Seminar 2 Flashcards
high flow oxygen, trach and chest tube care, ID injections, Sputum collection
are heard on
Fine crackles:
More heard on expiration, come periodically
are heard on
Coarse crackles:
Heard a lot on inspiration and expiration. Sounds like lungs are full.
are heard on
Asthmatic wheeze:
Heard on expiration, emergent, use bronchodilator to open airway
Agonal breathing:
gasping for air, often seen in code situation.
Kussmaul Breathing
characterized by rapid, deep breathing at a consistent pace. Usually a sign of DKA.
Cheyne Stokes Breathing
a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all
Rhonchi/Sonorous wheeze
low-pitched sounds
4 things
If the SPO2 of a patient is less than 92% what interventions should the nurse take? (first)
this is prior to giving oxygen
- Try to rouse the patient
- Encourage deep breathing and coughing
- Suction as required
- Reassess SPO2
3 things
If the SPo2 is greater than 96% on oxygen, what should the nurses next steps be?
- Decrease o2 liter flow by 1-2 L
- Change o2 delivery device to NP
- Decrease Fio2 by 5-10% if on high flow
Goal is to maintain 92%
When weaning 02 to the lowest level what SPO2 should be maintained?
92 % or greater
How soon after making changes to someones oxygen should we assess them again?
5 mins. And this needs to be done before any further changes are made.
3 things
If oxygen is still not greater than 92% after doing initial intervention techniques, what are the next steps a nurse should take?
- Increase oxygen liter flow by 1-2L/min
- Change of oxygen delivery device from NP to SM
- Increase FiO2 by 5-10% if on high flow
if greater than 40% or greater than 8L/min oxygen is required what should the RN do?
call RTT or MD
Low flow or HIgh flow
Inspiratory flow not met
?
Low flow
Low flow or High flow?
Inspiratory flow met/exceeded
High flow
low flow or high flow
Ventilatory pattern influences Fi02- more variable
Low flow
Low flow or high flow
Measured in L/min
Titrate by 1-2L
Low flow
Low flow or high flow?
Nasal prongs, simple mask, non-rebreather mask
Low flow
High flow or low flow
Ventilatory rate does not effect Fi02- more predictable
High flow
High flow or low flow
Measured in %
Titrate by 5-10%
High flow
high flow or low flow
Aerosol/Star Wars/Venturi/Trach Masks, Face Tent, T-piece Airvo/Optiflow (newer)
High flow
high flow or low flow
Humidified
High flow
High flow or low flow
Single or Double Flow
High flow
what is the purpose of providing humidification in oxygen therapy?
to loosen secretions and help remove mucus plugs.
Can high flow oxygen be applied for extended periods of time?
Yes, but they must be assessed often. once you are on oxygen rates of 60% or more you can develop oxygen toxicity.
Air Entrainment Port FiO2 level on a AquaPak Humidified O2 System
28-98%
How often should tubing be changed on a AquaPak humidifed O2 system?
Change tubing Q7Days
what is a AquaPak connected to ?
corrugated tubing
Aerosol mask administers a specific?
Administers a specific FiO2
On a aerosol mask the exhalation ports do what?
Exhalation ports allow air from the room if the oxygen were to be inadequate
How can you tell the difference between a aerosol mask and a simple mask
The aerosol mask is attached to corrugated tubing.
On the star wars mask, there is a).. inhaled from the exhalation ports.
a) Less air inhaled
What type of flow does the star wars mask require?
Generally requires “double flow” system
Trach mask have a a).. FiO2
a) imprecise
what type of flow is a trach mask?
single or double
A T-tube is attached too?
Attach to endotracheal tube or tracheostomy tube
A T-tube has a a) FiO2
a) precise
a T-tube can be what type of flow?
single or double
7 things
When dealing with oxygen therapy, nursing care includes,
- Label equipment with patient name and date
- Clean face masks/prongs.
- Assess straps (change when soiled).
- Observe for **pressure sores **
- Complete respiratory/cardio assessment as per, doctors orders, as per protocol and PRN.
- Ensure adequate sterile water and assess the setting levels.
- Assess tubing for excess water & empty as needed.
What are four difficulties with the old style of oxygen delivery options
- Transportation
- Eating
- Talking
- Comfortability
indication for high flow oxygen
clients with profound hypoxemia and/or mucocilliary clearance difficulties
Optiflow and Airvo do what two things to the oxygen being delivered?
Heat it to 37C and humidify it
When fitting someone for high flow Nasal prongs, what is one thing that should considered in regards to sizing the nare?
NP should not be more than 1/2 diameter of the nare
comes in small, medium and large sizes
Do optiflow and airvo deliver high or low flow?
BOTH :)
is Optiflow & Airvo a AGMP
Nope
can clients eat with Optiflow & Airvo
Yes :)
yum yum yum
does optiflow or airvo deliver precise or imprecise oxygen?
Precise
**Airvo 2 **
Flow range:
FiO2 range:
Flow range: 2-60 L/min
FiO2 range: 0.21-1.0
Optiflow
Flow range:
FiO2 range:
Flow range: 10-60 L/min
FiO2 range: 0.28-1.0
In the first 4 hours of a patient being on Optiflow and Airvo what two things does the nurse need to assess?
Respiratory/cardiovascular assessment and VS required by the nurse q4h and PRN for the first 24 hours
When delivering high flow o2 via a Optiflow and Airvo the humidty should be set to a).. unless the patient is on a trach or aerosol mask.
a).. invasive mode
FiO2 setting, flow rate, temperature, and sterile water bag should be monitored?
at least every 4 hours
4 things
Benefits of a oxygen concentrator
- Filters air to generate medical grade oxygen
- Unlimited supply
- Battery operated
- Light weight
what is the formula to calculate how long a oxygen cylinder will supply O2 to your patient
psi x 0.28
divided by
(x) L/min
note!!! psi: what is left in tank, 0.28: conversion factor
IF a client has a oropharyngeal airway, how often should mouth care be completed?
Mouth care every 2 hours or as per protocol
What type of patient is appropiate for inserting a Oropharyngeal Airway and why?
- Only use on patients with altered level of consciousness
- Can stimulate the gag reflex!
Oropharyngeal Airways should be taped into a patients mouth..
True or false
**FALSE. **
NEVER tape a oropharyngeal into the airyway. Patient needs to be able to spit out the tube if they regain conciousness
Inserting an Oral Airway
How should a nurse measure a patients airway when inserting a oral airway?
Measurethe oral airway from the center of the mouth to the angle of the jaw.
**or **
from the corner of the mouth to the earlobe.
Inserting an Oral Airway
When the distal end reaches of the oral airway reaches the a)… rotate the airway 180 degrees
a) soft palate
Inserting a Nasal Airway
How should the nurse measure the nasal airway when inserting a Nasopharyngeal airway?
Measurethe nasal airway from the clients earlobe to the tip of the nostril
Inserting a Nasal Airway
When inserting a nasal airway, the nurse should lubricate the airway with?
with water-soluble jelly
Inserting a Nasal Airway
Insert along the floor of the nostril with a slight a).. action, aim towards the back of the b)..
a) twisting
b) opposite eyeball
Where is the surgical incision site for the tracheostomy?
just below the larynx
3 components of a trach tube
- Outer cannula with a flange
- Inner Cannula
- Obturator
How often are trach ties replaced?
Changed PRN or 48-72 hours.
7 things
What emergency equipment should be a the bedside for a patient with a trach?
-Suction equipment
-Oxygen equipment with humidification
-Two replacement tracheostomy tubes (one of the same size, and one a smaller size than the current tube)
-Obturator and spare inner cannula
-10 ml syringe
-Tracheal dilators or forceps
-Sterile gloves
5things
Complications with tracheotomy
- Infection (More likely to get lung infections)
- Stenosis of trachea
- Pressure injuries
- Mucus plugs (biggest concern)
- Trauma to area if suctioning is happening too deep
4 things
indications for a trachostomy
- Spinal cord injuries
- Prolonged ventilator use
- Head or neck surgery
- Head or neck cancers.
3 things
Indications for a chest tube
- When pressure placed on the lung interferes with expansion
- When negative pressure needs to be restored
- When air or fluid needs to be drained
When draining a hemothorax, approx what intercostal spaces would we see the drainage tube
lower lateral chest wall,
approx (intercostal 4-7)
think “blood pools”
when draining a pneumothorax, approx where would we see the drainage tube
Upper anterior thorax,
approx (intercostal 2-4)
think “air rises”
Define empyema
an accumulation of pus in the pleural space, caused by pneumonia, lung abscess or contamination of the pleural cavity
how often should the nurse lift up a patients gown and inspect their chest tube site?
look at site q4h
closed or open
Chest tube system should remain?
closed
What should be recorded on a drainage chamber q shift?
Record date/time/amount of drainage on the outside of the chamber
open or closed
The blue clamp on the chest tube atrium should be?
Blue clamp is OPEN
what safety equipment should be at the bedside for a patient with a chest tube?
- Two clamps (non toothed or padded)
- Waterproof tape
When is it okay to clamp a chest tube?
ordered by MRP, changing chamber, checking for leaks, or if tube is dislodged
IF a patient with a chest tube is left clamped, what are they at high risk for?
tension pneumothorax
If a chest tube becomes disconnected from the drainage system what should the nurse do?
- Have patient exhale
- Double Clamp and/or submerge the end in 2cm of sterile water
- Clean ends with alcohol and reconnect immediately
- Unclamp
This is a emergency!
If a patients chest tube is pulled out, what should the nurse do?
- Cover the insertion site with a gloved hand, call for help!
- Cover site with a sterile gauze and tape- have patient exhale (ONLY tape top and both sides- leave the bottom open)
- Call MRP
This is a emergency!
If a chest tube has a leak, what should the nurse do?
- Begin at dressing and clamp momentarily, working towards drainage chamber at 20-30 cm intervals
- check the water-seal/air leak meter chamber for bubbling each time you clamp.
- When the clamp is between the source of air leak and the drainage chamber, the bubbling will stop.
if a clot blocks the tubing what can the nurse do? what should they not do?
Do not strip or “milk” tubing
* May need to change drainage system
*Notify MRP if needed
milking raises pressure in the lungs
What does this mean?
If the nurse notices that the drainage from a chest tube is suddenly bright red, what should they do?!
- This may indicate an active bleed
1. Monitor amount of drainage and vital signs
2. Notify the MRP
When should sharps container be changed?
2/3 full
NEVER a).. a used needle! Use needle safety device to cover
a) recap
The indradermal route has a).. absorption and b).. blood supply
a) slow
b) low
How many ml can be injected into the intradermal space
usually 0.1 ml
what needle length and gage should be used for a intradermal injection
Needle length: ¼ to ½”,
gauge: 25 to 27
When drawing up tuberculin, does the nurse need to inject air into the vial?
with tuberculin it is not necessary to insert air because it’s a very small dose
what should the nurse label a syringe with after preparing it?
- 2 client identifiers
- Name of the medication (ex. Tuberculin PPD)
- Dose and the amount (5TU/0.1ml)
What is the most common site for a intradermal injection
inner forearm 5-10cm from elbow
When giving a ID injection, what angle should the needle be?
5 to 15 degree angle
How deep should the nurse insert a ID injection into the skin?
Insert the needle 3mm into the skin
What size bleb or wheal should appear on the skin after giving a ID injection
A 6 to 10 mm ‘wheal’ or ‘bleb’ should form
6 things
what should be documented for a TB injection
date, dose, route, lot#, site location, and the measurement of the wheal/bleb
Does a TB test differentiate between latent or active
no:(
TB most common in a)..?, but can infect other areas such as b)..?
a) lungs
b) brain, kidney, spine
A TB skin test must be read within?
48-72 hours
TB skin test
A skin test of a).. is considered negative
0-4 mm
TB skin test
A skin test of a).. is considered positive in high risk populations, children <5yrs, or recent contacts.
5-10mm
TB skin test
A skin test of a).. is positive in anyone else
10mm
TB treatment
Combination of oral antibiotics for a)..
6 months or longer
Sputum is mucous secreted from the
lungs, bronchi, and trachea
A patient must do what in order to bring sputum up?
cough
distinguish between spit and sputum
AFB (acid-fast bacillus)
Requires serial collection often for how many days? and what does it test for?
3 consecutive days (early morning)
- TB
Cytology does what?
Identify origin, structure, function, and pathology of cells
when should sputum cultures be collected?
Collect in the morning, prior to eating
Patients should mouth wash before sputum culture
true or false
False.
However, they should do mouth care
How much sputum should be collected for a sputum collection
15 to 30 ml
What should be labeled on a sputum sample when sending it to the lab
- clients label (name, PHN, and hospital identifiers),
- date and time of collection,
- the collection source (sputum),
- and the required test (C&S, AFB, cytology),
- & nurses pneumonic
