Exam 2 Flashcards
Where does the airway begin & end?
Begins at nose, & ends at terminal bronchiole
Upper airway consists of
nose, larynx, pharynx, & epiglottis
Lower airway consists of
trachea, bronchial tree, R & L Bronchi, segmental bronchi & terminal bronchioles
Function of lower airway
conduct air, clear mucus by cilia, & produce pulmonary surfactant
Which is more anterior ? The trachea or the esophagus?
tracheae is anterior to the esophagus (hence back to sleep)
Trachea ends & becomes right & left lungs where?
at the 2nd intercostal space
Where do the lungs begin & end?
Apex of lungs extend above the clavicle
Base of lungs at the 6th rib
Posteriorly, lungs begin at ___
Base of lung at_?
Lungs begin @ T1
Base of lungs at T10
Deep breathing= T12
Right side of lung
Has 3 lobes, separated by Horizontal fissure
What are the other fissures of the lungs called?
Oblique fissure
ends at 6th rib
Right lower lobe
is practically under armpit
On the left anterior lobe we mostly auscultate
upper lobe
ends at 6th rib mid-clavicular, starts under armpit T3
Right thorax
5th rib mid axillary line unites all 3 lobes
Left thorax
Oblique fissure from T3 beginning -6th rib mid clavicular line
Factors that affect respiration
Hunchback of scoliosis
Air trapped in spaces
Copriised respiration
Right middle lobe
is not a part of posterior right lobe
Position
tripod position=can’t breathe–> drop diaphragm to try to expand their lung volume
Activity & exercise
promotes pulmonary exercise & respond better to respiratory distress
Pregnancy
3rd trimester
orthopnea: not able to be comfortable while laying flat
If patient is having a hard time breathing first thing you should do is
put the head of their bed up
Smoking
contributes to lung disease: macrophages in lung destroy the protein that allow the lungs to expand.
> mucus production
Air pollution
Room air is 21% oxygen
Asbestos & coal dust
cause lung disease
Cough is/signals
Cough is most important lung defense
Clears irritating substances in lungs
warning signal
Generation of cough
Histamine released due to irritated substance
Non-described, long standing cough
Something more serious is going on
Warning sign of HF, lung cancer, HTN
Productive cough has what characteristics
Produces sputum: volume, consistency, color & odor
Is shortness of breathe subjective?
Yes, you cannot tell just by looking at them. Explore degree with pt.
Word for subjective SOB
Dyspnea
What are the characteristics of central hypoxia?
confusion, anxiety, inability to follow direction
Signs of respiratory distress?
clubbed nails, tripod position, nasal flaring
breathing pattern characteristics
Rate, rhythm & depth
Signs of effort to breathe
distressed, diaphragmatic, labored, pursed lips
skin color
general color, lip color, nail bed
Hyperpnea
tachypnea but deeper
Hypoventiliation
breathing less than 12 bpm but more shallow
Cheyne-stokes
periods of apnea
Last 10-60 sec flowed by periods of hyperventilation
Common in people in comas or about to die
Pectus Excavatum
Congenital deformity
Hollow chest: internal cartilage & ribs are concave
Applies pressure to heart & lungs
Treatment: invasive surgery
Pectus Carintum
Pigeon chest–> sternum protrudes
Repair is easy
Develops during school age
Spinal Deformities
Hyphotic spine: more difficult to breathe,
< stature
Barrel Chest
Round chest configuration
Sternum pushed out
Common in COPD
1:1 ratio instead of normal anterior thorax is 2x as big as posterior
Normal chest configuration
Anterior/posterior diameter if chest is 1/2 the length of the transverse
Barrel chest
1:1 diameter of the chest
Commonly seen in: emphysema, cystic fibrosis, infants & elderly
Respiratory expansion
Palpation, assessing the symmetry of the chest expanding during inhale & exhale
Thumbs on T10 vertebrae with fingers spread apart, look for thumb movement & symmetry
Where to begin acultation?
on the back
Listen side–> side
Top to bottom
Compare to other side & look for asymmetry
Bronchial sound charactersitics
Over the trachea & larynx, LOUD, inspiration 1/3 of expiration
Bronchiovesicular
Over the sternum, 2-3 intercostal space
T3 & T4
I=
Vesicular sound
Everywhere else
Inspiration 2/3 expiration 1/3
GENTLE
When normal lungs are displaced?
Breathe sounds are diminished in intensity
Adventitious breathe sounds are…
Always abnormal but not always significant
The larger the airway
The louder the sound
Crackles
High pitched and discontinuous
Heard at the end of inspiration
Does not clear with coughing
Sign of buildup of phlegm & fluid in alveoli
Pneumonia crackles
Consolidation of alveoli
Airspace is filled with excaudate & anti-inflammatory modifirs
Crackles & bronchial breath sounds
Pulmonary Edema
Develop crackles due to excess of fluid in alveoli
Becomes more coarse over time
s/s of pulmonary edema
Dyspnea, SOB, lower, lower O2 saturation, air hunger, orthopnea, have productive cough
Wheeze
Heard on inspiration & expiration (usually louder on expiration)= continuous
High pitches/ musical
Asthma is…
What type of adventitious breathe sounds will you hear with it?
Wheeze
Chronic inflammation of the lungs: contact with allergen triggers- narrows airway & lungs swell
Stridor
Strong wheeze, obstructed airway associated with upper larynx & trachea
Croup is associated with ___ breathing
associated with stridor on inspiration, expiration sounds like barking seal
Swelling & inflammation of vocal cords & throat
Rhonchi
snoring, low pitched o
Heard on inspiration & expiration
May clear with coughing
Caused by air bubbling past secretions in large airways
Ronchi is associated with
Bronchitis
Inflammation of bronchi causing an > production of mucus on lining of upper airways
Air passing through mucus membrane causes bubbling rhonchi
Pleural friction rub
Low pitches, dry grating sound
Heard on inspiration & expiration
Pleural friction rub is associated with:
Pleurisy: inflammation of the lining of the lungs
-deeper breaths the more pain they experience
Breathe shallowly and < frequently
-hypotonia- (< muscle tone)
-hyperventilation
Pleural Effusion
Diminished or absent breathe sounds over effected area.
Collection of pleural fluids that is outside the lungs.
Pleural effusion is associated with:
Pneumothorax: Lung has collapsed, air around the lung cannot contract
You will hear normal breathe sounds on one side & none on side that is collapsed
Hemothorax
collection of blood outside the lungs
Chest Physiotherapy
Percussion called clapping! Also can do vibrations= manual compression & tremor on chest wall
Purpose: to loosen & mobilize secretions & cause clearance. Use gravity
People with _____ illnesses have large secretions & don’t have productive cough
pneumonia, cystic fibrosis, COPD
Chest X-ray
can see fluid/air in pleural space
Collapsed or under-inflated lung. Consolidation
Position of catheter tube
Peak flow meter
measure peak EXPIRATION
Reflects size of airways, severity of illness= how constricted
male expires ~600mL/min
Female expires ~475mL/min
Incentive spirometry
Measures maximal inhalation
8-10 breaths/Hr w/a
Male inhales ~3200mL
Females inhale ~2600mL
Prevents pneumonia & collapsed lung
Get secretions in lungs at level to be coughed out
aerosol therapy:
small volume nebulizers:
Add moisture to O2 delivered
Hydrates thick sputum (delivered to deep area of respiratory tract)
side effects of bronchodilators
> HR, BP, RR, agitation, anxiety, fluid retention
Aerosol therapy: steroids
Pt uses 4/5 L of O2
Inhale slowly, or hold breathe, exhale through nose, inhale
Keep in mouth until all medication is gone
Mouth care after they finish
Assess pt before & after pt uses med
Sputum culture
lab test (30 min) or C&S both tell you which antibiotics to order
after surgery there’s a risk for
lung collapse since cough reflex was suppressed, after surgery= pt in pain, alveoli not inflating secretions being retained
Types of cough
Deep cough: no pain, take a deep breathe & forceful expiration
Stacked cough: in pain
Series of short, quick coughs
Take in deep breathe in but force out is quick
Pursed lip breathing
Pt is having a difficult time breathing, keeps bronchial expanding
breathe through nose (for count of 2)
Exhale through the lips (for count of 4)
Lowest possible oxygen saturation & gas pressure in blood
93% o2 stat
68% gas pressure in blood
at what point should oxygen be humidified
5mL
always used during high flow oxygen
Nasal cannula has how much O2 dispersion?
24-44% 2L=28% 3L=32% 4L=36% 5L=40% 6L=44% (MAX AMOUNT)
Simple mask
40-60% oxygen
Most common but not specific, put oxygen at 5L and they receive 40-60% oxygen
contraindicated for people who need specific amounts of oxygen
Venturi
Delivers 24%-50% oxygen. Has potential to give more than nasal cannula, but can control unlike simple mask Blue=24% Yellow= 28% White= 31% Green= 35% Pink= 40% Orange= 50%
Reservoir mask
1st type
Rebreather mask (50-70% of oxygen) Non-specific
reservoir mask 2nd type
Non- rebreather mask (80-90% oxygen)
Bag attached to bottom: stays inflated all the time
White disks on each side of the patients mask
Disks off: patient rebreathing little CO2
Flow meter 10-15mL
Pts with COPD
no more than 32% oxygen
have humidor gently bubbling
Artificial Oral airway
for patients who are unconscious, extends t back of tongue & throat
prevents tongue from blocking airway
NEVER TAPE
Ambu Bag
Delivers artificial respiration
Use at normal RR
Never depress bag fully
how to keep oral secretions thin?
drink fluids
breathes sounds that are moderate “blowing” with I=E are
Bronchovesicular
What category of medications may be administered via nebulizer to open airways?
Bronchodilators
s/s f hypoxia
dyspnea, tachycardia, cyanosis
What question might the nurse ask to assess for orthopnea
How many pillows do you sleep with at night?
crackles are caused by
moisture in airway
How often should nurse check pt for effective coughing?
Q2hr
Postoperative pt can cough more effectively by:
holding a pillow or folded bath blanket over the incision
wheezes occur during
inspiration & expiration
The nursing process includes
Assessing, Diagnosing, Outcome Identification, Implementation, & Evaluation
The purpose of an assessment is to
Establish baseline VS & function
Determine normal fxn
Determine presence of dysfunction (maintain prior level f functioning)
Appraisal of the total patient situation
Physical, psychological, emotional, sociocultural, spiritual
Do you validate nursing diagnosis with the pt?
Yes
Assessment Data
Directly from patient or patient’s significant other (if impaired)
Secondary source of data:
- Family members, significant other from patient not impaired
- Health records
- Lab values, diagnosed test
Objective Data
BP, Vomiting, Age
Nursing Diagnosis is based on
Our assessments provide basis for nursing diagnosis
Identified pt problem
Actual Diagnosis has 3 factors
1) Diagnostic label
2) Relatable factors (etiology causing factor)
3) Defining characteristics (s/s, validates diagnosis)
how do you make a diagnosis stateent for risk?
2 part statement:
Diagnostic label related to etiology causes
Patient goals are written
As behavioral statements from patients POV
Cognitive
pt understands or has knowledge
Psychomotor
pt demonstrates that they can perform a skill
Psychologic:
Physical change in parameter
Affective
indicates change in pts attitude, values, and beliefs
Goal Outcome criteria
Pt will do what action, how well, & by when
What is an example of an affective outcome?
Mother will verbalize the benefits of following discharge instructions
Nursing Interventions
Independent nursing actions, physician initiated interventions, & collaborative interventions
Intervention and Rationales for Pain
Intervention: teach patient correct dosage, time frame, and precaution for taking analgesia
Rationale: knowing when and how to take pain medication will maximize pain relief and minimize adverse effects
Evaluation
Indicate if the outcomes/goals were met or unmet
Indicate actual behavior as supporting evidence
If goal was not met , make recommendations for revising the plan of care
What activity is carried out during the implementing step of the nursing process?
Planned nursing actions (interventions) are carried out.
A nurse writes down the following outcome for a depressed patient: “By 6/9/12, the patient will state three positive benefits of receiving counseling.” This is an example of which of the following types of outcomes:
affective
Who or what is the primary source of information for a nursing history:
the patient
Which of the following are verbs that are helpful in writing measurable outcomes:
Define, list, verbalize
A student identifies Fatigue as a health problem and nursing diagnosis for a patient receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this patient problem:
I think fatigue is a problem for you; do you agree?
What type of data would you call nausea and abdominal pain?
subjective
Which of the following patient care concerns is clearly a nursing responsibility:
Monitoring health status changes
This is an example of a:The patient will be able to list five symptoms of infection on discharge
well written outcome
Which part of this diagnosis is considered the problem statement?
Processes related to Alzheimer’s disease as evidenced by incoherent language.
Disturbed thought process
Can you give a pt’s spouse info over the phone w/o their permission?
No
HIPPA
1 Provides provision for patient: they can see and copy medical records at any time
2 Viewing medical records: patient is allowed, cannot review medical record unless that is your patient for that day
3Telephone conversation: who ru talking 2? Do u have permission to talk w them?
4Hallway/waiting room conversation: not talking about patients, keep patient conversation confidential
5Information to family members and friends: need to get patient’s permission
Goals of documentation?
Delivery of quality patient care Continuity of care Communication of treatment goals Progress toward goals Interdisciplinary consistency
Pt transfer should be done:
face to face, give synopsis of pt
SBAR
S= situation, what is occurring at the time
B=background, what lead up to current situation
A= assessment, what is going on
R=recommendation, what do we want/expect to correct current problem
Quality inferential statement
Seemed/appeared statement: not inappropriate
We can infer things based on knowledge and relationship of patient
But must provide reason why you think this is occurring
Documentation Errors
How to document errors on hard copies
Single line in the error
Write word ERROR
Take accountability (name, credential, time)
SOAP Notes
Subjective
Objective: measurable
Analysis
Plan: what should be done
DAR Note
Data, Action, Response
Charting By Exception
Conclusive to electronic record
Identify what hospital course should look like and critical pathway toward getting better
Much of it is a checklist
Variable chart
Electronic Heath Record
The patient is focus of the chart Report the facts New/change information and objectives Support subjective data with objective feeds Chart things done for the patient Avoid personal opinions and biased statements Chart problems with actions taken Chart patient response and reaction
In which of the following cases should a progress note be written:
When admitting a patient, When receiving a patient postoperatively, When a procedure is performed
What is evaluated when conducting a nursing audit
Patient records
Decode versus encode
decode= pt understanding the message recode= encoded message that nurse must decode
Genuineness
present yourself honestly and spontaneously
Empathy
ability to perceive another person’s’ situation and view it from that perspective
Concreteness
Promote understanding & sensibility
Vocal paralanguage
Our words & how we deliver them: Tone, pitch, volume, rate of speech
3 elements of communication
words 7%
tone 38%
body language 55%
Validating
You state the words as you heard them
Clarifying
You make sure you understand what the pt said
Reflection
repeating what the person said or describing the person’s implied feeling–> restate emotional component
Directing/focusing: ask for elaboration on the topic
asking for elaboration on a topic
Tell me more about _______
What term describes a nurse who is sensitive to the patient’s feelings but remains objective enough to help the patient achieve positive outcomes:
empthetic
Narrow index of therapeutic & toxicity
Liver
Kidney
GI
Height + weight can be used pharmokinetically
Body surface areas (BSA) used for drug dose calculations
FDA
Responsible for public safety of drug Responsible for sales and marketing (effectiveness) controls drug advertisement Control what drugs need prescriptions Prevents unsafe drugs for being marketed
Class 2
most perscribed drugs, usually narcotics, highly reguated, require 2 nurses
Class 5 drugs
OTC drugs
Drug order components
Patient name Date and time written Medication name Medication dose FREQUENCY OF ADMINISTRATION Route of administration SIGNATURE WHO GAVE THE ORDER
One time order
usually a loading dose
repeat order
use judgement with your assessment, usually a time parameter and may be ordered to give but otherwise use your judgement
1 grain=
60 mg
1mg=
1000mcg
1000mg
1,000,000mcg
1mL
15 gtts (drops)
15mL=
3tsp= 1TBL
30mL =
1 fl oz
240mL
8fl oz= 1 cup
How to pour liquid meds
Pour liquid medication at eye levels Read dose at the base of meniscus Pour away from label Drug calculation: Drug on hand/quantity on hand= dose required/ X quantity desired
3 administration checks
check drug matches, MARS when retrieve medication
Re-check ever med after retrieval against MAR
Before give each med, check MAR
Document
As soon as given, & give reason, document response to medication, 15-30 min after given
AD AS AU
AD= right ear AS= Left ear Au= both ears
NOC
night
DS
Double strength
ung
ointment
Write out daily, every other day, write out unit, use mL, use international units
tid is not as accurate as Q8hr
No QD or anythin
Do not use transdermal patch if
pt has temp > 102
when administering oticlly in adults
pull pinna up and back.
after giving meds, massage tragus
when administering otically in kids
pull pinna down and back
Intradermal injection locations:
inner forearm, upper arm, across scapula
technique for bevel needle in intradermal injection
Control depth
DO NOT BEVEL DOWN,Bevel down will push into subcutaneous tissue.
Inject at 5-15 degree angle
Measure induration of intrdermal injection
hardening of bleb is a positive reaction
Subcutaneous injection
0.5-1.0mL small gauge 25-28 gauge Sites: abdomen, upper arm, back of thigh Needle length Needle insertion angle 1 inch bunch: 45 degrees 2 inch bunch: 90 degrees
Insulin
agitate suspension Observe for lipodystrophy: depression of the skin due to bad rotation and cold insulin injection Use one inch rule 25-30 gauge 1/2-5/8 in needle Draw from NPH last
Heparin
25-28 gauge
5/8-7/8 needle length
insert away at 90’
Intramuscular Injection
use 3-5mL injection
19gauge-25 needle
5/8in-3in needle
Z-tracking recommended for all IM injections
Deltoid IM
Max 2mL midaxillary line 2.5-3cm below acromion process 5/8-1.5 in needle Close to radial nerve & brachial artery
Vastus Lateralis
Best for toddlers
Not around nerves or vessels. Inject into outer middle third
5/8 -1.5 needle
Ventrogluteal
Free of blood vessels & major nerves Considered safest & least painful Not recommended for older adults typically 1.5 in up to 3 mL Landmark: greater trochanter (heel of hand), anterior superior iliac ===spine (pointer), iliac crest (middle finger)
Dorsogluteal
Not recommended
Close to sciatic nerve
Superior gluteal artery
Thick layer of fat
Draw up orders
Draw up vial before ampule
Draw up multi-dose before ampule
Prefilled syringes are norally overfilled
Actovial
when you press down to the top, the diluent mix with the powder
Which parts of the needle should be kept sterile?
The needle, the inside of the barrel & the part of the plunger entering the barrel
What should you do if your needle is coated with liquid?
change needle
Viscous that can’t be in subcutaneous tissue change needle
Always change for z-tracking
Tuberculin Syringe (Tb)
Small and narrow Holds 1 mL .01 marking ¼ or ½ needle change needle for SL or IM use
Factors to consider for needle length
¼ - 3 inch)
Muscle mass
Adipose tissue
Look at patient and make judgment
Factors to consider for needle diameter
14-29
Lower number: the larger diameter
Considered by viscosity or medication to be administer
Contaminates the plunger after the medication is drawn into the syringe do you have to discard it?
No, administer as prescribed
