ATI - Chapter 53 Flashcards
Oxygen helps maintain adequate _____ for clients who have many acute and chronic respiratory problems (hypoxemia, cystic ribrosis, asthma). or are at risk for developing hypoxia.
cellular oxygenation
Maintaining a patient ____ is a nursing priority. It involves mobilizing secretions, suctioning the airway, and managing artificial airways (endotracheal tubes, tracheostomy tubes) to promote adquate gas exhange and lung expansion.
airway
A ___ is a device with a sensor probe that attaches securely to the fingertip, to =, birdge of nose, earlobe, or froehead with a clip or band.
pulse oximeter
A pulse oximeter measure pulse saturation (______) via a wave of infrared light that measures light absorption by oxygenated and deoxygenated hemoglboin in arterial blood.
SpO2
SpO2 reliably reflects the precent of saturation of ______ (sSaO2) when the SaO2 is greater than ____%
hemoglobin
70%
Oxygen is tasteless and colorless gas that accounts for 21% of ____.
atmospheric air
Oxygen flow rates vary to maintain an SpO2 of _____% to ___% using the lowest amount of oxygen to achieve the goal without risking complications.
95 - 100%
The fraction of inspired oxygen (FIO2) is the percentage of oxygen the client ____.
receives
Noninvasive measurment of the oxygen saturation of the blood for monitoring respiratory status when assessment finding inlcude any of the following.
increased work of breathing wheezing coughing cyanosis changes in respiratory rate or rhythm adventitious breath sounds restlessness, irritability, confusion
Interventions for readings less than 90% (indicating hypoxemia)
confirm probe placement
confirm that the oxygen delivery system is functioning and that the lcient is receiving the prescribed oxygen levels
place the client in semi-fowler’s or fowler’s position to promote chest expansion and to maximize ventilation
Encrougae deep breathing
Remain with the client and provide emotional support to decrease anxiety
The SpO2 expected reference range
95 -100
The SpO2 accepted levels reference range
91-100
Some illness states can allow for ____ to ____. Readings less than 90% reflect hypoxemia.
85-89
SpO2 values can be slightly lower for older adult clients and client who have ___.
dark skin
Additional reasons for low SpO2 levels include hypothermia, por peripheral blood flow, too much light (sun, infrared lamps), low hemoglobin levels, ______, movement, edema and nail polish.
jaundice
Oxygen is a thrapeutic gas that treats _____(low levels of arterial oxygen). Administering and adjusting it requires a prescription.
hypoxemia
Manifestations of early hypoxemia
tachypnea tachycardia restlessness, anxiety, confusion pale skin, mucous membranes elevated bp use of accessory muscles, nsala flaring, tracheal tugging, adventitious lung sounds
Manifestations of late hypoxemia
stupor cyonotic skin, mucous membranes bradypnea bradycardia hypotension cardiac dysrhythmias
Monitor respiratory rate and pattern, level of consciousness, SpO2, and _____ when giving oxygen therapy.
arterial blood gas
Provide oxygen therapy at the ___ liter flow that will correct hypoxemia.
lowest
Maske sure the mask creates a secure seal over the ______.
nose and mouth
Assess/monitor hypoxemia and hypercarbia (elevated levels of CO2); restlessness, hypertension and _____.
headache
Ausculate the lungs for breath sounds and adventitious sounds, such as _____.
crackles and wheezes
Assess/Monitor ______- status with pulse oximetery and arterial blood gases (ABGs)
oxygenation
When on oxygen therapy promote good ____.
oral hygiene
Encourage turning, coughing, deep breathing, and the use of incentive spirometry and _____.
suctioning
When on oxygen therapy promote rest and ____.
decrease environmental stimuli
When on oxygen therapy provide ____ support.
emotional
When on oxygen therapy assess nutritoinal status and provide ______.
supplements as needed
When on oxygen therapy assess skin integrity. Provide moisture and _____.
pressure relief devices
When on oxygen therapy assess and _____ response to therapy.
document
When on oxygen therapy titrate oxygen to maintain the recommended ____.
oxygen saturation
When on oxygen therapy discountinue _____.
gradually
When on oxygen therapy monitor for respiratory ______ (decreased resp rate and level of consciouness)
depression
Low flow oxygen delivery systems deliver varying amounts of oxygen based on the ______ and the client’s breathing pattern.
delivery method
Low flow oxygen delivery through a ______ is tubing with two small prongs for insertion into the nares.
nasal cannula
Fraction of inspired oxygen (FIO2) via a nasal cannula ranges from 24% to 44% at a flow rate of ____.
1 to 6 L/min
A cannula is a safe, simple, and _____ method.
easy to apply
A cannula is comfortable and ____.
well tolerated
With a ____ a client is able to eat, talk, and ambulate.
cannula
The FIO2 varies with the flow rate, and rate and depth of the client’s breathing which is a disadvantage when using a ____.
cannula
Extended use of a cannula can lead to ___ and dry mucous membranes.
skin breakdown
A disadvantage to a ______ is that it is easily dislodged.
cannula
When using a nasal cannula make sure to assess the patency of the nares. Ensure that the prongs fit in the nares properly. Use _____ to prevent dry nares. Provide humidification for flow rates of _____ or greater.
water soluble gel
4L or greater
A ______ covers the client’s nose and mouth.
simple face mask
A simple face mask delivers an FIO2 of _____ to _____ at a flow rate of 5 to 8 L/min.
40 to 60%
The minimum flow rate is _____ to ensure flushing of CO2 from the mask when using a simple face mask.
5 L/min
Advantages to a simple face mask is that it is easy to apply and can be more comfortable than a ____.
nasal cannula
The simple face mask is a simple _____.
delivery method
The simple face mask provides _____ oxygen
humidified
With a ______ flow rates less than 5L/min can result in rebreathing CO2.
simple face mask
Clients who have anxiety or claustrophobia do not tolerate a _____ well.
simple face mask
Eating, drinking, and ____ are imparied when using a simple face mask.
talking
Moisture and pressure can ___ under the simple face mask and cause skin breakdown.
collect
When using a simple face mask assess proper fit to ensure a secure seal over the nose and mouth. make sure the client wears a nasal cannula during meals. Use with caution for clients who have a high risk of _______ or airway obstruction.
aspiration
When using a simple face mask monitor for ____.
skin breakdown.
A _____ mask covers the clients nose and mouth.
partial rebreather
A partial rebreather mask delivers an FiO2 of ___ to ____ at flow rates of 6 -10 L/min.
40 to 70%
An advantage to a partial rebreather mask is that it has a reservoir bag attached with no valve, which allows the client to rebreathe up to ____ of exhaled air together with the room air.
1/3
With a ____ mask complete deflation of the reservoir bag during inspiration causes CO2 buildup.
partial rebreather
The FiO2 varies with the client’s _____ with a partial rebreather mask.
breathing pattern
Clients who have ____ or claustrophobia do not tolerate the partial rebreather mask well.
anxiety
With a partial rebreather mask eating, ____, and talking is impaired.
breathing
With a _____ mask it is necessary to keep the reservoir bag from deflating by adjusting the oxygen flow rate to keep the reservoir bag 1/2 to 1/3 full on inspiration
partial rebreather
With a _____ mask it is necessary to assess proper fit to ensure a secure seal over teh nose and mouth. Assess for skin breakdown beneath the edges of the mask and _____.
partial rebreather
bridge of the nose
Make sure the client uses a _____ during meals with a partial rebreather.
nasal cannula
A partial rebreather mask should be used with caution for patients who have a high risk of aspiration or ______.
airway obstruction
A nonrebreather mask covers the clients _____.
nose and mouth.
Fraction of inspired oxygen delivers ___ to ____ at flow rates of 10 - 15 L/min to keep the reservoir bag 2/3rds full during inspiration and expiration
60 to 100 %
A ____ mask delivers the highest O2 concentration possible (except for intubation).
nonrebreather
A one way valve situated between the mask and resrvoir allows the client to inhale maximum O2 from the reservoir bag. The two exhalation ports have flaps covering them that prevent room air from entering the _____ mask,
nonrebreather
The valve and flap on the mask must be intact and functional during each breath with a _____ mask.
nonrebreather
A nonrebreather mask is poorly tolerated by clients who have anxiety or ____.
claustrophobia
Eating, drinking, and ____ are impaired with a nonrebreather mask.
talking
Nonrebreather masks should be used with caution for clients who have a high risk of ____ or airway obstrction.
aspiration
Perform an ____ assessment on the valve and flap of a nonrebreather mask.
hourly
Assess proper fit ensure seal over the nose and mouth. Assess for skin breakdown ____ of the mask and the bridge of the nose with a nonrebreather mask.
beneath the edges
Low Flow oxygen delivery systems
nasal cannula
simple face mask
partial rebreather
nonrebreather
A venturi mask is a ____ flow oxygen delivery system that covers the client’s noe and mouth.
high
A venturi mask delivers an FiO2 of ___ to ___ flow rates of 4 to 12 L/min via different size adapters, which allows specific amounts of air to mix with oxygen.
24% to 60^
A ___ mask delivers the most precise oxygen concentration.
venturi
Humidification is not necessary with a ____ mask.
venturi
A _____ mask is best for clients who have chronic lung disease.
venturi
A disadvantage to a ___ mask it that it is expensive.
venturi
A venturi mask impairs ____, drinking, and talking.
eating
Assessment of a venturi mask needs to be frequent to ensure an ______ flow rate.
accurate
Assess proper fit to ensure a secure seal over teh nose and mouth. Assess for skin breakdown beneath the edges of the mask particularly on the ____ when using a venturi mask.
nares
Two types of aerosol masks
face tent
trachostomy collar
A ____ fits loosely around the face and neck.
face tent
A _____ is a small mask that covers the surgically created opening of the trachea.
tracheostomy collar
An ____ mask delivers an FiO2 of ____ to ____ at flow rates of at least 10 L/min.
aersol (face tent or tracheostomy collar)
An aerosol mask provides high ____ with oxygen delivery.
humidification
An _____ mask is a good option for those that do not tolerate masks well.
aersol mask
face tent or tracheostomy collar
_____ masks are useful for clients who have facial trauma, burns, and thick secretions.
aersol mask
A drawback to an aersol mask is that the high humidification requires ____.
frequent monitoring
Nurses need to empty ____ from the tubing often with aerosol masks.
condensation
Nurses need to ensure adequate water in the ____ _canister with aersol masks.
humidification
Nurses need to ensure that the ___ leaves from the vents during inspiration and expiration.
aerosol mist
Make sure the tubing does not pull on the _____ with a tracheostomy collar.
tracheostomy
______ can result from high concentrations of oxygen (typically greater than 50%), long durations of oxygen therapy (typically more than 24 to 48 hours) and the severity of lung disease.
oxygen toxicity
Nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, ____ and hypoventilation are manifestations of oxygen toxicity.
sore throat
With oxygen toxcity use the lowest level of oxygen necessary to maintain an adequate ____.
SpO2
Monitor _____ and notify the provider if SpO2 levels are outside the expected reference range to make sure oxygen toxicity.
ABGs
To prevent oxygen toxicity decrease the FiO2 as teh client _____ improves.
SpO2
Clients who have conditions that cause alveolar ________ can be sensitive to the administration of oxygen.
hypoventilation
In oxygen-induced hypoventilation monitor respiratory rate and pattern, level of consciousness , and _____.
SpO2
In oxygen-induced hypoventilation provide oxygen therapy at the lowest liter flow rate that manages ______.
hypoxemia
In oxygen-induced hypoventilation monitor if the client tolerates it, use a ______ to deliver precise oxygen levels.
Venturi mask
