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Adult Health I Test I > Week 3 Material > Flashcards

Week 3 Material Flashcards

1
Q

What is a possible complication of LRI/URI?

A

pyelonephritisi

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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
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3
Q

what is hypoxemia?

What can cause it?

A
  • Inadequate O2 in blood
  • caused by: hypovolemia, hypoventilation, interruption of arterial flow
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4
Q

what is hypoxia?

A
  • inadequate oxygen
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5
Q

name the low flow O2 delivery systems

A
  • nasal cannula
  • simple face mask
  • partial nonrebreather
  • nonrebreather mask
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6
Q

nasal cannula

A
  • FiO2: 24-44%
    • at flow rates of 1-6 L/min
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7
Q

nasal cannula: advantages

A
  • safe, easy to apply, comfortable, well tolerated
  • client can talk, eat, and ambulate
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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
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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
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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
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11
Q

simple face mask: advantages

A
  • easy to apply
  • more comfortable than NC
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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
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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
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14
Q

partial rebreather mask

A
  • covers nose and mouth
  • FiO2 40-75%
    • at flow rates of 6-11 L/min
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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
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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
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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
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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
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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
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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
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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
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22
Q

name the high flow O2 delivery systems

A
  • venturi mask
  • aerosol mask, face tent, trach collar
  • T piece
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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
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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
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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
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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
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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
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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
  • 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

Adult Health I Test I (5 decks)

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