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NRSG 202 > Seminar #2: Respiratory, Chest Tubes, Tracheostomy > Flashcards

Seminar #2: Respiratory, Chest Tubes, Tracheostomy Flashcards

1
Q

Adventitious sounds

A
  • crackles (coarse / fine)
  • death rattle
  • pleural friction rub
  • rhonchi/sonorous wheeze
  • stridor
  • wheeze: sibilant/sonorous
  • consodilation: bronchophony, ecophony
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2
Q

Abnormal respiratory sounds

A
  • cheyne stokes breathing
  • kussmaul breathing
  • agonal or guppy breathing
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3
Q

when do you hear coarse crackles?

A
  • pneumonia
  • aspiration
  • CHF
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4
Q

High Flow O2

A
  • inspiratory flow met/exceeded
  • ventilatory rates don’t affect FiO2, more predictable, positive pressure
  • measured in %, titrate by 5-10%
  • humidified –> loosens secretions + ensures nasal cannula doesn’t dry out
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5
Q

What are the high flow O2 masks?

A
  • aerosol
  • star wars
  • venturi
  • trach masks
  • face tent
  • t-piece
  • airvo
  • optiflow
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6
Q

can high flow o2 be applied for extended periods of time?

A

if over 16% for long periods of time, can develop o2 toxicity and/or atelectasis
- need to re-evaluate often

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7
Q

low flow O2

A
  • inspiratory flow not met
  • ventilatory pattern influences FiO2 - more variable
  • measured in L/min, titrate by 1-2L
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8
Q

Low Flow O2 masks

A

nasal prongs
simple mask
non-rebreather mask

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9
Q

AquaPak Humidified O2 system

A

air entrainment port: 28-98% FiO2
- patient specific
- connects to corrugated tubing
- replaced prefilled sterile h2o bottle as needed (always have extra pak @ bedside)
- change tubing q7days

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10
Q

Aerosol Mask - HF

A

administers specific FiO2 - determined by air entrainment port
- corrugated tubing collects moisture
- exhalation ports allow air from room if o2 were to be inadequate

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10
Q

Star Wars Mask

A

regular aerosol mask + two 6” pieces of corrugated tubing to be used as reservoirs
- less air inhaled from exhalation ports
- almost 100% FiO2 inhaled
- generally requires “double flow’ system
- ensure flowmeter(s) as directed by RT

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11
Q

Trach Mask - HF

A

placed around neck + trach to ensure adequate o2 + humidification delivery
- single or double flow
- imprecise FiO2

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12
Q

T piece - HF

A

attach to endotracheal tube or tracheostomy tube
- 6” reservoir tubing attached to other side of “T”
- precise FiO2
- single or double flow/ tubing

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12
Q

Optiflow & Airvo O2 therapy

A

HF o2 delivery system used for pts w/ profound hypoxemia and/or mucociliary clearance difficulties
- heated + humidified gas @ 37 degrees
- nasal, mask, or trach
- nasal shouldn’t be more than 1/2 diameter of nares

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13
Q

how to administer bronchodiltor on high flow o2?

A

NDI
with airvo + optiflow, can attach in-line, administer liquid form of bronchodilator
- don’t aerolize > 8-10L/min – will aerolize too quickly to be absorbed

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13
Q

Benefits of Optiflow + Airvo

A
  • not considered AGMP
  • comfort; can eat + drink
  • precise o2 concentration
  • decr WOB
  • promotes ciliary mov’t + secretion clearance
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13
Q

Optiflow vs Airvo

A

airvo
flow range 2-60L/min, FiO2: 0.21-1.0

optiflow:
flow range: 10-60L/min, FiO2: 0.28-1.0

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14
Q

Optiflow/Airvo Monitoring + documentation

A
  • resp/cvs/vs q4h & prn for first 24h
  • monitor as determined after 24h
  • changes in WOB, o2, trending/changing cvs decline
  • FiO2 setting, flow rate, temp, sterile h2o bag q4h
  • humidifier on “invasive mode” unless has trach or aerosol mask on
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14
Q

initiaton, titration, discontinuation, transpoort

Airvo/optiflow - who does what?

A

initiates: RT / CCN w/ doc order
titrates: RT / CCN only
discontinues: RT or CCN w/ doc order
transport: consult RT

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15
Q

student role/RN for airvo/optiflow?

A

proper documentation & assessment
- on acute care, most RNs don’t touch, RT’s job

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16
Q

How to calculate o2 in cylinder

A

o2 left = (psi x 0.28) / L/min

psi = what’s left in tank
multiply by conversion factor (E-class = 0.28)
divide by L/min required

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16
Q

when to use, what to do

Oropharyngeal airway

A
  • can stimulate gag reflex - only use on pts w/ altered LOC
  • don’t tape airway in place
  • mouth care q2h/ per protocol
  • suctioned prn (not studetn role)
  • remove and assess mouth q8h
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17
Q

how to insert oral airway?

A
  1. gloves
  2. measure oral airway from centre of mouth to angle of jaw, or from corner of mouth to earlobe
  3. with airway distal tip pointing up, open mouth and insert airway along tongue
  4. when distal end reaches soft palate, rotate airway 180 degrees
18
Q

why nasal over oral, when to reposition, what to do frequently

Nasopharyngeal airway

A
  • tolerated better by alert pts
  • inserted into nare
  • provide frequent oral + nasal care
  • reposition airway in other nare q8h if req
  • look for trauma, deviated septum, etc b4 inserting into nare
19
inserting nasal airway
1. don gloves 2. measure nasal airway from **earlobe to tip of nostril** 3. ensure diameter of airway is not larger than nostril 4. lubricate airway w/ h2o soluble jelly 5. insert along floor of nostril w/ slight twisting action, aim towards back of opposite eyeball
20
tracheostomy - what is it?
opening made for tube via surgical incision in trachea, just below larynx (tracheotomy - opening for tube = stomy - plastic or metal, various sizes
21
Cuff tracheostomy tubes? what do they have?
have inflatable cuff that produces airtight seal b/t tube & trachea - puffed up = decr aspirations
21
components of tracheostomy?
outer cannula w/ flange - always in stoma, changed couple times a year inner canula - change qshift/prn obturator - safety piece, helps guide inner cannula
22
Complications of tracheostomy?
- infection of trach site - lung infection - stenosis of trachea - PIs **- mucous plugs** - trauma to area if suctioning too deep
23
why would someone req tracheostomy?
- head & neck cancers - spinal cord injuries - prolonged ventilator use - head or neck surgeries
24
Bedside Safety equipment for tracheostomy
**1. suction equipment 2. o2 equipment w/ humidification 3. two replacement trach tubes (same size + smaller size) 4. obturator + spare inner cannula 5. 10mL syringe 6. tracheal dilators or forceps 7. sterile gloves** 8. h2o-soluble lubricant 9. spare ties 10. normal saline nebule 11. manua resuscitation device w/ appropriate size airway & mask (closeby) 12. if permanent stoma, have pediatric mask nearby 13. if wired jaw, jaw cutters available @ bedside
25
when is a chest tube needed?
- when pressure placed on lung interferes w/ expansion - when negative pressure needs to be restores - fluid or air need to be drained - for chronic conditions
26
Where to insert tube for pneumothorax? hemothorax?
pneumothorax: 2-4 intercostal space (air rises) - upper anterior thorax hemothorax: 4-7 (fluid sinks) - lower lateral chest wall
27
# what do you focus on? Assessment for Chest Tube
- prioritize chest tubes during QPA - start @ pt and work way down - advanced resp + cardio assessment - prn analgesic for pain - DB&C q2h, might be contraindicated for lobectomy - assist w/ ROM + mobilizing
28
Insertion site assessment - Chest tubes
palpate + listen for subcu emphysema pigtail = preferable for pneumo large bore = drain thick fluids, e.g., blood, bld clots, infections
29
Drainage system assessment
1. closed system 2. connections taped + secured 3. tubing free from kinks + compression 4. no dependent loops 5. drainage system below level of chest 6. drainage system secured 7. blue clamp** open** 8. check for "tidaling" w/ resps 9. bubbling in air leak monitor 10. record date/time/amount of drainage on outside of chamber 11. record amount + characteristics of drainage on fluid balance sheet + pt chart 12. replace chamber when full 13. suction control dial set to ordered level
30
What safety equipment @ bedside for chest tubes?
1. 2 clamps (non-toothed or padded) 2. waterproof tape
31
When do you clamp a chest tube?
Don't clamp (can cause tension pneumothorax) unless: - ordered by MRP - changing chamber - checking for leaks - dislodged
32
what is chest tube pulled out? ## Footnote Emergency!
1. cover insertion site w/ gloved hand, call for help 2. cover site w/ sterile gauze + tape, have pt exhale 3. only tape top + both side, leave bottom open --> 3-way valve, 4x4 tape 3 sides 4. call MRP
33
What if chest tube disconnected from drainage system? ## Footnote Emergency!
1. have pt exhale 2. double clamp and/or submerge end in 2cm sterile h2o 3. clean ends w/ alcohol & reconnect immediately **4. unclamp**
34
What if chest tube has air leak?
1. begin @ dressing and clamp momentarily, working towards drainage chamber @ 20-30cm intervals 2. each time you clamp, check h2o-seal / air leak meter chamber for bubbling 3. when clamp b/t source of air leak & drainage chamber, bubbling will stop 4. if bubbling stops the first time you clamp, air leak must be @ chest tube insertion site or lung
35
# what do you do Clot blocks chest tubing?
don't strip or "milk" tubing may need to change drainage system notify MRP if needed
36
if chest tube drainaeg bright red?
- may indicate active bleed - monitor amount of drainage and vital signs - notify MRP
37
# for injections Sharps safety
- recap sterile, unused needles using "scoop technique" - never recap used needle, use needle safety device to cover - discard in sharps container - change container / notify personnel if 2/3 full
37
# where? absorption rate? how much @ one time? intradermal injections
- injection into dermis: b/t epidermis & SC tissue - low blood supply, slow absorption - usually 0.1mL admin, very small amount - limited meds administered intradermally
38
Equipment needed for intradermal injections
1. 1mL TB syringe 2. attached safety needle 3. needle legnth 1/4 to 1/2", 25-27 gauge 4. alcohol swabs 5. medication 6. MAR
39
Intradermal injection site
- most common = inner forearm, 5-10 cm from elbow - avoid areas w/ abrasions, lesions, edema, burns, rashes, visible veins
40
how to administer intradermal injection?
1. clean w/ alcohol swab 2. hold skin taut 3. 'bevel' up 4. position needle @ 5-15 degree angle 5. insert needle 3mm into skin 6. slowly inject med 7. 6-10 mm 'wheal'/'bleb' should form 8. remove needle in opp direction of entry 9. activate needle safety device + discard in sharps - don't cover or massage injection site
41
# Intradermal injections wheal/bleb formation size?
immunocompromised = 5-10mm health = < 10mm, 6-10
42
When to repeat intradermal / TB site?
- no wheal or bleb forms - solution leaks out - select site 2-4" from initial site
43
TB skin test results
negative = 0-4mm positive = 10mm high risk positive = 5-10mm (children < 5, recent contacts)
44
# from where + how? Sputum collection
- sputum = mucous secreted from lungs, bronchi, trachea - must cough to bring sputum up from lungs, bronchi, trachea - offer mouth care to reduce oral microorganisms; done before breakfast - DB & C 3x , collect 15-30mL of sputum into specimen container
45
# why? Cytology collection
identify origin, structure, function, and pathology of cells - often req serial collection of 3 early morning specimens
45
# why? Sputum for C&S
collected to identify organisms + drug sensitivities
46
# sputum collection, why? acid-fast bacillus (AFB)
requires serial collection often for **3 consecutive days** - test for **TB **

NRSG 202 (9 decks)

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