Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Exam 3 > Chapter 14 > Flashcards

Chapter 14 Flashcards

1
Q

Airway Management?

A

-Managing airway compromise includes respiratory assessment and measuring vital signs , including oxygen saturation via pulse oximetry and administration of oxygen

-Maintaining a patent airway is a nursing priority .

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Physiology?

A

-Hypoxia reduced oxygen content in tissue and cells) occurs, cell metabolism slows down, and cells begin to die.

-Oxygen is treated as a drug; therefore, it is important to follow the six rights of drug
administration when administering oxygen.

-Thorough assessment of the respiratory system must be done.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Manifestations Of Hypoxia Early ?

A

-Tachypnea (abnormally rapid rate of breathing-fast breathing)

-Tachycardia (fast heart rate)

-Restlessness,( anxiety, confusion )

-Pale skin, mucous membranes

-Elevated blood pressure

-Use of accessory muscles, nasal flaring, adventitious lung sounds.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Manifestations of Hypoxia Late ?

A

-Stupor (repeated attempts to arouse the person only briefly )

-Cyanotic skin (blue skin), mucous membranes

-Bradypnea (slow breathing )

-Bradycardia (slow heart rate)

-Hypotension low blood pressure)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Nursing Actions?

A
  • Monitor respiratory rate and pattern, level of consciousness and SpO2

-Provide oxygen therapy at the lowest liter flow that will correct hypoxia

-Make sure the mask creates a secure seal over the nose and mouth

-Assess/monitor hypoxia and hypercarbia(elevated levels of )

  • Auscultate the lungs for breath sounds and adventitious sounds

-Assess/monitor oxygenation status with pulse oximetry and ABGS

-Promote oral hygiene

-Encouraging turning, coughing, deep breathing and the use of incentive spirometry and suctioning

-Promote rest and decrease environmental stimuli

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Nasal Cannula ?

A

1-6L /min

Tubing with two small prongs for insertion onto the nares

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Nasal Cannula assessment Advantages ?

A

-A cannula is a safe , simple , and easy -to-apply method

-A cannula is comfortable and well tolerated

-The client is able to eat , talk , and ambulate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Nasal Cannula disadvantage?

A

-The , FiO2 varies with the flow rate, and depth of the clients breathing

-Extended use can lead to skin breakdown and dry mucous membranes

-Tubing is easily dislodge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Nasal Cannula nursing action ?

A

-Assess the patency of the nares
-Ensure that the prongs fit it in the nares properly
-Use water - soluble gel to prevent dry nares
-Provide humidifier for flow rates of /min and greater
-Low-Flow oxygen delivery systems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Simple Face Mask ?

A

5-8 L/min

-cover the client nose and mouth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Simple face A face mask advantage ?

A

-is easy to apply and can be more comfortable than a nasal cannula

-it a simple delivery method

-It provides humidified oxygen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Simple face Disadvantage?

A

-Flow rates less than 6L/min can result in rebreathing of CO2

-Clients who have anxiety or claustrophobia do not tolerate it well.

-Eating, drinking and talking are impaired .

-Moisture and pressure can collect under the mask and cause skin breakdown

-Face masks pose a greater risk of aspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Simple face Nursing Action ?

A

-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 aspiration or airway obstruction

-Monitor for skin break down
-Low -Flow Oxygen Delivery Systems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Partial Rebreather Mask ?

A

6-12 L/min

-cover the client nose and mouth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Partial Rebreather Mask Advantages?

A

-The mask has a reservoir bag attached with no valve, which allows the client to re-breathe up to 1/3 of exhaled air together with room air.

It also allows easier humidification of oxygen .

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Partial Rebreather Mask Disadvantages?

A

-Complete deflation of the reservoir bag during inspiration causes buildup .

-The FiO2varies with the client’s breathing pattern.

-Clients who have anxiety or claustrophobia do not tolerate it well.

-Eating, drinking, and talking are impaired.

-The bag can twist or kink easily.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Partial Rebreather Mask Nursing Actions?

A

-Keep the reservoir bag from deflating by adjusting the oxygen flow rate to keep the reservoir bag 1/3 to full on inspiration .

-Assess proper fit to ensure a secure seal over nose and the mask and bridge of the nose.

-Make sure the client uses a nasal cannula during meals.

-Use with caution for clients who have a high risk of aspiration or airway obstruction. -Low-Flow Oxygen Delivery System

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Non-Rebreather Mask ?

A

6-15 L/min

-cover the client nose and mouth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Non-Rebreather Mask Advantages?

A

-It delivers the highest concentration possible (except for intubation)

-A one-way valve situated between the mask and reservoir allows the client to inhale maximum 02 from the reservoir bag.

The two exhalation ports have flaps covering them that prevent room air from entering the mask

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Non-Rebreather Mask Disadvantage?

A

-The valve and flap on the mask must be intact and functional during each breath.

-It is poorly tolerated by clients who have anxiety or claustrophobia.

-Eating, drinking, and talking are impaired

-Use w/caution for clients who have a high risk of aspiration or airway obstruction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Non-Rebreather Mask Nursing Actions?

A

-Perform an hourly assessment of the valve and flap

.-Assess proper fit to ensure a secure seal over the nose and mouth.

-Assess for skin breakdown beneath the edges of the mask and bridge of the nose .

-Make sure the client uses a nasal cannula during meals

-low -Flow oxygen Delivery Systems **

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Venturi Mask ?

A

4-12 L/min

-covers the client nose and mouth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Venturi Mask Advantage ?

A

-It delivers the most precise oxygen concentration with humidity added

-Best for clients who have chronic lung disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Venturi Mask Disadvantages?

A

-Use is expensive

-Eating , drinking , and talking are impaired

-The mask and added humidity can lead to skin breakdown .

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Venturi Mask Nursing Actions ?

A
  • Assess frequently to ensure and accurate flow rate

-Assess proper fit to ensure a secure seal over the nose and mouth

-Assess for skin breakdown beneath the edges of the mask , particularly on the nares

-Make sure the tubing is free of kinks -Ensure that the client wears a nasal cannula during meals .

-High-Flow Oxygen Delivery Systems **

26
Q

Aerosol Mask (aka face tent ) ?

A

Fits loosely around the face and neck

27
Q

Aerosol Mask (aka face tent -Tracheostomy collar ?

A

a small mask that covers the surgically created opening of the trachea

28
Q

Aerosol Mask (aka face tent ) Advantages ?

A

-Use with clients who do not tolerate masks well

-Useful for clients who have facial trauma, burns and thick secretions

29
Q

Aerosol Mask (aka face tent) Disadvantages ?

A

High humidification requires frequent monitoring

30
Q

Aerosol Mask (aka face tent ) Nursing Actions?

A
  • Empty condensation from the tubing often

-Ensure adequate water in the humidification canister

-Ensure that the aerosol mist leaves from the vents during inspiration and expiration

-Make sure the tubing does not pill on the tracheostomy.

-High-Flow Oxygen Delivery System***

Book

31
Q

Faceplate ?

A

-This is the “collar” of the trach tube, to which the ties or sutures are connected to secure the tube in place

-On this you will see numbers and letters that tell your healthcare provider what kind of trach tube you have place as well as the dimensions of the tube

32
Q

Outer Cannula?

A
  • Most tubes have an outer” and an “inner” tube or cannula

-The outer cannula is connected to the face plate and stays in place until it is time for your tube to be replaced

-The width, or diameter, of the outer cannula takes up space in your trachea.

-If the outer cannula diameter (0.D . ) is too large in comparison with your trachea, there may be difficulty using certain speaking valves.

33
Q

Shaft?

A

-This refers to the portion of the tube behind the face plate. In other words the part of the tube that is inside the body.

-Standard adult tracheostomy tubes are typically 75mm in length which is generally sufficient for most adults

-For necks that may be thicker in diameter, longer tracheostomy tubes are available.

-This means the shaft will be longer than the standard, however, the portion of the tube in front of the face plate is usually the same length as a standard tube

34
Q

Curvature?

A
  • The curvature of the tube refers to the area where there is a bend in the shaft.

-The curvature is generally standardized across tubes although custom tubes may be ordered to accommodate a different location and/or angle of curvature.

-There are some tubes that are flexible as well, allowing the the to curve according to the patient’s anatomy

-The curvature is an important feature of the tracheostomy tubeIn order to be effective, the tube must be rigid enough to maintain an open airway also important that the shaft of the tube not come in contact with the trachea once it passes through the tracheostomy site.

-The tissues of the trachea are somewhat delicate and direct contact with the trach tube may result in injury/trauma to the trachea

-The curvature specified so that the shaft of the tube passes essentially horizontally through the soft tissues of the neck enters the trachea, and the curvature should ensure the shaft of the tube is “floating within the tracheaLike tube within a tubeIf the curvature is not appropriate for the patient, the tube may then rest or even push against the trachea causing damage

35
Q

Fenestration?

A
  • A fenestration is a hole in the shaft of the tracheostomy tube, above the curvature, and therefore also above the cuff of a cuffed trach tube.

-The purpose of a fenestration is to allow for airflow upward and through the vocal cords. Without airflow through the vocal cords, a tracheostomy patient will not be able to produce a voiceFor more information regarding voice production

  • A fenestration is not necessary to be able to talk with a tracheostomy tube, although it will likely improve the loudness and ease of producing a voice

-On a fenestrated tube, there is a fenestration in the outer cannulaIn order for the fenestration to be of any benefit for voicing however, the inner cannula must also be fenestrated

-There are advantages and disadvantages to fenestrated tubes

36
Q

Cuff?

A
  • The cuff of a tracheostomy tube is a balloon-like structure attached to the outer cannula below the level of the curvature.

-A cuff can be inflated with air to fill the space in the trachea between the tracheal wall and the outer cannula.

-When a cuff is not needed, however, it can be deflated as well

-There are various types of coughs as well as reasons for using cuffed tracheostomy tubes

37
Q

Pilot Balloon?

A

-is a small plastic balloon with a valve seal that is attached to the shaft of the balloon by a lead line.

-The pilot balloon lead line is usually attached to the outer cannula near the face plate.

-The cuff is inflated and deflated via this balloon and the status of the cuff inflation can also be determined fairly well by the inflation status of the pilot balloon. Since the cuff itself sits deep within the trachea, it is impossible to see the cuff status directly.

-However, if the pilot balloon is inflated, this is an indication the cuff inflated as wellSimilarly, if the balloon is flat, or deflated, this is an indication the cuff is likely deflated

-Although the pilot balloon is an indication regarding the status of the cuff, it is impossible to determine the exact degree of inflation vs deflation based on the pilot balloon alone.

38
Q

Inner Cannula?

A
  • The inner cannula sits inside the outer cannula and is designed to be removed and cleaned or removed and replaced.

-As builds up within the inner cannula (normal) the airway is narrowed. By removing the inner cannula, the airway is improved as the patient is able to breathe freely through the space of the outer cannula.

-This is especially important in the event of a mucous plug that may block the entire inner cannula.

-The resulting inability to breath is quickly corrected by removing the inner cannula

39
Q

Hypoxia ?

A

(reduced oxygen content in tissue and cells) occurs , cell metabolism slows down , and cells begin to die

40
Q

Oxygen therapy must be order by?

A

-ordered by a health care provider and closely monitored by the nurse to ensure proper administration

-oxygen treated as drug

41
Q

Some oxygen delivery devices?

A

such as the continuous positive airway pressure (CPAP )

42
Q

The percentage or concentration of oxygen delivered is called the ?

A

fraction of inspired oxygen (Fi*O_{2})

43
Q

An oxygen flowmeter?

A

is the device used to set the prescribed rate of oxygen

44
Q

Look pg 340 photo

A
45
Q

Safety Precaution During Oxygen Use ?

A

-Instruct the patient , the family , and visitors that smoking is not permitted because oxygen supports combustion (burning)

-Know the facility’s fire procedure and the locations of fire extinguishers .

46
Q

Delivering through a nasal cannula?

A

-( device consisting of small tubes inserted into the nares ) is the most common way to administer oxygen , but it also can be delivered by a Venturi mask

47
Q

Signs and Symptoms of Hypoxia ?

A

-Apprehension , anxiety , restlessness

-Behavioral changes Cardiac dysrhythmias

-Cyanosis

-Decreased ability to concentrate

-Decreased level of consciousness

-Digital clubbing (with chronic hypoxia )

-Dyspnea (difficult breathing )

-Elevated blood pressure

-Increased fatigue

-Increased pulse rate : As hypoxia advances , bradycardia results , which in turn results in decreased oxygen saturation

-Increased rate and depth of respiration : As hypoxia progresses , respirations become shallow and slower , and apnea develops

-Pallor ( pale appearance) -Vertigo ( nausea, vomiting)

48
Q

arterial partial pressure oxygen (PaO2) level ?

A

(the amount of oxygen found in the arterial circulation )

49
Q

An endotracheal (ET ) tube?

A

is a tube inserted through the patient’s mouth and into the upper airway to provide a patent airway

-Suctioning of secretions also can be performed

50
Q

A tracheostomy?

A

an artificial opening made by a surgical incision into the trachea

51
Q

apnea?

A

(cessation of breathing ) or some form of respiratory obstruction.

52
Q

Maintain nutritional levels ?

A

-Patients with ET tubes are allowed nothing by mouth (NPO)

-patient is able to eat, a cuffless tracheostomy tube is best

-risk for aspiration because of swallowing difficulties or who are receiving mechanical ventilation

53
Q

The nurse is responsible for evaluating the patient’s airway patency?

A

(openness) and response to airway suctioning.

54
Q

Common vacuum settings for wall suction units ?

A

(1) Infants: 60 to 80 mm Hg
( 2) Children: 100 to 120 mm Hg
( 3) Adults: 120 to 150 mm Hg b

55
Q

Common catheter sizes?

A

( 1) Infant : 6-Fr to 8 -Fr
( 2) Children : 10-Fr to 12-Fr
( 3) Adults: 12 -Fr to 14-Fr

Look book

56
Q

Nasogastric Suctioning ?

A

-adult 20 to 24cm

-Observe patient closely, and limit suction to 10 to 15 seconds

-Suctioning longer than 10 to 15 seconds risks causing cardiopulmonary compromise.)

57
Q

Who can put the oxygen ?

A
  • EMPT
    -RN
    -Respiratory oxygen
58
Q

the use of cupped hands to clap rhythmically on the chest to break up secretions?

A

Percussion

59
Q

the use of a shaking movement during exhalation to help remove secretions?

A

Vibration

60
Q

the use of various positions to allow secretions to drain by gravity?

A

Postural drainage

61
Q

Physiology Oxygen therapy must be ordered by?

A

a health care provider and closely monitored by the nurse to ensure proper administration

62
Q

Physiology Oxygen is needed?

A

by all cells of the body to metabolize nutrients and produce the energy needed to function.

Exam 3 (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions