Unit 5 Flashcards
Common signs of inadequate oxygenation
- decreased energy
- restlessness
- rapid, shallow breathing
- rapid heart rate
- sitting up to breath
- nasal flaring
- use of accessory muscles
- hypertension
- sleepiness, confusion, stupor, coma
Promoting oxygenation
- positioning
- breathing techniques
- oxygen therapy
Fowlers position
upright seated position
tripod position
seated position with the arms supported on pillows or arm rest
orthopneic position
pt leans forward over bedside table or chair back
chest physiotherapy
techniques including the postural drainage, percussion, and vibration
inspiration
breathing in
expiration
breathing out
ventilation
movement of air in and out of lungs
respiration
exchange of oxygen and carbon dioxide
external respiration
takes place at the most distal point in the airway between the alveolar and capillary membranes
internal respiration
occurs at the cellular level by means of hemoglobin and body cells
hypoxemia
insufficient oxygen within arterial blood
hypoxia
inadequate oxygen at the cellular level
normal pH **
7.35-7.45
normal Pao2
80-100 mmHg
normal PaCO2***
35-45mmHg
normal Sao2
95%-100%
normal HCO3**
22-26 mEq
ABG
lab test using arterial blood to evaluate or assess oxygenation
incentive spirometry
- technique for deep breathing using a calibrated device
- encourages pts to reach a certain volume of inspired air
hypercarbia
excessive levels of carbon dioxide in the blood
oxygen therapy
administering more oxygen than is present in the atmosphere to relieve or prevent hypoxemia
liquid oxygen unit
device that converts cooled liquid oxygen to a gas by passing it through heated coils
oxygen concentrator
collects and concentrates oxygen from room air and stores it for client use
flowmeter
gauge used to regulate the amount of oxygen delivered to pt
fraction of inspired oxygen
concentration of oxygen
oxygen analyzer
measures the percentage of delivered oxygen
nasal cannula
- most common oxygen delivery device
- hollow tube w/ 1/2 inch prongs placed into nostrils
simple mask
fits over nose and mouth and allow atmospheric air to enter and exit through side ports
partial rebreather mask
client inhales a mix of atmospheric air, oxygen from its source, and oxygen contained within s reservoir bag
non-rebreather mask
- all exhaled air leaves the mask
- deliver an FIO2 of 90%-100%
- one way valves that allow only oxygen from its source and oxygen in the reservoir bag
venturi mask
mixes a precise amount of oxygen and atmospheric air
face tent
- used for pts with facial trauma or burns
- oxygen is inconsistent
tracheostomy collar
delivers oxygen near an artificial opening in the neck
nasal catheter
- delivering oxygen with a tube inserted through the nose
- used for pts who are mouth breathers or claustrophobic
transtracheal catheter
hollow tube inserted within the trachea to deliver oxygen
oxygen tent
- clear plastic enclosure that provides cool humidified air
- most used on active toddlers
oxygen toxicity
lung damage when oxygen concentrations of more than 50% are administered
Positive ariway pressure machines
devices that help to relieve impaired oxygen levels caused by apnea or hypopnea during sleep
CPAP mask
attached to a portable ventilator and maintains continuous positive airway pressure
Signs/symptoms of oxygen toxicity
- nonproductive cough
- substernal chest pain
- nasal stuffiness
- nausea and vomiting
- fatigue
- headache
- sore throat
- hypoventilation
BiPAP mask
provides two different levels of airway pressure : inspiratory positive airway and expiratory positive airway pressure
water-seal chest tube drainage
- technique for evacuating air or blood from the pleural cavity
- chest tube must never be separated from the drainage system unless it is clamped ***
airway management
essential nursing skills that maintain natural or artificial airways for compromised pts
Upper airway
nose and pharynx
lower airway
trachea, brochi, brochioles, and alveoli
sputum
mucus raised to the level of the upper airways
inhalation therapy
respiratory treatments that provide a mixture of oxygen, humidification, and aerosolized medications directly to the lungs
Postural drainage
a positioning technique that promotes the drainage of secretions from various lobes or segments of the lungs with the use of gravity
Percussion
rhythmic striking of the chest wall
Vibration
uses the palms of the hands to shake underlying tissue and loosen retained secretions
suctioning
relies on negative pressure to remove liquid secretions with a catheter
nasopharyngeal suctioning
removing secretions from the throat through a nasally inserted catheter
nasotracheal suctioning
removing secretions from the upper portion of the lower airway through a nasally inserted catheter
oropharyngeal suctioning
removing secretions from the throat through an orally inserted catheter
oral suctioning
removing secretions from the mouth
oral airway
curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway
tracheostomy
surgically created opening into the trachea
tracheostomy tube
- curved hollow plastic tube
- aka a cannula
outer cannula
remains in place until the entire tube is placed
inner canula
removed periodically for cleaning
obturator
curved guide with a bullet-shaped tip
fenestrated tracheostomy tube
one with holes in the outer canula
speaking valve
a device that directs exhaled air through the upper airway
tracheostomy care
cleaning the skin around the stoma, changing the dressing, and cleaning the inner canula
intubation
placement of a tube into a body structure
orogastric intubation
insertion of a tube through the mouth into the stomach
nasogastric intubation
insertion of a tube through the nose into the stomach
nasointestinal intubation
insertion of a tube through the nose into the intestine
ostomy
surgically created opening
reasons gastric or intestinal tubes are used
- performing a gavage(giving food)
- administering oral medications that pt cant swallow
- obtaining a sample of secretions for testing
- performing a lavage (cleaning out the stomach)
- promoting decompression
- controlling gastric bleeding
gavage
providing nourishment
lavage
removing substances from the stomach
decompression
removing gas ad liquid contents from the stomach or bowel
tamponade
pressure
French scale
used to measure the outside diameter of most tubes
lumen
channel within the tube
sump tubes
double-lumen tubes
gastric reflux
reverse flow of gastric contents
transabdominal tubes
tubes placed through the abdominal wall
gastrostomy tube (G-tube)
transabdominal tube located within the stomach
jejunostomy tube (J-tube)
transabdominal tube that leads to the jejunum of the small intestine
percutaneous endoscopic gastrostomy tube
- PEG tube
- transdominal tube inserted under endoscopic guidance
percutaneous endoscopic jejunostomy tube
- PEJ tube
- tube that is passed though a PEG tube into the jejunum
preintubation assessment
- LOC
- weight
- bowel sounds
- abdominal distention
- integrity of nasal and oral mucosa
- ability to swallow, cough, gag
- any nausea and vomiting
NEX
length from nose to earlobe to the xiphoid process
enternal nutrition
nourishment provided through the stomach or small intestine
dumping syndrome
cluster of symptoms from the rapid deposition of calorie-dense nourishment into the small intestine
bolus feeding
instillation of liquid nourishment in less than 30 minutes 4 to 6 times a day
intermittent feeding
gradual instillation of liquid nourishment 4 to 6 times a day
cyclic feeding
the continuous instillation of liquid nourishment for 8 t 12 hours
continuous feeding
instillation of liquid nutrition without interruption
gastric residual
- volume of liquid within the stomach
- should be no more than 100 mL or no more than 20% of previous hour’s tube feeding***
Valsalva maneuver
bearing down
defecation
bowel elimination
peristalis
ryhthmic contractions of intestinal smooth muscle that facilitate defacation
gastrocolic reflex
increased peristaltic activity
anal sphincters
ring shaped bands of muscles
factors affecting bowel elimination
- type of food consumed
- fluid intake
- drugs
- emotions
- neuromuscular function
- abdominal muscle tone
- opportunity for defecation
bowel regularity range
3 times a day to 3 times a week
COCA
- color
- odor
- consistency
- amount
melena
blood in stool
heme
iron compound in blood present within stool
fecal occult blood test
- FOBT
- self collecting screening test from 3 separate stools
fecal immunochemical test
- FIT
- more specific than an FOBT because it uses antibodies to detect globin
globin
- protein removed from heme
- present exclusively in the lower intestine
colonoscopy
visual inspection of the interior colon using a flexible lighted endoscope
sigmoidoscopy
visual endoscopic inspection limited to the sigmoid portion of the large intestine
colonography
CT scan without colonoscope
tenesmus
rectal pressure
constipation
elimination problem characterized by dry,hard stool that is difficult to pass
primary constipation
results from lifestyle factors such as inactivity, inadequate intake of fiber, insufficient fluids, or ignoring the urge to go
secondary constipation
consequence of a pathologic disorder such as a partial bowel obstruction
latrogenic constipation
consequence of other medical treatments
pseudoconstipation
- pt believes they are constipated, even though they are not
- often overuse or abuse laxatives
fecal impaction
results from unrelieved constipation, retained barium from and intestinal xray, dehydration, weakness of abdominal muscles
flatulence (flatus)
excessive accumulation of intestinal gas
diarrhea
urgent passage of watery stool
fecal incontinence
inability to control the elimination of stool
enema
- introduces a solution into the rectum
- lay on left side
cleansing enema
- use different type of solution to remove feces from the rectum
- defecation usually occurs within 5 to 15 minutes after `
tap water and normal saline enema
- preferred for their nonirritating effects
- esp for clients with rectal diseases or those being prepared for rectal exam
soap solution enema
- mixture of water and soap
- soap causes chemical irritation of the mucous membrane
hypertonic saline enema
draws fluid from body tissues into the bowel
retention enema
uses a solution held within the large intestine for a specific period usually at least 30 minutes
stoma
entrance to the opening
ileostomy
surgically created opening to the ileum
colostomy
surgically created opening to a portion of the colon
appliance
bag or collection device over the stoma to collect stool
excoriation
chemical injury of the skin
karaya
- barrier substance
- plant substance that becomes gelatinous when moistened
enterostomal therapist
nurse certified in caring for ostomies and related skin problems
continent ostomy
surgically created opening that controls the drainage of liquid stool or urine
respiratory alkalosis
- high pH
- low PCO 2
Respiratory acidosis
- low pH
- high PCO 2
metabolic alkalosis
- high pH
- high HCO 3
Metabolic acidosis
- low pH
- low HCO 3
