Study Guide Test 5 Flashcards
the exchange of oxygen and carbon dioxide
Respiration
air pulled in
Inspiration in: Diaphragm
air blown out
Expiration: Diaphragm
What should your physical assessment include?
• monitoring the client’s respiratory rate
• observing the breathing pattern and effort
• checking chest symmetry
• auscultating lung sounds
Additional assessments include recording the heart rate and blood pressure, determining the client’s level of consciousness, and observing the color of the skin, mucous membranes, lips, and nail bed
What about finger clubbing?
An abnormal, rounded shape of the nail bed
What are ABG’s?
An arterial blood gas (ABG) assessment is a laboratory test using arterial blood to evaluate or assess oxygenation, ventilation, and acid–base balance. It measures the partial pressure of oxygen dissolved in plasma (PaO2), the percentage of hemoglobin saturated with oxygen (SaO2), the partial pressure of carbon dioxide in plasma (PaCO2), the pH of blood, and the level of bicarbonate (HCO3) ions.
What is the nurse’s role when collecting an ABG?
The nurse notifies the laboratory of the need for the blood test, records pertinent assessments on the laboratory request form and in the client’s medical record, prepares the client, assists the laboratory technician who obtains the specimen, and implements measures for preventing complications after the arterial puncture
What action would a nurse take to prevent complications after an ABG is drawn?
The nurse notifies the laboratory of the need for the blood test, records pertinent assessments on the laboratory request form and in the client’s medical record, prepares the client, assists the laboratory technician who obtains the specimen, and implements measures for preventing complications after the arterial puncture.
What is the normal range for pulse oximetry?
The normal Spo2 is 95% to 100%.
What are some ways we can position our clients to promote adequate oxygenation?
Fowler
Tripod
Orthopneic
eases breathing by allowing the abdominal organs to descend away from the diaphragm
Fowler position
increases a client’s breathing capacity by using the arms to lift the chest upward
Tripod position
allows room for maximum vertical and lateral chest expansion and provides comfort while resting or sleeping.
Orthopneic position
Oxygen is humidified only when?
• more than 4 L/minute is administered for an extended period. When humidification is desired, a bottle is filled with distilled water and attached to the flowmeter
Administers low concentrations of oxygen
Nasal Cannula
02 is delivered at no less than 5 L/minute.
Simple Mask
is an oxygen delivery device in which all the exhaled air leaves the mask rather than partially entering the reservoir bag (Fig. 21-17). It is designed to deliver a Fio2 of 90% to 100%. This type of mask contains one-way valves that allow only oxygen from its source, as well as the oxygen in the reservoir bag, to be inhaled. No air from the atmosphere is inhaled. All the air that is exhaled is vented from the mask. None enters the reservoir bag.
Non-Rebreather Mask
mixes a precise amount of oxygen and atmospheric air
Venturi mask
What is a disadvantage of the Face Tent?
A disadvantage is that the amount of oxygen clients receive may be inconsistent with what is prescribed because of environmental losses.
What is a CPAP mask?
A CPAP mask is attached to a portable ventilator that maintains continuous positive airway pressure keeping the alveoli partially inflated even during periods of expiration.
When would it be used?
The positive pressure prevents the airway from collapsing, allowing inflated alveoli to diffuse oxygen into the blood during apneic episodes that may last 10 or more seconds as frequently as 10 to 15 times an hour.
What type of client would use CPAP?
Patients with sleep apnea
refers to lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours.
Oxygen toxicity
Give S/S of oxygen toxicity
Nonproductive cough
• Substernal chest pain
• Nasal stuffiness
• Nausea and vomiting
• Fatigue
• Headache
• Sore throat
• Hypoventilation
What is water-seal chest tube drainage used for?
a technique for evacuating air or blood from the pleural cavity, which helps restore negative intrapleural pressure and reinflate the lung.
List the 3 Chambers of a chest tube:
- One chamber collects blood or acts as an exit route for pleural air.
- A second compartment holds water that prevents atmospheric air from reentering the pleural space (hence the term “water seal”)
- A third chamber, if used, facilitates the use of suction, which may speed the evacuation of blood or air.
What item should the nurse always include at the client’s bedside who has a chest tube?
Why?
• pair of hemostats (instruments for clamping) is at the bedside.
• Facilitates checking for air leaks in the tubing or clamping the chest tube in the event the drainage system must be replaced to prevent the reentry of atmospheric air within the pleural space, thus maintaining lung expansion
Why are good body mechanics so important?
increases muscle effectiveness, reduces fatigue, and helps avoid repetitive strain injuries
General principles for positioning are as follows:
• Change the inactive client’s position at least every 2 hours.
• Enlist the assistance of at least one other caregiver.
• Raise the bed to the height of the caregiver’s elbow.
• Remove pillows and positioning devices.
• Unfasten drainage tubes from the bed linens.
• Use a low-friction fabric or gel-filled plastic sheet, roller sheet with handles, or a repositioning sling to slide rather than to drag or lift the client while turning or transferring from bed to a stretcher
the person lies on his or her back
Supine Position
a side-lying position
Lateral Position
• a semiprone position
• the client lies on the left side with the right knee drawn up toward the chest (Fig. 23-11). An arm is positioned along the client’s back, and the chest and abdomen are allowed to lean forward.
Sim’s Position
a semi-sitting position
Fowler’s Position
is recommended as a way to reduce the incidence of sudden infant death syndrome among newborns
Supine
This position produces less pressure on the hip than a strictly lateral position and reduces the potential for skin breakdown.
Lateral Oblique
used for the examination of and procedures involving the rectum and vagina
Sim’s
helpful for clients with dyspnea because it causes the abdominal organs to drop away from the diaphragm.
Fowler’s
Trochanter Rolls: prevent what?
Prevent the legs from turning outward. The trochanters are the bony protrusions at the head of the femur near the hip.
Trapeze: any client considerations?
A trapeze is a triangular piece of metal hung by a chain over the head of the bed. The client grasps the trapeze to lift the body and move about in bed.
What are side rails helpful with?
are a valuable device to aid clients in changing their position and moving while in bed. With side rails in place, the client can safely turn from side to side and sit up in bed.
Bedrails x2
(half bed)- head rails
Bedrails x4
(full bed)- head rails and foot rails
What is a bed/foot cradle used for?
A cradle is a metal frame secured to or placed on top of the mattress. It forms a shell over the client’s lower legs to keep bed linen off the feet or legs.
are flat, flexible tubes that provide a pathway for drainage toward the dressing.
Open wound
are tubes that terminate in a receptacle.
Closed wounds
