Chapter 39 Nursing
adventitous
abnormal breath sound heard over lungs
The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?
an infant with a resp rate of 16 bpm -infant normal range is 20-40 bpm -child normal range is 20-32 bpm -child 6-12 is 18-26 bpm
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
arterial blood gas -include levels of oxygen, CO2, bicarbomate, and pH -they determune the adequacy of alveolar gas exchange and the ability of the ungs and kidneys to maintain the acid ase balance of body fluids
tracheosotomy
artifial opening made in trachea through which a tracheostomy tube is inserted
The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take?
assess oxygen tubing connection
wheezes
continuous high pitched squeak or muscial sound made as air moves through narrowed or partially obstructed airwway
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
corticosterdoids -open airways and ease breathing and releive inflammattion
hypoxemia
deficient oxygenation of blood
surfactant
detergent like phospholipid that reduces surface tension pf fluid in alveoli
dyspnea
difficult or labored breathing
nasal cannula
disposable plastic devie taht delivers oxygen via two protruding prongs for insertion into the nostrils
crackles
fine crakling sounds made as air moves throuhg the wet secretions in the lungs
While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?
fluid in lungs
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?
high fowlers position -postural drainage makes use of gravity to drain sectetion from lungs from smally pulmonary branches into larger ones where they can be removed by coughing
bronchial sounds
high pitches harsh blowing sounds -sound on expiration is longer than inspiration -heard over larynx and trachea
nursing diagnoses
identofy problems related to alteration in cardiopulmonary function and problems for which alterations in cardiopulmonary function are the etiology
hypoxia
inadequate amounf os oxygen available to cells
atelectasis
incomplete expansion or collapse of part of the lungs
spirometer
instrument used to measure lung capacities and volumes, one type is used to encourage deep breathing
oxygen analyzer
measures the percentage of delivered oxygen to determine whether the client is recieving the prescribed amount
brondodilator
medication that relaxes contractions of smooth muscles of the bronchioles
canography
method to monitor ventilation and indirectly, blood flow through lungs
brionchiovesicular sounds
moderate blowing sounds -inspiration = expiration - heard over mainstem bronchus
Factors that can interfere with accurate pulse oximetry
nail polish, thickness of nails, acrylic nails, peripheral vascular disease
vesicular sounds
normal sound of respiration heart on auscultation over peripheral lung areas
nursing assessment
nursing history, physcial assessment, and review of medical info including pertinent diagnostic tests
face tents
open and loose around the face, should be used on patients with facial burns or trauma -simple mask or nasal canua\la would irritae the facial skin
Which statement accurately describes a general consideration when performing CPR on a client?
perform cpr the same as you would on both obese and non obese clients -cpr should be initaited even if nurse is unsure if client has a pulse, if available, use a one way valve mask over childs nose and mouth
factors effecting oxygenation
persons level of health, developmental stage, use of medications, lifestyle, environment, and psychological health
endotracheal tube
polyvinyl-chloride airway that is inserted through nose or mought into the trachea, uses laryngoscope as a guide
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
poor tissue perfusion -chronically poor perfsion may result in hair loss in affected aea, discolored skin, thickend nails, shiny dry skin indicative of inadequare tissue nutrition
Hypoxia can result from
problems with ventilation, respiration, or perfusion
perfusion
process by which oxygenated blood passes through the body tissues
nursing interventions
promote optimal functioning of the cardiopulmonary systems, promote comfort, promote and control coughing, meet resp needs with meds, provide oxygen, manage chest tubes, use artifical airways, suction airway, clear obstructed airway, administer cardiopulmonary resuscitation
tachypnea
rapid rate of breathing
sputum
respiratory secretion expelled by coughing or clearing the throat
dysrythmia/arrhythmia
result of problems with electrical impulse generation or abnormal conduction of electrical impulses through the heart
bradypnea
slow rate of breathing
cardiac output
stroke volume x heart rate
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
suction the trach tube using sterile technique -area around new tracheostomy may need to be assessed and cleaned every 1-2 hrs -
angina
temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles
A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?
trauma to tracheal mucosa -occluding the y port is what creates the suction
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?
vesicular -described as low pitched, soft sounds over the lungs peripheral fields -
Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?
when holding airway on side of face it should reach from tragus of ear to tip of nostril