Chapter 21 Oxygenation
wall oxygen
Outlet Connected to a large central reservoir filled with oxygen on a routine basis.
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: "He will require additional testing to determine the cause." "He is using his chest muscles to help him breathe." "His infection is causing him to breathe harder." "His lung muscles are swollen so he is using abdominal muscles."
"He is using his chest muscles to help him breathe." RATIONALE: The client will use accessory muscles to ease dyspnea and improve breathing.
During a physical assessment, a client reports a desire to reduce snoring because it interferes with the spouse's ability to sleep properly. What suggestion could the nurse make to improve the client's condition? Instruct the client on the use of the pursed-lip breathing technique. Encourage the client to take deep breaths before going to bed. Tell the client to use nasal strips when sleeping. Teach the client to perform diaphragmatic breathing.
"Nasal strips may reduce or eliminate snoring." RATIONALE: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring. The other responses are inappropriate.
Signs of Inadequate Oxygenation
- Restlessness, Agitation,Confusion - Use of accessory muscles - Abnormal breath sounds - Abnormal blood gases - Changes in blood pressure, heart rate, dysrhythmias (ECG changes) - Decreased urine output - Flushed, cool skin, or cyanosis
simple mask
-delivers between 40-55% -Min flow needed to continually flush out CO2 - 6 lpm -Acceptable flow rate 5-10 lpm -Low flow divice
humidifier
A device connected to the flowmeter to add moisture to the dry oxygen coming from an oxygen cylinder.
NURSING ASSESSMENT FOR HYPOXEMIA OR HYPOXIA
Determine the client's respiratory rate and effort. Check the radial or apical pulse rate. Measure the client's blood pressure. Note the client's level of consciousness and mental status. Assess for the evidence of a cough and its characteristics. Observe the use of accessory thoracic and abdominal muscles for breathing. Observe the client's chest contour. Inspect the skin, oral mucous membranes, and nail beds for signs of cyanosis. Palpate the client's abdomen for evidence of distention that could crowd the diaphragm. Note the client's body position, which may or may not facilitate breathing. Measure the client's SpO2 with a pulse oximeter. Review the results of arterial blood gas measurements. Auscultate anterior, posterior, and lateral lung sounds. Ask the client to describe his or her current status of oxygenation. Perform a pain assessment. Inquire as to the client's medical history of respiratory disorders or other conditions that can affect ventilation. Identify the client's smoking history. Review the client's current medication history for drugs that can impair oxygenation.
internal respiration
Exchange of gases between cells of the body and the blood
Hypoxia
Low oxygen saturation of the body, not enough oxygen in the tissue
Portable Tank
When oxygen is not piped into individual rooms or if the client needs to leave the room temporarily, oxygen is provided in portable tanks (Fig. 21-7) that hold various volumes under extreme pressure. A large tank of oxygen contains 2,000 lb of pressure per square inch. Therefore, tanks are delivered with a protective cap to prevent accidental force against the tank outlet. Any accidental force applied to a partially opened outlet could cause the tank to take flight like a rocket with disastrous results. Therefore, oxygen tanks are transported and stored while strapped to a wheeled carrier. Before oxygen is administered from a portable tank, the tank is "cracked," a technique for clearing the outlet of dust and debris. Cracking is done by turning the tank valve slightly with a wrench to allow a brief release of pressurized oxygen (Fig. 21-8). The force causes a loud hissing noise, which may be frightening. Therefore, it is best to crack the tank away from the client's bedside.
A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: diminished stroke volume. adequate tissue perfusion. heart failure. high cardiac output.
adequate tissue perfusion. RATIONALE: Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.
Non-rebreather mask
allows higher levels of oxygen to be added to the air taken in by the patient
Face tent mask
are used to provide a controlled concentration of oxygen and increase moisture for patients who have facial burn or a broken nose, or who are claustrophobic. greater than 10 L
Oxygen tent
clear plastic enclosure that provides cooled, humidified oxygen
The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? mineral oil normal saline tap water distilled water
distilled water RATIONALE: Distilled water is used when humidification is desired. Other answers are incorrect.
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? oxygen analyzer nasal cannula nasal strip flow meter
flow meter RATIONALE: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.
The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? low blood pressure high temperature low pulse rate high respiratory rate
high respiratory rate RATIONALE: A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.
Ventilation
movement of air in and out of the lungs
hypoxemia
deficient amount of oxygen in the blood
The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize? "Are you sleeping better now that you are using the concentrator?" "Have you discussed a back-up system with your health care provider in case your electricity goes out?" "Does your family help you with the concentrator?" "Have you noticed an improvement in how you are feeling?"
"Have you discussed a back-up system with your health care provider in case your electricity goes out?" RATIONALE: The concentrator depends on electricity to work correctly, so each client should have a backup system in case the electricity goes out to ensure he or she will still be able to obtain the oxygen level needed. Some of the newer models are now using the DC outlets found in motor vehicles and have rechargeable batteries; however, the client should still have a backup plan. The questions could be asked during the assessment; however, asking about a backup system is the priority.
A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response? "Let me teach you about incentive spirometry." "Have you tried nasal strips?" "Pursed-lip breathing can reduce your amount of snoring." "There is very little that can be done for snoring."
"Have you tried nasal strips?" RATIONALE: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring. Other choices are incorrect.
A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? "You will need to use a bedpan while the chest tube is in position." "Let me get the unlicensed assistive personnel (UAP) for you." "I can assist you to the bathroom and back to bed." "The chest tube cannot be moved."
"I can assist you to the bathroom and back to bed." RATIONALE: The client can move in bed, and ambulate while carrying the drainage system, as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted to make sure it stays intact and to monitor for safety. Other answers are incorrect.
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." "Take in a small amount of air very quickly and then exhale as quickly as possible." "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." RATIONALE: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize? "Is your mask causing discomfort?" "Did someone loosen the straps on your mask?" "Did you remove your dentures?" "Did someone take your mask off?"
"Is your mask causing discomfort?" RATIONALE: It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.
The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response? "It will help you breathe much easier and feel better." "Wounds heal because HBOT helps to regenerate new tissue quickly." "You will be treated for decompression sickness." "HBOT treats aerobic infections."
"Wounds heal because HBOT helps to regenerate new tissue quickly." RATIONALE: Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. HBOT is used to treat anaerobic infections. The other responses are inappropriate.
A client with a nonhealing pressure injury has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response? "It will help you breathe easier and feel better more quickly." "In the chamber, you will be treated for decompression sickness." "When you become oxygen-toxic, the wound will heal faster." "Wounds heal because HBOT helps to regenerate new tissue quickly."
"Wounds heal because HBOT helps to regenerate new tissue quickly." RATIONALE: The rationale for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. Other answers are incorrect.
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "Oxygen is a flammable gas." "You should never smoke when oxygen is in use." "An occasional cigarette will not hurt you." "I understand; I used to be a smoker also."
"You should never smoke when oxygen is in use." RATIONALE: The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.
SaO2 (percentage of hemoglobin saturated with oxygen)(Oxygen Saturation)
*95 - 100%* Normal [> 90% is normal, < 86% is emergency; < 70% is life-threatening] <95% is hypoventilation and Anemia.
Oxygen Concentrator (molecular sieve device)
-Most commonly used device for home care - Requires electricity only (must use three prong plug) - Circuit breaker is safer then a fuse in electrical panal - produces up to 6 lpm -Extracts oxygen from room air -change filter and check flow reg. (calibrated by RT) -Appropriate lode capacity ( ensure the home can handle the extra electricity) -Tank or other back up O2 source is recommended -not able to deliver 100% O2 -do not use with high flow devices (not capable of high flow)
The nurse is using an oxygen analyzer to determine whether a client is receiving the amount prescribed by the health care provider. The nurse first checks the room air. What finding indicates a normal mixture of oxygen and other gases in the environment? 21% (0.21) 41% (0.41) 11% (0.11) 31% (0.31)
21% (0.21) RATIONALE: If there is a normal mixture of oxygen and other gases in the environment, the analyzer indicates 21% (0.21).
HCO3(the PH of blood and the level of bicarbonate ions)range
22-26 mEq/L > or < indicate compensation for acid-base imbalance
ABG PaCO2(partial pressure of carbon dioxide in plasma)
35 -45 mm Hg < range = Respiratory Alkalosis(hyperventilation) > range = Respiratory Acidosis(hypoventilation)
ABG pH
7.35 - 7.45 < range = Acidosis, > range = Alkalosis
ABG PaO2(measures the partial pressure of oxygen dissolved in plasma) range
80-100 mmHg 60-80 is mild hypoxemia 40-60 is moderate hypoxemia <40 is severe hypoxemia >100 is hyperoxemia
Venturi mask
A face mask and reservoir bag device that delivers specific concentrations of oxygen by mixing oxygen with inhaled air.
nasal cannula
An oxygen-delivery device in which oxygen flows through two small, tubelike prongs that fit into the patient's nostrils; delivers 24% to 44% supplemental oxygen, depending on the flow rate.
A nurse is conducting a physical assessment of a client at the health care facility. To assess the quality of the client's oxygenation, the nurse requires the client to exhale additional air. What should the client do to exhale additional air? Elevate the ribs and sternum. Relax the respiratory muscles. Expand the thoracic cavity. Contract the abdominal muscles.
Contract the abdominal muscles. RATIONALE: To get the client to exhale additional air to check the quality of oxygenation, the nurse should instruct the client to contract the abdominal muscles. A person can forcibly exhale additional air by contracting abdominal muscles, such as the rectus abdominis, transverse abdominis, and external and internal obliques. The client elevates the ribs and sternum and expands the thoracic cavity during inspiration. The client relaxes the respiratory muscles during normal expiration.
Fire potential
Does support combustion, avoid petroleum products, use O2 signs, open flames, and secure O2 bottles.
NURSING DIAGNOSES FOR HYPOXEMIA OR HYPOXIA
INEFFECTIVE BREATHING PATTERN IMPAIRED GAS EXCHANGED ACTIVITY TOLERANCE ANXIETY RISK FOR INJURY RELATED TO OXYGEN HAZARDS
Respiration
Inhalation and exhalation of air.
The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply. Over time, begin to increase the length of the exhale. Shape the lips as if you were about to blow a whistle. Keep abdominal muscles in a relaxed state. Ensure that the exhale lasts twice as long as the inhale. Exhale slowly through pursed lips. Inhale slowly through the nose for a count of three.
Inhale slowly through the nose for a count of three. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale. RATIONALE: Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing. This is another technique for improving gas exchange, which helps clients eliminate more than the usual amount of carbon dioxide from the lungs when done correctly. Pursed-lip breathing and diaphragmatic breathing are especially helpful for clients who have chronic obstructive pulmonary disorders (COPD), such as emphysema. The key with this intervention is to encourage the client to slow down breathing to allow for the development of increased lung capacity over time to ease the work of breathing. The longer exhale supports the removal of carbon dioxide, which can lead to impaired cognition for individuals with this disease. The nurse will teach the client to contract the abdominal muscles during pursed-lip breathing as this aids in longer exhalations. Keeping the abdominal wall relaxed will limit the effectiveness of this intervention.
Physical Assessment of the oxygenation status of a client bedside
Monitor the client's RR, observe breathing patterns and effort, checking chest symmetry, and auscultating lung sounds.
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention? Explain uses of BiPAP masks versus CPAP masks. Document assessment and plan for intervention. Notify the healthcare provider of the client's current status. Inquire about factors that contribute to non-adherence.
Inquire about factors that contribute to non-adherence. RATIONALE: The nurse must first assess the reasons that contribute to non-adherence; interventions cannot be determined without a thorough assessment. Other interventions take place after assessment.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? It prescribes oxygen concentration. It regulates the amount of oxygen received. It determines whether the client is getting enough oxygen. It decreases dry mucous membranes via delivering small water droplets
It determines whether the client is getting enough oxygen. RATIONALE: The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen? It prescribes oxygen concentration. It determines whether the client is getting enough oxygen. It decreases dry mucous membranes via delivering small water droplets. It regulates the amount of oxygen received.
It regulates the amount of oxygen received. RATIONALE: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.
nasal catheter
Method for delivering oxygen with a tube inserted through the nose into the posterior nasal pharynx.
Nursing Intervention: Improve Ventilation and Oxygenation
Positions- High Fowler, tripod position, and orthopneic. Breathing Techniques- deep breathing maximizes ventilation due to taking in a large volume of air filling the alveoli to a greater capacity. Incentive Spirometry- technique for deep breathing using a calibrated device, encouraging clients to reach a goal-directed volume of inspired air. Pursed Lip Breathing- form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing to improve gas exchange. Helpful with COPD clients. Diaphragmatic Breathing- breathing that promotes the use of the diaphragm rather the upper chest muscles to increase the volume of air exchanged during inspiration and expiration. Reduces respiratory effort and relieves rapid, ineffective breathing.
INTERVENTIONS AND RATIONALES FOR HYPOXEMIA OR HYPOXIA
Provide periods of rest between activities. Rest decreases oxygen demand and facilitates maintenance or restoration of oxygen within blood. Elevate the head of the bed up to 90 degrees. Head elevation lowers abdominal organs by gravity and provides an increased area for chest expansion when the diaphragm contracts. p. 461 p. 462 Teach how to perform diaphragmatic and pursed-lip breathing and practice same at least b.i.d. Pursed-lip breathing decreases respiratory rate, increases tidal volume, decreases arterial CO2, increases arterial oxygen, and improves exercise performance. Provide a minimum of 2,000 mL of oral fluid per 24 hours. Adequate hydration liquefies respiratory secretions and facilitates expectoration. Expectoration of sputum clears the airway and promotes ventilation. Ensure a daily dietary intake of approximately 2,000-2,500 calories. The act of breathing creates additional caloric demands for energy. Administer oxygen per nasal cannula at 2 L/minute as prescribed by the physician if SpO2 falls below 90% and is sustained there. Supplemental oxygen relieves hypoxemia. Administering 2-3 L/minute prevents suppressing the hypoxic drive to breathe, experienced by clients with chronic respiratory diseases. Explore nicotine cessation therapy with transdermal skin patches. Transdermal nicotine skin patches reduce symptoms associated with nicotine withdrawal. The dose of nicotine can be reduced gradually to promote nicotine cessation.
The nurse has completed a focused respiratory assessment of a client and is documenting the assessment findings in the client's medical record. How should the nurse document the results of pulse oximetry testing? SpO2 = 96% SaO2 = 96% PO2 = 96% PaO2 = 96%
SpO2 = 96% RATIONALE: The measurement of oxygen saturation when obtained by pulse oximetry is abbreviated and recorded as SpO2 to distinguish it from the SaO2 measurement obtained from arterial blood.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. False True
TRUE RATIONALE: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.
Explain the difference between ventilation and respiration.
Ventilation facilitates respiration. Ventilation is mechanical and involves the movement of air, respiration is physiologic and involves the exchange of gases in the alveoli (external respiration) and in the cells (internal respiration)
The nurse would expect to recommend an oxygen tent for which client? a child who will not leave a facemask or cannula in place an adult client who has COPD an older adult client who is unable to get out of bed a comatose client who has a head injury
a child who will not leave a facemask or cannula in place RATIONALE: Oxygen tents are often used in children who will not leave a facemask or nasal cannula in place. The oxygen tent gives the client freedom to move in the bed or crib while humidified oxygen is being delivered; however, it is difficult to keep the tent closed, because the child may want contact with his parents. It is also difficult to maintain a consistent level of oxygen and to deliver oxygen at a rate higher than 30% to 50%.
Partial rebreather mask
a face mask and reservoir oxygen bag with no one-way valve to the reservoir bag so some exhaled air mixes with the oxygen; used in some patients to help preserve carbon dioxide levels in the blood to stimulate breathing
Flowmeter
a gauge used to regulate the amount of oxygen delivered to the client and is attached to the oxygen source prescribed by the physician.
transtracheal catheter
a hollow tube inserted within the trachea to deliver oxygen
tracheostomy collar
a small oxygen-delivery apparatus that fits over a tracheostomy site and is held in place by an adjustable elastic strap that fits around the patient's neck; also called a tracheostomy mask
arterial blood gases (ABGs)
a test performed on arterial blood to determine levels of oxygen, carbon dioxide, and other gases present
CPAP
continuous positive airway pressure a treatment for apnea involving keeping a patient's airways open using air pressure delivered via a face mask
oxygen toxicity
refers to lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours.
hyperbaric oxygen therapy
delivery of 100% oxygen at three times the normal atmospheric pressure within an airtight chamber (Fig. 21-26). Treatments, which last approximately 90 minutes, are repeated over days, weeks, or months of therapy. Providing pressurized oxygen can deliver 15 times as much oxygen to tissues as can be obtained by breathing room air (Mayo Clinic Staff, 2014). Providing clients with brief periods of breathing room air helps prevent oxygen toxicity. HBOT helps regenerate new tissue at a faster rate; thus, its most popular use is for promoting wound healing. It is also used to treat carbon monoxide poisoning, gangrene associated with diabetes or other conditions of vascular insufficiency, decompression sickness experienced by deep sea divers, anaerobic infections (especially in burn clients), and several other medical conditions.
liquid oxygen unit
device that converts cooled liquid oxygen to a gas by passing it through heated coils
T-piece
device that fits securely onto a tracheostomy tube or endotracheal tube
positive airway pressure machines
devices that help to relieve impaired oxygen levels caused by apnea or hypopnea during sleep
external respiration
exchange of gases between lungs and blood
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? flow meter oxygen analyzer nasal strip nasal cannula
flow meter RATIONALE: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.
pulse oximetry
noninvasive technique that measures the oxygen saturation (SaO2) of arterial blood 95%-100 is normal <90% is concerning and if remains low, the client needs oxygen therapy.
The nurse has completed a respiratory assessment of an elderly client with numerous health problems. The results of the assessment include a respiratory rate of 24 breaths per minute and pulse oximetry of 90%. The nurse's next action should be to: position the client in a high Fowler position. administer bronchodilators by metered dose inhaler or nebulizer. page the respiratory therapist. perform percussion to the client's posterior thorax.
position the client in a high Fowler position. RATIONALE: The client is exhibiting mild hypoxia, but pulse oximetry of 90% does not normally warrant respiratory therapy or immediate pharmacologic interventions. Unless contraindicated by their condition, clients with hypoxia are placed in a high Fowler position. This position eases breathing by allowing the abdominal organs to descend away from the diaphragm. Chest percussion is unlikely to resolve the client's hypoxia.
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? prolongs expiration to reduce airway resistance uses upper chest muscles more effectively reduces the need for PRN pain medications replaces the use of incentive spirometry
prolongs expiration to reduce airway resistance RATIONALE: Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance. Pursed-lip breathing does not replace incentive spirometry but is a way to train a client to have more control of their dyspnea. This does not use upper thoracic muscles more effectively.
BiPAP (bilevel positive airway pressure)
provides two different levels of airway pressure: inspiratory positive airway pressure, which is higher during inhalation, and expiratory positive airway pressure, which is lower during expiration. The variation promotes better tolerance among those requiring positive airway pressure therapy. Further modifications are available. They include systems known as automatically adjusting positive airway pressure (APAP) and variable positive airway pressure (VPAP) machines. The APAP machine adjusts the pressure according to the sleeper's position in bed and stages of sleep. A VPAP device normalizes breathing on a breath-by-breath basis, thus suppressing apnea and promoting the time spent in REM sleep
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? peak expiratory flow rate thoracentesis pulse oximetry spirometry
pulse oximetry RATIONALE: Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.
A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from? chronic bronchitis pneumonia sleep apnea chronic obstructive pulmonary disease (COPD)
sleep apnea RATIONALE: This client has all the risk factors of sleep apnea, which consists of multiple periods of apnea during sleep. These periods of apnea cause the person to move into a lighter sleep more often than someone without this disease, thus causing the daytime sleepiness.
water-seal chest tube drainage
technique for evacuation air of blood from the pleural cavity which helps to restore negative intrapleural pressure and re-inflate the lung
Allen Test
test that determines the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery
NASAL STRIPS
used to reduce airflow resistance by widening the breathing passageways of the nose
