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pnl > Respiratory Assessment week 1 > Flashcards

Respiratory Assessment week 1 Flashcards

1
Q

Normal Range

A

(12-20 per min)

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2
Q

-observation and auscultation are the way to check resps.

A

Tachypnea- more than 20
Bradypnea (less than 12)
eupnea (normal range)

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3
Q

O2 SAT

A 
Normal Range (O2 SAT: 95%-100%)
Procedure (no movement)
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4
Q

Chest Assessment

A

Anterior Thorax - front of chest

Lateral Thorax - side of chest

Posterior Thorax - back of chest

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5
Q

Chest Auscultation

A

Enables the nurse to identify normal
and abnormal heart and lung sounds

 Move from right to left on the front   
 and then the back
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6
Q

Normal Breath Sounds

A

Vesicular (around the alveoli)

Bronchovesicular (around the trachea)

Bronchial (near the neck)

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7
Q

Adventitious Breath Sounds

A

Fine Crackles (formerly known as rales)

Coarse Crackles

Friction Rub

Sonorous Wheeze (formerly known as Rhonchi)

Sibilant Wheeze (such as asthma,high pitch)

Stridor

Atelectasis

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8
Q

Physiology of Respirations (Review)

A

Diffusion

Hematocrit (how thick the blood, lows oxygenation)

Hemoglobin (carries blood)
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9
Q

Alterations in Respiratory Function

A
  • Obstruction
  • Cheyne-Stokes (cranial pressure, before death)
  • Biot’s ( damage to the resp center)
  • Dyspnea (difficulty breathing)
  • Orthopnea ( inability to breath except in an upright or standing position)
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10
Q

Hypoxemia -

A

reduced levels of O2 in the blood

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11
Q

Hypoxia -

A

Inadequate tissue oxygenation a the cellular level

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12
Q

Cyanosis -

A

Hypoxemia and Hypoxia left untreated cyanosis develops (late stage of hypoxemia and hypoxia)

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13
Q

What can the nurse do to assist in the promotion of oxygenation?

A
  • tripod position
  • high Fowler position
  • any upright position
  • moving them around, if they can
  • fluids (prevents sec that can make it tick and promotes circulation)
  • coughing
  • lastly give meds and oxygen
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14
Q

ppl with COPD

A

oxygen can be worse for them

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15
Q

When should oxygen be administered to a patient and what information about caring for a patient with oxygen should the nurse be aware of?

A

always need an order

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16
Q

What safety precautions need to be taken for a patient with oxygen therapy? (discharged paitents)

A

liquid oxygen tanks make sure there is enough in the tank. (like if they are discharged)

  • it is flammable
  • wool
  • wires
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17
Q

Oxygen Delivery Devices

A

Nasal Cannula ( nasal prongs) (drys out nose and cause irritation)(can get pressure ulcers)( can get clogged)

Simple Face Mask (not proper oxygen being given)

Partial and Nonrebreather Masks (google)

Venturi Mask (gives accurate amount of oxygen being given)

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18
Q

oxygen in room air

A

21% oxygen

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19
Q

Ambu Bag

A

A hand-held device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately.

The patient is frequently referred to as “bagging” the patient.

Frequently used in emergencies, in the OR, ambulances

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20
Q

What is the difference between CPAP and BiPAPand how does the nurse care for patient’s using this equipment?

A

CPAP- sleep apnea continuous air pressure
BIPAP- diff levels of air pressure
- the nurse gotta check if it works, fits,

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21
Q

What nursing interventions should the nurse include when caring for a client with a chest tube?

A
  • check enviroment
  • vitals
  • drainage
  • resp assessment
  • need clamps
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22
Q

Perioperative refers to the three phases of surgery:

A

Preoperative

Intraoperative (in the OR)

Postoperative.

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23
Q

perioperative

A

The goal of perioperative care is to provide better conditions for patients before operation, during operation, and after operation.

Surgery is classified according to the purpose, urgency, level of invasiveness, body part, type of equipment, degree of risk.

24
Q

Surgical Risk Factors

A
  • age
  • immuno suppressed
  • any health probs
25
Q

What does the nurse include as part of their preoperative assessment?

A

consent

and signature from the person operating

26
Q

external resp

A

interchange of oxygen and CO2 between the alveoli of the lings and th pulmoanry blood

27
Q

internal respirations

A

takes place throughout the body. change of gases between circ blood and the cells of body tissues

28
Q

ventialtion

A

movement of air in and out of lungs

29
Q

two types of breathing

A

costal (thoracic)

diaphragmatic (abdominal)

30
Q

during inhalation

A

diaphragm contracts, ribs move upward and outward, sternum outward

31
Q

exhalation

A

diaphragm relaxes ribs move inward and down,

32
Q

respiration is controlled by

A

the resp cenetr in the medulla oblongata and the pons of the brain, AND the chemoreceptors in the medulla

33
Q

tidal volume

A

noral volume a person breathes in (usually ~500 ml)

34
Q

kussmauls breathing

A

abnormal deep breaths, rapid and sighing.

DIABETIC KETOACIDOSIS

35
Q

dyspnea

A

difficulty breathing

36
Q

orthopnea

A

ability to breath only upright

37
Q

pulse oximeter

A

can detect hypoxemia before it happens

38
Q

normal and abnormal O2sat

A

95-100% is normal
91-,85% is mild to sever hypoxia
any thing less then 70% are unreliable

39
Q

several factors can affect oxygen saturation readings.

A
  1. hemoglobin
  2. circulation
  3. activity-
  4. Carbon monoxide poisoning
40
Q

infants can have –% AND neonates can have —%

A

95% and 80%

41
Q

Normal breath sounds

A
  1. vesicular- base of lungs
  2. bronchovesicular- scapulae and lateral to sternum and at he first and secind intercostal space.
  3. bronchial- anteriorly over the trachea
42
Q

crackles

A

air passing through mositure

43
Q

wheeze

A

air passing through narrowing or obstruction

44
Q

stridor

A

partial obstruction of larynx or trachea

45
Q

infants chest ratio is

A

1:1

46
Q

lung complinace

A

strechability of lung tissue

at ventilation

47
Q

atelectasis

A

collapse of portion of the lung

48
Q

cardiac output

A

the amount of blood pumped by the ventricles in 1 in is 5L

49
Q

hematocrit

A

the propartion of erythrocytes to plasma

50
Q

cystic fibrosis

A

congential disorer that affects the lungs causing them to become congested with mucus

51
Q

hypoxia VS hypoxemia

A

reduced levels of O2 levels in the blood. VS insuff O2 anywhere in the body

52
Q

semi fowlers of high

A

allows for maximum chest expansion

53
Q

meds

A
  1. bronchodliators
  2. anti-inflammatory drugs
  3. leukotriene modifier
  4. ….
54
Q

incentive spirometers

A

measure the flow of air inhaled through a mouth piece and are used to help with improving ventilation, loosen secretions, expand collapsed alveoli

55
Q

postural drainage

A

the drainage by gravity of secs. from various lung segments.

pnl (10 decks)

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