Oxygenation

Four basic factors that influence circulation, perfusion, and transport of respiratory gases to the tissues

1) physiological 2) developmental 3) lifestyle 4) environmental

3 steps in the process of oxygenation:

1) ventilation: process of moving gases into and out of the lungs 2) perfusion: relates to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs 3) diffusion: responsible for moving the respiratory gases from one area to another by concentration gradients

Incentive spirometer

A patient inhales slowly and with an even flow to elevate the balls and keep them floating as long as possible to ensure a maximally sustained inhalation Recommended 5-10 breath sessions every hour awake

Nasal cannula

A simple, comfortable device used for precise oxygen delivery Attach to humidified oxygen source with a flow rate up to 6L/min (24% to 40% oxygen) If >4L/min, must humidify because of drying effects

Nebulization

Adds moisture or medications to inspired air by mixing particles of varying sizes with the air Ex. bronchodilators and mucolytic agents

Hypoventilation

Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide Caused by atelectasis and collapsed alveoli In patients with COPD, the administration of excessive oxygen results in hypoventilation S/S: mental status changes, dysrhythmias, and potential cardiac arrest

Tracheostomy

An opening made surgically directly into the trachea to establish an airway. A tracheostomy tube is inserted into the opening and the tube attaches to the mechanical ventilator or other type of oxygen delivery device. Can be temporary or permanent. Interventions: - Assess respirations & for bilateral breath sounds - Monitor arterial blood gasses and pulse ox - Encourage coughing & breathing exercises - Maintain a semi-Fowler's to high Fowler's position - Monitor for bleeding, difficult with breathing, absence of breath sounds, and crepitus (subcutaneous emphysema), which are indications of hemorrhage or pneumothorax - Suction fluids as needed; hyper oxygenate the client before suctioning - Assess the stoma and secretions for blood & purulent drainage - Obtain assistance in changing tracheostomy ties; after placing the new ties, cut and remove the old ties holding the tracheostomy in place

When do you change the chest tube dressing?

Around 72 hours Only as needed

Face mask with reservoir bag

Capable of delivering higher concentrations of oxygen - Partial rebreather: reservoir bag should be at least 1/3 to 1/2 full on inspiration ; delivers from 40% to 70% FIO2 with a flow rate of 6 to 10 L/min Frequently inspect the reservoir bag to make sure it is inflated! High-flow systems should be humidified

Valsalva maneuver

Chest tubes the client may be asked to take a deep breath, exhale, & bear down as the chest tube is removed

Closed pneumothorax

Chest wall is intact Rupture of the lung and visceral pleura (or airway) allows air into the pleural space

Tension pneumothorax

Chest wall is intact (closed) Air enters the pleural space from the lung or airway, and it has no way to leave There is no vent to the atmosphere as there is in an open pneumothorax Most dangerous when patient is receiving positive pressure ventilation in which air is forced into the chest under pressure The positive pressure is transmitted to the mediastinum (heart and great vessels) Mediastinal shift occurs when the pressure gets so high that it pushes the heart and great vessels to the unaffected side of the chest * can quickly lead to cardiovascular collapse * the vena cava cannot accept venous return * with no venous return, there is no cardiac output

Dyspnea management

Clinical sign of hypoxia - subjective sensation of difficult or uncomfortable breathing Associated with exaggerated respiratory effort, use of accessory muscles of respiration, nasal flaring, and marked increases in the rate and depth of respirations Airway management (keep airways patent) Hydration (maintain thin secretions with a fluid intake of 1500 to 2500 mL/day) Mobilization of pulmonary secretions Humidification with more than 4L/minute of oxygen Nebulization Chest physiotherapy

Thoracostomy

Creates an opening in the chest wall through which a chest tube (aka thoracic catheter) is placed, which allows air and fluid to flow out of the chest

How does a chest tube drain?

Gravity Suction

Chest physiotherapy (CPT)

Group of therapies for mobilizing pulmonary secretions Include postural drainage, chest percussion, and vibration Postural drainage: drainage, positioning, and turning. Sometimes accompanied by chest percussion and vibration. Chest percussion: rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration (hands should be cupped) - Contraindicated for patients with bleeding disorders, osteoporosis, or fractured ribs. Avoid over burns, open wounds, or skin infections of the thorax. Vibration: gentle, shaking pressure applied to the chest wall to shake secretions into larger airways

Suctioning

Includes oropharyngeal, nasopharyngeal, orotracheal, nasotracheal, & tracheal Apply negative pressures (not greater than 150 mmHg) during withdrawal of the catheter, never on insertion!!

Spirometry

Measures the volume of air entering or leaving the lungs Post-op patient: incentive spirometer

Name some nervous system diseases that may affect breathing

Myasthenia gravis (chronic autoimmune condition that causes weakening of skeletal muscles) Guillain-Barre (autoimmune condition in which the PNS is attacked) Polio

Hemothorax

Occurs after thoracic surgery and many traumatic injuries The negative pressure between the pleurae is disrupted, and the lung will collapse to some degree, depending on the amount of blood Risk of mediastinal shift is insignificant, as the amount of blood needed to cause it would result in life-threatening intravascular loss

Exhalation

Occurs when the phrenic nerve stimulus stops The diaphragm relaxes and moves up in the chest This reduces the volume of the thoracic cavity (pressure increases) Air flows out of the lungs to the lower atmospheric pressure

Pneumothorax

Occurs when there is an opening on the surface of the lungs or in the airways, in the chest wall, or in both The opening allows air to enter the pleural space between the pleurae, creating an actual space Two types: open and closed

Open pneumothorax

Opening in the chest wall (with or without lung puncture) "Sucking chest wound" Allows atmospheric air to enter the pleural space Air moves in and out of the chest through the opening of the chest wall. Looks bad and sounds worse, but the opening acts as a vent so pressure from trapped air cannot build up in the chest Penetrating trauma (stab, gunshot, impalement) or surgery

Tracheal suctioning

Performed through an artificial airway such as an endotracheal tube or a tracheostomy tube Size of catheter should be about half the internal diameter of the lumen Never apply suction pressure while inserting the catheter to avoid traumatizing the lung mucosa One inserted, maintain suction pressure between 120 and 150 mmHg as you withdraw Apply suction intermittently only while withdrawing the catheter Rotating the catheter enhances the removal of secretions that have adhered to the sides of the tube

Under what conditions will a patient have a chest tube? What thoracic surgeries?

Pneumothorax Hemothorax Coronary artery bypass graft Valve surgery

Conditions requiring chest drainage

Pneumothorax (air between the pleurae) Hemothorax (blood in the pleural space) Pleural effusion (transudate or exudate in the pleural space)

Maintenance and promotion of lung expansion

Positioning - semi-Fowler's * reduces pulmonary stasis, maintains ventilation and oxygenation * uses gravity to assist in lung expansion and reduces pressure from the abdomen on the diaphragm Incentive spirometry: * encourages voluntary deep breathing * used to prevent or treat atelectasis Chest tubes * a catheter placed through the thorax to remove air and fluids from the pleural space or to prevent air from reentering or to reestablish intrapleural and intrapulmonic pressures

Conditions affecting chest wall movement

Pregnancy Obesity Musculoskeletal abnormalities Trauma Neuromuscular disease CNS alterations

Oral airway

Prevents the obstruction of the trachea by displacement of the tongue into the oropharynx

Endotracheal airway

Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, & clear secretions

Tidal volume

The amount of air exhaled in a normal breath

Hyperventilation

The lungs remove carbon dioxide faster than it is produced by cellular metabolism Can be caused by severe anxiety, infection, drugs, or an acid-base imbalance S/S: rapid respirations, sighing breaths, numbness and tingling of hands/feet, light-headedness, and loss of consciousness

Humidification

The process of adding water to gas Necessary for patients receiving oxygen therapy at greater than 4L/min

What are some of the complications of nasal cannula O2 delivery?

Ulcers or sores Could come out of nose easily Dry mucous membranes

Simple face mask

Used for short-term oxygen therapy Delivers 35% to 50% FIO2 Contraindicated for patients with CO2 retention because retention can be worsened Flow rates should be 5L or more to avoid rebreathing exhaled CO2 retained in the mask

Nasopharyngeal suctioning

Used when the client can cough effectively but is not able to clear secretions

Oropharyngeal suctioning

Used when the client can cough effectively but is not able to clear secretions

Nasotracheal suctioning

Used when the client is unable to manage secretions Sterile technique Preferred to orotracheal suctioning because the stimulation of the gag reflex is minimum The entire procedure from catheter passage to its removal is done in less than 15 seconds Allow patient to rest between passages unless in respiratory distress

Orotracheal suctioning

Used when the client is unable to manage secretions Sterile technique The entire procedure from catheter passage to its removal is done in less than 15 seconds Allow patient to rest between passages unless in respiratory distress

Health promotion for oxygenation

Vaccinations: Influenze, pneumococcal Healthy lifestyle: Eliminate risk factors, eat right, regular exercise Environmental pollutants: Second-hand smoke, work chemicals, & pollutants

When do you change the drainage system?

When it is full When it tips over If it is compromised

Boyle's Law

When temperature is constant, pressure is inversely proportional to volume When the volume of a container increases, the pressure decreases When the volume of a container decreases, the pressure increases

Inspiration

When the diaphragm contracts, it moves down, increasing the volume of the thoracic cavity (decreased pressure) Air moves from an area of higher pressure (the atmosphere) to an area of lower pressure (the lungs)

Atelectasis

a collapse of alveoli that prevents normal exchange of oxygen and carbon dioxide

When preparing the patient for trach tube cleansing, sensations the patient may experience that may cause the patient to experience anxiety would include a feeling of: a. choking b. coolness c. warmth d. tightness

a. choking

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? a. record the amount and continue to monitor drainage b. notify the health care provider c. strip the chest tube staring at the chest d. increase the suction by 10 mmHg

a. record the amount & continue to monitor drainage

Which of the following behaviors could indicate that a patient is beginning to experience hypoxia? a. restlessness, anxiety, and mild confusion b. anger, blurred vision, and cyanosis c. aggression, drowsiness, and vertigo d. apathy, blurred vision, and cyanosis

a. restlessness, anxiety, and mild confusion

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? a. blow into the spirometer to elevate the balls in the device b. cough deeply after each use c. clean the mouth piece with an alcohol swab after each use d. use the spirometer q8h

b. cough deeply after each use Proper use loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs. - The patient should inhale deeply to elevate the balls - Clean the mouthpiece with water and dry it after each use - Use the spirometer several times every hour while awake

All of the following conditions are contraindications to the use of percussion and vibration except: a. pneumothorax b. hemoptysis c. cystic fibrosis d. chest pain

c. CF

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? a. postural drainage b. chest percussion c. incentive spirometer d. suctioning

c. incentive spirometer

Quad cough

clients without abdominal muscle control use this while breathing out with maximal effort

When placing a child in an oxygen mist tent, it is important to: a. check the temperature of the child frequently b. keep the linens dry c. check the temperature inside the tent d. all of the above

d. all of the above Used for children with illnesses such as croup and tracheitis to liquefy secretions and help reduce fever. The nebulizer at the top of the humidity tent remains filled with water to prevent non humidified air or oxygen from entering the tent. Air in the tent sometimes becomes cool and falls below 68 degrees F, causing the child to become chilled. Therefore, children in oxygen mist tents require frequent changes of clothing and bed linen to remain warm and dry.

Before evaluating the effects of postural drainage, the nurse understands that the primary reason for this therapy is to help: a. dilate the bronchioles b. promote better use of the diaphragm c. improve circulation in the chest cavity d. clean the lungs of mucopurulent material

d. clean the lungs of mucopurulent material

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? a. open all sterile supplies and solutions b. stabilize the tracheostomy tube c. don sterile gloves d. perform hand hygiene

d. perform hand hygiene This is vital because contamination of the nurse's hands is a primary source of infection

Pursed-lip breathing

deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse

Oxygen masks

fits snugly over mouth and nose two primary types: delivery of low and high concentrations of oxygen

Some nursing interventions of complications of nasal cannula O2 delivery?

humidify the O2 water based lubricant

Intrapleural pressure:

negative! less than atmospheric pressure, which is 760 mmHg at sea level

Nerve that stimulates the diaphragm to contract during inspiration

phrenic nerve

Diaphragmatic breathing

requires the client to relax intercostal and accessory muscles whiles taking deep inspirations

Huff cough

the client stimulates a natural cough reflex that is effective for clearing the airway

Cascade cough

the client takes a slow, deep breath and holds it for 2 seconds while contracting the expiratory muscles. The client opens mouth and performs a series of coughs throughout exhalation, progressively lowering lung volumes

Physiological factors affecting oxygenation

- decreased oxygen-carrying capacity (CHF, anemia) - decreased inspired oxygen (chronic lung disease) - hypovolemia (anemia, dehydration) - increased metabolic rate (fever, SOB)

Any condition that reduces the chest wall movement will result in decreased ____________

Ventilation If the diaphragm is unable to descend fully with breathing, the volume of inspired air decreased, delivering less oxygen to the alveoli and all tissues

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? a. a client who has heart failure and is receiving 100% oxygen via a partial rebreather mask b. a client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula c. a client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar d. a client who has COPD and is receiving oxygen at 2L/min via nasal cannula

a. a client who has heart failure and is receiving 100% oxygen via a partial rebreather mask The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe his own exhaled CO2 instead of receiving the prescribed oxygen dose. Also, oxygen is a gas that can cause toxicity and is high combustible. The higher concentrations of oxygen increase the risk of client injury.

The following supplies are appropriate when giving care to the patient with a tracheostomy: a. non-cotton filled sterile gauze pads for changing soiled dressing b. tissues to wipe secretions after the patient coughs c. a plastic bib to cover the trach opening when feeding an infant d. all of the above

a. non-cotton filled sterile gauze pads for changing soiled dressing - Always use non-cotton products, as cotton can fray and create aspiration risks

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? a. place the client in Trendelenburg's position b. perform percussions directly over the client's bare skin c. use a flattened hand to perform percussions d. remind the client that chest percussions can cause mild pain

a. place the client in Trendelenburg's position The nurse should place the client in right side lying position in Trendelenburg's position to promote draining from the client's left lower lobe

A patient is admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? a. sharp pleuritic pain that worries on inspiration b. crackles over lung bases of affected lung c. tracheal deviation toward the affected lung d. increased diaphragmatic excursion on side of rib fractures

a. sharp pleuritic pain that worries on inspiration Tracheal deviation toward the affected lung (would be TENSION PNEUMOTHORAX!) Would not hear crackles - lung sounds would be absent on the affected side

The patient is admitted with respiratory acidosis. He has rapid respirations, SOB, and a barrel chest. Which of the following results would be the best indication that breathing exercises were effective? a. patient is breathing slower and easier b. blood gases have returned to normal c. patient's skin is warm and dry d. patient is no longer anxious

b. blood gases have returned to normal Because the patient has respiratory acidosis, we would need to know that blood gases have returned to a neutral level (i.e., CO2 levels have decreased) Breathing exercises include: - pursed-lip breathing - diaphragmatic breathing

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? a. antibiotics b. frequent change of position c. oxygen humidification d. chest physiotherapy

b. frequent change of position

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? a. exhale slowly to reach goal volume b. hold breath for 5 seconds after goal volume is reached c. continue to deep breathe between each cycle d. limit repeat pattern of breathing to 5 breaths

b. hold breath for 5 seconds after goal volume is reached Hold breath for 3-5 second after reaching maximal inspiratory volume to decrease the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia - Patient should inhale slowly - Patient should breathe normally for short periods of time between each cycle of breaths to reduce hyperventilation and fatigue - The patient should repeat patterns of breathing 10-20 times every hour while awake

A client who reports SOB requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? a. encourage the client to take deep breaths b. observe the rate, depth, and character of the client's respirations c. prepare to administer oxygen d. give the client a back rub to help her relax

b. observe the rate, depth, and character of the client's respirations

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? a. obtaining hydrogen peroxide for tracheostomy care b. obtaining cotton balls for the tracheostomy care c. obtaining sterile gloves for the tracheostomy care d. obtaining a sterile brush for the tracheostomy care

b. obtaining cotton balls for the tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess.

Use of pulse oximetry with a patient who has a tracheostomy may provide indication that the patient needs: a. hydration b. suctioning c. humidification d. none of the above

b. suctioning The pulse ox will tell the RN if the patient's oxygen levels are falling below the acceptable range, as suctioning removes oxygen along with secretions. Hence the need for hyper oxygenating patients before and between each pass of suctioning

The oxygen delivery system that can provide the highest concentration of oxygen is the: a. nasal cannula b. oxygen tent c. mask with reservoir bag d. mask without reservoir bag

c. mask with reservoir bag *Partial rebreather mask with a reservoir bag that should be at least one third to one half full on inspiration and delivers from 40% to 70% FIO2 with a flow rate of 6 to 10 L/min.

The pressure gauge setting for suctioning indicates: a. maximal pressure exerted by the system b. the pressure appropriate for each age group c. the partial pressure without occlusions d. the highest and lowest safe pressures

c. the partial pressure without occlusions

Use of excessive negative pressure when suctioning the patient's airway may lead to: a. bradycardia b. hypoxia c. cardiac dysrhythmia d. all of the above

d. all of the above - Bradycardia because - Hypoxia because suctioning a patient's airway not only removes secretions, but it also removes oxygen as well. Hence the reason we hyper oxygenate prior to suctioning and between each pass. - Cardiac dysrhythmia because

The purpose of tracheostomy site maintenance care include: a. preventing decannulation b. providing a stable, secure airway c. preventing obstruction d. all of the above

d. all of the above - decannulation is the removal of the tracheostomy tube; maintenance of the site ensures that the tube is secured via the ties - maintenance includes suctioning, which removes any secretions that buildup in the tube that could obstruct airflow - by ensuring that the site is free from obstructions and properly secured, the airway remains patent

Duration of suctioning is r/t development of hypoxemia; an early sign of hypoxemia is: a. vagal stimulation b. bradycardia c. diaphoresis d. tachycardia

d. tachycardia The brain tries to compensate for reduced oxygen by increasing the heart rate to increase the cardiac output

The oxygen system which allows a fixed oxygen delivery at a fixed or predicted (FIO2) is: a. mask with reservoir bag b. oxygen tent c. oxygen hood d. venturi mask

d. venturi mask The Venturi mask delivers higher oxygen concentrations of 24% to 60% with oxygen flow rates of 4 to 12L/min, depending on the flow-control meter selected.

Venturi mask

delivers oxygen at higher concentrations of 24% to 60% with oxygen flow rates of 4 to 12 L/min depending on the flow-control meter selected

Correct nasotracheal suctioning includes: a. hyperventilating the patient for several minutes prior to suctioning b. insertion upon taking a breath, but not during swallowing c. apply intermittent suction for up to 10 to 15 seconds after insertion d. noting if there is a change in pulse of 20 bp or pulse ox falls before 90% of 5% of baseline e. all of the above

e. all of the above

The nurse assesses a client with a closed chest tube drainage system. On inspection, the nurse notes that the system is cracked. What should the nurse do?

If the nurse notes that the chest tube drainage system is cracked, the chest tube should be disconnected from the system and submerged in a bottle of sterile water in order to maintain the water seal. The system will then need to be replaced. A clamp should be kept at the bedside in case the system needs to be changed. However, the nurse should never clamp a chest tube without a written prescription from the health care provider and per agency policy. The drainage system (chest tube & bottle of sterile water) should also be maintained below the level of the chest if this complication occurs.

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? a. nasal cannula b. Venturi mask c. simple face mask without inflated reservoir bag d. plastic face mask with inflated reservoir bag

a. nasal cannula

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing b. allow 30 seconds between suctioning passes c. hyperventilate the client with 50% oxygen for 30 seconds d. perform a maximum of 4 passes with the suction catheter

a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing The nurse should pull the suction catheter back 1cm when the client starts to cough, or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning. - The nurse should allow 1 minute between suctioning passes to prevent hypoxia & to hyperventilate the client - The nurse should administer 100% oxygen for at least 2 minutes prior to suctioning to decrease hypoxia - The nurse should perform a max of 3 passes with the suctioning catheter

The patient is receiving intermittent suctioning. The nurse waits between suctioning attempts to allow: a. the patient to cough up secretions b. the patient to replenish oxygen stores c. time for readjusting the suction pressure d. time to clear the suction catheter of mucus

b. the patient to replenish oxygen stores A major consequence of suctioning is that it removes oxygen, which can cause a patient to experience hypoxia.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? (select all that apply) a. excessive bubbling in the water seal chamber b. vigorous bubbling in the suction control chamber c. drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. occlusive dressing in place over the chest tube insertion site f. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

c. drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. occlusive dressing in place over the chest tube insertion site f. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation The bubbling of water in the water seal chamber indicates air drainage from the client and is usually seen when intrathoracic pressure is higher than atmospheric pressure (negative pressure is desired). Bubbling in the water seal chamber may indicate an air leak, which is an unexpected finding. Gentle (not vigorous) bubbling should be noted in the suction control chamber. Positioning below the client's chest allows gravity to drain the pleural space. A total of 50 mL of drainage is not excessive in a client returning to the unit. More than 70-100 mL/h is considered excessive. Fluctuation of water in the tube during inhalation and exhalation is expected. If fluctuation is absent, it may indicate that the tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space.

The following factors influence tracheostomy functioning: a. patient's ability to cough b. patient's hydration and nutrition c. infection d. all of the above

d. all of the above

The purpose of teaching the patient pursed-lip breathing is to help: a. increase intrapulmonic pressure b. promote a regular breathing pattern c. increase alveolar ventilation and oxygenation d. all of the above

d. all of the above

The nurse is caring for a pt who exhibits labored breathing and uses accessory muscles. The pt has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (select all that apply) a. SpO2 levels b. amount of sputum production c. change in respiratory rate and pattern d. pain in lower calf area

a. SpO2 levels b. Amount of sputum production c. Change in respiratory rate & pattern

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client & family? a. use battery-operated equipment for personal care b. apply mineral oil to protect the facial skin from irritation c. remove the television set from the client's bedroom d. wear cotton clothing to avoid static electricity

d. wear cotton clothing to avoid static electricity The use of cotton clothing will limit the buildup of static electricity. Oxygen is highly combustible. - Electrical equipment in good condition with no frayed wires is acceptable - Most oils & petroleum products are flammable when used on the body! - As long as the TV is in good working order, it is fine.

Chest tube drainage system

The chest tube drainage system returns negative pressure to the intracellular space - Used to remove abnormal accumulations of air and fluid in the pleural space Water seal chamber: - water oscillates (moves up as they inhale & down when they exhale) - excessive bubbling indicates an air leak Suction control chamber: - gentle bubbling indicates there is suction and does not indicate that air is escaping from the pleural space An occlusive sterile dressing is maintained at the insertion site Keep the drainage system below the level of the chest and the tubes free of kinks, dependent loops, and other obstructions Encourage coughing and deep breathing Change position frequently to promote drainage and ventilation If the drainage system cracks or breaks, insert the chest tube into a bottle of sterile water, remove the cracked or broken system, & replace with a new system

A safety measure when performing tracheostomy care without an assistant is to: a. pre-cut ties so the patient is off ventilation a shorter time b. cut off old ties after new ties are in place and securely tied c. not change ties until you have assistance d. change ties only when they are soiled

b. cut off old ties after new ties are in place and securely tied - NEVER cut ties yourself. Can fray! - You can change ties without assistance, as long as you place the new ones on before removing the old ones