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Basic Nursing Skills > Unit 5 > Flashcards

Unit 5 Flashcards

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1
Q

Common signs of inadequate oxygenation

A
  • decreased energy
  • restlessness
  • rapid, shallow breathing
  • rapid heart rate
  • sitting up to breath
  • nasal flaring
  • use of accessory muscles
  • hypertension
  • sleepiness, confusion, stupor, coma
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2
Q

Promoting oxygenation

A
  • positioning
  • breathing techniques
  • oxygen therapy
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3
Q

Fowlers position

A

upright seated position

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4
Q

tripod position

A

seated position with the arms supported on pillows or arm rest

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5
Q

orthopneic position

A

pt leans forward over bedside table or chair back

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6
Q

chest physiotherapy

A

techniques including the postural drainage, percussion, and vibration

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7
Q

inspiration

A

breathing in

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8
Q

expiration

A

breathing out

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9
Q

ventilation

A

movement of air in and out of lungs

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10
Q

respiration

A

exchange of oxygen and carbon dioxide

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11
Q

external respiration

A

takes place at the most distal point in the airway between the alveolar and capillary membranes

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12
Q

internal respiration

A

occurs at the cellular level by means of hemoglobin and body cells

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13
Q

hypoxemia

A

insufficient oxygen within arterial blood

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14
Q

hypoxia

A

inadequate oxygen at the cellular level

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15
Q

normal pH **

A

7.35-7.45

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16
Q

normal Pao2

A

80-100 mmHg

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17
Q

normal PaCO2***

A

35-45mmHg

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18
Q

normal Sao2

A

95%-100%

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19
Q

normal HCO3**

A

22-26 mEq

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20
Q

ABG

A

lab test using arterial blood to evaluate or assess oxygenation

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21
Q

incentive spirometry

A
  • technique for deep breathing using a calibrated device

- encourages pts to reach a certain volume of inspired air

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22
Q

hypercarbia

A

excessive levels of carbon dioxide in the blood

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23
Q

oxygen therapy

A

administering more oxygen than is present in the atmosphere to relieve or prevent hypoxemia

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24
Q

liquid oxygen unit

A

device that converts cooled liquid oxygen to a gas by passing it through heated coils

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25
Q

oxygen concentrator

A

collects and concentrates oxygen from room air and stores it for client use

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26
Q

flowmeter

A

gauge used to regulate the amount of oxygen delivered to pt

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27
Q

fraction of inspired oxygen

A

concentration of oxygen

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28
Q

oxygen analyzer

A

measures the percentage of delivered oxygen

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29
Q

nasal cannula

A
  • most common oxygen delivery device

- hollow tube w/ 1/2 inch prongs placed into nostrils

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30
Q

simple mask

A

fits over nose and mouth and allow atmospheric air to enter and exit through side ports

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31
Q

partial rebreather mask

A

client inhales a mix of atmospheric air, oxygen from its source, and oxygen contained within s reservoir bag

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32
Q

non-rebreather mask

A
  • 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
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33
Q

venturi mask

A

mixes a precise amount of oxygen and atmospheric air

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34
Q

face tent

A
  • used for pts with facial trauma or burns

- oxygen is inconsistent

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35
Q

tracheostomy collar

A

delivers oxygen near an artificial opening in the neck

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36
Q

nasal catheter

A
  • delivering oxygen with a tube inserted through the nose

- used for pts who are mouth breathers or claustrophobic

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37
Q

transtracheal catheter

A

hollow tube inserted within the trachea to deliver oxygen

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38
Q

oxygen tent

A
  • clear plastic enclosure that provides cool humidified air

- most used on active toddlers

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39
Q

oxygen toxicity

A

lung damage when oxygen concentrations of more than 50% are administered

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40
Q

Positive ariway pressure machines

A

devices that help to relieve impaired oxygen levels caused by apnea or hypopnea during sleep

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41
Q

CPAP mask

A

attached to a portable ventilator and maintains continuous positive airway pressure

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42
Q

Signs/symptoms of oxygen toxicity

A
  • nonproductive cough
  • substernal chest pain
  • nasal stuffiness
  • nausea and vomiting
  • fatigue
  • headache
  • sore throat
  • hypoventilation
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43
Q

BiPAP mask

A

provides two different levels of airway pressure : inspiratory positive airway and expiratory positive airway pressure

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44
Q

water-seal chest tube drainage

A
  • technique for evacuating air or blood from the pleural cavity
  • chest tube must never be separated from the drainage system unless it is clamped ***
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45
Q

airway management

A

essential nursing skills that maintain natural or artificial airways for compromised pts

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46
Q

Upper airway

A

nose and pharynx

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47
Q

lower airway

A

trachea, brochi, brochioles, and alveoli

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48
Q

sputum

A

mucus raised to the level of the upper airways

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49
Q

inhalation therapy

A

respiratory treatments that provide a mixture of oxygen, humidification, and aerosolized medications directly to the lungs

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50
Q

Postural drainage

A

a positioning technique that promotes the drainage of secretions from various lobes or segments of the lungs with the use of gravity

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51
Q

Percussion

A

rhythmic striking of the chest wall

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52
Q

Vibration

A

uses the palms of the hands to shake underlying tissue and loosen retained secretions

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53
Q

suctioning

A

relies on negative pressure to remove liquid secretions with a catheter

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54
Q

nasopharyngeal suctioning

A

removing secretions from the throat through a nasally inserted catheter

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55
Q

nasotracheal suctioning

A

removing secretions from the upper portion of the lower airway through a nasally inserted catheter

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56
Q

oropharyngeal suctioning

A

removing secretions from the throat through an orally inserted catheter

57
Q

oral suctioning

A

removing secretions from the mouth

58
Q

oral airway

A

curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway

59
Q

tracheostomy

A

surgically created opening into the trachea

60
Q

tracheostomy tube

A
  • curved hollow plastic tube

- aka a cannula

61
Q

outer cannula

A

remains in place until the entire tube is placed

62
Q

inner canula

A

removed periodically for cleaning

63
Q

obturator

A

curved guide with a bullet-shaped tip

64
Q

fenestrated tracheostomy tube

A

one with holes in the outer canula

65
Q

speaking valve

A

a device that directs exhaled air through the upper airway

66
Q

tracheostomy care

A

cleaning the skin around the stoma, changing the dressing, and cleaning the inner canula

67
Q

intubation

A

placement of a tube into a body structure

68
Q

orogastric intubation

A

insertion of a tube through the mouth into the stomach

69
Q

nasogastric intubation

A

insertion of a tube through the nose into the stomach

70
Q

nasointestinal intubation

A

insertion of a tube through the nose into the intestine

71
Q

ostomy

A

surgically created opening

72
Q

reasons gastric or intestinal tubes are used

A
  • 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
73
Q

gavage

A

providing nourishment

74
Q

lavage

A

removing substances from the stomach

75
Q

decompression

A

removing gas ad liquid contents from the stomach or bowel

76
Q

tamponade

A

pressure

77
Q

French scale

A

used to measure the outside diameter of most tubes

78
Q

lumen

A

channel within the tube

79
Q

sump tubes

A

double-lumen tubes

80
Q

gastric reflux

A

reverse flow of gastric contents

81
Q

transabdominal tubes

A

tubes placed through the abdominal wall

82
Q

gastrostomy tube (G-tube)

A

transabdominal tube located within the stomach

83
Q

jejunostomy tube (J-tube)

A

transabdominal tube that leads to the jejunum of the small intestine

84
Q

percutaneous endoscopic gastrostomy tube

A
  • PEG tube

- transdominal tube inserted under endoscopic guidance

85
Q

percutaneous endoscopic jejunostomy tube

A
  • PEJ tube

- tube that is passed though a PEG tube into the jejunum

86
Q

preintubation assessment

A
  • LOC
  • weight
  • bowel sounds
  • abdominal distention
  • integrity of nasal and oral mucosa
  • ability to swallow, cough, gag
  • any nausea and vomiting
87
Q

NEX

A

length from nose to earlobe to the xiphoid process

88
Q

enternal nutrition

A

nourishment provided through the stomach or small intestine

89
Q

dumping syndrome

A

cluster of symptoms from the rapid deposition of calorie-dense nourishment into the small intestine

90
Q

bolus feeding

A

instillation of liquid nourishment in less than 30 minutes 4 to 6 times a day

91
Q

intermittent feeding

A

gradual instillation of liquid nourishment 4 to 6 times a day

92
Q

cyclic feeding

A

the continuous instillation of liquid nourishment for 8 t 12 hours

93
Q

continuous feeding

A

instillation of liquid nutrition without interruption

94
Q

gastric residual

A
  • volume of liquid within the stomach

- should be no more than 100 mL or no more than 20% of previous hour’s tube feeding***

95
Q

Valsalva maneuver

A

bearing down

96
Q

defecation

A

bowel elimination

97
Q

peristalis

A

ryhthmic contractions of intestinal smooth muscle that facilitate defacation

98
Q

gastrocolic reflex

A

increased peristaltic activity

99
Q

anal sphincters

A

ring shaped bands of muscles

100
Q

factors affecting bowel elimination

A
  • type of food consumed
  • fluid intake
  • drugs
  • emotions
  • neuromuscular function
  • abdominal muscle tone
  • opportunity for defecation
101
Q

bowel regularity range

A

3 times a day to 3 times a week

102
Q

COCA

A
  • color
  • odor
  • consistency
  • amount
103
Q

melena

A

blood in stool

104
Q

heme

A

iron compound in blood present within stool

105
Q

fecal occult blood test

A
  • FOBT

- self collecting screening test from 3 separate stools

106
Q

fecal immunochemical test

A
  • FIT

- more specific than an FOBT because it uses antibodies to detect globin

107
Q

globin

A
  • protein removed from heme

- present exclusively in the lower intestine

108
Q

colonoscopy

A

visual inspection of the interior colon using a flexible lighted endoscope

109
Q

sigmoidoscopy

A

visual endoscopic inspection limited to the sigmoid portion of the large intestine

110
Q

colonography

A

CT scan without colonoscope

111
Q

tenesmus

A

rectal pressure

112
Q

constipation

A

elimination problem characterized by dry,hard stool that is difficult to pass

113
Q

primary constipation

A

results from lifestyle factors such as inactivity, inadequate intake of fiber, insufficient fluids, or ignoring the urge to go

114
Q

secondary constipation

A

consequence of a pathologic disorder such as a partial bowel obstruction

115
Q

latrogenic constipation

A

consequence of other medical treatments

116
Q

pseudoconstipation

A
  • pt believes they are constipated, even though they are not

- often overuse or abuse laxatives

117
Q

fecal impaction

A

results from unrelieved constipation, retained barium from and intestinal xray, dehydration, weakness of abdominal muscles

118
Q

flatulence (flatus)

A

excessive accumulation of intestinal gas

119
Q

diarrhea

A

urgent passage of watery stool

120
Q

fecal incontinence

A

inability to control the elimination of stool

121
Q

enema

A
  • introduces a solution into the rectum

- lay on left side

122
Q

cleansing enema

A
  • use different type of solution to remove feces from the rectum
  • defecation usually occurs within 5 to 15 minutes after `
123
Q

tap water and normal saline enema

A
  • preferred for their nonirritating effects

- esp for clients with rectal diseases or those being prepared for rectal exam

124
Q

soap solution enema

A
  • mixture of water and soap

- soap causes chemical irritation of the mucous membrane

125
Q

hypertonic saline enema

A

draws fluid from body tissues into the bowel

126
Q

retention enema

A

uses a solution held within the large intestine for a specific period usually at least 30 minutes

127
Q

stoma

A

entrance to the opening

128
Q

ileostomy

A

surgically created opening to the ileum

129
Q

colostomy

A

surgically created opening to a portion of the colon

130
Q

appliance

A

bag or collection device over the stoma to collect stool

131
Q

excoriation

A

chemical injury of the skin

132
Q

karaya

A
  • barrier substance

- plant substance that becomes gelatinous when moistened

133
Q

enterostomal therapist

A

nurse certified in caring for ostomies and related skin problems

134
Q

continent ostomy

A

surgically created opening that controls the drainage of liquid stool or urine

135
Q

respiratory alkalosis

A
  • high pH

- low PCO 2

136
Q

Respiratory acidosis

A
  • low pH

- high PCO 2

137
Q

metabolic alkalosis

A
  • high pH

- high HCO 3

138
Q

Metabolic acidosis

A
  • low pH

- low HCO 3

Basic Nursing Skills (6 decks)

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