Oxygenation

Question 1

Inspriation

Answer 1

Air flows into the lungs

Question 2

Expiration

Answer 2

Air flows out of the lungs

Question 3

Cheyne-Stokes Respirations

Answer 3

Increased and Decreased rate and depth of ventilation followed by apnea lasting 20-60 seconds

Question 4

Kussmaul Respirations

Answer 4

Deep, Grasping, Rapid breathing

Question 5

Biot’s Respirations

Answer 5

Rapid, Deep respirations with abrupt pauses between each breath

Question 6

Obstructive Breathing Pattern

Answer 6

Inhale & Exhale Ratio of 1:4 or Greater

Question 7

Apnea

Answer 7

Stopping breathing for more than 15 seconds

Question 8

Orthopnea

Answer 8

Difficulty breathing while lying down

Question 9

Dyspnea

Answer 9

Difficulty breathing, with:
~ Shortness of Breath
~Nostril Flaring
~ Increased Heart Rate

Question 10

Dyspnea stems from what?

Answer 10

A cardiac or respiratory problem

Question 11

What is the definition of Hypoxia?

Answer 11

Reduced Oxygen Level in the Blood

Question 12

What does the body do to compensate for Hypoxia?

Answer 12

Increases Heart Rate and Increased Cardiac Output

Question 13

What causes Hypoxia?

Answer 13

Conditions that Impair Alveolar-Capillary Diffusion (e.g. Pulmonary Edema)

Question 14

What are the symptoms of Hypoxemia?

Answer 14

~ Rapid Pulse
~ Cyanosis
~ Substernal or Intercostal retractions
~ Rapid, shallow respirations
~Dyspnea
~ Flaring of the nares
~ Increased restlessness or lightheadedness

Question 15

Condition of insufficient oxygen in body tissue; results from unresolved hypoxemia

Answer 15

Hypoxemia

Question 16

Nursing Interventions to Promote Oxygenation

Answer 16

Position the client for maximum chest expansion (semi or high Fowler’s)
Encourage or provide for frequent position changes
Encourage Deep breathing and coughing
Implement Comfort Measures

Question 17

How to promote Oxygen Therapy through Nursing interventions

Answer 17

Check Vital Signs and Oxygen Saturation Level
Ordered for clients with hypoxemia, anemia, and blood loss
Nurse may implement oxygenation in an emergency, then call provider

Question 18

Tracheostomy

Answer 18

It is an opening in the trachea. The patient cannot speak
It has an outer and inner canula, obturatory, and a flange with tubes or ties
Contains an airtight seal, which prevents aspiration and air leakage

Question 19

What does nursing care for a Tracheostomy involve?

Answer 19

Cleaning and Suctioning

Question 20

What does Suctioning with A Tracheostomy do?

Answer 20

Aspirates secretions through a catheter that is connected to a suction machine or a wall section outlet

Question 21

During Trach Suctioning, what should the nurse do?

Answer 21

Assess for respiratory distress

Question 22

How would you decrease the complications of Trach Suctioning??

Answer 22

Hyperinflation
Hyperoxygention
Hyperventilation
Gently Rotate catheter, withdraw while suctioning. Suction for 5-10 seconds

Question 23

What are the possible complications of Trach Suctioning that the Nurse should be aware of?

Answer 23

Hypoxemia
Trauma to the airways
Nosocomial Infection
Cardiac Dysrhythmia

Question 24

What are the implications for Trach Suctioning???

Answer 24

Client is unable to cough up snd expectorate secretions
Dyspnea
Poor Skin Color
Bubbling or Rattling breath sounds
Decreased O2 saturation

Question 25

Procedure for a Tracheostomy Suctioning and things to keep in mind.

Answer 25

•Assess for adventitious sounds and cough reflex
•Do not delegate to UAP
•Review documentation; note responses if client has been suctioned previously
•Explain procedure and tell client it may cause coughing
•Wash hands
•Place client in semi-Fowler’s if possible
•Resuscitation apparatus attached to O2 adjusted at 100%
•Sterile saline/water in sterile basin; sterile towel over client’s chest
•Suction pressure per agency (usually 80-120 mmHg adults, 60-100 mmHg children)
•Apply PPE and sterile gloves
•Attach catheter (in dominant hand) to suction tubing connector (nondominant hand)
•Flush and lubricate catheter with sterile saline
•Hyperventilate lungs before suctioning
–Exception: If secretions are copious, hyperventilation could push them deeper. Instead, increase oxygen to 100% for a few breaths.
•Insert catheter without applying suctioning 12.5 cm (5 in) into trachea or till client coughs
•Apply suctioning for 5-10 sec (thumb over port) while rotating and withdrawing catheter
•Stop suction
•Hyperventilate client; reassess; repeat suctioning if needed.
–After each suction, ventilate with up to 3 breaths
–Observe respirations, skin color
–Encourage deep breathing, coughing
–2-3 min with O2 if possible between suctions
–Flush catheter and repeat suctioning until airway clear, breathing not labored
•Document

Question 26

How to provide Tracheostomy Care

Answer 26

•Establish sterile field
•Pour soaking solution and saline into containers
•Apply gloves
•Remove O2 source
•Unlock and remove inner cannula (if present); place in soaking solution (unless disposable)
•Remove soiled trach dressing; dispose of dressing and gloves; apply sterile gloves
•Clean lumen and inner cannula with brush or pipe cleaner; rinse in sterile saline; dry inner surface of cannula only
•Reinsert inner cannula and lock in place
•Clean incision and tube flange with sterile technique
•Apply sterile trach dressing
•Change trach ties or Velcro collar
–2-strip method
–1-strip method
–Velcro collar method
•Remove and discard gloves
•Perform hand hygiene
•Document

Question 27

How many times do you do incentive spirometry and how often?

Answer 27

Several times and then 4-5 times every hour

Question 28

Things to remember about suctioning!

Answer 28

•Decrease complications by
–Hyperinflation
–Hyperoxygenation
–Hyperventilation
–Gently rotate catheter, withdraw while suctioning, suction for 5-10 seconds