Exam 2 Flashcards
what device is used when tongue or epiglottis fall back against posterior pharynx in unconscious patients
OPA (oropharyngeal airways)
A curved piece of plastic inserted over the tongue that creates an air passageway between the mouth and the posterior pharyngeal wall.
OPA (oropharyngeal airways)
which device is indicated for patient’s who do not have couch, gag or swallow reflex
OPA (oropharyngeal airway)
in what patient would an OPA (oropharyngeal airway) be contraidicated in
person who is conscious and has intact cough, gag, or swallow reflex
two types of OPA’s
guedel, and berman
could you see the use of an OPA in intubated patient’s, if so, why
yes in order to prevent them from biting the tube
how often should you perform mouth care with an OPA
every two hours
what to assess with OPA
oral mucosa and tongue
device inserted into the nostril to create air passage
NPA (nasopharyngeal airway)
what device would be used in patient’s with an intact but weak cough and gag reflex but require frequent suctioning and are unable to cough forcefully and clear secretions
NPA (nasopharyngeal airway)
before insertion of NPA what would you do
apply water based lubricant to NPA
NPA’s are contraindicated in what patients
- anticoagulated
- low platelet count
- skull fracture or facial trauma
how often would you remove NPA and do assessment
at least every 8 hrs
what assessment do you do with both the OPA and NPA
check for breath and for lung sounds
if a persons cough is intact what is the most effective method for clearing the airway
cough and deep breathing
device that promotes deep breathing and good inspiratory effect
incentive spirometer
what does an incentive spirometer decrease the risk of in post op patients
development of atelectasis or pneumonia
provides baseline of best maximal expiration to evaluate airway diameter
peak flow measurement
nebulizer delivers meds over what duration usually
5-10 minutes
what should flow be for nebulizer and run on air or oxygen
air preferably at 6-8 liters
preferred method for inhaled medications
metered dose inhaler with spacer
if patient is on multiple inhaled meds what should be done first
bronchodilator and then any steroid
before administering inhalers what should be assessed
ascultate lungs, work of breathing, O2 sat, RR, HR, BP and color
technique that utilizes gravity to facilitate movement and expectoration of secretions and mucous from various lobes of lungs and airway
postural drainage
gentle rhythmic clapping parts of lungs to move and loosen mucus from bronchioles
cupping
what is PD & C
postural drainage and cupping
PD & C is commonly indicated for what patient;s
cystic fibrosis, spinal cord injury, pneumonia
PD & C is contraindicated in what patients
head injuries, COPD, history of cardiac disorders
patient who is unable to clear secretions and it is affecting respiratory function, may require
suctioning
device indicated for hypoxia, hypoventilation, resp. failure, resp. arrest
bag valve mask devices and ventilation (resuscitation breathing bags)
assessment for all drainage systems includes
- amount of drainage
- consistency
- color
- monitor temp
- wound site
change of the consistency of drainage should change from what to what
blood, then serosanguinous, then serous
flexible, rubber, tube/drain that uses gravity to pull drainage out
penrose drain
drain that removes fluid by creating suction in a bulb
jackson pratt drain
when should JP drain be emptied
every 8 to 12 hours
when does the JP drain get removed
when fluid is less than 30 ml in 24 hrs
can patients go home with JP drain
yes, but drain gets removed at office
drain that also uses suction but is larger than JP drain
hemovac
device that as piece of foam with an open cell structure which is placed in the wound to remove blood and serous fluid
Vacuum-Assisted Closure Device (VAC)
benefits of VAC therapy
- entire surface is exposed to negative pressure effect
- maintains contact with edges and prevents tissue necrosis
- decreases risk of infection
- enhances formulation of granulation tissue
- increase blood flow to area
when air collects in he pleural space it is called
pneomothorax
signs pneumothorax
tachypnea, tachycardia, decreased or absent breath sounds
symptoms of pneumothorax
pain that worsens with inspiration, dyspnea, couch, sudden stabbing pain on side of pneumo
when air enters pleural space but chest wall remains intact it is
closed pneumothorax
air in pleural space but chest wall and pleural space are penetrated
open pneumothorax
blood in pleural space is called
hemothorax
causes of hemothorax
- blood clotting disorder
- pulmonary infarction
- lung cancer
- tear in blood vessel
blood and air in the pleural space
hemopneumothorax
what would require two chest tubes to be inserted
hemopneumothorax one at apex and one as base
when air leaks from a tear in the lung into the pleural space
tension pneumothorax
accumulation of lymphatic fluid in the pleural space
chylothorax
purulent drainage or pus from infection accumulating in pleural space
empyema
chest tube is needed when
negative pressure in pleural space is disrupted resulting in pulmonary compromise
when chest tube is place to put fluids in pleural space to prevent pleural effusions
pleurodesis
chest tubes placed high for what
air accumulation
chest tubes placed low for what
fluid accumulation
can the chest tube tubing every be clamped
no
if what type of drainage exists you should notify the provider
purulent
every assessment of chest tube should include
noting color and quantity of fluid, and amount of drainage
what are the fluctuations in the fluid level in the chest drainage unit indicative of
tidaling
when water level rises in the tube and remains above 2cm is indicates that what is present
negative pressure in the pleural space
how often should vitals be taken when person has a chest tube
every 2 hrs
assessment of pt on chest tube includes
vitals, assess breath sounds, heart sounds, and skin and color temp
how often should drainage be recorded with chest tube
every 8 hrs
what is evidence of a leak with a chest tube
continuous rapid bubbling in water seal chamber
when does normal bubbling occur with chest tube
during expiration
if chest tube falls out what should you do
cover site with vaseline gauze and notify provider asap
indications for tracheostomy tube
- severe reccurent upper airway obstruction
- facial trauma
- inability to remove airway secretions
- head/neck surgery
prolonged mechanical ventilation
complications of trachs
bleeding, infection, erosion of mucosal lining, compromised breathing, plugged with mucous, esophogeal fistual, crepitus
how often is trach care performed when first put in
q 8 hrs
how often is trach care performed after trach site is healed
daily
what is not done for the first 72 hrs after trach is placed
the tie change
after 72 hrs how often do you change the trach ties
daily or prn
which suctioning procedure is a clean technique
only oral suctioning
when is suctioning indicated for a patient
- when they ask for it
- decreased LOC
- inability to clear secretions due to ineffective, weak cough
- persistant coughing (though strong) that doesn’t clear secretions
- decreased O2 sat
- increased work of breathing, RR
how long should wait in between suctioning
1-2 minutes
was is the max number of times you can suction
3 passes
suction should be set at what range for adults
100-120 mm Hg
suction should be set at what range for peds
60-80 mm Hg
what is important to make sure before applying suction
most patients will need to be pre-oxygenated
max duration of a suction pass
10 seconds
hazards of suctioning include
hypoxia, vomiting, aspiration, cardiac dysrhythmias, hypotension
a valve that is used for pt’s who have adequate laryngeal and articulatory function
passy-muir speaking valve
how often is the pt history record in eRecord when pt is on PCA pump
every 4 hrs
vital signs and assessment done how often when on PCA
q 30 min for first hr
q 1 hr for 3 hrs
q 4 hrs for duration of therapy
if respiratory depression occurs when on PCa what should nurse do
discontinue infusions and prepare to admin narcan
how to alleviate itching related to PCEA opioid admin
benadryl per orders
warning signs of complications for PCEA opioids
dizziness, ringing in ears, metal taste, seizure, lathergy, numbness of tongue
p wave represents what
atrial depolarization
qrs complex represents
ventricular depolarization
T wave represents
ventricular repolarization
U wave represents
purkinje fiber repolarization
first step in analyzing a ekg rhythm strip
regular or irregular rhythm
how is rhythm on ekg determined
cadence between R to R intervals
second step in analyzing ekg rhythm strip
calculate ventricular rate by counting number of QRS complexes in six seconds and multiply that by 10 for beats per minute
third step in analyzing rhythm strip on ekg
p waves, do they look alike, or are they different, and their relationship to QRS complex
