Respiratory Assessment + Trach

Question 1

What are some health promotion and maintenance factors?

Answer 1

— assess smoking habits
— promote smoking cessation
*pack years = # of years smoked ❎ packs smoked
— determine exposure to other inhalation irritants
— protect the respiratory system

Question 2

What are changes in the respiratory system related to aging?

Answer 2

Alveoli
— airways close early
— elastic recoil decreases
— diffusion capacity decreases
Lungs
— vital capacity decreases
— impaired gas exchange
— decreased elasticity
Pharynx and larynx
— muscle atrophy
— lose elasticity
— airways lose cartilage
Susceptibility to infection
Mobility of chest wall decreases
Exercise intolerance
Muscle strength decreases
Risk for hypoxia increases

Question 3

What do you assess with skin and mucous membranes?

Answer 3

Assess the nail beds and mucous membranes of the oral cavity
Examine fingernails for clubbing (indicates long term hypoxia)

Question 4

What do you assess with the general appearance?

Answer 4

— long term respiratory problems lead to weight loss and loss of muscle mass
— arms and legs appear thin or poorly muscled
— neck and chest muscles may be hypertrophied

Question 5

What do you assess with endurance?

Answer 5

— decreases whenever gas exchange is inadequate
— observe how easily rage patient moves and whether the SOB is at rest or upon exertion
— note how often patient pauses for breath between words when talking

Question 6

What is apart of the psychological assessment?

Answer 6

— SOB often induces anxiety and anxiety can make shortness of air even worse
— stress may worsen some respiratory problems
— discuss coping mechanisms
— chronic respiratory disease: changes in relationships, social isolation, financial problems/unemployment, disability
— assist the patient to identify available support systems

Question 7

What does RBC labs tell you?

Answer 7

Data about the transport of oxygen
*normal range = M: 4.0-5.9, F: 3.8-5.2
RBC count decreases with age

Question 8

What does hemoglobin do?

Answer 8

Transports oxygen to the tissues
*deficiency could cause hypoxemia

Question 9

What does WBC tell you?

Answer 9

Indication of infection

Question 10

Common labs and imaging assessments:

Answer 10

Sputum culture, chest x-ray, chest CT

Question 11

What does pulse oximetry indicate?

Answer 11

Identifies hemoglobin saturated with oxygen
Normal: 95%-100%
*below 91% requires immediate assessment and treatment

Question 12

What does a pulse oximetry of 85% tell you?

Answer 12

Body tissues have a difficult time becoming oxygenated

Question 13

What is capnometry and capnography testing?

Answer 13

How quickly and how often someone exhales

Question 14

What is a laryngoscopy and what does it do?

Answer 14

Scope inserted into larynx to assess the function of the vocal cords
— used to remove foreign bodies caught in the larynx
— obtains tissue samples for biopsy or culture
*patients receive sedation

Question 15

What is a mediastinoscopy and what are the uses?

Answer 15

Insertion of a flexible tube through the chest wall just above the sternum into the area between the lungs
— examine for tumors
— obtain tissue samples for biopsy or culure
*performed under general anesthesia

Question 16

What is a bronchoscopy?

Answer 16

Insertion of tube in the airways, usually as far down as the secondary bronchi
— views the airway structures
— remove excessive secretions or foreign bodies
*risk for pneumothorax + bleeding

Question 17

What are some nursing interventions for post procedure?

Answer 17

Monitor VS, O2 saturation, and breath sounds every 15 minutes for 2 hours
Monitor return of gag reflex
Assess for possible complications of bleeding, infection, or hypoxemia

Question 18

What is a thoracentesis?

Answer 18

Needle aspiration of pleural fluid or air from the pleural space
*not sedated

Question 19

Conditions that will increase the body’s need for more oxygen

Answer 19

— infection in blood
— temp of 101
— hbg of 8.7

Question 20

What parameters does the nurse monitor to ensure that the patients response to oxygen therapy is adequate?

Answer 20

— LOC
— respiratory pattern
— pulse ox

Question 21

When a patient is requiring oxygen therapy what is the most important for the nurse to know?

Answer 21

Why the patient is receiving oxygen, expected outcomes and complications

Question 22

What are considered hazards of oxygen therapy?

Answer 22

— increased combustion
— oxygen toxicity
— absorption atelectasis
— oxygen induced hypoventilation

Question 23

Oxygen delivery devices:

Answer 23

— nasal cannula
— face mask
— Venturi mask
— 100% non rebreather mask
— face tent (usually used for humidifying)
— tracheostomy mask

Question 24

What nursing interventions should be included when a patient is receiving oxygen?

Answer 24

— ensure humidificarían
— assess for skin breakdown
— assess mucous membranes for dryness and bleeding
— assess for patency of tubing
— educate patients regarding oxygen safety

Question 25

A patient is receiving pre operative teaching for a partial laryngectomy and will have a tracheostomy. How does the nurse define a trach to the patient?

Answer 25

An opening in the trachea that enables breathing

Question 26

A patient returns from the operating room after a trach placement. While assessing the patient what observation may warrant immediate notification to the provider?

Answer 26

Skin is puffy at the neck area with crackling sensation *small amount of bleeding at incision is normal, along with noisy respirations

Question 27

What are some indications for a placement of a trach?

Answer 27

— stenosis of airway — obstruction of airway —tracheomalacia (softening of cartilage) — laryngeal or neck trauma — neck cancer — extended need for mechanical ventilation

Question 28

What are some complications of a tracheostomy?

Answer 28

— dislodgement — obstruction — SQ emphysema — skin breakdown — infection — bleeding

Question 29

To prevent accidental decannulation of a trach tube, what does the nurse do?

Answer 29

Secure the tube in place using ties or fabric fasteners

Question 30

The patient has a recent trach. What equipment does the nurse ensure is kept at the bedside?

Answer 30

— ambu bag (CPR bag) — oxygen tubing — suction

Question 31

What nursing interventions should be included when caring for a patient with a trach?

Answer 31

— stoma care — humidification — suctioning — ensure placement and patency — oral care — aspiration precautions

Question 32

A nurse is educating a client who will be going home with a trach. When discussing suctioning frequency, what should be included in education?

Answer 32

The trach should be suctioned when secretions can not be cleared and physical symptoms are present

Question 33

What are complications of suctioning?

Answer 33

— hypoxia — tissue trauma — infection — bronchospasm — cardiac Dysrhythmia

Question 34

What are the causes of the complications?

Answer 34

— ineffective oxygenation — use of catheter is too large for artificial airway — prolonged suctioning time — excessive suction pressure — too frequent suctioning

Question 35

What are the steps for suctioning?

Answer 35

1. Assess need for suctioning 2. Wash hands, don protective eyewear 3. Explain to patient sensations such as SOB and coughing are to be expected 4. Check the suction source 5. Set up a sterile field 6. Preoxygenate patient with 100% oxygen prior to suction 7. Quickly insert the suction catheter until resistance is met, do not apply suction during insertion 8. Withdraw catheter 1-2cm and apply suction, never suction longer than 15 seconds 9. Hyperoxygenate for 5 min or until patients baseline HR and oxygen are within normal limits

Question 36

A patient with a trach is unable to speak and is trying to communicate with the nurse. What should you do

Answer 36

Ask yes or no questions

Question 37

What is non-invasive positive airway pressure?

Answer 37

Uses positive airway pressure to keep alveoli open and improves gas exchange — uses a tightly fitted mask around nose, or nose and mouth — can be used without O2

Question 38

What are different types of non-invasive positive airway pressure?

Answer 38

CPAP: continuous positive airway pressure — one set pressure, delivered with each cycle of inhalation/exhalation BIPAP: bi-level positive airway pressure — different pressure is set for inhalation and exhalation

Question 39

How often do you change the inner cannula on a trach?

Answer 39

Change or clean once a day