Exam 1 Flashcards
1
Q
tidal volume
A
amount of air exhaled following normal inspiration
2
Q
crackles/rales
A
- fine to coarse bubbly sounds, associated with air passing through fluid or collapsed small airways
- not cleared by cough
- discontinuous
3
Q
wheezes
A
- high pitched whistling, narrow obstructed airways
- musical noise
- continuous
4
Q
rhonchi
A
- loud low pitched rumbling, fluid or mucous in airways
- can resolve with coughing or suctioning
- snore sound
- continuous
5
Q
stridor
A
- choking, children
- emergency
6
Q
bronchial
A
- high pitch
- normally heard over trachea
7
Q
bronchial vesicular
A
- medium pitch
- heard over mainstream bronchi
8
Q
vesicular
A
- low pitch
- heard over most of normal lung
9
Q
bradypnea
A
- rate of breathing is regular but abnormally slow
- less than 12 breaths/min
10
Q
tachypnea
A
- rate of breathing is regular but abnormally rapid
- greater than 20 breaths/min
11
Q
hyperpnea
A
- respirations are labored, increased in depth, and increased in rate
- greater than 20 breaths/min
- occurs normally during exercise
12
Q
apnea
A
- respirations cease for several seconds
- persistent cessation results in respiratory arrest
13
Q
hyperventilation
A
- rate and depth of respirations increase
- hypocarbia sometimes occurs
- removing CO2 father than it is produced by cellular metabolism
14
Q
hypoventilation
A
- respiratory rate is abnormally low and depth of ventilation is depressed
- hypercarbia sometimes occurs
- inadequate alveolar ventilation to meet demand
- not enough oxygen and/or too much carbon dioxide
15
Q
factors affecting oxygenation
A
- decreased oxygen carrying capacity
- hypovolemia
- decreased inspired oxygen concentration
- chest wall movement
16
Q
PaO2
A
80-100
17
Q
PaCO2
A
35-45
18
Q
SpO2 (oxygenation saturation)
A
greater than 95%
19
Q
EtCo2
A
35-45
20
Q
causes of hypoventilation
A
- medications
- sedatives
- alveolar collapse
21
Q
signs and symptoms of hypoventilation
A
- mental status changes (early sign)
- dysrhythmias
- cardiac arrest
- convulsions
- unconsciousness
- death
22
Q
causes of hyperventilation
A
- anxiety attacks (severe)
- infection/fever
- drugs
- acid-base imbalance (pH)
- aspirin poisoning
- amphetamine use
23
Q
signs and symptoms of hyperventilation
A
- rapid respirations
- sighing breaths
- numbness/tingling of hands/feet
- light-headedness
- loss of consciousness
24
Q
atelectasis
A
- collapsed alveoli
- prevents normal respiratory gas exchange
- can lead to lung collapse
25
Q
conditions associated with atelectasis
A
- immobility
- obesity
- sleep apnea
- chronic lung conditions
26
Q
hypoxia
A
- inadequate tissue oxygenation
27
Q
causes of hypoxia
A
- decreased hemoglobin levels/low oxygen-carrying capacity
- diminished oxygen concentration of inspired oxygen
- inability of tissues to get oxygen from blood
- decreased diffusion of oxygen from alveoli to blood-infections/pneumonia
- poor perfusion with oxygenated blood
- impaired ventilation from traumas
28
Q
signs and symptoms of hypoxia
A
- apprehension
- restless
- inability to concentrate
- decreased LOC
- behavioral changes
- difficultly lying flat
- cyanosis (late sign of hypoxia)
29
Q
central cyanosis
A
- tongue
- soft palate
- conjunctiva of the eye
- hypoxemia
30
Q
peripheral cyanosis
A
- extremities
- nail beds
- ear lobes
- vasoconstriction
31
Q
early signs of hypoxia
A
- restlessness
- anxiety
- tachycardia/tachypnea
32
Q
late signs of hypoxia
A
- bradycardia
- extreme restlessness
- dyspnea
33
Q
chronic hypoxia
A
- associated with chronic lung conditions
- COPD most common
34
Q
common findings in chronic hypoxia
A
- cyanotic nailbeds
- sluggish capillary refill
- clubbing
- barrel chest
35
Q
dyspnea
A
- subjective sensation of difficult or uncomfortable breathing
- associated with hypoxia
- related to shortness of breath
36
Q
signs and symptoms of hypoxia
A
- use of accessory muscles
- nasal flaring
- increased rate/depth
37
Q
cough
A
- protective reflex to clear trachea, bronchi and lungs of irritants and secretions
- adequate hydration and coughing helps patient maintain airway patency
38
Q
nursing diagnoses related to oxygenation
A
- ineffective airway clearance
- risk for aspiration
- impaired gas exchange
- activity intolerance
39
Q
long term preventative measures
A
- vaccinations
- healthy lifestyle
- environmental and occupational exposures
40
Q
dyspnea management
A
- difficult to treat
- treat the underlying condition
- oxygen therapy
- pharmacologic treatment
41
Q
airway maintenance
A
- CAB: circulation, airway, breathing
- maintaining patent airway is a nursing priority
42
Q
managing pulmonary secretions
A
- mobilize
- hydrate
- humidification
- medications
43
Q
positioning
A
- position for maximum respiratory function
- change frequently
- helps prevent atelectasis
- helps mobilize secretions
- upright, unsupported position is optimal
44
Q
cough and deep breath
A
- helps keep airways clear
- nursing intervention
- cough every 2 hours
- deep breathing increases air to the lower lobes of the lungs
45
Q
chest physiotherapy
A
- mobilize pulmonary secretions
46
Q
postural drainage
A
- lay on unaffected side to promote drainage of one particular lobe
47
Q
chest percussion
A
- used frequently in those with chronic diseases
- neuromuscular conditions
- cystic fibrosis
48
Q
suctioning
A
- indicated when patients cannot clear secretions on their own through coughing or CPT
49
Q
suctioning
A
- indicated when patients cannot clear secretions on their own through coughing or CPT
50
Q
incentive spirometer
A
- promotes lung expansions through deep breathing
- prevents or treats atelectasis
51
Q
oxygen therapy
A
- prevent or relieve hypoxia
- gives oxygen at higher concentration than our ambient air (21%)
- must have healthcare order to administer
52
Q
oxygen therapy guidelines
A
- can delegate to CNA to apply nasal cannula, oxygen mask
- nurse must assess respiratory system, response to therapy, setup, adjustment responses
53
Q
nasal cannula
A
- 1-6L/min 22-44%
- safe and well tolerated
- FiO2 can very, skin breakdown, tubing dislodges
- use humidification if greater than 4L of flow
54
Q
simple face mask
A
- 6-12L/min 33-55%
- best for short periods, transportation
- not great for claustrophobic patients, skin breakdown, higher risk of aspiration
- assess for fit, watch for aspiration
55
Q
partial rebreather mask
A
- FiO2: 6-11 L/min; 60-75%
- used for short periods of dyspnea or other increased oxygen needs
- rebreather up to 1/3 of exhaled air
- helps with humidification
- keep reservoir bag partially inflated
- watch for aspiration and assess every hour
56
Q
non-rebreather mask
A
- higher non-invasive oxygen delivery
- FiO2: 10-15 L/min; 80-95%
- best for patient in critical need of oxygen
- watch for aspiration and assess every hour
57
Q
venturi mask
A
- FiO2: 4-12 L/min; 24-60%
- provides the ability to deliver precise oxygen concentration with humidity
- not preferable for long periods of time
- used for patients who need highly regulated oxygen concentrations (chronic lung disease)
58
Q
face tent (aerosol mask)
A
- fits loosely around face and neck
- 24-100% oxygen
- provides relatively high humidity
- post-operative
59
Q
oxygen humidification
A
- prevents drying out of mucous membranes
- use with oxygen greater than 4LPM or greater than 24 hours supplemental oxygen
60
Q
complications of oxygen therapy
A
- drying effects of respiratory mucous membranes
- oxygen toxicity
- skin breakdown
61
Q
artificial airway
A
- inserted in a patient who may or may not be breathing on their own
62
Q
tracheostomy tube
A
- plastic or metal tube that fits through a stoma in the neck
63
Q
trach indications
A
- acute airway obstruction
- airway protection
- facilitate removal of secretions
- prolonged intubation
64
Q
shiley trach
A
- plastic, short-term
- disposable inner canula, cuff, obturator
65
Q
Jackson trach
A
- metal, long-term
- reusable inner canula, no cuff, obturator
66
Q
purpose of trach cuff
A
helps create a snug fit in trachea
- prevent aspiration
- help ventilator give stronger breaths
67
Q
inflated cuffs
A
- patient mechanically ventilated
- inflation specifically ordered by physician
68
Q
dangers of prolonged or over-inflation of cuff
A
- increased mucosal pressure
- causing ischemia
- softening cartilage
- mucosal erosion
69
Q
Passy-muir speaking valve
A
- cuff is deflated when in use
- do not use if in respiratory distress
70
Q
nursing problems for patient with a trach
A
- ineffective airway clearance
- impaired verbal communication
- risk for infection
- impaired swallowing
- body image disturbance
- anxiety
- pain
