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Adv. Med Surg > Respiratory > Flashcards

Respiratory Flashcards

1
Q

WHAT IS O2 TOXICITY AND ITS SYMPTOMS
(8)

A

Oxygen toxicity:
O2 concentrations of greater than 50% for extended periods of time (longer than 24 hours) can cause an overproduction of free radicals, which
can severely damage cells

  • Symptoms include:
    nonproductive cough,
    substernal discomfort,
    paresthesias,
    dyspnea,
    restlessness,
    fatigue,
    malaise,
    progressive respiratory difficulty

Use lowest effective concentrations of oxygen

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2
Q

OXYGEN SAFETY

A
  • No smoking, (have signs up)
  • Notify local fire department/electric company
  • No paint thinners, cleaning fluids, gasoline, aerosol sprays
  • Keep O2 delivery system 15 feet away from matches,
    candles, stove, open flame
  • Keep 5 feet away from TV, radio, other appliances
  • O2 tank away from direct sunlight
  • When traveling place in tank on floor behind front seat

** No electric razor, hair dryer, wool blankets (static), oil, alcohol, and nail polish**

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3
Q

Nasal Mask

A

* Flow rates of 1-6 L/min
* O2 concentration of 24%-44% (1-6 L/min)
* Assess patency of nostrils
* Assess for changes in respiratory rate and depth

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4
Q

Simple Facemask

A
  • Delivers O2 up to 40%-60%
    Minimum of 5 L/min
  • Mask fits securely over nose and mouth
  • Monitor closely for risk of aspiration
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5
Q

Partial NON-Rebreather Mask

A
  • Provides 60%-75% with flow rate of 6-11 L/min
  • Rebreathe one-third exhaled tidal volume with
    each breath
    Adjust flow rate to keep reservoir bag 2/3 inflated
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6
Q

NON-REBREATHER MASK

A
  • High O2 level; flow rate 12 L/min
  • Can deliver FIO2 greater than 90% (100%)
  • Used for unstable patients requiring intubation
  • Ensure valves are patent and functional
    Keep reservoir bag 2/3 full (inflated)*
    *Valve b/t mask and bag should CLOSE during expiration and OPEN during inhalation
    *Flaps on mask opens during exhalation and close during inhalation
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7
Q

What are your 5 high flow delivery systems

High flow system- designed to deliver precise and specific percentage of oxygen independent of the patient’s breathing
* Can deliver 24%-100% at 8-15 L/min

A
  • Venturi mask (best source for COPD/CLD pts)
  • Face tent
  • Aerosol mask
  • Tracheostomy collar (ensures humidifiers creates enough mist)
  • T-piece (ensures humidifiers creates enough mist)

Used for COPD pt because it allows for control and you won’t exceed delivered air & Unstable pts pending intubation

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8
Q

Incentive Spirometer (IS)

A

device that measures how deeply you can inhale (breathe in). It helps you take slow, deep breaths to expand and fill
your lungs with air → helps expand lungs and alveoli
used to prevent/treat atelectasis
Education on how to use this should be given prior to surgery
- Sit upright - Inhale slowly → hold 5 seconds → exhale through pursed lips
- 10 x/hour while awake

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9
Q

3 types of breathing exercises

A
  1. Diaphragmatic breathing: strengthening diaphragm
    * Sitting upright, leaning forward
    * Place one hand over the abdomen (just above the ribs) while inhaling and the other hand on the middle of chest
    * Inhale slowly and deeply through nose, the abdomen should expand with inhalation
    * Exhale slowly through pursed lips while contracting abdominal muscle
  2. Pursed-lip breathing: exhale 2- 3 x longer than inhalation
  3. Effective coughing: “Huff coughing”
    * Sitting upright, leaning forward; splint abdomen
    * Take 3-4 deep breaths using pursed lip and diaphragmatic breathing
    * Should cough 3 -4 x during exhalation (on the 3rd exhalation)
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10
Q

Nursing Interventions for CPT (2)

A
  1. Morning on arising, 1 hr before meal, or 2-3 hrs after meal (on an empty stomach)/ Administer bronchodilator 15 min before
  2. Wear gown or pajama
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11
Q

Postural Drainage (PD)

A

 Assume dependent position that involved area is up
 Lying on unaffected side & head down
 ** Percuss** the area 1-2 min
Vibrate the same area during exhalation of 4-5 deep breaths
 Percussion and vibration total 3-5 min
 Remain in each position for 10-15 min during the procedure (with pursed lip breathing)

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12
Q

Nursing Care for ET Tube

A

Verifying Tube Placement- the first intervention
-First, check End-tidal carbon dioxide levels
-*Assess for breath sounds bilaterally, symmetrical chest movement, air emerging from ET tube → Secure tube with tape
* Chest x-ray (the tip of tube 2 to 3 cm above the carina in the adult) to confirm
**Position change every 2 hrs **
* Insert an oral airway to prevent biting the tube
* Check pilot balloon
* Prevent movement of tube by patient: Soft wrist restraints, Mechanical sedation
* Oral hygiene /Suction prn through ET tube or mouth

***Maintaining proper cuff inflation **
* Serves to stabilize and “seal” ET tube within trachea
* Excess volume → tracheal damage
* Cuff pressure **15-20 mmHg **
* Check cuff pressure Q 6-8 hrs
* Use manometer to verify cuff pressure

*Do not use longer than 14 -21 days → tracheostomy

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13
Q

Tracheostomy Complications

A
  • **Pneumothorax **→ air can enter pleura and get
    stuck
  • Subcutaneous emphysema → air leaks out and
    gets trapped in skin → ↑swelling may compromise airway; you will feel the air (crepitus) when you palpate skin **Bleeding*
    *Infection **
    **Trachea-innominate (brachiocephalic) artery fistula **→ MEDICAL EMERGENCY → is an abnormal connection (fistula) between the innominate artery (brachiocephalic trunk or brachiocephalic artery) and the trachea
  • Pressure from the tracheostomy tube against the trachea causes the tissue to breakdown eventually creating a fistula between the trachea and the brachiocephalic artery → results in massive bleeding → you will see the tube pulsating
    REPORT IMMEDIATELY A PULSATING TUBE
    Tube dislodgement → Retention sutures are left in place so that if needed they can be pulled and open incision for insertion of replacement tube at bedside
  • First 5 -7 days are more dangerous → if tube comes out, opening will instantly begin to close → compromising airway
  • Doctor will do first tube change, do not change ties for initial 24 hrs
  • If it comes out in the first 72 hours and you cannot reinsert tube → try inserting catheter, if not possible then cover trach and bag pt
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14
Q

TRACH CARE

A

**Cleansing nondisposable inner cannula **( Q8 hours)
* Gather equipment, position patient, don PPE, set up equipment.
* Don sterile gloves.
* Unlock and remove inner cannula; Cleanse with sterile saline, shake to dry, reinsert.
* Cleanse stoma
* Remove dried secretions from stoma using 4x4 gauze pad soaked in sterile water or saline. Gently pat area around the stoma dry. Be sure to clean under
the tracheostomy faceplate, using cotton swabs to reach this area
Changing tie- apply a new tie first before removing old tie to prevent an accidental dislodgement
* Do not cut the dressing gauze
* Tube with inflated cuff is used if the patient is at risk of aspiration or in mechanical ventilation.
* Inflate cuff with minimum volume required to create an airway seal.
* Should not exceed 20 mm Hg in order to prevent tracheal necrosis
Monitor cuff pressure every 8 hour

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15
Q

Complications of Suctioning (6)

A
  1. Hypoxia,
  2. Ttissue (mucosal) trauma,
  3. infection
  4. Vagal stimulation—stop suctioning immediately and oxygenate patient manually with 100% oxygen
  5. Bronchospasm
  6. Cardiac dysrhythmias from hypoxia caused by suctioning
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16
Q

Retention Sutures

A

** Potential for Dislodgement**

  • Retention sutures; half circle b/t 2 & 3rd rings of trachea
  • Free ends taped to skin and leave accessible in case tube is dislodged
  • Most dangerous first 5-7 days
  • Precautions to prevent:
  • Replacement tube at bedside
  • Do not change ties for first 24 hours.
  • Physician performs first tube change
17
Q

VAP Nursing Care

A

Ventilator-Associated Pneumonia (VAP ) → pulmonary infection d/t ventilator caused while in hospital (nosocomial infection) → hospital becomes financially responsible for care needed after infection, so prevention is priority
**HOB 30 -45 degrees **
0.12% chlorhexidine oral rinse to ↓ bacteria in mouth done Q shift
** Sedation Vacation **→ daily assessment of pt off sedation (awake) to asses readiness to be extubated → is pt able to breathe on their own, it is better to extubate pt than keep them on the ventilator → the earlier they are extubated the less likely to get a bacterial infection
No tubing changes
↓ risk of peptic ulcers → PPI or H2 blocker
**DVT ppx **because of immobility
**Maintain cuff pressure at 20 mmHg **
o Continuous suction of subglottic secretions to reduce the bacterial growth

18
Q

Chest tube chambers and Pleural Drainage

A

 Collection chamber – monitor hemorrhage –Notify immediately !
* > 100 mL/hr, becomes bright red, or increase suddenly

 Water-seal chamber (MIDDLE CHAMBER)
* Intermittent bubbling, tidaling (fluctuation) [NORMAL]
 If disappears -Tube obstruction, dependent loop, or as lung fully reexpands
 Continuous bubbling indicates air leak
* Initially large air leak expected- Eventually disappears

 Suction control chamber: water and dry
* Amount of water in chamber controls suction to lungs.
* Typically filled to 20 cm of water:
* The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system
* Turn suction up until gentle bubbling
* Excessive bubbling does not increase the amount of applied suction but does increase the rate of evaporation of the column of water and the amount of noise made by the device

19
Q

Chest Tube Chambers
Nursing Management

A

Maintain patency of drainage system .
* Keep tubing loosely coiled, tape connections tightly
* No Milking or stripping chest tube – Gently!

 ** Assess patient’s clinical status**
* Vital signs, lung sounds, pain
* Encourage deep breathing, range-of-motion exercises, incentive spirometry
* **Monitor Subcutaneous emphysema/tension pneumothorax **
* If unit overturned, have patient exhale and cough

 **If break in system, Do NOT clamp; place distal end in sterile water to maintain water-seal and replace it with a new system **
* If the air leak persists, briefly and methodically move the clamps down the tubing away from the patient until the air leak stops. The leak will then be present between the last two clamp points. If the air leak persists all the way to the
drainage unit, replace the unit.

20
Q

Oxygen home care

A

• Post “No Smoking—Oxygen In Use” signs on doors.
• Notify local fire department and electric company of oxygen use in home.
• Never use paint thinners, cleaning fluids, gasoline, aerosol sprays, and other flammable materials while using oxygen.
• Keep all methods of oxygen delivery at least 15 ft away from matches, candles, gas stove, or other source of flame, and 5 ft away from television, radio, and other appliances.
• Keep oxygen tank out of direct sunlight.
• When traveling in automobile, place oxygen tank on floor behind front seat.

21
Q

Atelectasis Manifestations

A

insidious,
include cough,
sputum production,
low-grade fever/ respiratory distress,
anxiety,
hypoxia occurs if large areas of the lung are affected

22
Q

Atelectasis Nurse Management (5)

A

Turn, cough, deep breathe
Early mobilization
Incentive spirometer

23
Q

Risk Factors for TB

A

Homeless, Residents of inner-city neighborhoods
Foreign-born persons, Asian descent
Living or working in institutions (includes health care workers)
Poverty, poor access to health care
Alcohol or IV injecting drug users/ Older client, malnutrition
Long-term care or MH facility; prison (correctional facility)
Immunosuppression –HIV,
organ transplant,
Long-term steroid use

24
Q

How many classes of TB?
Which are active?

A

0 = No TB exposure
1 = Exposure, no infection (history of exposure, negative tuberculin skin test)
2 = Latent TB Infection (LTBI), no disease: TB infection without disease (significant reaction to tuberculin skin test, negative bacteriologic studies, no x-ray findings compatible with TB, no clinical evidence of TB); An estimated 10to 15million Americans have LTBI, of which 5-10% will develop active TB disease at some point. Therefore treatment of LTBI is important.
3 = TB, clinically active
4 = TB, not clinically active: No current disease (history of previous episode of TB or abnormal, stable x-ray findings in a person with a significant reaction to tuberculin skin test; negative bacteriologic studies if done; no clinical or x-ray evidence of current disease)
5 = TB suspected; (diagnosis pending); person should not be in this classification for more than 3 months

25
Q

Clinical Manifistations of TB

A

Takes 2-3 weeks to develop symptoms; insidious onset
Persistent cough; that frequently becomes productive with mucoid or mucopurulent sputum
Constitutional symptoms (fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats)
Dyspnea and hemoptysis late symptoms
Hemoptysis is not common and is usually associated with advanced disease.
Dyspnea may signify considerable pulmonary disease or a pleural effusion.
Can also present more acutely

26
Q

clinical manifistations of
extrapulmonary TB

A

The clinical manifestations of extrapulmonary TB are dependent on the organs infected.
For example, renal TB can cause dysuria and hematuria. Bone and joint TB may cause severe pain. Headaches, vomiting, and lympadenopathy may be present with TB meningitis

27
Q

Tuberculin skin test (TST) - PPD Mantoux test

A

Assess for induration (not redness) in 48 – 72 hours
Results: exposure to TB
Positive if ≥ 10 mm – normal or slightly impaired immunity
Positive if ≥ 5 mm HIV+, immunosuppressed (on steroids)- because response ↓ in immune-compromised patients
+HIV (or AIDS)
**Reactions ≥5 mm considered positive +symptoms →*isolation (priority)
Reaction < 5mm: x-ray and sputum culture to confirm
False positive – BCG vaccine
False negative: Some people who were previously infected with TB may have a waning immune response to the TST **

Two-step testing; recommended for newly hired health care workers for 1st time PPD test and elderly (because of delayed response to allergens)
Initial positive—need further evaluation
Second positive—new infection or boosted reaction to old infection

28
Q

Diagnostic Studies for TB (5)

A

Interferon-γ (gamma) release assays (IGRAs): screening tool for TB
QuantiFERON-TB Gold test; blood test

** Chest x-ray**

** Sputum studies**
Three consecutive sputum specimens collected on different days (at 8 to 24 hours intervals) are obtained and sent for smear and culture
The initial testing involves a microscopic examination of stained sputum smears for acid-fast bacilli (AFB test)- if positive, isolate the suspected patient and initiate the treatment

**Sputum culture **identifying Mycobacterium tuberculosis confirms diagnosis; but may take up to 4 (8) weeks
To determine the effectiveness (check monthly)-usually will have negative cultures after 3 months of treatment

29
Q

S/S of ATELECTASIS (6)

A

Symptoms:
insidious,
include cough,
sputum production,
low-grade fever/ respiratory distress,
anxiety,
hypoxia occurs if large areas of the lung are affected

30
Q

Nursing Management OF ATELECTASIS

A

Turn, cough, deep breathe
Early mobilization
Incentive spirometer

Adv. Med Surg (8 decks)

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