Week 3 Material Flashcards
1
Q
What is a possible complication of LRI/URI?
A
pyelonephritisi
2
Q
interventions for pyelonephritis
A
- Assess nutritional status, F&E, I/O, temperature, complete pain assessment
- Increase fluid intake to 2L/day unless contraindicated
- Assist with hygiene and provide emotional support
- Administer antipyretic (APAP) for fever and opioid analgesics for pain
- ABX
3
Q
what is hypoxemia?
What can cause it?
A
- Inadequate O2 in blood
- caused by: hypovolemia, hypoventilation, interruption of arterial flow
4
Q
what is hypoxia?
A
- inadequate oxygen
5
Q
name the low flow O2 delivery systems
A
- nasal cannula
- simple face mask
- partial nonrebreather
- nonrebreather mask
6
Q
nasal cannula
A
- FiO2: 24-44%
- at flow rates of 1-6 L/min
7
Q
nasal cannula: advantages
A
- safe, easy to apply, comfortable, well tolerated
- client can talk, eat, and ambulate
8
Q
nasal cannula: disadvantages
A
- FiO2 varies with flow rate and client’s rate/depth of breathing
- extended use can lead to skin breakdown and drying of mucous membranes
- tubing is easily dislodged
9
Q
nasal cannula: nursing actions
A
- assess patency of nares
- ensure that prongs fit properly
- use water soluble gel to prevent dry nares
- provide humidification of flow rates of 4L/min and greater
10
Q
simple face mask
A
- covers the client’s nose and mouth
- FiO2 40-60%
- at flow rates of 5-8 L/min
- minimum is 5L/min to ensure flushing of CO2 from mask
11
Q
simple face mask: advantages
A
- easy to apply
- more comfortable than NC
12
Q
simple face mask: disadvantages
A
- flow rates of less than 5L/min can result in rebreathing of CO2
- device is poorly tolerated by clients with anxiety or claustrophobia
- eating, drinking, talking impaired
- use caution if clients have aspiration risk
- moisture and pressure can collect and cause skin breakdown
13
Q
simple face mask: nursing actions
A
- assess proper fit to ensure a secure seal over the nose and mouth
- ensure that the client wears a NC during meals
14
Q
partial rebreather mask
A
- covers nose and mouth
- FiO2 40-75%
- at flow rates of 6-11 L/min
15
Q
partial rebreather mask: advantages
A
- mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to 1/3 of exhaled air together with room air
16
Q
partial rebreather mask: disadvantages
A
- complete deflation of bag during inspiration causes CO2 buildup
- FiO2 varies with breathing pattern
- mask poorly tolerated if client has anxiety/claustrophobia
- eating, drinking, talking impaired
- use with caution for clients who have a high risk aspiration
17
Q
partial rebreather mask: nursing actions
A
- keep reservoir bag from deflating by adjusting O2 flow rate to keep it inflated
- assess proper fit to ensure a secure seal over the nose and mouth
- assess for skin breakdown
- ensure client has NC during meals
18
Q
nonrebreather mask
A
- covers nose and mouth
- FiO2: 80-95%
- at flow rate of 10-15 L/min to keep reservoir bag 2/3 full during inspiration and expiration
19
Q
nonrebreather mask: advantages
A
- delivers highest O2 conc except for intubation
- one way valve situated b/w the mask and reservoir allows the client to inhale max O2 from reservoir bag
- 2 exhalation ports have flaps covering them that prevent room air from entering mask
20
Q
nonrebreather mask: disadvantages
A
- valve and flap on mask must be intact and functional during each breath
- poorly tolerated if client has anxiety or claustrophobia
- eating, drinking, talking impaired
- use with caution if client has high risk for aspiration
21
Q
nonrebreather: nursing actions
A
- perform hourly assessment of valve and flap
- assess proper fit to ensure secure seal
- assess for skin breakdown
- ensure client uses NC during meals
22
Q
name the high flow O2 delivery systems
A
- venturi mask
- aerosol mask, face tent, trach collar
- T piece
23
Q
venturi mask
A
- covers client’s nose and mouth
- FiO2 24-50%
- at flow rates of 4-10 L/min via different sizes of adaptors which allow specific amounts of air to mix with oxygen
24
Q
venturi mask: advantages and disadvantages
A
- advantages:
- delivers MOST precise O2 concentration
- humidification is not required
- best suited for clients who have chronic lung dz
- disadvantage:
- expensive
25
Q
venturi mask: nursing actions
A
- assess frequently to ensure proper flow rate
- make sure tubing is free of kinks
- assess for skin breakdown
- ensure that client wears NC during meals
26
Q
aerosol mask, face tent, and trach collar
A
- face tent fits loosely around face and neck
- trach collar is small mask that covers a surgically created opening in the trachea
- FiO2 24-100%
- at flow rates of 10 L/min
- should provide high humidification w/ O2 delivery
27
Q
aerosol mask, face tent, and trach collar: advantages and disadvantages
A
- advantages:
- good for clients who do not tolerate masks well
- useful for clients who have facial trauma, burns, or thick secretions
- disadvantages:
- high humidication requires frequent monitoring
28
Q
aerosol mask, face tent, and trach collar: nursing actions
A
- empty condensation from tubing often
- ensure that there is adequate water in humidification cannister
- ensure that aerosol mist leaves from vents during inspiration and expiration
- make sure tubing does not pull on tracheostomy
29
Q
T Piece
A
- FiO2 24-100%
- at flow rates of at least 10 L/min
30
Q
T piece: advantages and disadvantages
A
- advantages: can be used for clients with tracheostomies, laryngectomies, ET tubes
- disadvantages: high humidication requires frequent monitoring
31
Q
T piece: nursing actions
A
- ensure exhalation port is open and uncovered
- ensure that the T piece does not pull on tracheostomy or ET tube
- ensure mist is evident during inspiration and expiration
32
Q
what are early findings that would indicate a need for O2 therapy?
A
- tachypnea
- tachycardia
- restlessness
- pale skin and mucous membranes
- elevated BP
- symptoms of respiratory distress (use of accessory Ms, nasal flaring, tracheal tugging, adventitious lung sounds)
33
Q
what are late findings that would indicate a need for O2 therapy?
A
- confusion and stupor
- cyanotic skin and mucous membranes
- bradypnea
- bradycardia
- hypotension
- cardiac dysrhythmias
34
Q
Preparing the Client for O2 therapy:
A
- explain prcedures
- place client in semi Fowler’s or Fowler’s to facilitate breathing and promote chest expansion
- ensure that all equipment is working properly
35
Q
ongoing care associated with O2 therapy
A
- provide O2 at lowest flow that will correct hypoxemia
- assess RR, rhythm and effort, lung sounds
- assess O2 status with pulse ox and ABGs
- good oral care
- promote turning, coughing, deep breathing, use of IS, and suctioning
- promote rest
- provide emotional support
- assess nutritional status
- assess skin integrity
- titrate O2 to maintain prescribed O2 sats
- d/c gradually
36
Q
what are manifestations of hypoxemia?
A
- SOB
- anxiety
- tachypnea
- tachycardia
- restlessness
- pallor or cyanosis of skin or mucous membranes
- adventitious breath sounds
- confusion
37
Q
what are manifestations of hypercarbia?
A
- restlessness
- HTN
- HA
38
Q
respiratory distress: interventions
A
- position client in Fowler’s or Semi Fowler’s (for max ventilation)
- complete focused respiratory assessment
- promote deep breathing
- stay w/ client and provide emotional support if anxious
- promote airway clearance by encouraging coughing and suctioning
39
Q
what are complications of O2 therapy use?
A
- oxygen toxicity
- oxygen induced hypoventilation
- combustion
40
Q
what is oxygen toxicity?
A
- manifestations: nonproductive cough, substernal pain, nasal stuffiness, n/v, fatigue, HA, sore throat, hypoventilation
- Typically with high concentrations O2 (>50%) over 24-48 hours
41
Q
diagnostics and interventions for oxygen toxicity
A
- diagnostics: ABGs–notify provider if PaO2<90 mmHg
- Interventions:
- use lowest amount of O2 client can tolerate
- use CPAP or biPAP or device with PEEP (positive end expiratory pressure) to reduce amount of oxygen needed
42
Q
who can oxygen induced hypoventilation develop in?
A
- clients with COPD
- clients with chronic hypoxemia w/ hypercarbia
43
Q
oxygen induced hypoventilation: interventions
A
- monitor RR and pattern, LOC, SaO2
- provide O2 therapy at lowest level that manages hypoxemia
- if client tolerates it, use venturi mask to deliver precise O2 administration
- notify provider of impending respiratory depression
44
Q
combustion: nursing actions
A
- Oxygen is flammable!
- Post no smoking signs, signs stating oxygen in use
- Fire extinguishers
- Use clothing and blankets that do not generate static electricity
- Cotton instead of wool or synthetics
- Ensure safe function and grounding of all electrical equipment
- Do not use volatile chemicals around Pt receiving O2
45
Q
explain a CPAP
A
- continuous positive airway pressure
- provides positive pressure using a leak proof mask via non invasive positive pressure ventilation device
- device is used to keep airways open throughout respiratory cycle and improve gas exchange
- most effective tx for sleep apnea b/c positive pressure acts as a splint to keep the upper airway and trachea open during sleep
46
Q
what is biPAP? who is it most often used for?
A
- bi level positive airway pressure
- machine cycles to provide a set positive inspiratory pressure when inspiration takes place and then during expiration to deliver a lower set end expiratory pressure
- requires wearing a leak proof mask
- most often used for clients who have COPD and require ventilatory assistance
47
Q
biPAP nursing actions
A
- asess skin breakdown
- check % of O2 on machine for both inspiratory and expiratory pressure
48
Q
explain transtracheal oxygen therapy
A
- delivers O2 directly to the lungs per a small, flexible catheter that is passed thru the trachea via a small incision
- O2 delivery is reduced by 55% for a client at rest and 30% for client who is active
- catheteris less visible and avoids irritation that occurs from the use of nasal prongs
49
Q
ET tube: indications
A
- a tube is inserted thru client’s nose or mouth into trachea to allow for emergency airway mgmt
- mouth intubation is easiest and quickest form of intubation and is often performed in the ED
- nasal intubation is performed when the client has facial or oral trauma
- do not use this route if the client has a clotting problem
50
Q
ET tube: placement
A
- performed by CRNA or anethesiologist
- CXR verifies placement
- can be cuffed or uncuffed:
- cuff on tracheal end is inflated to ensure proper placement and formation of seal b/w cuff and tracheal wall–>prevents air from leaking
- seal ensures an adequate amount of tidal volume is delivered by mechanical ventilator when attached to external end of ET tube
- client is unable to talk when cuff inflated
51
Q
ET tube: nursing actions
A
- have resuscitation equipment at bedside at all times
- ensure intubation attempts last no longer than 30 sec, then reoxygenate before trying again
- monitor V/S
- check tube placement
- auscultate breath sounds bilaterally after intubation
- observe for symmetric chest movement
- stabilize tube
- monitor for hypoxemia, dysrhythmias, and aspiration
52
Q
mechanical ventilation
A
- provides breathing support until lung funciton is restored
- delivers warm (body temp) O2, 100% humidified oxygen at FiO2 b/w 21-100%
- positive pressure ventilators deliver air to lungs under pressure throughout inspiration and/or expiration to keep alveoli open during inspiration and to prevent alveolar collapse during expiration
- benefits:
- forced/enhanced lung expansion
- improved gas exchange
- dec WOB
- benefits:
- can be delivered via ET tube and tracheostomy tube
53
Q
mechanical ventilation: potential diagnoses
A
- hypoxemia, hypoventilation with respiratory acidosis
- airway trauma
- exacerbation of COPD
- acute pulmonary edema
- asthma attack
- head injuries, CVA, coma
- neurological disorders (MS, myasthenia gravis,)
- OSA
- respiratory support after surgery
- respiratory support while under general anesthesia/sedation
54
Q
mechanical ventilation: preparing the client
A
- explain procedure
- establish a method for client to communicate
55
Q
mechanical ventilation: ongoing care
A
- maintain patent airway
- assess tube placement
- suction secretions
- assess respiratory status every 1-2 hours
- suction tracheal tube to clear secretions
- monitor and document ventilator settings hourly
- monitor ventilator alarms
- maintain adequate volume in the cuff
- assess pressure every 8 houts and maintain below 20 mmHg
- administer meds
- reposition oral ET tube every 24 hrs and assess for skin breakdown
- provide adequate nutrition: assess GI fcn every 8 hours, monitor bowel sounds
- monitor client during weaning process
- assess SpO2 and V/S every 5 min after extubation
- encourage IS, deep breathing
- reposition client to promote mobility of secretions
56
Q
explain the alarms on the ventilator
A
- low pressure: volume alarm
- indicate low exhaled volume d/t disconnection, cuff leak, tube displacement
- high pressure: pressure alarm
- indicate excess secretions, client biting tubing, kinks in tubing, client coughing, pulmonary edema, bronchospasm, pneumothorax
- apnea alarms: indicate ventilator does not detect spontaneous respiration in a preset time period
57
Q
what are the medications that may be used with oxygen therapy?
A
- analgesics
- sedatives
- neuromuscular blocking agents
- ulcer preventing agents
- antibiotics
58
Q
analgesics for O2 therapy
A
- morphine and fentanyl
59
Q
sedatives for O2 therapy
A
- propofol, diazepam, lorazepam, midazolam, haloperidol
- may be used to prevent competition b/w extrinsic and intrinsic breathing and the resulting effects of hyperventilation
60
Q
neuromuscular blocking agents for O2 therapy
A
- pancuronium, atracurium, vecuronium–>infrequently used due to long half life
- paralyze muscles but do not sedate or relieve pain
- use of sedative or analgesic in combination is common
61
Q
ulcer preventing agents for O2 therapy
A
- famotidine
- lansoprazole
62
Q
name the possible complications from O2 therapy
A
- trauma
- fluid retention
- oxygen toxicity
- hemodynamic compromise
- aspiration
- GI ulcers
63
Q
explain trauma as a complication of O2 therapy
A
-
barotrauma: damage to lungs by positive pressure
- can occur due to pneumothorax, subQ emphysema, or pneumomediastinum
- volutrauma: damage to lungs by volume delivered from one lung to the other
64
Q
explain fluid retention as a complication of O2 therapy
A
- due to dec CO, activation of RAAS, and/or ventilator humidification
- nursing actions:
- monitor I/O
- weight
- breath sounds
- ET secretions
65
Q
explain oxygen toxicity as a complication of O2 therapy
A
- can result from high concentration of oxygen (greater than 50%), long durations of O2 therapy (more than 24-48 hours), and/or client’s degree of lung dz
- nursing actions:
- monitor for fatigue, restlessness, severe dyspnea, tachycardia, tachypnea, crackles, cyanosis
66
Q
explain hemodynamic compromise as a complication of O2 therapy
A
- mechanical vent can cause inc thoracic pressure which can result in dec venous return
- nursing actions:
- monitor for tachycardia, hypoTN, urine output less than or equal to 30 mL/hr; cooly, clammy skin; dec peripheral pulses, dec in LOC
67
Q
explain aspiration as a complication of O2 therapy
A
- keep head of bed elevated at all times to dec risk of aspiration
- nursing actions:
- check residuals every 4 hr if the client is receiving enteral feedings to dec risk of aspiration
68
Q
explain GI ulcers as a complication of O2 therapy
A
- stress ulcers
- nursing actions:
- monitor GI drainage and stools for occult blood
- administer ulcer prevention meds
