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
venturi mask: nursing actions
* 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
aerosol mask, face tent, and trach collar
* 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
aerosol mask, face tent, and trach collar: advantages and disadvantages
* 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
aerosol mask, face tent, and trach collar: nursing actions
* 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
T Piece
* FiO2 24-100%
* at flow rates of at least 10 L/min
30
T piece: advantages and disadvantages
* advantages: can be used for clients with tracheostomies, laryngectomies, ET tubes
* disadvantages: high humidication requires frequent monitoring
31
T piece: nursing actions
* 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
what are early findings that would indicate a need for O2 therapy?
* 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
what are late findings that would indicate a need for O2 therapy?
* confusion and stupor
* cyanotic skin and mucous membranes
* bradypnea
* bradycardia
* hypotension
* cardiac dysrhythmias
34
Preparing the Client for O2 therapy:
* 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
ongoing care associated with O2 therapy
* 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
what are manifestations of hypoxemia?
* SOB
* anxiety
* tachypnea
* tachycardia
* restlessness
* pallor or cyanosis of skin or mucous membranes
* adventitious breath sounds
* confusion
37
what are manifestations of hypercarbia?
* restlessness
* HTN
* HA
38
respiratory distress: interventions
* 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
what are complications of O2 therapy use?
* oxygen toxicity
* oxygen induced hypoventilation
* combustion
40
what is oxygen toxicity?
* 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
diagnostics and interventions for oxygen toxicity
* 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
who can oxygen induced hypoventilation develop in?
* clients with COPD
* clients with chronic hypoxemia w/ hypercarbia
43
oxygen induced hypoventilation: interventions
* 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
combustion: nursing actions
* 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
explain a CPAP
* 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
what is biPAP? who is it most often used for?
* 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
biPAP nursing actions
* asess skin breakdown
* check % of O2 on machine for both inspiratory and expiratory pressure
48
explain transtracheal oxygen therapy
* 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
ET tube: indications
* 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
ET tube: placement
* 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
ET tube: nursing actions
* 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
mechanical ventilation
* 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
mechanical ventilation: potential diagnoses
* 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
mechanical ventilation: preparing the client
* explain procedure
* establish a method for client to communicate
55
mechanical ventilation: ongoing care
* 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
explain the alarms on the ventilator
* 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
what are the medications that may be used with oxygen therapy?
* analgesics
* sedatives
* neuromuscular blocking agents
* ulcer preventing agents
* antibiotics
58
analgesics for O2 therapy
* morphine and fentanyl
59
sedatives for O2 therapy
* propofol, diazepam, lorazepam, midazolam, haloperidol
* may be used to prevent competition b/w extrinsic and intrinsic breathing and the resulting effects of hyperventilation
60
neuromuscular blocking agents for O2 therapy
* 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
ulcer preventing agents for O2 therapy
* famotidine
* lansoprazole
62
name the possible complications from O2 therapy
* trauma
* fluid retention
* oxygen toxicity
* hemodynamic compromise
* aspiration
* GI ulcers
63
explain trauma as a complication of O2 therapy
* _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
explain fluid retention as a complication of O2 therapy
* due to dec CO, activation of RAAS, and/or ventilator humidification
* nursing actions:
* monitor I/O
* weight
* breath sounds
* ET secretions
65
explain oxygen toxicity as a complication of O2 therapy
* 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
explain hemodynamic compromise as a complication of O2 therapy
* 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
explain aspiration as a complication of O2 therapy
* 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
explain GI ulcers as a complication of O2 therapy
* stress ulcers
* nursing actions:
* monitor GI drainage and stools for occult blood
* administer ulcer prevention meds
