Oxygenation

Surfactant

- Helps hold alveoli open so they maintain their shape when their is not enough then the alveoli collapse and change shape (Atelectasis). Patients at risk are: 1. COPD patients - there is not enough alveoli 2. Premature babies - don't make enough 3. Patients with diffusion and air exchange problems where oxygen & Co2 is not getting exchanged - This increases the patient's need for oxygen

Auscultation

- Normal and abnormal heart and lung sounds -Bronchial: Loud pitched hollow quality, expiration longer than inspiration over the trachea -bronchovesicular -vesicular

Inspection

- Skin and mucous membranes, level of consciousness (LOC), breathing patterns, chest wall movement Shape Symmetry Work of Breathing Cough Trachea- midline

Alcohol

-dehydration and malnutrition -increases workload of the respiratory system

more air pollution under age of 10

-increase chance of schizophrenia - cancer - bipolar disorder

Listening Anterior lungs

1) apex of lungs first 2) 2nd intercostal(rt & lt upper lobe) 3) 4th intercostal(rt & lt middle lobe) 4) 6 intercostal space(rt & left lower lobe)

Diagnostic

Chest X-Ray MRI Bronchoscopy Biopsy Pulmonary Function Test Spirometry Pulmonary Stress Test

A patient developed facial erythema and pruritus after washing with hot water and using a new herbal soap. On examination, the nurse finds scaling lesions that are oozing. Which instruction would the nurse provide to the patient? 1 Stop using the herbal soap. 2 Stop using hot water for bathing. 3 Take antihistamines before bathing. 4 Apply dressings on the lesions.

1 The presence of scaly, oozing lesions following the use of an herbal soap indicates that the patient has contact dermatitis. The best immediate step is to avoid the causative agent (the herbal soap). Warm water, not hot, is recommended for regular bathing, but water temperature is not the cause of the patient's facial lesions. Taking an antihistamine may help the patient after the development of dermatitis but is not recommended for use before bathing. The lesions should be left open to air for healing, not dressed.

Listening posterior lungs

1) apex of lungs b/n scapula and spine 2) c7 to t3 b/n shoulder blades and spinr(rt & left upper lobes) 3) t3 to t10(rt & lt lower lobes)

Why would the nurse request a humidification device while delivering oxygen to a patient in the home care setting? 1 Oxygen delivery greater than 4 L/minute 2 Storing oxygen delivery devices upright 3 Symptoms of hypoxia are noticed in the patient 4 Equipment is placed at least 8 ft from heat source

1 Oxygen delivery greater than 4 L/minute may cause drying of the mucosal membrane; therefore, a humidification device may be required while delivering oxygen. Storing oxygen delivery devices upright helps ensure safe use of equipment. If symptoms of hypoxia are noticed in the patient, the oxygen demand may be increased and the primary health care provider should be notified. Placing equipment at least 8 ft from a heat source prevents injury from a possible fire.

Which oxygen delivery system is indicated for long-term oxygen use at home? 1 Oxymizer 2 Partial mask Incorrect3 Nasal cannula 4 Nonbreather mask

1 Oxymizer (oxygen-conserving cannulas) are indicated for long-term oxygen use at home. Partial masks, nasal cannulas, and nonrebreather masks are used for short periods.

While inserting an endotracheal tube, the nurse instructs the patient to avoid coughing. What is the rationale behind this instruction? 1 To reduce anxiety 2 To prevent the need for more adhesive tape 3 To reduce the risk of accidental extubation 4 To reduce the transmission of microorganisms

1 The nurse instructs the patient to avoid coughing to reduce anxiety. Carefully removing the tape from the endotracheal tube and patient's face prevents adhesion of tape. Obtaining assistance from available staff to insert the endotracheal tube will reduce the risk for accidental extubation. Placing a towel across the patient's chest will reduce the risk of transmission of microorganisms.

Which position is appropriate in a patient who has a chest tube drainage system, in order to drain fluid from the chest? 1 Supine 2 High-Fowler's 3 Semi-Fowler's 4 Trendelenburg's

2 The patient should be placed in the high-Fowler's position to drain fluids from the chest. The patient should not be placed in the supine position, because it may increase the risk of reduced lung volume. The semi-Fowler's position is appropriate to evacuate air in conditions such as pneumothorax. The patient should not be placed in the Trendelenburg's position, because it may increase the risk of reduced lung volume.

What are the disadvantages of using an oxygen-conserving cannula? Select all that apply. 1 Increases risk of aspiration 2 Cannula cannot be cleaned 3 May induce feelings of claustrophobia 4 More expensive than standard cannula 5 Contraindicated in patients who retain carbon dioxide Oxygen-conserving cannula cannot be cleaned and are more expensive. Simple face masks may increase the risk of aspiration and induce feelings of claustrophobia.

2,4 Oxygen-conserving cannula cannot be cleaned and are more expensive. Simple face masks may increase the risk of aspiration and induce feelings of claustrophobia. Simple face masks are contraindicated in patients who retain carbon dioxide.

While caring for a patient who has a nasal cannula, the nurse loosens the elastic strap. Which unexpected patient outcome is responsible for the nurse's action? 1 Epistaxis 2 Skin irritation 3 Continuous hypoxia 4 Dry upper airway mucosa

2. Skin irritation is responsible for the nurse's action, because breakdown or irritation of the skin at the bridge of the nose, nares, or at ears occurs as an unexpected outcome requiring an intervention; therefore adjusting the tightness of the elastic strap to a looser level is beneficial for the patient. Obtaining an order for administering sterile nasal saline intermittently is beneficial for patients suffering epistaxis. Obtaining an order for ABG assessment is beneficial in instances of continued hypoxia. Providing frequent oral care is beneficial in cases of dry upper airway mucosa.

Factors Influencing Oxygenation

:Decreased oxygen carrying capability(Hb)- lowered by trauma, heavy menstrual cycle, and decreased production in RBCs because of anemia or meds(chemotherapy- DESTROYS blood cells) CAUSES - iNCREASED WORKLOAD OF THE RESPIRATORY SYSTEM, INCREASED HEART RATE, DECREASED BLOOD PRESSURE, DECREASED O2 SAT :Hypovolemia - caused by major bloodless or severe dehydration decreased vascular space. tissues don't recieve enough oxygen which causes the respiratory system to overwork itself :Increased metabolic rate overworks respiratory rate because protein gets broken down at a rapid rate causes muscle loss and wasting which will impact accessory muscles and diaphragm increasing the bodies need for oxygen - Factors: stress, anxiety, hyperventilation(respiratory work increase)

Abnormal Lung sounds

;Wheezes- high pitched whistling(narrowing of airway) Intervention- open up airway w/ bronchodilator or NEB treatment(FIX PROBLEM) ;Crackles- rattling sound(salt shaker): from fluid, mucous, or consolidation in lungs Interventions- turn, cough, deep breath, IS,AND Hydration ;Rhonchi- snoring sound from mucous build-up intervention - coughing ;Stridor(DEATH RATTLE- can't clear airway - drowning in secretions)- high pitched wheezing from narrowing of airway Intervention- robinul and scopolomine patch- adminstered behind ear ;Pleural friction rub- from inflammation from lung rubbing against pleural cavity -harsh grating sound,

Palpation

- Chest, feet, legs, pulses Tactile Fremitus- say "999 111"- fluid accumulation in chest

Labs

Arterial Blood Gasses (ABG)- oxygen concentration and co2 levels CBC (Reticulocyte Count, Anemia) Sputum culture - sterile cannot eat or drink 30 minutes pryer and don't sit by the window Tuberculin Test

Which condition may cause decreased tissue oxygenation due to decreased oxygen-carrying capacity of the blood? 1 Obesity 2 Anemia 3 Pregnancy 4 Neuromuscular disease

2. Anemia decreases the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen. The other conditions cause decreased oxygenation for other reasons: Decreased oxygenation may result from reduced lung volumes in patients who are obese. Increased metabolic rate may result in decreased oxygenation in patients who are pregnant. Impaired ability to expand and contract the chest wall may result in decreased tissue oxygenation in patients who have neuromuscular diseases.

Fluid likes dependent areas

So you hear abnormal sound a the base first

Cystic Fibrosis patients have problems with diffusion and thickening of the capillaries

The goal of the nurse is to decrease the workload of the body system by supplementing oxygen and monitor hemoglobin levels. The lower HB the more the resp work Co2 regulates breathing Monitor CNS system

Conditions affecting chest wall movement

- Pregnancy because women cannot take full breath because the fetus is constantly pressing on the diaphragm - obesity because the diaphragm cannot fully expand the lungs - muscular dystrphy - emphysema(barrel chest)- accessory muscles - muscle skeletal abnormalities: flailed chest- breathing in causes contraction instead of expansion and when breathing out it bulges(barely getting air to supply the body with oxygen - patient have to be intubated) caused by trauma and airbag(ACUTE PT) :INTERVENTION- monitor o2 sat, resp rate, rhythm, are they getting enough oxygen? CNS Alterations- cns depressants (opiods- narcotics), impacts chest wall movement rate may be normal but the rhythm is shallow Chronic lung diseases also impacts chest wall movements

The thickness of the alveolar capillary membrane

- affects the rate of diffusion.

Hyperventilation

- breathing really quickly and pt is unstable if they are sedentary and breathing like this. - insensible water loss (dehydration), so the nurse has to monitor urine output and skin turgor - check respiratory rate

Assessment

- do a thorough health history - if assessing the respiratory system also assess the circulatory as well - know allergies - do physical exam- inspect, palpate, and auscultate - color of skin - mucous membranes(conjunctiva) - level of consciousness (resp rate and depth) - look at chest wall movement(does it move symmetrically) - look at skin and coloring -shape of chest -make sure patient is coughing(wet(sputum what it looks like- pink - pulmonary edma green- pneumonia),dry) - if not coughing then you have remove secretion manually - trachea should be midline: tugging indicate trauma, foreign body - inadequate air exchange - look into back of throat for obstruction - say "999 111" tactile fremitus- fluid accumulation in chest

Infants

- have a very high risk of developing respiratory infections because they don't have enough antibodies and they put everything in their mouth

Hypoventilation

- pts on CNS depressants - low respiratory rate - patient retain co2 and become very acidic - can become very lethargic

Middle age

- respiratory rate increases b/c of sedentary lifestyle(obesity) and alveoli stretching out and causing diffusion problems - not as many cilia because to move bacteria out of the lungs - lung compliance decrease b/c of muscle athrophy and commobities - obese pts wob increases and resp rate increases - eating big meals increase the workload of the respiratory system

Oxygen

-Check oxygen flow meter -lay in bed with patient when transporting - has to have Christmas attached to flowmeter for tubing to connect - check for suction, christmas tree, tubing when dealing with respiratory patient - keep o2 sat 92%

COPD

-DIAPHRAGM IS MISSHAPED - So it is harder for the lungs to expand during inspiration - decrease compliance, increase airway resistance, increase WOB

Monitoring Chemotherapy patients

-not be able to handle certain activities w/o shortness of breath - monitor CBC

Patients with head trauma or who are paralyzed

can't regulate breathing or rhythm BECAUSE THE CNS ( cerebral cortex) controls the respiratory rate, depth, and rhythm

Outcomes/Goals

Respiratory status: gas exchange The patient's sputum will be clear, and thin in consistency within 36 hours. The patient's lung sounds will be clear within 36 hours. The patient's respiratory rate will be between 16 and 24 breaths per minute within 24 hours. The patient will be able to clear airway secretions by coughing in 24 hours. The patient's SpO2 will be greater than 85% within 24 hours.

Oxygen Therapy, Maintenance and Promotion of Oxygenation

Purpose—relieves hypoxemia Hypoxemia—low levels of oxygen in the blood Hypoxia—decreased tissue oxygenation Goal—use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects Oxygen therapy To prevent or relieve hypoxia Supply of oxygen Tanks or wall-piped system Methods of oxygen delivery COPD(retain co2 decrease resp. drive)- too much oxygen can cause them to be dependent

Nasal Cannula- lowest flow and level of oxygen

(prongs pointed down, with the curvature of the nares). Flow rates of 1-6 L/min(no higher than 6) O2 concentration of 24%-44% (1-6 L/min) Flow rate >6 L/min does not increase O2 because anatomical dead space is full Assess patency of nostrils Assess for changes in respiratory rate and depth always check tubes patient just needs a little bit of oxygen contraindicated- deviated septum, mouth breather, and wound in nose

Interventions

Vaccinations Healthy Lifestyle Dyspnea management Hydration- breakup mucous Humidification- for comfort hook to flowmeter so patient does not get dried out(on oxygen longer than three days) Nebulization- open airway(open up bronchioles) Cough and Deep breath- considilation Chest Physiotherapy Suctioning Positioning Ambulation Breathing exercises - pursed lips- COPD(Airtrapping) get rid of co2

A patient was admitted after a motor-vehicle accident with multiple fractured ribs. During respiratory assessment, which signs and symptoms of secondary pneumothorax would the nurse expect to find? 1 Sharp pleuritic pain that worsens on inspiration 2 Crackles over lung bases of affected lung 3 Tracheal deviation toward the affected lung 4 Increased diaphragmatic excursion on side of rib fractures

1 When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.

While caring for a patient who has a chest tube, the nurse finds continuous bubbling in a water-seal chamber. Which intervention would be beneficial for the patient? 1 Unclamping the chest tube 2 Obtaining a large-gauge needle 3 Obtaining a flutter (Heimlich) valve 4 Determining that the chest tube is not occluded

1 Continuous bubbling in a water-seal chamber is an unexpected outcome when experienced in patients with chest tubes. Unclamping the chest tube is beneficial for the patient. Obtaining a large-gauge needle or a flutter (Heimlich) valve and determining that chest tubes are not occluded would be beneficial should tension pneumothorax occur. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

Which action by the nurse involves squeezing, twisting, and kneading the chest tube to create a burst of suction to move clots? 1 Milking 2 Tidaling 3 Stripping 4 Suctioning Milking involves squeezing, twisting, and kneading of the chest tube in a process of creating a bust of suction to move clots from the chest tube. Tidaling is the action of watching for movement of the fluid level with breathing for ensuring proper functioning of the chest tube. Stripping involves compression of the chest tube with the thumb and forefinger and pulling the tube away from the chest wall with the other hand. Suctioning involves the removal of the excess mucus from the lungs.

1 Milking involves squeezing, twisting, and kneading of the chest tube in a process of creating a bust of suction to move clots from the chest tube. Tidaling is the action of watching for movement of the fluid level with breathing for ensuring proper functioning of the chest tube. Stripping involves compression of the chest tube with the thumb and forefinger and pulling the tube away from the chest wall with the other hand. Suctioning involves the removal of the excess mucus from the lungs.

Which person is at the lowest risk for developing pulmonary disease? 1 A person who lives in a rural region 2 A person who smokes 3 A person who lives in a smoggy city 4 A person who works in a factory where asbestos is present

1 Of these people, the person living in a rural area is less exposed to pollution and is therefore at a lesser risk for developing pulmonary disease. Smoking, exposure to pollution and smog, and exposure to a health-hazardous substance like asbestos all increase the risk for pulmonary disease.

The registered nurse is teaching a patient about diaphragmatic breathing. Which statement if made by the patient indicates the need for further teaching? 1 "I should practice the exercise initially in the sitting position and then in the supine position." 2 "I should place one hand flat below the breastbone and another hand flat on the abdomen." 3 "I should inhale slowly, making the abdomen push out and moving the lower hand outward." 4 "I should practice these exercises often with the pursed-lip breathing technique."

1 The patient should practice the exercise initially in the supine position, because it is easier to perform when starting out than, and then switch to a sitting or standing position. The patient should place one hand flat below the breastbone and other hand flat on the abdomen. The patient should inhale slowly, making the abdomen push out and moving the lower hand outward. The patient should practice these exercises often with the pursed-lip breathing technique.

While caring for a patient who has a chest tube, the nurse places the patient in a high-Fowler's position. What is the reason behind this nursing action? 1 To promote draining of fluid 2 To evacuate air from the lungs 3 To prevent formation of blood clots 4 To prevent excessive negative intrapleural pressure

1 The patient who has a chest tube is positioned in a high-Fowler's position to promote draining of fluids from the chest in conditions such as hemothorax and emphysema. The patient is positioned in a semi-Fowler's position to evacuate air from the lungs in conditions such as pneumothorax. The tubing is adjusted to hang in a straight line from the top of the mattress to drainage chamber to prevent blood from accumulation. Stripping the tube should be avoided to prevent excessive negative intrapleural pressure. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104° F (40° C). Which physiological process explains why the child is at risk for developing dyspnea? 1 Fever increases metabolic demands, requiring increased oxygen need. 2 Blood glucose stores are depleted, and the cells do not have energy to use oxygen. 3 Carbon dioxide production increases as a result of hyperventilation. 4 Carbon dioxide production decreases as a result of hypoventilation.

1 When the body cannot meet the increased oxygenation need, the increased metabolic rate causes the breakdown of protein and wasting of respiratory muscles, increasing the work of breathing. Carbon dioxide production increases due to the increased metabolism stemming from the fever, not as a result of hyperventilation.

The nurse is performing a routine physical examination of a patient and observes the patient's breathing patterns. Which factors might the nurse observe? Select all that apply. 1 Bradypnea is less than 12 breaths per minute. 2 Tachypnea is greater than 20 breaths per minute. 3 Apnea is the increased number of breaths per minute. 4 Apnea is the absence of respirations for some time. 5 Increased blood flow to the brain causes Cheyne-Stokes respiration.

1,2,4 At rest the breathing rate for normal adults is 12 to 20 regular breaths per minute. Bradypnea occurs when the respiratory rate decreases below 12 breaths per minute. Tachypnea occurs when the respiratory rate increases above 20 breaths per minute. Apnea is the absence of respiration for a period of time, when the patient will not have any breath sounds. An increase in the number of breaths per minute is called tachypnea. Cheyne-Stokes respiration is caused by decreased blood flow or injury to the brainstem and is characterized by periods of apnea followed by periods of deep breathing, then shallow breathing, followed by more apnea.

On the first postoperative day, a patient who underwent a cholecystectomy complains of shortness of breath. The x-ray indicates that the patient has atelectasis. Which intervention could have prevented this complication? 1 Incentive spirometry 2 Early mobilization of the patient 3 Nebulization of the patient after surgery 4 Administration of oxygen to the patient

1. The patient's symptoms and signs indicate atelectasis. Patients who undergo abdominal surgery are at increased risk of atelectasis postoperatively. Incentive spirometry encourages these patients to practice deep breathing by providing visual feedback about inspiratory volume. This expands the alveoli and prevents lung collapse. Early mobilization of the patient does not prevent atelectasis but is important to prevent such complications as pneumonia and deep vein thrombosis (DVT). Nebulization or administration of oxygen will not prevent lung collapse.

A patient with chronic obstructive pulmonary disorder (COPD) is administered oxygen therapy using a simple oxygen face mask. After some time, the patient's blood analysis reveals abnormally high levels of carbon dioxide. Which should be the nurse's immediate next step? 1 Remove the mask and apply a new oxygen mask. 2 Reset the mask to cover the patient's nose only. 3 Remove the mask and use a nasal cannula for oxygen supply. 4 Reset the mask to cover the patient's mouth and nose.

3 Simple face masks are designed to deliver 6 L/min or more of oxygen. However, in patients with chronic obstructive pulmonary disorder (COPD), this results in hypoventilation. These patients have adapted to a high level of carbon dioxide so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Because the stimulus to breathe is a decreased arterial oxygen level, administration of oxygen greater than 1 to 3 L/min prevents the PaO 2 from falling to a level that stimulates the peripheral receptors. This destroys the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide. Additionally, the patient may inhale exhaled carbon dioxide retained in the mask. Therefore, masks are contraindicated in patients with COPD. However, a nasal cannula does not cause rebreathing of exhaled carbon dioxide and allows for safe delivery of lower rates of oxygen. Hence, the nurse should immediately remove the mask and use a nasal cannula for oxygen supply. Applying a new mask or resetting the mask will not improve the patient's condition.

Which patient finding indicates the need for home oxygen therapy? 1 Heart rate 72 bpm 2 Respiratory rate 24 bpm 3 Arterial partial pressure 50 mm Hg 4 Serum carbon dioxide level 24 mEq/L

3 The indications for home oxygen therapy include an arterial partial pressure less than 55 mm Hg and partial oxygen saturation less than 88%. The normal heart rate is 60 to 80 bpm. Therefore, the rate of 72 bpm is a normal finding. A respiratory rate of 24 bpm is also a normal finding. The normal level of serum carbon dioxide is 23 to 30 mEq/L. Therefore, the level of 24 mEq/L is a normal finding and is not an indication for home oxygen therapy.

While refilling the oxygen device, the registered nurse instructed the nursing student to disengage it when the hissing noise changes and a vapor cloud begins. What is the rationale behind this instruction? 1 To remove moisture from oxygen system 2 To ensure appropriate oxygen prescription 3 To prevent malfunction to the ambulatory unit 4 To prevent injury from improper placement of the oxygen system

3 The registered nurse instructed the nursing student to disengage the unit when the hissing noise changes and the vapor cloud begins to prevent malfunction to the ambulatory unit. The nurse wipes both filling connectors with a clean, dry, lint-free cloth to remove moisture from the oxygen system. The nurse adjusts the prescribed flow rate to ensure appropriate oxygen prescription. The nurse places the oxygen-delivery system in the clutter-free environment to prevent injury from improper placement of the oxygen system. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.

The nurse is caring for a patient who has a chest tube drainage system. The nurse notices continuous bubbling in the water seal chamber. What could be the reason for this? 1 The patient has hypoxia. 2 The chest tube is clamped. 3 The chest tube is blocked with clots. 4 There is a leak between the patient and the chamber.

4 Continuous bubbling in the water seal chamber indicates that an air leak is present between the patient and the water seal. Hypoxia does not lead to bubbling in the water seal chamber. Clamping of the chest tube may lead to tension pneumothorax. Kinking of the tube may result in the formation of clots that may not lead to bubbling in the water seal chamber.

Which diagnostic test provides instant feedback about a patient's oxygenation status? 1 Capnography 2 Bronchoscopy 3 Thoracentesis 4 Pulse oximetry

4 Pulse oximetry is a diagnostic test provides instant feedback about a patient's oxygenation level. Capnography is a diagnostic test that provides instant information about the patient's ventilation and perfusion. Bronchoscopy allows for visual examination of the tracheobronchial tree. Thoracentesis is a surgical procedure done on the chest wall and pleural space to take a biopsy specimen.

In which position would the nurse place a patient with a pneumothorax and chest tubes for optimal lung expansion? 1 High-Fowler's 2 Sitting 3 Supine 4 Semi-Fowler's

4 The chest tube is a catheter inserted into the thorax to remove air and fluids from the pleural space and to prevent them from reentering that space, or to reestablish normal intrapleural and intrapulmonic pressures. Researchers have shown that a semi-Fowler's position is optimal for promoting lung expansion and reduced abdominal pressure on the diaphragm. The sitting and high-Fowler's positions are similar and preferred when examining apical lung segments. The supine position is preferred to examine the right anterior upper lobe lung segment.

While preparing a patient for an endotracheal tube, the nurse uses a Yankauer suction tip. What is the rationale for this nursing action? 1 To reduce anxiety and encourage cooperation Incorrect2 To reduce the risk of accidental extubation of the artificial airway 3 To facilitate procedure completion without causing discomfort 4 To reduce the transmission of microorganisms to linens and bedclothes

4 The transmission of microorganisms to linens and bedclothes during endotracheal suctioning may lead to infection. Using a Yankauer suction tip to clear the secretions during endotracheal tube care helps to maintain asepsis. Explaining the importance of the patient's participation helps to reduce anxiety and encourages cooperation. Obtaining staff nurse assistance during the procedure helps to reduce the risk of accidental extubation. To facilitate procedure completion without causing discomfort, the nurse should assist the patient to sleep in a supine or semi-Fowler's position. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Nursing Diagnosis and Planning

Activity intolerance Decreased cardiac output Fatigue Impaired gas exchange Impaired spontaneous ventilation Impaired verbal communication Ineffective airway clearance- can't clear secretions NEB and bronchodilator Ineffective health maintenance Risk for aspiration Risk for infection Risk for suffocation Risk for imbalanced fluid volume Ineffective breathing pattern

Evaluation

Ask about Degree of breathlessness (Is it better or worse than before?) If distance ambulated without fatigue has increased Rating the breathlessness from 0 to 10 Which interventions reduce dyspnea Frequency of cough and sputum production Perform Observe respiratory rate before, during, and after any activity. Assess any sputum produced. Auscultate lung sounds for improvement in adventitious sounds.

School age and adolescents

At risk for respiratory problems becuase of their risky behaviors with smoking- big impact on lungs b/c they destroy capillary beds and slows down the rate of healing which increases the metabolic rate(risk of infection)

Restorative and Continuing Care

Cardiopulmonary rehabilitation Controlled physical exercise; nutrition counseling; relaxation and stress management; medications; oxygen; compliance; systemic hydration Respiratory muscle training Coughing Techniques Cascade Cough- takes a slow deep breath and holds for 2 seconds while contracting expiratory muscles. Then performs a series of coughs Huff Cough- while exhaling the pt. opens the glottis by saying the word huff Quad Cough- for pts without abdominal muscle control. As the patient breaths out the nurse or the pt. pushes inward and upward on the abdominal muscles Breathing exercises Pursed-lip breathing Diaphragmatic breathing

Hazards & Complications of Oxygen Therapy

Combustion- no smoking or cooking with oxygen tank and can't use oil based lubricants Oxygen-induced hypoventilation Hypercarbia—retention of CO2 CO2 narcosis—loss of sensitivity to high levels of CO2 Oxygen toxicity Absorption atelectasis—new onset of crackles/decreased breath sounds Drying of mucous membranes Infection Oxygen has to be stored upright and in container

Clinical Manifestations of Respiratory Distress

Dyspnea - pain when breathing Kussmaul - Hyperventilation(diabetic ketoacidosis and stress/anxiety- very alkalotic) Cheyne- Stokes- Irregular breathing pattern. Med emergenncy- if they have a dnr(real fast and then real slow from dying or neuro problems) Apnea - patient stops breathing for a couple seconds. sleep apnea can lead to heart problems. babies forget to breath Nasal flaring- using accessory Use of accessory muscles to breathe Pursed-lip or diaphragmatic breathing - patient need to do this when they are retaining co2( hyperventilating ). Helps airtrapping in COPD patient. should not be done for long Decreased endurance Skin, mucous membrane changes (pallor, cyanosis)- Decreased O2 saturation

Compliance and airway resistance

Patients with chronic lung conditions have decreased lung compliance and increased airway resistance. These patient's WOB is also increased as an affect and the respiratory workload is increased Factors that affect lung compliance: 1) Aging - because of muscle atrophy Interventions- make sure the patient turns coughs and deep breath(IS)

Simple Face Mask

Potter and Perry 6-12L (O2 concentration 35%-50%) ATI 5-8 L ( O2 concentration 40%- 60%) For mouth breathers nasal congestion patient little oxygen contraindicated- in babies and confused patients patients who are eating

Partial and Nonrebreather(bag) masks lot of oxygen concentration

Potter and Perry text- 10-15L (O2 concentration 60-90%) ATI text Partial 6-10L (O2 concentration 40-70%)- some atmospheric air/ flow meter not as high ATI text Nonrebreather 10-15L (O2 concentration 40-70%) Not breathing atmospheric oxygen for acute distress

Early Signs of Hypoxemia(matter of seconds)

Restlessness Anxiety Tachycardia- tries to compensate(heart rate is perfused) Tachypnea Confusion- see them fist neuro- ox (blood clot ) Pale skin, mucous membranes- Elevated blood pressure- vasoconstriction to get more oxygen Use of accessory muscles, nasal flaring, tracheal tugging, Adventitious breath sounds- Elevated resp

Late Signs of Hypoxemia

Stupor - patient cannot be aroused Cyanosis (Central,1st peripheral- mouth, mucous membranes- conjuctiva)- absent pulses to hands and feet Decreased LOC Bradypnea Bradycardia Hypotension Cardiac Dysrhythmias- ABNORMAL BEATS B/C OF ELECTRICAL SYSTEM MESS UP Decrease in CNS BLOOD PRESSURE GOES DOWN PULSE- hands are perfused

Venturi Face Mask (if you need a specific concentration)

The Venturi mask delivers higher oxygen concentrations of 24% to 60%, with oxygen flow rates of 4 to 12 L/min, depending on the flow control meter selected. Can adjust concentation and is most accurate can go from nasal to simple

Work of Breathing (WOB)

Ways the Nurse can notice the patients effort to breath: - The patient's use of accessory muscles - if they diaphoretic(sweating) - their is a change in their skin color - the patient is experiencing anxiety, - Babies present with nasal flaring - Females clavicles muscles are being used(upper muscles) - Men breath with their abdomen - chest (diaphragmatic)

Hemoglobin

carries O2 AND CO2

over zyphoid process(7th intercostal- bases)

is where you stop listening to lungs

Pulse ox

let you know periheral oxygen not internal

Stridor

obstruction in throat