oxygenation Flashcards
1
Q
respiratory system includes
A
upper airways, lungs, lower airways, and alveolar air sacs (base of lungs)
2
Q
the lungs aid the body
A
in oxygenation and tissue perfusion
3
Q
noninvasive procesures
A
- chest x-ray (CXR): use lead sheild for adults who are childbearing age
- pulse oximetry
- pulmonary function tests
- sputum culture
- ct scan
- mri
4
Q
hypoxemia
A
when there is a limited amount of oxyegen in the blood
5
Q
retractions
A
- when the muscles are pulled inward and occur between the ribs when inspiration occurs
- intercostal retractions are a sign that the airway is blocked
6
Q
Hypoxia
A
lack of oxygen at the cellular level
7
Q
clinical manifestation of hypoxia and hypoemia
A
tachypnea tachycardia restlessness pale skin and mucous membranes elevated blood pressure use of accessory muscles, nasal flaring, adventitious lung sounds
8
Q
nursing actions for hypoxia and hypoxemia
A
- monitor respiratory rate and pattern, level of consciousness
- provide oxygen therapy at the lowest liter flow that will correct hypoxia
- make sure the mask creates a secure seal over the nose and mouth
- assess/monitor restlessness, hypertension, and headache
- wheezing because of inflammation on inhaling or exhale
- auscultate the lungs for breath sounds and adventitious sounds (crackles and wheezes)
- assess/ monitor oxygenation status with pulse oximetry
- promote oral hygiene
- encourage turning, coughing, deep breathing, and the use of incentive spirometry and suctioning
- promote rest and decrease environmental stimuli
9
Q
oxygen therapy
A
- a therapeutic gas that treats hypoxemia (low levels of arterial oxygen)
- administering and adjusting oxygen requires a prescription
10
Q
oxygen delivery devices
A
- nasal cannula
- simple face mask
- partial rebreather mask
- non-rebreather mask
- venturi mask
- aerosol mask, face tent
- t-piece
11
Q
nasal cannula
A
tubing with two small prongs for insertion into the nares
- fraction of inspired oxygen: delivers an Fio2 of 24% to 44% at a flow rate of 1-6 l/min
12
Q
nasal cannula advantages
A
- safe, simple, easy to apply method
- cannula is comfortable and well tolerates
- client is able to eat, talk, and ambulate
13
Q
nasal cannula disadvantages
A
- FiO2 varies with flow rate, and the rate and depth of the clients breathing
- extended use can lead to skin breakdown and dry mucous membranes
- tuning is easily dislodged
14
Q
nasal cannula nursing actions
A
- assess the patency of the nares
- ensure that the prongs fit in the nares properly
- use water-soluble gel to prevent dry nares
- provider humidication for flow rates of 4l/min and greater **
15
Q
simple face mask
A
- covers the client’s nose and mouth
- delivers an Fi02 of 35% to 50% at flow rates of 6 to 12 l/min
- minimum flow rate is 6l/min to ensure flushing of CO2 from the mask
16
Q
simple face mask advantages
A
- face mask is easy to apply and can be more comfortable than a nsal cannula
- provides humidified oxygen
17
Q
simple face mask disadvantages
A
- flow rates less than 6L/min can result in rebreathing of co2
- clients who have anixety or claustrophobia do not tolerate it well
- eating, drinking, and talking are impaires. mositure and pressure can collect under mask and cause skin breakdown
- face mask pose a greater risk of aspiration
18
Q
simple face mask nursing actions
A
- assess proper fit to ensure a secure seal over the nose and mouth
- make sure the client wears a nasal cannula during meals
- use with caution for clients who have a high risk of aspiration or airway obsutrction
- monitor for skin breakdown
19
Q
non-rebreather mask fraction of inspired oxygen
A
- delivers an FiO2 of 80% to 95% at flow rates of 10-15 l/min to keep the reservoir bag 2/3 full during inspiration and expiration
20
Q
non-rebreather mask advantages
A
- it delivers the highest 02 concentration possible
- a one-way valve situated between the mask and reservoir allows the client to inhale maximum 02 from the reservoir bag
- the two exhalation ports have flaps covering them that prevent room air from entering the mask
21
Q
non-rebreather mask disadvantage
A
- the valve and flap on the mask must be intact and functional during each breath
- it is poorly tolerated by clients who have anxiety or claustrophobia
- eating drinking and talking are impaired
- use with caution for clients who have high risk of aspiration or airway obstruction
22
Q
non-rebreather mask nursing actions
A
- perform and hourly assessment of the valve and flap
- assess proper fit to ensure a secure seal over the nose and mouth
- assess for skin breakdown beneath the edges of the mask and bride of the nose. make sure the client uses a nasal cannula during meals
23
Q
oxygen complications
A
- oxygen toxicity can result from high concentrations of oxygen (typically greater than 50%)
- long duration of oxygen therapy (typically more than 24 to 48 hours) and the severity of lung disease
24
Q
oxygen toxicity manifsations
A
- nonproductive cough
- substernal pain
- nausea
- vomiting
- fatigue
- dyspnea
- restlessness
- paresthesias
25
Q
oxygen toxicity nursing actions
A
- use the lowest level of oxygen necessay to maintain an adequate spo2
- monitor abg and notify the provider if sp02 levels are outside the expected reference range
- decrease the fio2 as the clients spo2 imrpoves
26
Q
combustion nursing actions
A
- post “no smoking” or “oxygen in use” signs to alert others of the fire hazard. known where to find the closest fire extinguisher
- educate about the fire hazard of smoking with oxygen use
- have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity
27
Q
combustion
A
- ensure that all electric devices (razors, hearing aids, radios) are working well
- make sure all electric machinery (monitors, suction machines is grounded
- do not sure volatile, flammable materials (alcohol, acetone) near clients receiving oxygen
28
Q
specimen collection and airway clearance
A
- mucoasl secretion buildup or aspiration of emeis can obstruct a clients airway
- adequate hydration and coughing help the client maintain airway patency
- these interventions promote adequate gas exchange and lung expansion
29
Q
specimen collection and airway clearance nursing actions that mobilize secretions and maintain airway patency include:
A
- assistance with coughing
- hydration
- positioning
- humidification
- nebulizer therapy
- chest phsiotherapy
- suctioning
30
Q
suctioning
A
don the required personal protective equitment
- assist the client to high-fowelers or fowlers position for suctioning if possible
- encourage the client to breathe deeply and cough in a an attempt to clear secretions without artifical suction
31
Q
suctioning nursing actions
A
- obtain baseline breath sounds and vital signs, including sao2 by a pulse oximeter
- can monitor sao2 continually during the procedure
- oropharyngeal suctioning use a yankauer or tonsil tipped rigid suction catheter and move the catheter around the mouth, gum line, and pharynx
