 inches RESCUE BREATHS: Compressions only when rescuer is untrained or trained, but not proficient: 1 breath q6seconds (10/min) Ratio of compressions to ventilation until advanced airway is in place: 30:2 (one/two rescuers) Duration 1 second w/ visible rise in chest

16. Know about incentive spirometers

Incentive Spirometry: technique used for deep breathing using a calibrated device, encourages client to reach a goal-directed volume of inspired air. all are marked to 100 mL increments. the measurement helps the nurse evaluate the effectiveness if the clients breathing efforts. place mouthpiece in mouth, inhale slowly, raise piston to best level. Remove mouthpiece and hold breath 3 seconds then exhale. repeat 10-12 time per hour. report dizziness, lightheadedness, or increased wound or incisional pain. stop and call if you have chest pain or feel faint

10. What are the disadvantages to the various Oxygen delivery devices?

MASKS Disadvantages: interfere with eating make verbal communication difficult to understand some clients become anxious when nose/mouth are covered, "feeling suffocated" skin care becomes a priority due to mask pressure and moisture. some carbon dioxide always remains within the mask and is reinhaled. ___________________________________________________ FACE TENT disadvantage: the amount of oxygen clients receive may be inconsistent with what is prescribed b/c of environmental losses. ______________________________________________________ T-Piece DISADVANTAGES: although the gauze around the trach, usually remains dry, the moisture that collects within the tubing tends to condense and may enter the airway during position changes if it is NOT periodically drained. weight of the T-Piece, or its manipulation, may pull on the tube, causing the client to cough or experience discomfort to avoid displacement of tubing the piece needs to be supported with a rolled towel. ___________________________________________________ OXYGEN CONCENTRATOR Disadvantages: increase the clients electric bill generates heat from its motor and it produces an unpleasant odor or taste if the filter is not cleaned WEEKLY. best that clients have a secondary source of oxygen available in case of power failure. portable oxygen concentrator extracts nitrogen and concentrates oxygen to enable clients who require oxygen therapy to travel about or maintain their lifestyle without the need for multiple tanks of oxygen.

39. What is a priority in post-op recovery of EGD?

OBTAINED ONLINE PREP Certain medications (such as aspirin and the anti-inflammatory drugs called NSAIDs) should be discontinued at least seven days before an EGD to reduce the risk of bleeding. Patients will be asked not to eat or drink anything for at least six to 12 hours before the procedure to ensure that the upper intestinal tract will be empty. Before the procedure, patients may be given a sedative and/or pain medication, usually by intravenous injection. AFTERCARE After the procedure, the patient will be observed in the endoscopy suite or in a separate recovery area for an hour, or until the sedative or pain medication has worn off. Someone should be available to take the patient home and stay with them for a while. Eating and drinking should be avoided until the local anesthetic has worn off in the throat and the gag reflex has returned, which may take two to four hours. To test if the gag reflex has returned, a spoon can be placed on the back of the tongue for a few seconds with light pressure to see if the patient gags. Hoarseness and a mild sore throat are normal after the procedure; the patient can drink cool fluids or gargle to relieve the soreness. The patient may experience some bloating, belching, and flatulence after an EGD because air is introduced into the digestive tract during the procedure. To prevent any injury to the esophagus from taking medications by mouth, patients should drink at least 4 or more ounces of liquid with any pill, and remain sitting upright for 30 minutes after taking pills that are likely to cause injury. The doctor should be notified if the patient develops a fever; difficult or painful swallowing (dysphagia); breathing difficulties; or pain in the throat, chest, or abdomen.

11. Be sure you know the signs and symptoms of oxygen toxicity

OX 21-2 S/S of oxygen toxicity nonproductive cough substernal chest pain nasal stiffness N/V fatigue Headache Sore Throat Hypoventilation

29. How long does it take for bacteria to grow from a throat culture?

Obtain specimen from palatine tonsil abbreviated test (rapid preliminary) - approx 10 min done in office if not clearly negative a f/u specimen is obtained which generally take 24-72 hrs and is sufficient for microbial growth to take place.

32. What pre and post instructions do you ask/tell someone getting and MRI?

Patient needs to know the duration of the test and that it requires being in a noisy environment Knocking, silence, knocking... Patient may become claustrophobic during test- open MRI Patient needs to know deep-breathing and relaxation techniques Instruct to lie very still Remove any transdermal medication patches, such as nicotine patches, from the patient because the metal backing on the patch may cause a burn.

7. What happens to O2 delivery for people with COPD? What is the maximum amount O2 given in COPD.?

Person with respiratory disease (COPD) is stimulated to breathe by "hypoxic drive" or low levels of oxygen The stimulus to breathe in a person with COPD is a low oxygen level rather than a carbon dioxide level, as in normal persons. If high flow oxygen were given, the oxygen level would increase, and the respiratory drive would cease. _________________________________________________________ COPD patients given only 2 to 3 L/min to prevent causing respiratory arrest

3. AED use, pad placement

Portable, battery-operated device that analyzes heart rhythms and delivers an electrical shock to restore a functional heartbeat Will shock for ventricular fibrillation Asystole (flat line) will follow if no shock delivered Best outcome if defibrillation occurs within 3 minutes ______________________________________________________ ADULT PLACEMENT Right upper clavicle and on left lower chest (5th ICS) must be places at least 1 inch from implanted defibrillator or pacemaker if AED analyzes and says "error" check pad placement- will not stick if patient is diaphoretic (sweating heavily) _________________________________________________ if no pedi pads are available, adult pads should be placed on the front center of the chest and in the middle of the childs back between the shoulder blades. PP-center of chest and upper back.

3. How does the LVN encourage better breathing? What can cause confusion in elderly patients?

Positioning Fowler's position and Orthopneic positioning Breathing techniques Deep breathing - Page 442 Diaphragmatic breathing- page 444 Pursed-lip breathing-page 443 Incentive spirometry Nasal strips Fowlers position: good for clients w/ hypoxia, this eases breathing by allowing by allowing the abdominal organs to descend away from the diaphragm. As a result the lungs have the potential to fill with greater volume of air. Tripod Postion: client is seated in a position with the arms supported on pillows or the arm rests of a chair. increases a clients breathing capacity by using arms to lift the chest upward Orthopneic Position: client leans forward over the bedside table or a chair back. allows room for maximum vertical and lateral chest expansion and provides comfort while resting or sleeping. Breathing Techniques Deep Breathing: MAXIMIZES ventilation taking in large volume of air fills alveoli to a greater capacity, thus improving gas exchange. deep breathing is therapeutic for clients who are: - inactive - in pain Encourage client to: take in as much air as possible hold the breath deeply exhale slowly in some cases it is helpful to use a spirometer, it deep breathing in itself is performed efficiently it is sufficient in its own. __________________________________________________________ Incentive Spirometry: technique used for deep breathing using a calibrated device, encourages client to reach a goal-directed volume of inspired air. all are marked to 100 mL increments. the measurement helps the nurse evaluate the effectiveness if the clients breathing efforts. _______________________________________________________________ Pursed-Lip Breathing: form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing. or a breathing technique designed to make your breaths more effective by making them slower and more intentional. You do this after inhaling by puckering your lips and exhaling through them slowly and deliberately, often to a count. Pursed lip breathing gives you more control over your breathing, which is particularly important for people with lung conditions such as COPD (emphysema) COPD is characterized by chronic hypoxemia or hypercarbia (excessive levels of carbon dioxide in the blood) used to improve gas exchange, which if done correctly helps a client eliminate more than the usual amount of carbon dioxide from the lungs. PERFORMED AS FOLLOWS: -inhale slowly through the nose while counting to three -purse the lips as though to whistle -contract the abdominal muscles -exhale through pursed lips for a count of six or more expiration should be 2-3 xs longer than inspiration. not all can achieve initially, but with practice length of expiration can increase. ______________________________________________________ Breathing Techniques cont. Diaphragmatic Breathing: breathing that promotes the use of the diaphragm rather than the upper chest muscles. used to increase the volume of air exchanged during inspiration and expiration. with practice, reduces respiratory effort and relieves rapid, ineffective breathing. FAMILY TEACHING -lie down with knees slightly bent -place one hand on the abdomen and the other on the chest -inhale slowly and deeply through the nose while letting the abdomen rise more than the chest. -purse the lips -contract the abdominal muscles and begin to exhale -press inward and upward with the hand on the abdomen while continuing to exhale -repeat the exercise for 1 minute; rest for at least 2 minutes. -practice the breathing exercises at least 2x day for a period of 5-10 minutes -progress to doing diaphragmatic breathing while upright and active ___________________________________________________________ Nasal Strip used to reduce airflow resistance by widening the breathing passageways of the nose. increasing the nasal diameter promotes easier breathing. common users: -people w/ ineffective airways -athletes another use is to reduce/eliminate snoring. __________________________________________________ inadequate oxygenation delirium or dementia.

15. What positions may be used for testing?

REFER TO # 10

41. Make sure you understand about water sealed chest tube maintenance. Too much bubbling, crackling of tissue , air leak

REFER TO SKILL 21-3, question #23 ________________________________ technique for evacuating air or blood from the pleural cavity, which helps to restore negative intrapleural pressure and reinflate the lung. clients who require this have 1 or 2 chest tubes connected to the drainage system. all of these products consist of a 3-chamber system 1) one chamber collects blood or acts as an exit route for pleural air 2) a second compartment holds water that prevents atmospheric air from reentering the pleural space ("waterseal") 3) third chamber, if used, facilitates the use of suction, which may speed the evacuation of blood or air. chest tubes must NEVER be seperated from the drainage system unless it is clamped. even then, the tube is clamped for only a brief time.

10. Common positions used for tests and procedures

SUPINE POSITION client lies supine, arms and legs extended. used for exams of: head neck chest abdomen extremities PRONE POSITION lies prone (on abd.) with the head turned to one side arms may be above the head or at the side of the body used for exams of: -posterior head -bacl -buttocks -extremities DORSAL RECUMBENT POSITION reclining position with knees bent, w/ hips rotated outward, and feet flat. used for exams of: -external genitalia inspection -vaginal exam -rectal exam -urinary catheter insertion LITHOTOMY POSITION reclining position with the feet in metal supports "stirrups" used for exams of: -internal pelvic examinations -OB delivery -cystoscopic (bladder) examination -rectal exam SIMS POSITION lies on LEFT side with the chest leaning forward, the right knee bent toward the head, the right arm forward, and the left arm extended behind the body. alt. gynecologic position for client who cannot abduct the hips. used for exams of: -rectal exam -vaginal exam -rectal temp assessment -suppository insertion -enema administration KNEE CHEST POSITION "genupectoral" position the client rest on the knees and chest. turns head, which is supported in a small pillow, to one side. pillows are placed under chest for additional comfort. arms are above the head or bent at the elbows so that they rest alongside the clients head. used for exams of: -rectal and lower intestinal exams -prostate gland exam MODIFIED STANDING POSITION client stands with upper half of body leaning forward used for exams of: -prostate

8. Know the correct technique for suctioning a client

SKILL 36-1 ASSESSMENT assess the clients lung sounds, respiratory effort, and oxygen saturation level determine client understanding inspect the nose to determine which nostril is more patent PLANNING consider using face shield and wearing a cover gown in addition to gloves when suctioning a client obtain suction kit. ALL kits contain a basin and one or two sterile gloves. some also have a suction cath. if the kit doe not include a cath, select one that will not occlude the nostril; usually a 12-18 French catheter is appropriate for adults. obtain a flask of sterile NS and a suction machine if a wall outlet is unavailable attach the suction canister to the wall outlet or plug a portable suction machine into an electrical outlet connect the suction tubing to the canister turn on the suction machine, occlude the suction tubing, and adjust the pressure gauge to the desired amount. open the container of NS IMPLEMENTATION privacy curtain elevate head, unless contraindicated wash hands pre-oxygenate client for 1-2 minutes until the SpO2 is maintained @ 95-100% open the suction kit without contaminating the contents put on sterile gloves. if the kit only provides one, put one clean glove on the non-dominant hand and then put the sterile glove on the dominant hand pour sterile Ns into the basin with your non-dominant hand. consider the non-dominant hand contaminated pick up the suction cath with your sterile (dominant) hand and connect it to the suction tubing. place the cath tip in the saline and occlude the vent insert the cath without applying suction along the floor of the nose or side of the mouth advance the cath 5-6 in in thenose or 3-4 in in the mouth for tracheal suctioning, wait until the client takes a breath and then advance the tubing 8-10 in encourage the client to cough if coughing does not occur spontaneously occlude the air vent and rotate the catheter as it is withdrawn complete the process in NO MORE than 15 seconds from insertion to removal of cath, occluding the No longer than 10 seconds rinse secretions from the cath by inserting its tip in the basin of salin applying suctioning provide 2-3 min of rest while the client continues to breathe oxygen suction again if necessary remove the gloves to enclose cath in an inverted glove discard suction kit, cath, and gloves in a lined waste receptacle EVALUATION the airway is cleared of secretions the SpO2 remains @ 95% or higher the client demonstrated breathing that requires less effort DOCUMENT preassessment data type of suctioning performed appearance of secretions clients response

18. What do you use radionuclide imagine for?

THYROID AND BONE SCAN Thyroid scans and Bone scans are scheduled prior to any study using barium canning device that detects radiation creates an image of the size, shape, and concentration of the organ containing the radionuclide. Nuclear medicine is a branch of medical imaging that uses small amounts of radioactive material to diagnose and determine the severity of or treat a variety of diseases, including many types of cancers, heart disease, gastrointestinal, endocrine, neurological disorders and other abnormalities within the body.

8. Normal lab values

The study of blood and its components Complete blood count (CBC) Information about state of health or presence of illness Hematocrit (Female 37-47 or Male 42-52) The separation of blood and the amount of blood cells in relation to the amount of plasma Hemoglobin (Female12-16 Male 14-18) Capacity of blood to transport oxygen from lungs to tissues Platelets (150,000- 400,000) Essential to blood clotting What can happen when platelet count falls below 20,000/mm3 of blood? (spontaneous bleeding) MUST KNOW Red Blood Cell RBC Male 4.7-6.1 Female 4.2-5.4 White Blood Cell WBC 4,500-10,000 mm3 Hemoglobin Hgb Male 14-18 Female 12-16 Hematocrit Hct Male 42-52 Female 37-47 Platelets 150,000-400,000 Potassium K 3.5-5.5 mEq/L Sodium Na 135-145 mEq/L Chloride Cl 95-105 mEq/L Carbon Dioxide CO2 23-30 mEq/L Calcium Ca 8.5-10.5 mg/dl Glucose 70-115 mg/dl BUN 7-18 mg/dl Creatinine 0.6-1.2 mg/dl

37.What pre and post instructions do you ask/tell someone getting a cholangiopancreatography?

Used to identify a cause of biliary obstruction such as stricture, cyst, stones, or tumor Endoscope is inserted through the mouth and into the duodenum after intravenous sedation A catheter is inserted into the pancreatic duct via the endoscope and a contrast medium is injected X-rays are taken Pills with dye are given night before exam- assess for seafood or iodine allergy

2. When to do cardiac catheterization?

done within 90 minutes of ER admission with chest pain.

40. Know about Ova and Parasite testing.

from specimens of feces, blood, urine, wound drainage, or samples of body tissue or fluids. screening questions you should ask: have you eaten any sushi or rare steak recently? have you recently traveled outside of the US? how long have you had diarrhea? have you taken any antidiarrheal, laxatives, or antacids in the last week?

6. Be sure you know how to insert an oral airway

gather: various sizes or oral airways (most adult 80mm airway), gloves, tongue blade, and suction equipment. place the airway on the outside of the clients cheek so that the front portion is parallel with with the front teeth. note: whether or not the back of the airway reaches the angle of the jaw. wash your hands/alcohol rub explain the procedure to the client perform oral suctioning if necessary position clients supine with the neck hyperextended unless contraindicated open the clients mouth using a gloved finger and thumb or a tongue blade hold the airway so that the curved tip points upward toward the roof of the mouth or the side of the cheek . insert it about halfway. rotate the airway over the top of the tongue and continue inserting it until the front flange is flush with the lips assess breathing remove the airway q4hrs, provide oral hygiene, and clean and reinsert the airway as the clients LOC improves, many clients extubate themselves independently.

1. Know the factors that can jeopardize airway patency

increased volume of mucus thick mucus fatigue or weakness a decreased LOC ineffective cough impaired airway

33. What pre and post instructions do you ask/tell someone getting radionuclide imaging?

inquire about a womans menstrual and OB Hx, notify nuclear medicine dept. if client is pregnant or breast feeding. ask about allergy Hx bc iodine commonly is used assist the client with gown, robe, and slippers. make sure there are no internal metal devices or external metal objects b/c these interfere with diagnostic findings obtain an accurate wight bc does of radionuclide is calculated by weight. inform the client he/she will be radioactive for a brief period (usually <24hrs) but that the body fluids, such as urine, stool, and emesis can be safely flushed away. instruct premenopausal women to abstain form intercourse or use an effective contraceptive method for a short period during which radiation continues to be present

17. Know about pulse oximeters

non-invasive, transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. composed of: photodetector sensor red AND infrared light emitter microprocessor can be attached to: -finger -toe -earlobe -the bridge of the nose using a spring tension, or adhesive. the sensor detects the amount of light absorbed by hemoglobin. the microprocessor then displays it on a monitor. when oxygen saturation is obtained by pulse oximetry it is abbreviated SpO2. based on oxygen-hemoglobin dissociation curve , it is IMPOSSIBLE to infer the PaO2 from the pulse oximetry measurement. Pulse Oximetry Normal SpO2 = 95 - 100% a sustained level of < than 90% is cause for concern. Oxygen therapy is needed if level remain low. FACTORS THAT AFFECT ACCURACY OF READINGS : -troubleshooting equipment -performing current physical assessment -obtaining an ABG -movement of the sensor tremor, restlessness, loss of adhesion -poor circulation @ site peripheral vascular disease edema tourniquet effect from taped sensor vasoconstrictive drug effects -barrier to light nail polish thick toenails acrylic nails -Extraneous light direct sunlight treatment lights -hemoglobin saturation with other substances carbon monoxide poisoning

5. What is normal PaO 2 ? What is normal SpO2?

nrml PaO2: 80-100 mmHg abnormal ranges: 60-80 mmHg mild hypoxemia 40-60 mmHg moderate hypoxemia <40 mmHg severe hypoxemia >100 mmHg hyperoxygenation nrml SpO2: 95-100%

7. Know what a Yankauer -tip suction device is for

removing secretions through the mouth , involved a device called a YANKAUER-TIP CATH or TONSIL-TIP CATH The Yankauer suction tip (pronounced yang´kow-er) is an oral suctioning tool used in medical procedures. It is typically a firm plastic suction tip with a large opening surrounded by a bulbous head and is designed to allow effective suction without damaging surrounding tissue.

7. Client assessment after EGD

report difficulty in arousing a client, sharp pain, fever, unusual bleeding, N/S, difficulty with urination after any endoscopic exam. relieve the clients sore throat with ice chips fluids or gargles when safe to do so if topical anesthesia is used to facilitate the passage of an endoscope into the airway or upper GI tract, with hold food and fluids for at least 2 hours AFTER the procedure and until swallow, cough, and gag reflexes return

6. D/C instructions for upper GI series

report if you have not passed a stool (white or clay colored in 2 days take M.O.M(milk of magnesia) after the exam

34. What pre and post instructions do you ask/tell someone getting a pelvic ultrasonography

schedule abdominal and pelvic US before and examination that uses a barium for the best visualization instruct clients to drink 5-6 glasses of fluid approx 1 -2 hrs before . to ensure full bladder, urination should be avoided until AFTER the exam. explain that acoustic gel, which may be cold is applied over the are where the transducer is placed.

23. Be sure you study the skill 21-3, Maintaining a water-seal chest tube drainage system

review the clients medical record to determine the condition that necessitated inserting a chest tube. determine if the physician has inserted one or two chest tubes note the date of chest tube(s) insertion check the medical orders to determine whether the drainage is being collected by gravity or with the addition of suction PLANNING: arrange to perform physical assessment of the client and equipment as soon as possible after receiving the report locate a roll of tape and a container of sterile distilled water IMPLEMENTATION: introduce yourself explain procedure wash hands check to see that a pair of hemostasis (instruments for clamping) is at the bedside turn off the suction regulator, if one is used, before assessing the client. assess the clients lung sounds inspect the dressing for signs that it has become loose or saturated with drainage palpate the skin around the chest tube insertion site to feel and listen for air crackling in the tissues. inspect all connections to determine that they are taped and secure. reinforce connections where the tape may be loose check that all tubing is unkinked and hangs freely into the drainage system. observe the fluid level in the water-seal chamber to see if it is at the 2-cm level and that the water in the suction chamber is at the 20-cm mark or the pressure prescribed by the MD add sterile distilled water to the 2-cm mark in the water-seal chamber or 20 cm mark to the suction control chamber if the fluid is below standard. note if the water is TIDALING (the rise and fall of water in the water-seal chamber that coincides with respiration) observe for continuous bubbling in the water-seal chamber if constant bubbling is observed, clamp hemostats at the chest and within a few inches away; observe if the bubbling stops; continue releasing and reapplying the hemostats toward the drainage system until the bubbling stops. apply tape around the tube above where the last clamp was applied when the bubbling stopped regulate the wall suction so that produces gentle bubbling observe the nature and amount of drainage in the collection chamber keep the drainage system below chest level position the client to avoid compressing the tube curl and secure excess tubing on the bed milk the tubing, a process of compressing and stripping the tubing to remove stationary clots, but ONLY if necessary encourage coughing and deep breathing at lead q2hours while awake instruct the client to move about in bed, ambulate while carrying the drainage system, and exercise the shoulder on the side of the drainage tube(s) NEVER clamp the chest tube for an extended period if the tube and drainage system become separated insert a separated chest tube within sterile water until it can be reattached and secure to the drainage system prevent air from entering the tube insertion site by covering it with a gloved hand or woven fabric if the tube is accidentally pulled out mark the drainage level on the collection chamber at the end of each shift EVALUATION client exhibits no evidence or respiratory distress dressing is dry and intact no subcutaneous air is detected around the site of the tube insertion equipment is functioning appropriately water is @ recommended levels DOCUMENT assessment findings care provided amt of drainage during period of care

16. What is contrast medium?

substances such as : barium sulfate iodine adds density to a body organ or cavity. it makes a hollow body area appear more distinct when imaged on X-Ray film. administered orally, rectally, injected intravenously "a substance introduced into a part of the body in order to improve the visibility of internal structure during radiography"

19. What do you use radiography for?

to produce electromagnetic energy that passes through the body structures, leaving an image of dense tissue on special film. Produce data to be used in diagnosis: X-ray: most common Produces image of the denser tissues by passing rays through the part to expose a film Chest X-Ray is ordered P, A, and Lateral views Fluoroscopy: examines movement X-rays passed through the body part and projected on a fluorescent screen (image in real time) Cineradiography Adding a video camera to the fluoroscope equipment and making a photographic record of the procedure

21. What do you use ultrasonography for?

u/s are used to visualize breast, abdominal, and pelvic organs; male reproductive organs; structures in the head and neck; the heart and valves; and structures within the eyes. air filled structures such as lungs or the intestines and extremely dense tissue such as bone and do not image well.

20. What do you use endoscopy for?

visual exam of internal structures performed using an optical scope. they have lighted mirror-lens systems attached to a tube and are quite flexible so that they can be advanced through a curved structures.

1. DR'S CAB

-circulation -airway -breathing, if the rescuer is trained provider, or hands only chest compressions if untrained in defibrillation or CPR

26. What is a glucometer for

A blood glucose meter is a small, portable machine that's used to measure how much glucose (a type of sugar) is in the blood

18. Know about sleep apnea

A potentially serious sleep disorder in which breathing repeatedly stops and starts. sleeper stops breathing or breathing slows for 10 seconds or longer five or more times per hour. ventilation decreases and blood oxygenation drops the accumulation of carbon dioxide and the fall in oxygen cause brief period of awakening throughout the night. this disturbs the normal transitions and periods of NREM and REM sleep. people with sleep apnea feel tired after having slept, or worse, their Sx may cause heart attack, stroke, or sudden death from hypoxia of the heart, brain, and other organs.

5. What is radionuclide imaging, endoscopy, ultrasonography, radiography?

A radionuclide scan is a way of imaging bones, organs and other parts of the body by using a small dose of a radioactive chemical. There are different types of radionuclide chemical. The one used depends on which organ or part of the body is to be scanned. ____________________________________________________________ ENDOSCOPY visual exam of internal structures performed using an optical scope. have lighted mirror-lens systems attached to a tube and are quite flexible so that they can be advanced through a curved structures. ____________________________________________________________ ULTRASONOGRAPHY soft tissue examination that uses sound waves in ranges beyond human hearing. transducer projects sound through the body's surface. the waves cause vibrations within body tissues, producing images as the waves are reflected back toward the machine. the reflected sound waves are converted into visual images called ultrasonogram, sonogram, echogram ____________________________________________________________ RADIOGRAPHY or roentgenography (general term for procedures that use roentgen rays, or X-Rays) produces images of body structures. they produce electromagnetic energy that passes through the body structures, leaving an image of dense tissue on special film.

22. Be sure you study the skill 21-1, Using a Pulse Oximeter

ASSESSMENT: assess potential sensor sites for quality of circulation, edema, tremor, restlessness, nail polish, or artificial nails. review medical Hx for data indicating vascular or other pathology, such as anemia or carbon monoxide inhalation. check prescribed medications for vasoconstrictive effects determine how much the client understands about pulse oximetry PLANNING: patient teaching obtain equipment IMPLEMENTATION wash hands or hand rub for antisepsis position probe so that the photodetector sensor is directly opposite of the source of light emission. attach sensor cable to machine observe the numeric display, audible sound, and waveform on the machine set alarms for saturation level and pulse rate according to manufacturers directions move an adhesive finger sensor if the finger becomes pale, swollen, or cold; remove and reapply a spring-tension sensor q2hours. EVALUATION: SpO2 measurements remain within 95-100% client exhibits no hypoxemia or hypoxia SpO2 measurement correlate with SaO2 measurements. DOCUMENT: norml SpO2 measurements at least once a shift unless otherwise ordered abnrml SpO2 measurements when they are sustained nursing measures to improve oxygenation if SpO2 levels fall below 90% and are prolonged person to whom abnormal measurements have been reported and outcome communication removal and relocation of sensor condition of skin at sensor site

13. Know about informed consent

CLARIFYING EXPLANATIONS sign consent, which legally must contain three elements: 1)capacity- client has the ability to make a rational decision; if not spouse, parent, or legal guardian must do so. 2)comprehension-client understands the Mds explanation, and risks, benefits and alternatives that are available 3)voluntariness- client is acting on their own will without coercion or the threat of intimidation. PHYSICIANS are responsible for giving clients sufficient info for the informed consent NURSES, might repeat, simplify, clarify, or expand the original explanation due to the patient being to anxious to process details, feeling insecure to ask more questions, or relaying additional concerns to the MD. it is BEST to find out how much the patient understands and use the clients questions as a guide for providing further info.

14. What is client and family teaching preparation for special examinations or tests?

Call if test prep instructions are not clearly understood or cannot be followed refrain from eating or drinking anything for at least 8 hours before a test or examination that requires a fasting state follow all dietary specifications for eating or omitting certain foods exactly as directed check with the physician about taking or readjusting the time schedule for taking prescribed medications on the day of test or exam bathe or shower as usual on the day of dress casually and in layers so that items of clothing can be removed or added to maintain comfort in the test environment ask a friend or family member to provide transportation to and from the site if there is a potential for drowsiness, lingering pain, or weakness after procedure arrive @ least 30 minutes before scheduled identify oneself at the information or appointment desk upon arrival bring information to verify insurance or medicare coverage.

36. What pre and post instructions do you ask/tell someone getting a electroencephalography?

EEG Pretest: Most patients are instructed to have no stimulants, no sedatives, and no anticonvulsant drugs, such as phenytoin (Dilantin), for 48 hours before the test unless necessary to control seizures. Physician will determine which meds need to be held before the EEG Try to stay awake the night before the test- gives better results Instruct to eat 4 hours before the exam but avoid caffeinated products EEG Procedure: Scalp may be rubbed with mild, scratchy cleanser that may cause mild discomfort for a short while Discs will be attached with cream, gel or adhesives You may be asked to open and close your eyes and to do breathing exercises. A light may be flashed in your eyes. Heart may be monitored with ECG at the same time Post test: Tech will remove gel with water, adhesive removed with special cleanser Shampoo your hair after the test to remove remaining cream or gel.

11. All EKG rhythms (Know the EKG strips posted on pp)

EKG: Normal Sinus Rhythm Rate 60 to100 Sinus Bradycardia Rate >40 and < 60 Sinus Tachycardia Rate > 100 and < 170 ATRIAL RHYTHMS Atrial Flutter Rate 250-350, regular Saw tooth P waves Atrial Fibrillation Atrial rate > 350 Ventricular 60-100 VENTRICULAR RHYTHMS Ventricular Fibrillation No p wave No QRS Ventricular Tachycardia Rate 150-250, irregular Wide and Bizarre QRS Ventricular Standstill Atrial rate only, no QRS Asystole No rhythm ARRHYTHMIAS Premature Ventricular Contraction (PVC) Irregular rhythm Pacemaker Rhythms

be sure you can recognize the obvious EKG patterns such as NSR, atrial fibrillation, atrial flutter, v-tach, v-fib

EKG: Normal Sinus Rhythm Rate 60 to100 Sinus Bradycardia Rate >40 and < 60 Sinus Tachycardia Rate > 100 and < 170 ATRIAL RHYTHMS Atrial Flutter Rate 250-350, regular Saw tooth P waves Atrial Fibrillation Atrial rate > 350 Ventricular 60-100 VENTRICULAR RHYTHMS Ventricular Fibrillation No p wave No QRS Ventricular Tachycardia Rate 150-250, irregular Wide and Bizarre QRS Ventricular Standstill Atrial rate only, no QRS Asystole No rhythm ARRHYTHMIAS Premature Ventricular Contraction (PVC) Irregular rhythm Pacemaker Rhythms

27. Why is a paracentesis performed? Why is a lumbar puncture performed?

PARACENTESIS: procedure for withdrawing fluid form the abdominal cavity. done most commonly to relieve abdominal pressure and to improve breathing, which generally becomes labored when fluid crowds the lungs. _______________________________________________________ LUMBAR PUNCTURE procedure for withdrawing spinal fluid Dx conditions that raise the pressure within the brain, such as brain or spinal cord tumors or infections such as meningitis also withdrawn before instilling a contrast medium for X-Rays of the spinal column. the treatment of some conditions requires instillation of medication directly into the spinal fluid after withdrawing a similar amount Information gathered from a lumbar puncture can help diagnose: Serious bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis. Bleeding around the brain (subarachnoid hemorrhage) Certain cancers involving the brain or spinal cord.

14. Know about partial re-breather masks. Know about Venturi masks

PARTIAL REBREATHER 6-10 L/min; FIO2 35-50% delivers higher percentage of oxygen than a simple mask oxygen delivery device through which a client inhales a mixture of atmospheric air, oxygen from its source, and oxygen contained within a reservoir bag. provides means for recycling oxygen and venting all the carbon dioxide during expiration from the mask. during expiration the first third of the exhaled air enters the reservoir bag. the portion of exhaled air in the reservoir bag contains high proportion of oxygen b/c it comes directly from the upper airways the gas in this area has not been involved in gas exchange at the alveolar level. once the bag is filled, the remainder of exhaled air is forced from the mask through the small ports. ___________________________________________________________ VENTURI MASK "VENTI MASK" 4-8 L/min; FIO2 24-40% mixes precise amounts of oxygen and atmospheric air. has a large ringed tube extending from it... adapters within the tube, which are color coded or regulated by a dial system, permit only specific amounts of room air to mix with the oxygen. this feature ensures that the venturi mask delivers the EXACT amount of prescribed oxygen. unlike masks with reservoir bags, humidification CAN be added when a venturi mask is used.

4. What is the difference between a PaO2 and a SpO2?

PaO2- partial pressure of oxygen dissolved in plasma SpO2- percentage saturation form pulse oximetry PaO2 stands for the partial pressure of O2 in arterial blood, measured in mmHg. ... SaO2 (and its indirect measurement SpO2) describe the amount of oxygen bound to hemoglobin in arterial blood. The term "saturation" likens hemoglobin to a sponge that becomes saturated with oxygen.

15. Know about simple face masks, Know about oxygen tents, CPAP

SIMPLE MASK fits over the nose and mouth and allows atmospheric air to enter and exit through side ports. used to administer oxygen allows for administration of higher levels of oxygen than are possible with a cannula. sometimes substituted for a cannula when the client has nasal trauma or breathes through the mouth. oxygen is delivered @ NO LESS than 5L/min. Disadvantages: interfere with eating make verbal communication difficult to understand some clients become anxious when nose/mouth are covered, "feeling suffocated" skin care becomes a priority due to mask pressure and moisture. some carbon dioxide always remains within the mask and is reinhaled. ________________________________________________________ OXYGEN TENT clear plastic enclosure that provides cool, humidified oxygen. MOST OFTEN USED IN: care of active toddlers children are less likely to keep a mask on or cannula in place to receive oxygenation and humidification for things like croup or bronchitis. face-hood may be used for less-active infants oxy. concentrations are difficult to control when an oxygen tent is used. when caring for a child in an oxygen tent the edges of the tent must be tucked securely beneath the mattress; limit opening the zippered access ports so that the oxygen does not escape to freely. ox. levels MUST be monitored with an oxygen analyzer. _________________________________________________________ CPAP MASK attached to a portable ventilator and maintains continuous positive airway pressure keeping the alveoli partially inflated even during periods of expiration. the + airway pressure prevents the airway from collapsing allowing inflated alveoli to diffuse oxygen into the blood during apneic episodes that may last 10 or more seconds as frequently as 10-15 x's per hr. some abandon treatment due to discomfort and switch to the alternative BiPAP.

42. Know what the normal chemistry six and CBC labs are.

To detect changes in biochemical reactions in the body and determine a diagnosis Electrolytes Blood glucose tests -Essential in the diagnosis and control of diabetes Alanine aminotransferase (ALT), alkaline phosphatase (ALP), and Bilirubin and Ammonia -Used to measure liver function Blood urea nitrogen (BUN) and creatinine levels -Important indicators of kidney dysfunction Lactate dehydrogenase (LDH), creatine kinase (CK), and aspartate aminotransferase (AST), -Detect muscle damage Troponin, Myoglobin, and CPK-MB -Cardiac heart muscle damage Some institutions use automated computerized blood chemistry testing. Examples of tests available Serum albumin, ALP, AST Total bilirubin, serum calcium, cholesterol, glucose, LDH, phosphate, total protein, BUN, uric acid CBC COUNT Red Blood Cell RBC Male 4.7-6.1 Female 4.2-5.4 White Blood Cell WBC 4,500-10,000 mm3 Hemoglobin Hgb Male 14-18 Female 12-16 Hematocrit Hct Male 42-52 Female 37-47 Platelets 150,000-400,000

24. What is an electroencephalogram for?

a test or record of brain activity produced by electroencephalography. Localize and diagnose brain lesions, scars, epilepsy, infections, blood clots, and abscesses Also to determine brain death in comatose patients on life support systems Neurologic and physiologic activity produces electrical charges measured as brain waves

9. Know about trach care. Communication with a tracheostomy patient

clean the skin around the stoma, change dressing, clean the inner cannula. performed at least every 8 hours or PRN to keep secretions from becoming dried, which may narrow or occlude the airway. SKILL 26-2 ASSESSMENT check the nursing care plan to determine the schedule for providing care review record for documentation concerning previous trach care assess the condition of the dressing and the skin around the trach tube determine the clients understanding PLANNING consult with client on an appropriate time for trach care if only routine care is needed consider using a face shield and wearing a cover gown in addition to gloves when suctioning obtain a container of hydrogen peroxide and a flask of NS, remove the cap from each container IMPLEMENTATION wash your hands raise bed place client in supine or fowlers position put on clean a clean glove; remove the soiled stomal dressing and discard, glove and all, in a lined waste receptacle wash hands open trach kit, taking care not to contaminate its contents put on sterile gloves add equal parts of sterile NS and sterile hydrogen peroxide to one basin and sterile NS to the other unlock the inner cannula (using one hand, which is now considered contaminated) by turning it counterclockwise; deposit it in the basin with the hydrogen peroxide and saline solution clean the inside and outside of the cannula deposit contaminated supplies in a lined or waterproof wast receptacle rinse the cleaned cannula in the basin of NS tap the rinsed cannula against the edge of the basin and wipe the excess solution with a gauze square replace the inner cannula and turn it clockwise within the outer cannula clean around the stoma with an applicator moistened with diluted peroxide NEVER go back over an area once you have cleaned it wipe the same are in the same manner with anoth applicator moistened with saline place the sterile stomal dressing beneath the flanges and outer cannula of the trach tube. change the trach ties by threading them through the slits of each flange of the tracheostomy tube and tying them in place wait to remove the previous ties until after the new ones are secure if working alone. otherwise have an assistant stabilize the trach tube while you cut the soiled ties and apply the new ones tie the two ends snugly, but not tightly, at the side of the neck. make sure there is room to insert your little finger within the ties before securing the ends. discard all soiled supplies, remove gloves, and wash hands return the client to a safe and comfortable position restore a means that the client can use to signal for assistance EVALUATION the trach tube remain patent the stomal dressing is clean w/out evidence of infection the dressing is clean and dry the skin around the neck is intact DOCUMENT pre-assessment date procedure as it was performed appearance of skin and secretions clients response _________________________________________________________ FENESTRATED TRACHEOSTOMY TUBE: one with holes in the outer cannula, which allows air to pass through the vocal cords allowing speech. SPEAKING VALVE: device that directs exhaled air through the upper airway.

3. What liter flow is normal for a nasal cannula? What liter flow is normal for a nasal cannula with a humidifier?

common : 2-6 L/min; FIO2 24-40% w/humidifier: >or= 4L

10.Oral airway insertion and management in an unconscious client

curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway. commonly used for unconscious clients who cannot protect their airway. (recovering from general anesthesia, seizure) inserted by nurses only in place for a brief period of time

13. Know what are the signs and symptoms of inadequate oxygenation.

decreased energy restlessness rapid, shallow breathing rapid HR Sitting up to breathe nasal flaring use of accessory muscles hypertension sleepiness, confusion, stupor (a state of near-unconsciousness or insensibility), coma

4. How is inhalation therapy performed?

delivered through mask or handheld mouth piece.

8. O2 delivery for people with sleep apnea. Type of mask used ?

devices that help to relieve impaired oxygen levels caused by apnea or hypopnea during sleep. underlying cause of apnea/hypopnea is a temporary relaxation of muscles that should support structures in the soft palate and tongue. as a result the airway becomes obstructed breathing becomes difficult or temporarily ceases. _________________________________________________________ sleep apnea can be relieved with one of several positive airway machines that keep the airways open with controlled ventilation.... CPAP MASK attached to a portable ventilator and maintains continuous positive airway pressure keeping the alveoli partially inflated even during periods of expiration. the + airway pressure prevents the airway from collapsing allowing inflated alveoli to diffuse oxygen into the blood during apneic episodes that may last 10 or more seconds as frequently as 10-15 x's per hr. some abandon treatment due to discomfort and switch to the alternative BiPAP. BiPAP MASK provides two different levels of airway pressure: inspiratory positive pressure, which is higher during inhalation & expiratory positive pressure, which is lower during expiration. the variation promotes better tolerance among those requiring + airway pressure therapy. further modifications available: automatically adjusting + airway pressure (APAP) & variable + airway pressure (VPAP). APAP- adjusts the pressure according to the sleepers position in bed and stages of sleep. VPAP-normalizes breathing on a breath-by-breath basis thus suppressing apnea and promoting the time spent in REM sleep.

3. What is inhalation therapy?

inhalation therapy: respiratory treatments that provide a mixture of oxygen, humidification, and aerolized medications directly to the lungs. delivered through mask or handheld mouth piece.

25. What is a bronchoscopy for?

inspection of the bronchi Direct exam larynx, trachea, bronchi done in OR with sedative and amnesic Permit, NPO 6-8 hours prior and after until gag reflex returns, observe V/S, coughing up blood

2. Know the anatomy and physiology of breathing.

inspiration and expiration ventilation: movement of air in and out of the lungs; facilitates respiration Respiration: exchange of oxygen and carbon dioxide External respiration: takes pace at most distal point in airway: between the alveolar-capillary membranes Internal Respiration: occurs at the cellular level between hemoglobin and body cells

4. Recovery position

side lying position that helps to maintain an open airway and prevent aspiration of fluids

1. Different types of O2 masks used and the percentage O2 delivered by each

simple mask: 5-8 L/min; FIO2 35-60% fits over the nose and mouth and allows atmospheric air to enter and exit through side ports. used to administer oxygen allows for administration of higher levels of oxygen than are possible with a cannula. sometimes substituted for a cannula when the client has nasal trauma or breathes through the mouth. oxygen is delivered @ NO LESS than 5L/min. Disadvantages: interfere with eating make verbal communication difficult to understand some clients become anxious when nose/mouth are covered, "feeling suffocated" skin care becomes a priority due to mask pressure and moisture. some carbon dioxide always remains within the mask and is reinhaled. ______________________________________________________________ PARTIAL REBREATHER 6-10 L/min; FIO2 35-60% delivers higher percentage of oxygen than a simple mask oxygen delivery device through which a client inhales a mixture of atmospheric air, oxygen from its source, and oxygen contained within a reservoir bag. provides means for recycling oxygen and venting all the carbon dioxide during expiration from the mask. during expiration the first third of the exhaled air enters the reservoir bag. the portion of exhaled air in the reservoir bag contains high proportion of oxygen b/c it comes directly from the upper airways the gas in this area has not been involved in gas exchange at the alveolar level. once the bag is filled, the remainder of exhaled air is forced from the mask through the small ports. ____________________________________________________________ NON_REBREATHER 6-10 L/min FIO2 60-90% can deliver the highest amount of oxygen without the use of a mechanical ventilator. oxygen delivery device in which all the exhaled air leaves the mask rather than partially entering the reservoir bag. designated to deliver an FIO2 (the portion of oxygen in relation to total inspired gas) of 90-100% contains one-way valves that allow only oxygen from its source, as well as the oxygen in the reservoir bag, to be inhaled. NO air from the atmosphere is inhaled. Clients who use NRBM: those who require high concentrations of oxygen, usually are critically ill and may eventually need mechanical ventilation. despite the high concentration of oxygen, humidification is not employed when a mask with a reservoir bag is used. Also, clients with partial and non-rebreather masks are monitored closely to ensure that the reservoir bag remains partially inflated at all times. oxygen toxicity, can develop among clients who require the prolonged use of a rebreather mask. __________________________________________________________ VENTURI MASK 4-8 L/min : FIO2 24-40% mixes precise amounts of oxygen and atmospheric air. has a large ringed tube extending from it... adapters within the tube, which are color coded or regulated by a dial system, permit only specific amounts of room air to mix with the oxygen. this feature ensures that the venturi mask delivers the EXACT amount of prescribed oxygen. unlike masks with reservoir bags, humidification CAN be added when a venturi mask is used. ________________________________________________________ FACE TENT 8-12 L/min; FIO2 30-55% provides oxygen to the nose/mouth without the discomfort of a mask. open and loose around the face, clients feel less claustrophobic used for clients with: facial trauma burns disadvantage: the amount of oxygen clients receive may be inconsistent with what is prescribed b/c of environmental losses. __________________________________________ TRACH COLLAR 4-10 L/min; FIO2 30-55% delivers oxygen near an artificial airway opening in the neck, when the client is not able to breathe through nose/mouth. applied over a tracheostomy. b/c it bypasses the warming and moisturizing functions of the nose, a trach collar provides a means for both oxygenation and humidification. ____________________________________________________ T-Piece 4-10 L/min; FIO2 24-100% fits securely onto a tracheostomy tube or endotracheal tube. similar to trach. collar but is directly attached to the artificial airway. DISADVANTAGES: although the gauze around the trach, usually remains dry, the moisture that collects within the tubing tends to condense and may enter the airway during position changes if it is NOT periodically drained. weight of the T-Piece, or its manipulation, may pull on the tube, causing the client to cough or experience discomfort to avoid displacement of tubing the piece needs to be supported with a rolled towel.

19. What is an Allen test?

the allen test determines if the hand has an adequate ulnar arterial blood supply should the radial artery become damaged or occluded. the radial artery should be punctured if the allen test shows absent or poor collateral arterial blood flow as evidenced by continued blanching after pressure on the ulnar artery has been released. alternative sites include the brachial, femoral, or dorsalis pedis arteries. _______________________________________________________ checks blood flow through the arteries carrying blood to your hands. In the Allen's test, you make a tight fist, which forces the blood out of your hand. Your doctor presses on the arteries at each side of your wrist to slow the flow of blood back into your hand, making your hand lose its normal color. Next, you open your hand and your doctor releases the pressure on one artery, then the other. How quickly the color returns to your hand may give a general indication about the health of your arteries. Slow blood flow into your hand may indicate a problem, such as Buerger's disease.

5. Name three ways to mobilize secretions.

to mobilize secretions from distal airways, providers often use chest physiotherapy (techniques including postural drainage, percussion, and vibration) deep-breathing exercises may help older adults clear their airway. POSTURAL DRAINAGE positioning technique that promotes the drainage of secretions from various lobes or segments of the lungs with the use of gravity. in hospitals- RT are responsible for draining long-term care, & home-health nurses may teach clients and family to perform the technique. combining postural drainage with percussion and vibration enhances overall effectiveness. PERCUSSION rhythmic striking of the chest wall, helps to dislodge respiratory secretions that adhere to the bronchial walls. cup two hands, keeping the fingers and thumb together, apply hand to chest as if trapping air between them and the thoracic wall. VIBRATION uses the palms of the hands to shake underlying tissue and loosen retained secretions. performed while hands are on back during inhalation and nurse vibrates as client exhales to increase the intensity of expiration. used as an alternative to percussion ESPECIALLY for frail clients.

28. What are ultrasounds utilized for?

u/s are used to visualize breast, abdominal, and pelvic organs; male reproductive organs; structures in the head and neck; the heart and valves; and structures within the eyes. air filled structures such as lungs or the intestines and extremely dense tissue such as bone and do not image well. Records the reflection of sound wave directed into the tissues Used to diagnose pathologic conditions of: Uterus, ovaries, prostate, heart, liver, kidneys, pancreas, gallbladder, lymph nodes, thyroid, eyes, and peripheral blood vessels Often used in conjunction with nuclear medicine scans Abdominal Ultrasound Patient must drink full liter water to make sure bladder is full