Study Guide Test 5 Flashcards
1
Q
the exchange of oxygen and carbon dioxide
A
Respiration
2
Q
air pulled in
A
Inspiration in: Diaphragm
3
Q
air blown out
A
Expiration: Diaphragm
4
Q
What should your physical assessment include?
A
• 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
5
Q
What about finger clubbing?
A
An abnormal, rounded shape of the nail bed
6
Q
What are ABG’s?
A
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.
7
Q
What is the nurse’s role when collecting an ABG?
A
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
8
Q
What action would a nurse take to prevent complications after an ABG is drawn?
A
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.
9
Q
What is the normal range for pulse oximetry?
A
The normal Spo2 is 95% to 100%.
10
Q
What are some ways we can position our clients to promote adequate oxygenation?
A
Fowler
Tripod
Orthopneic
11
Q
eases breathing by allowing the abdominal organs to descend away from the diaphragm
A
Fowler position
12
Q
increases a client’s breathing capacity by using the arms to lift the chest upward
A
Tripod position
13
Q
allows room for maximum vertical and lateral chest expansion and provides comfort while resting or sleeping.
A
Orthopneic position
14
Q
Oxygen is humidified only when?
A
• 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
15
Q
Administers low concentrations of oxygen
A
Nasal Cannula
16
Q
02 is delivered at no less than 5 L/minute.
A
Simple Mask
17
Q
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.
A
Non-Rebreather Mask
18
Q
mixes a precise amount of oxygen and atmospheric air
A
Venturi mask
19
Q
What is a disadvantage of the Face Tent?
A
A disadvantage is that the amount of oxygen clients receive may be inconsistent with what is prescribed because of environmental losses.
20
Q
What is a CPAP mask?
A
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.
21
Q
When would it be used?
A
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.
22
Q
What type of client would use CPAP?
A
Patients with sleep apnea
23
Q
refers to lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours.
A
Oxygen toxicity
24
Q
Give S/S of oxygen toxicity
A
Nonproductive cough
• Substernal chest pain
• Nasal stuffiness
• Nausea and vomiting
• Fatigue
• Headache
• Sore throat
• Hypoventilation
25
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.
26
List the 3 Chambers of a chest tube:
1. One chamber collects blood or acts as an exit route for pleural air.
2. A second compartment holds water that prevents atmospheric air from reentering the pleural space (hence the term “water seal”)
3. A third chamber, if used, facilitates the use of suction, which may speed the evacuation of blood or air.
27
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
28
Why are good body mechanics so important?
increases muscle effectiveness, reduces fatigue, and helps avoid repetitive strain injuries
29
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
30
the person lies on his or her back
Supine Position
31
a side-lying position
Lateral Position
32
• 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
33
a semi-sitting position
Fowler’s Position
34
is recommended as a way to reduce the incidence of sudden infant death syndrome among newborns
Supine
35
This position produces less pressure on the hip than a strictly lateral position and reduces the potential for skin breakdown.
Lateral Oblique
36
used for the examination of and procedures involving the rectum and vagina
Sim's
37
helpful for clients with dyspnea because it causes the abdominal organs to drop away from the diaphragm.
Fowler's
38
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.
39
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.
40
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.
41
Bedrails x2
(half bed)- head rails
42
Bedrails x4
(full bed)- head rails and foot rails
43
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.
44
are flat, flexible tubes that provide a pathway for drainage toward the dressing.
Open wound
45
are tubes that terminate in a receptacle.
Closed wounds
46
A clean separation of skin and tissue with smooth, even edges
Incision
47
A clean separation of skin and tissue with smooth, even edges
Laceration
48
A wound in which the surface layers of skin are scraped away
Abrasion
49
Stripping away of large areas of skin and underlying tissue, leaving cartilage and bone exposed
Avulsion
50
A shallow crater in which the skin or the mucous membrane is missing
Ulceration
51
An opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object
Puncture
52
Injury to soft tissue underlying the skin from the force of contact with a hard object, sometimes called a bruise
Contusion
53
During wound repair, how long does the inflammation stage last?
lasts approximately 2 to 5 days
54
Briefly describe the inflammation stage. - the physiologic process immediately after tissue injury
1st - During the first stage, local changes occur. Immediately following an injury, blood vessels constrict to control blood loss and confine the damage. Shortly thereafter, the blood vessels dilate to deliver platelets that form a loose clot. The membranes of the damaged cells become more permeable, causing the release of plasma and chemical substances that transmit a sensation of discomfort. The local response produces the characteristic signs and symptoms of inflammation:
55
The local response produces what signs and symptoms? First stage
swelling, redness, warmth, pain, and decreased function.
56
Describe the 2nd wave of defense
A second wave of defense follows the local changes when polymorphonuclear leukocytes (neutrophils) and macrophages (monocytes), types of white blood cells, migrate to the site of injury, and the body produces more and more white blood cells to take their place.
57
is an increased production of white blood cells.
Leukocytosis
58
What test do nurses monitor in this scenario?
Confirmed and monitored by a laboratory test called a white blood cell count and differential count (counting the number and type of white blood cells in a sample of the client’s blood)
• Increased production of white blood cells, particularly neutrophils and monocytes, suggests an inflammatory and, in some cases, infectious process.
59
What is the proliferation phase and how long does it last?
A period during which new cells fill and seal a wound; occurs from 2 days to 3 weeks after the inflammatory phase
60
How is the skin integrity restored?
Resolution
Regeneration
Scar formation
61
a process by which damaged cells recover and reestablish their normal functions
Resolution
62
cell duplication
Regeneration
63
replacement of damaged cells with fibrous scar tissue
Scar formation
64
What occurs during the remodeling phase and how long does it last?
A period during which the wound undergoes changes and maturation; follows the proliferative phase and may last 6 months to 2 years.
• During this time, the wound contracts and the scar shrinks
65
(primary intention) is a reparative process in which the wound edges are directly next to each other; wound space is narrow, only a small amount of scar tissue forms
First-intention healing
66
the wound edges are widely separated, leading to a more time-consuming and complex reparative process; wound edges are not in direct contact, conspicuous scar results
• Healing by second intention is prolonged when the wound contains body fluid or other wound debris. Wound care must be performed cautiously to avoid disrupting the granulation tissue and retarding the healing process.
Second-intention healing
67
the wound edges are intentionally left widely separated and are later brought together with some type of closure material; results in a broad deep scar.
• Wounds are deep and are likely to contain extensive drainage and tissue debris. To speed up healing, they may contain drainage devices or be packed with absorbent gauze.
Third-intention healing
68
What are some key factors that affect wound healing? (Gerontologic considerations & Nutrition notes)
• compromised circulation, infection, and purulent, bloody, or serous fluid accumulation that prevent skin and tissue approximation, excessive tension or pulling on wound edges contributes to wound disruption and delays healing. (One or several of these factors may be secondary to poor nutrition, impaired inflammatory or immune responses related to drugs like corticosteroids, and obesity)
• Diminished immune response from reduced T-lymphocyte cells predisposes older adults to wound infections.
• Signs of inflammation may be subtle in older adults.
• Diabetes or other conditions that may interfere with circulation increase the older adult’s susceptibility to delayed wound healing and wound infections.
69
What do we need for wound healing?
adequate blood flow to the injured tissue.
70
Wounds may require increased amounts of neutrophils and monocytes These play important roles in
wound healing.
71
What factors interfere with wound healing?
• Type of wound injury
• Expanse or depth of wound
• Quality of circulation
• Amount of wound debris
• Presence of infection
• Status of the client’s health
72
the separation of wound edges.
Dehiscence
73
wound separation with the protrusion of organs
Evisceration
74
When would dihiscence and evisceration most likely occur, and what could they be caused by?
• May be caused by insufficient dietary intake of protein and sources of vitamin C.
• Premature removal of suture or staples
• Unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves or hiccuping
• Weak tissues or muscular support secondary to obesity
• Distinction of the abdomen from accumulated intestinal gas
• Compromised tissue integrity from pervious surgical procedure in same area
75
What might a client describe if this occurs and what should you as the nurse do?
The client may describe that something has “given away.”
D: Disruption may be suspected, the nurse positions client to put the least amount of strain on the open area.
E: if evisceration occurs, the nurse places sterile dressing’s moistened with normal saline over the protruding organs and tissues.
76
What is a pressure ulcer (tissue injury) caused from?
Is a wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissues. Often appear over bony prominence of the sacrum, hips, heels.
77
What is the purpose of a dressing?
• keeping the wound clean
• absorbing drainage
• controlling bleeding
• protecting the wound from further injury
• protecting the wound from further injury
• holding medication in place
• maintaining a moist environment
78
primarily blood
Sanguinous
79
containing blood ( may also be present in a health, healing wound)
Serosanguinous
80
thick, white, and pus-like (may be indicative of infection and should be cultured)
Purulent
81
clear and thing ( may be present in a healthy, healing wound)
Serous
82
are clear, acrylic film wound coverings.
Transparent Dressing
83
How long can a Hydrocolloid be left in place?
it can be left in place for up to 1 week
84
When would a dressing be changed and what should you be sure of before you start a dressing change?
when a wound requires assessment or care and when the dressing becomes loose or saturated with drainage. In some cases, the physician may choose to assume total responsibility for changing the dressing—at least for the initial dressing change. Nurses, however, commonly reinforce dressings (apply additional absorbent layers) when dressings become moist.
85
are flat, flexible tubes that provide a pathway for drainage toward the dressing. Draining occurs passively by gravity and capillary action (the movement of a liquid at the point of contact with a solid, which in this case is the drain).
Open drains
86
are tubes that terminate in a receptacle. Some examples of closed drainage systems are the Hemovac and the Jackson–Pratt drain (Fig. 28-12). Closed drains are more efficient than open drains because they pull fluid by creating a vacuum or negative pressure.
Closed drains
87
What are the purposes for bandages and binders
• Holding dressings in place, especially when tape cannot be used or if the dressing is extremely large
• Supporting the area around a wound or injury to reduce pain
• Limiting movement in the wound area to promote healing
88
4 different types of debridement
Sharp debridement
Enzymatic debridement
Autolytic debridement
Mechanical debridement
89
is the removal of necrotic tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments
Sharp debridement
90
involves the use of topically applied chemical substances that break down and liquefy wound debris. A dressing is used to keep the enzyme in contact with the wound and to help absorb the drainage.
Enzymatic debridement
91
or self-dissolution, is a painless, natural physiologic process that allows the body’s enzymes to soften, liquefy, and release devitalized tissue. It is used when a wound is small and free of infection. The main disadvantage in autolysis is the prolonged time it takes to achieve desired results
Autolytic debridement
92
involves the physical removal of debris from nonhealing wounds. One technique is maggot therapy, which was approved by the U.S. Food and Drug Administration in 2004. Medical maggots are the larvae of a species of blow flies. Once the maggots are sterilized by a supplying laboratory, they are deposited into the wound.
Mechanical debridement
93
(the therapeutic use of water), in which the body part with the wound is submerged in a whirlpool tank. The agitation of the water, which contains an antiseptic, softens the dead tissue
hydrotherapy
94
is generally carried out just before applying a new dressing. This technique is best used when granulation tissue has formed. Surface debris should be removed gently without disturbing the healthy proliferating cells.
Wound irrigation
95
flushes a toxic chemical from one or both eyes or displaces dried mucus or other drainage that accumulates from inflamed or infected eye structures
Eye irrigation
96
removes debris from the ear.
Ear irrigation
97
List common uses for heat & cold therapy:
• Heat:provide warmth
• Promotes circulation
• Speed healing
• Relieves muscle spasm
• Reduces pain
• Cold: reduces fever
• Prevents swelling
• Controls bleeding
• Relieves pain
• Numb sensation
98
Where do pressure ulcers (tissue injury) most often appear?
Over the bony prominence of the sacrum, hips and heels. Back of head, ears, shoulders, back of knees and ankle
99
Be able to describe the different stages of pressure ulcers?
I Intact but reddened or darken skin
II red and accompanied by blistering or skin tear with out slough
III shallow skin crater that extends to the subcutaneous tissue maybe accompanied by serous drainage (leaking plasma) undermining slough or purvlent drainage caused by a wound infection
IV life threatening tissue deeply ulcerated, exposing muscle and bone slough and narcotic tissues may be endent. The dead and infected tissue may produce a foul order
100
Can an LVN stage tissue injury ulcers?
No, can describe and only if has been staged before can it be staged
101
How can pressure ulcers be prevented?
Identify clients with risk factors for pressure ulcers. Then implement measures that reduce conditions under which pressure ulcers are likely to form
102
List risk factors for developing pressure ulcers (tissue injury):
*inactivity
*immobility
*malnutrition
*emaciation
*incontinence
*vascular disease
*localized edema
*dehydration
*sedation
103
How would you know if a wound is healing?
*scabs
*swelling
*tissue growth
*scarring
104
What does the upper airway consist of?
Nose and pharynx which is subdivided into the nasal pharynx, oropharynx, and larynogopharynx
105
Lower airway?
T Treachea
B Bronchi
B Bronchioles
A Alveoli
106
What does hydration have to do with mucus?
Adequate hydrate liquefies respiratory secretions and facilitates expectoration. Expectoration of sputum clears the airways and promotes ventilation.
107
What does inhalation therapy do?
Improves breathing.
Encourages spontaneous coughing
Humidification
108
When is a sputum specimen collected?
Just after the client awakens or after the aerosol treatment.
The timing allows for a collection when more mucus is available or is in a thinner state.
109
When would an oral airway be used?
Used in clients who are unconscious and cannot protect their own airways, such as recovering from general anesthesia or a seizure.
110
What is the purpose of a tracheostomy tube with a cuff?
To form a seal between the tracheostomy tube and tracheal wall to prevent aspiration and or facilitate effective ventilation with a ventilation bag/mechanical ventilator.
111
Suctioning and care of a tracheostomy would include?
When suctioning a tracheostomy, the nurse inserts the catheter a short distance because the tube already lies in the trachea. The resistance is caused by contact between the catheter tip and the carina, the ridge at the lower end of the tracheal
112
How often should it be performed? Suctioning and care of a tracheostomy
It should be cared for every 8 hours
113
PPE: Is it really necessary?
PPE wouldn’t be necessary but wearing a mask would.
114
How long would a nurse apply suction? ___________________________
As often as clients need to keep the secretions from becoming dried, which may narrow or occlude the airway.
