Oxygen/Trach/Respiratory Assessment Flashcards
PaO2 range
80-100 mmHg
pH range
7.35-7.45
PaCO2 range
35-45 mmHg
HCO3 range
22-26 mEq/L
Respiratory acidosis
results when respiratory function is impaired and causes retention of CO2
Conditions that result in Respiratory acidosis
respiratory depression due to anesthetics
electrolyte imbalance
inadequate chest expansion
airway obstruction
reduced alveolar capillary diffusion
treatment for respiratory acidosis
focus on improving ventilation and oxygenation and maintaining a patent airway
metabolic acidosis
state of excess acid or reduced base bicarbonate in the body
conditions that result in metabolic acidosis
excessive oxidation of fatty acids
hyper metabolism
excessive ingestion of acids
kidney failure
pancreatitis, liver failure, or dehydration
diarrhea
treatment for metabolic acidosis
focused on hydration and drugs or treatments to control the problem causing the acidosis: IV sodium bicarbonate
Respiratory alkalosis
caused by an excessive loss of CO2 through hyperventilation
conditions that result in respiratory alkalosis
fear, anxiety, mechanical ventilation, salicylate toxicity, high altitudes, shock, early stage acute pulmonary problems
treatment for respiratory alkalosis
correct the underlying cause; if due to hyperventilation/anxiety and panic attack- instruct breathing exercises.
metabolic alkalosis
caused by either an increase of bases (base excess) or a decrease of acids (acid deficit)
conditions that result in metabolic alkalosis
increase of base components (oral ingestion of antacids, blood transfusion, sodium bicarbonate, TPN)
treatment of metabolic alkalosis
correct underlying cause
non invasive positive airway pressure
uses positive pressure to keep alveoli open and improve gas exchange
uses a tightly fitting mask around nose or nose and mouth
can be with or without oxygen
indications for non invasive positive airway pressure
sleep apnea
hypercarbia (increase of CO2 in blood stream)
acute COPD
manage acute dyspnea
pulmonary edema
CPAP
continuous positive airway pressure
one set pressure or volume is delivered with each cycle of inhalation/exhalation
BiPAP
bi-level positive airway pressure
different pressure is set for inhalation and exhalation
Nursing consideration for non invasive positive airway pressure
ensure mask has an adequate seal, monitor for skin breakdown, monitor for vomiting/aspiration
transtracheal oxygen
oxygen delivered through a small flexible catheter that is places in the trachea through a small incision
used for patients with long term O2 needs
avoids irritation that nasal prongs cause
typically require less O2 when delivered in this method
tracheotomy
surgical incision into trachea for purpose of establishing an airway
tracheostomy
stoma that results from tracheotomy
may be temporary or permanent
indications for a tracheostomy
stenosis of airway
obstruction of airway
laryngeal or neck trauma
neck cancer
extended need for mechanical ventilation
complications of tracheostomy
dislodgment
obstruction (mucus plugging)
SQ emphysema
skin breakdown (moisture and pressure)
infection (lung infection)
bleeding (from mucosal irritation)
features of tracheostomy tubes
single lumen and dual lumen
cuffed and un-cuffed
reusable and disposable
fenestrated and un-fenestrated
nursing care with trachs
stoma care
humification of airway
suctioning
ensure placement and patency
monitor cuff pressures
maintain extra trach and obturator at bedside
frequent oral care
aspiration precaution
complications of trach suctioning
hypoxia
tissue trauma
infection
vagal stimulation and bronchospasm
cardiac dysrhythmias
nutritional concerns with trachs
aspiration- inflated cuff can interfere with passage of food through the esophagus and weakened muscles
elevate HOB 30 min after eating
may need enteral feeding tube
weaning from trach tubes
trials of cuff deflation
gradual decrease in size of trach tube
may change from cuffed to un-cuffed
may change to fenestrated tube
cap trach with speaking valve or trach button
psychosocial considerations with trachs
communication
support for patients and families
become involved in self care activities
room air is what percent O2
21%
hypoxemia
low 02 levels in blood
hypoxia
low O2 levels in tissue
O2 therapy
the purpose of oxygen therapy is to use the lowest fraction of inspired oxygen (Fio2) to have acceptable blood oxygen level without causing harmful side effects
measured in FiO2 or L/min
Means to monitor oxygen
ABGs
SpO2
Capnography
ABG
most accurate, invasive, obtained by arterial blood draw
SpO2
non invasive, easy to obtain, use pulse oximetry to measure
capnography
non invasive, measures exhaled CO2
hazards of oxygen therapy
combustion, oxygen induced hypoventilation, oxygen toxicity, absorption atelectasis, dry mucous membranes, infection
oxygen delivery systems
low flow
high flow
non invasive positive pressure ventilation
invasive ventilation
type of ventilation is determined by O2 need, patient comfort, expense and mobility
low flow oxygen types
nasal cannula, simple face mask, partial non rebreather, non rebreather
high flow oxygen types
venturi mask, aerosol mask and face tent, tracheostomy mask, t tube/t piece
nursing considerations for O2 therapy
ensure humidification
asses for skin breakdown
assess mucous membranes for dryness and bleeding
asses for patency of tubing
education patients regarding oxygen safety
Health promotion and maintenance of respiratory assesment
asses smoking habits
promote smoking cessation
determine exposure to other inhalation irritants
protect the respiratory system
changes in respiratory system related to aging
alveoli (decreased SA, decrease diffusion capacity, decrease elastic recoil)
lungs (increased residual volume, vital capacity decreases, elasticity decreases)
pharynx and larynx (muscles atrophy, vocal cords become slack, airway lose cartilage)
pulmonary vasculature (resistance to blood flow through pulmonary vascular system increases)
exercise intolerance
muscle strength (decrease in strength of diaphragm and intercostals)
increase susceptibility to infection (decrease cilia effectiveness)
Chest wall (AP diameter increases, thorax is shorter, progressive kypho-scoliosis)
psychosocial assessment
shortness of air often induces anxiety and anxiety can exacerbate shortness of air
RBC count
data about the transport of oxygen
Hemoglobin
transports oxygen to the tissues
deficiency could cause hypoxemia
WBC count
indication of infection
ABG
data on oxygenation as well as acid base balance
sputum
culture and sensitivity
cytology
chest x-rays
very common diagnostic tool
typically one of the first tools
CT chest
with contrast or without
pulse oximetry
normal 95-100
below 91 requires immediate assessment and treatment
below 85 body tissues have a difficult time becoming oxygenated
Pulmonary function test
PFTs: forced vital capacity, forced expiratory volume, peak expiratory flow
forced vital capacity
volume of air exhaled from the full inhalation to full exhalation
forced expiratory volume
volume of air blown out as hard and fast as possible during the first second of the most forceful exhalation after the greatest inhalation
peak expiratory flow
fastest airflow rate reached at any time during exhalation
Laryngoscopy
scope inserted into larynx to asses the function of the vocal cords
mediastinoscopy
insertion of a flexible tube through the chest wall just above the sternum into the area between the lungs
bronchoscopy
insertion of a tube in the airways usually as far as the secondary bronchi
thoracentesis
needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes
lung biopsy
performed to obtain tissue for histologic analysis, culture, cytologic examination
Which condition will increase the
body’s need for more oxygen? (select
all that apply)
– A. Hypothyroid
– B. Infection in blood
– C. Diabetes Mellitus
– D. Temperature of 101 F
– E. Hbg of 8.7 g/dL
BDE
Which parameters does the nurse
monitor to ensure that a patient’s
response to oxygen therapy is
adequate? (select all that apply)
– A. Level of consciousness
– B. Respiratory pattern
– C. Oxygen flow rate
– D. Pulse oximetry
– E. Adequate humidification of O2
ABD
When a patient is requiring oxygen
therapy what is most important for the
nurse to know?
– A. Patients require 1-10 L/min by nasal
cannula for oxygen to be effective
– B. Oxygen induced hypoventilation is the
priority when the pCO2 levels are unknown
– C. Why the patient is receiving oxygen,
expected outcomes and complications
– D. The highest FiO2 possible for the
particular device being used
C
What are considered hazards of
oxygen therapy? (select all that
apply)
– A. Increased combustion
– B. Oxygen narcosis
– C. Oxygen toxicity
– D. Absorption atelectasis
– E. Oxygen induced hypoventilation
ACDE
A patient is receiving preoperative
teaching for a partial laryngectomy and
will have a tracheostomy. How does the
nurse define a tracheostomy to the
patient?
– A. Opening in the trachea that enables
breathing
– B. Temporary procedure that will be
reversed later
– C. Technique using positive pressure to
improve gas exchange
– D. Procedure that holds the airway open
A
A patient returns from the operating
room after a tracheostomy placement.
While assessing the patient which
observations by the nurse warrant
immediate notification to the provider?
– A. Patient is alert but unable to speak
– B. Small amount of bleeding present at
incision
– C. Skin is puffy at the neck area with a
crackling sensation
– D. Respirations are audible and noisy with
increased respiratory rate
C
To prevent accidental decannulation
of a tracheostomy tube, what does
the nurse do?
– A. Obtain an order for continuous upper
extremity restraints
– B. Secure the tube in place using ties or
fabric fasteners
– C. Allow some flexibility in motion of the
tube while coughing
– D. Instruct the patient to hold the tube
with a tissue while coughing
B
A patient has a recent tracheostomy.
What necessary equipment does the
nurse ensure is kept at the bedside?
(select all that apply)
– A. Ambu bag
– B. Pair of wire cutters
– C. Oxygen tubing
– D. Suction equipment
– E. Tracheostomy tube with obturator
ACDE
A patient currently has an artificial
airway in place. Oxygen is administered
directly from the wall source. Why
would warmed and humidified oxygen
be a more appropriate choice for this
patient?
– A. Prevent drying damage of mucous
membranes
– B. Promotes thick secretions which are
easier to suction
– C. Is more comfortable for the patient
– D. Is less likely to cause oxygen toxicity
A
A nurse is educating a client who will be going home with a tracheostomy. When discussing suctioning frequency, what should be included in the education?
– A. The tracheostomy should be suctioned every 4 hours
– B. The tracheostomy should be suctioned when secretions can not be cleared and physical symptoms are present
– C. The tracheostomy should only be suctioned in an emergency
– D. The tracheostomy should only be suctioned at times when the home health nurse is available.
B
A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach to the situation?
– A. Rely on the family to interpret for the patient
– B. Ask questions that can be answered with a yes or no
– C. Obtain an immediate speech consult
– D. Encourage the patient to rest rather than struggle with communication
B
steps for trach suction
- Assess the need for suctioning (routine unnecessary suctioning causes mucosal damage, bleeding, and bronchospasm).
- Wash hands. Don protective eyewear. Maintain Standard Precautions.
- Explain to the patient that sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief.
- Check the suction source.
- Set up a sterile field.
- Preoxygenate (hyperventilate) the patient with 100% oxygen for 3 ventilations prior to suction.
- Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion.
- Withdraw the catheter 1 to 2 m, and begin to apply suction. Apply suction and use a twirling motion of the catheter during withdrawal. Never suction longer than 10 to 15 seconds.
- Hyperoxygenate for 1 to 5 minutes or until the patient’s baseline heart rate and oxygen saturation are within normal limits.
Which of the following is true about
changes in the respiratory system
associated with aging? (Select all that
apply)
A. Exercise tolerance decreases
B. Respiratory muscle strength
increases
C. Cough reflex increases
D. Airways lose cartilage and elasticity
E. Response to hypoxia and hypoxemia
decreases
F. Vocal cords become stronger
ADE
The nurse is inspecting a patient’s chest
and observes an increase in
anteroposterior diameter of the
chest. When is this an expected
finding?
A. In older adults
B. With a pulmonary mass
C. Upon deep inhalation
D. With chest trauma
A
A patient reports smoking a pack of
cigarettes a day for 9 years. He then
quit for 2 years, and then smoked 2
packs a day for the last 30 years.
What are the pack-years for this
patient?
A. 19.5 years
B. 39 years
C. 41 years
D. 69 years
D
Which assessment finding is an
objective sign of chronic oxygen
deprivation?
A. Continuous cough productive of
clear sputum
B. Clubbing of fingernails and a barrel-
shaped chest
C. Audible inspiratory and expiratory
wheeze
D. Chest pain that increases with deep
inspiration
B
A patient reports fatigue and shortness
of breath when getting up to walk to
the bathroom; however, the pulse
oximetry reading is 99%. The nurse
identifies a diagnosis of activity
intolerance. Which laboratory value is
consistent with the patient’s
subjective symptoms?
A. Hemoglobin of 9 g/dL
B. BUN of 15 mg/dL
C. White blood cell count (WBC) of
8000/mm3
D. Glucose 160 mg/dL
A
What is a pulse oximeter used to
measure?
A. Oxygen perfusion in the extremities
B. Pulse and perfusion in the
extremities
C. Hemoglobin saturation
D. Generalized tissue perfusion
C
The nurse is caring for several patients
who had diagnostic testing for
respiratory disorders. Which
diagnostic test has the highest risk for
the post procedure complication of
pneumothorax?
A. Bronchoscopy
B. Laryngoscopy
C. Computed tomography of lungs
D. Lung biopsy
D
After a bronchoscopy procedure, the
patient coughs up bright red blood.
What is the best nursing action at this
time?
A. Assess vital signs and respiratory status
and notify the provider of the findings
B. Monitor the patient for 24 hours to see
if blood continues in the sputum
C. Send the sputum to lab for cytology for
possible lung cancer
D. Reassure the patient this is a normal
response after a bronchoscopy
A
What is the best position for a patient
to assume for a thoracentesis?
A. Side-lying, affected side exposed,
head slightly raised
B. Sitting up, leaning over a bedside
table
C. Lying flat with arm on affected side
across the chest
D. Prone position with arms above the
head
B
A patient is recovering after laryngoscopy
and bronchoscopy. Which of the
following is important to assess in the
immediate post-procedure phase of
recovery? (Select all that apply)
A. Vital signs
B. Level of consciousness
C. Breath sounds
D. Chest X-ray
E. Presence of bleeding
F. Ability to talk
G. Gag reflex
ABCDEFG
APAP
automatic positive airway pressure
machine adjusts pressure based on patient needs
