Chapter 41: Oxygenation Part 2 (Nursing Process)

Question 1

During assessment gather a

Answer 1

complete history

Question 2

History of Respiratory Function

Answer 2

• presence of cough: productive/nonproductive, hemoptysis
• dyspnea (asthma, bronchitis, pneumonia)
• pain: rule out chest pain
• environmental exposure/allergies
• frequency of respiratory tract infections: +TB, HIV
• pulmonary risk factors
• past respiratory problems
• current medications
• smoking history and/or secondhand smoke exposure

Question 3

Types of Chest Pain

Answer 3

1. pleuritic chest pain
2. pericardial chest pain
3. musculoskeletal pain

Question 4

pleuritic chest pain

Answer 4

radiates to scapular regions

coughing and inspiration worsen pain.

Question 5

pericardial chest pain

Answer 5

results from inflammation of the pericardia sac.

occurs on inspiration, does not usually radiate

Question 6

musculoskeletal pain

Answer 6

usually following exercise, rib trauma, prolonged coughing episodes

Question 7

Breathing Patterns include

Answer 7

1. Kussmaul Respirations
2. Cheyne-Stokes
3. Apnea

Question 8

Kussmaul Respirations

Answer 8

increased rate and depth in response to decreased pH

Question 9

Cheyne-Stokes

Answer 9

due to decreased blood flow or injury the the brainstem.

deep breaths mixed with shallow breaths mixed with apnea.

Question 10

apnea

Answer 10

absence of respirations for a period of time

Question 11

During assessment, the nurse needs to

Answer 11

• inspect chest wall movement (retraction, use of accessory muscles)
• palpate peripheral pulses, capillary refill
• auscultate: normal/abnormal lung and/or heart sounds
• review diagnostic tests

Question 12

Nursing Diagnosis RT Oxygenation

Answer 12

• Decreased CO
• Fatigue
• Activity Intolerance
• Impaired Gas Exchange
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Risk for Aspiration

Question 13

Implementations RT Oxygenation

Answer 13

• health promotion
• airway maintenance
• mobilization of pulmonary secretions
• suctioning
• artificial airways
• maintenance and promotion of lung expansion

Question 14

Health promotion includes

Answer 14

• vaccinations: pneumococcal, influenza
• healthy lifestyle: low-fat, high-fiber diet, maintain body weight, exercise
• environmental pollutants: smoke/secondhand smoke, chemicals

Question 15

hydration

Answer 15

fluid intake of 1500-2500/day unless contraindicated

Question 16

humidification

Answer 16

keeps airways moist and loosens pulmonary secretions. Necessary for patients receiving > or equal to 4 L of O2/NP

Question 17

Nebulization

Answer 17

adds moisture to medication-enhances mucociliary clearance

Question 18

Chest physiotherapy (CPT)

Answer 18

1. postural drainage
2. chest percussion
3. vibration

Question 19

Mobilization of Pulmonary Secretions include

Answer 19

• hydration
• humidification
• nebulization
• coughing and deep breathing
• chest physiotherapy

Question 20

Suctioning Techniques

Answer 20

process no longer than 15 sec.

includes oro and naso pharyngeal; oro and naso tracheal

Question 21

Oro and Naso pharyngeal

Answer 21

patient able to cough but can not expectorate the secretions

Question 22

Oro and Naso tracheal

Answer 22

sterile technique

unable to manage by coughing

Question 23

Artificial Airways

Answer 23

places patient at high risk for infection.

includes oral, endotracheal and tracheal airways

Question 24

Oral airway

Answer 24

maintains the tongue in the normal position

Question 25

endotracheal airway

Answer 25

through the mouth past the vocal cords into the trachea

Question 26

tracheal airway

Answer 26

surgical incision into the trachea

Question 27

Noninvasive maintenance and promotion of lung expansion

Answer 27

• ambulation
• positioning
• incentive spirometry
• noninvasive ventilation

Question 28

How does ambulation help promote lung expansion?

Answer 28

decreases atelectasis, decreases VAP and decreases functional limitations

Question 29

How does positioning promote lung expansion?

Answer 29

45 degree semi fowlers promotes lung expansion

Question 30

How does incentive spirometry promote lung expansion?

Answer 30

encourages deep breathing (visual)

Question 31

What are the noninvasive ventilations?

Answer 31

1. CPAP - Continuous Positive Airway Pressure
2. BiPAP - bi-level positive airway pressure-provides both inspiratory positive pressure and a lesser expiratory airway pressure (PEEP)

Question 32

Invasive maintenance and promotion of lung expansion

Answer 32

-chest tube insertion

Question 33

Chest tube insertion

Answer 33

restoring lung expansion.

removes air and/or fluid from the pleural space

Question 34

2 Types of Pneumothorax

Answer 34

1. primary

2. secondary

Question 35

primary pneumothorax

Answer 35

genetic condition: “bleb” on lung; occurs unexpectedly

Question 36

secondary pneumothorax

Answer 36

result of chest trauma (stabbing, rib fractures), lung diseases (emphysema), invasive procedures (surgery, placement of subclavian IV line), mechanical ventilation

Question 37

Hemothorax

Answer 37

accumulation of blood and fluid in the pleural cavity

Question 38

Methods of Oxygen Delivery

Answer 38

1. nasal cannula

2. masks: simple face mask, partial non-rebreather, non-rebreather, and venturi mask

Question 39

Restorative and Continuing Care include

Answer 39

• CPR
• Respiratory Muscle Training
• Breathing Exercises

Question 40

Respiratory Muscle Training

Answer 40

incentive spirometer

Question 41

Breathing Exercises

Answer 41

• Coughing and Deep Breathing Exercises
• Pursed Lip Breathing
• Diaphragmatic Breathing

Question 42

Pursed-Lip Breathing

Answer 42

deep inspiration and prolonged expiration with pursed lips

Question 43

Diaphragmatic Breathing

Answer 43

helps expel trapped air; often used in conjunction with pursed-lip breathing