Nursing Management of Respiratory/Pulmonary Disorders Flashcards
Name 3 acute pulmonary conditions
ARDS, PE and acute infections such as penumonias, SARS, Avian influenza and TB
Acute exacerbation of chronic conditions are:
Respiratory failure, status asthmaticus and acute infections
This diagnostic test looks at the lungs if a sputum sample can’t be obtained
bronchoscopy
The subjective assessment for respiratory nursing care include:
SOB, pain and dyspnea
What are some symptom characteristics of respiratory disorders?
Time, duration, frequency, risk factors in hx, effect of symptoms on ADLs, relationships, employment, coping
What are the outcomes of impaired gas exchange?
ABGs, SaO2, color, RR, LOC, behavior
Inadequate airway will result in
Stridor, noisy, retractions, flaring nares, labored with use of accessory muscles
Tachypnea, apnea, cheyne-stokes and RR are all indicative of
ineffective breathing patterns
Name some nursing interventions for a pt with respiratory disorder
Assess, monitor and report, position upright and elevated, maintain O2, assess effectiveness, TCDB, ICS, collaborate with RT, evaluate meds, relieve pain, suction PRN
What are some procedures to follow for bronchial and oral hygiene?
Turn and reposition Q1-2 hrs, support out of bed activities, encourage ambulation, coughing and deep breathing, chest percussion, vibration, postural drainage to promote pulmonary cure, avoid glycerine swabs or mouthwash for ulcers, bacterial or fungal growth and infections
Hazards and complications of oxygen therapy include?
combustion, oxygen induced hypoventilation, toxicity, absorption atelactasis, drying of mucous membranes and infection
Lungs can only tolerate and use _____% of O2
21%
Causes release of free O2 radicals which leads to alveolar/capillary membrane damage
Hyperoxia
Nasal cannula, simple face mask, partial rebreather mask and non rebreather mask are all what kind of oxygen delivery systems?
Low flow
What is the goal of oxygen management?
> 60mmHg PaO2, > 90% SaO2
High flow oxygen delivery system include
venturi, trach collar, and T piece
Oropharyngeal, nasopharyngeal, endotracheal and trachesostomy are all what kind of airways?
Artificial
BiPAP (Bi-level positive airway pressure) and CPAP (continuous positive airway pressure) are what kind of management?
Non-invasive
Noninvasive positive pressure ventilation technique uses + pressure to keep alveoli open and improve gas exchange w/o airway intubation. T/F
TRUE
BiPAP improves what kind of volume? How?
Tidal volume; BiPAP cycling machine delivers a set inspiratory positive airway pressure each time the client begins to inspire. At exhalation, it delivers a lower set end-expiratory pressure
CPAP delivers a set of positive pressure airway to open up the collapsed alveoli. T/F
TRUE
Clients who benefit from this type of non-invasive ventilation are those with atelactasis after surgery or cardiac induced PE
CPAP
What is a mechanical ventilator?
It is an invasive machine that generates a controlled flow of gas into a patient’s airways. Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension
Nursing management of the mechanically ventilated patient includes assessment and documentation. Name them.
Verify position of ETT in reference to lip/teeth w/ securing device change and position changes, assess skin condition around ETT/oral mucosa, verify ventilator settings q shift and monitor pt for tolerance of ventilator support
What would you assess and document for a pt on a mechanical ventilator?
Breath sounds, RR and pattern, SpO2, peak inspiratory pressure, exhaled tidal volume/min. volume, amount/consistency of secretions, response to suctioning/ventilator changes/activity, anxiety and rest/activity balance
Sedation to optimize pt comfort, communication via pen/paper/board, keeping pt’s family informed of progress and an oral airway are all interventions for the mechanically ventilated patient. T/F
TRUE
What is a tracheotomy?
It is the surgical incision into the trachea for the purpose of establishing an airway and may be permanent or temporary
Complications of a tracheotomy include:
misplacement, bleeding, hemorrhage, laryngeal nerve damage, pneumothorax, pneumomediastinum, cardiac arrest, stomal infections, stenosis, fistulas, subcutaneous emphysema
What are the primary care issues for a tracheostomy pt?
Prevention of tissue damage, air warming and humidification
This procedure maintains a patent airway and promotes gas exchange, removes secretions to promote coughing and can be done through the nose or mouth
Suctioning
Suctioning can cause
Hypoxia, tissue trauma, infection, vagal stimulation and bronchospasm, cardiac dysrhythmias from hypoxia caused by suctioning
If you cause vagal stimulation or bronchospasm for a pt while suctioning, what would you do?
Stop suctioning immediately and oxygenate client manually with 100% oxygen/may require a bronchodilator
The purpose of this is to remove air or fluid that has entered the lung pleural space by surgical intervention, can function w/ or w/o suction allowing fluid to move upward w/ inhalation and downward on exhalation.
Chest tube
What kind of precaution do you take on a pt w/ TB?
Air and droplet precaution
Which patient population would you retest delayed hypersensitivity test on?
HIV patients starting on highly active antiretroviral therapy (HAART)
Management of TB includes:
respiratory precautions and drug treatment (INH)
