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Foundations > Exam 3: Respiratory > Flashcards

Exam 3: Respiratory Flashcards

1
Q

What is Fi02?

A

Percentage of oxygen in the air that is available to the client

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2
Q

What is the first sign of hypoxia?

A

neurological deficits like altered mental status, restlessness, confusion, or anxiety

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3
Q

What are the signs and symptoms of hypoxia?

A

Restlessness
Decreased LOC
Dizziness
Behavioral changes
Fatigue
Agitation
Tachycardia
Cyanosis – Not a reliable indicator

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4
Q

Why is cyanosis not a reliable indicator of hypoxia?

A

can be difficult in darker skinned clients

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5
Q

How do we assess for cyanosis is darker skinned clients?

A

Central Cyanosis in the tongue and conjunctiva. The bluish appearance of either is a more reliable indicator of hypoxia.

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6
Q

What are signs that your client has an airway obstruction?

A

Not talking, stridor, unconscious (tongue)

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7
Q

What are some common airway obstructions?

A

Tongue
FBO
Vomit, secretions, mucus
Toys, nails, cereal

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8
Q

How is a foreign body removed from the airway?

A

CPR, Heimlich, backblows

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9
Q

What are interventions to address airway issues?

A

suctioning, pulmonary hygiene, artificial airway, intubation, trach

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10
Q

What are indications for suctioning?

A

when patients are unable to clear respiratory secretions from the airways by coughing or other less invasive procedures

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11
Q

What is the purpose of pulmonary hygiene/toilet?

A

the action of mobilizing respiratory secretions for removal

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12
Q

What is the benefit of hydration in pulmonary hygiene?

A

Adequate hydration helps to maintain the ability to clear secretions by liquifying the sputum making it thin and easily removable with minimal coughing

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13
Q

How would you hydrate a client who is NPO?

A

IV hydration

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14
Q

What are the dangers of retained mucus?

A

Increases WOB
Traps bacteria allowing them to colonize
Leads to excessive coughing
Can lead to formation of mucus plugs which hinder gas exchange

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15
Q

What is the purpose of incentive spirometry?

A

encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume

prevent atelectasis

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16
Q

What is atelectasis?

A

condition that prevents the alveoli from expanding causeing portions of the lungs to collapse and is a complication when recovering from surgery

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17
Q

What are the benefits of ambulation in pulmonary hygiene?

A

increase the general strength of the client as well as increase lung expansion. This expansion shifts mucus to the larger airways and is easier to expectorate.

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18
Q

Which clients are candidates for early ambulation?

A

Critically ill clients can be placed into early ambulation programs with assistance from respiratory therapy and physical therapy

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19
Q

When is an artificial airway indicated?

A

Anytime you use BVM

decreased level of consciousness or airway obstruction

20
Q

What are indications and contraindications for an oropharyngeal and nasopharyngeal airway?

A

OPA

Displaces tongue
Unconscious - cannot have a gag reflex

NPA

Patient can be conscious
Cannot suspect a facial fracture

21
Q

What is the nurse’s role in endotracheal intubation?

A

Call provider to update on status and potential need for further respiratory intervention
Inform and educate patient and family – this is a major event in the care of the patient and family should be notified
Confirm that the patient and/or family wants further intervention
Gather supplies for intubation procedure
Notify respiratory therapist for mechanical ventilator to be brought to room

22
Q

What is the most common complication of a tracheostomy tube?

A

partial or total airway obstruction caused by buildup of respiratory secretions

23
Q

What are safety precautions that we take with tracheostomy clients?

A

Always know the size of your clients trach –
Always have a new trach usually a size below your patients current trach at the bedside for emergencies – if the trach comes out you can place the smaller trach in the stoma to provide ventilation an oxygenation

24
Q

How is oxygen administered to a client with a tracheostomy?

A

Oxygen delivery for trach is via a trach collar which is a specific device designed to fit over the trach
Oxygen delivery is through a humidification cylinder and communicated and regulated as FiO2 % as opposed to Liters of oxygen
Example: 40% TC (trach collar) as opposed to 6 L NC (nasal cannula)

25
Q

What are the signs that a client requires suctioning?

A

Coughing
Mucus in the tube
Alarms
Patient request

26
Q

Describe the process of using in-line suction on a client?

A

Suction catheter is advanced into the endotracheal tube. Suction is engaged by pressing a button on the end of the catheter. Suction is engaged intermittently as the nurse slowly retracts the catheter out of the ET tube. 1 to 3 passes may be necessary to clear all the secretions. Never suction more than 10 seconds. Allow your client to rest between suction procedures.

27
Q

Why is VAP a concern?

A

because the ET tube gives harmful bacteria a pathway to bypass all of the anatomical defenses in the upper airway and go directly to the client’s lungs

leading cause of death in HAIs -> pts are already critically ill to need vent

28
Q

What are components of a VAP bundle?

A

Elevate HOB to at least 30 degrees
Daily Sedation Vacations and weaning assessment
Daily Oral Care
Delirium Monitoring
Early Mobilization
PUD prophylaxis – Doesn’t directly prevent VAP
DVT prophylaxis – Doesn’t’ directly prevent VAP

29
Q

What are the head of bed degrees for the different Fowler’s positions?

A

30° for semi-Fowler’s
45° to 60° for Fowler’s
90° for high Fowler’s

30
Q

Which Head of bed position is recommended for clients with difficulty breathing?

A

High Fowlers

31
Q

How do we know that a client requires supplemental oxygen?

A

assessment data - SpO2, WOB, dyspnea

32
Q

Why is an airway assessment important prior to providing supplemental oxygen?

A

b/c blocked airway needs to be cleared first

33
Q

How do we know what adjunct to use and how many liters to place on the client?

A

Follow the O2 protocol but use lowest amount necessary for shortest period of time (2L NC)

Indicators of effectiveness: color, LOC, HT, WOB, ABGs, SPO2

34
Q

What should we do if our client has a sudden increase in their supplemental oxygen requirement?

A

Call RRT and increase per protocol

35
Q

What is the Fi02 delivered by a nasal cannula and a nonrebreather mask?

A

NC = 22-44%
NRB = 90-100%

36
Q

What flow rate should you use when applying a nonrebreather mask?

A

15LPM

37
Q

What are indications that your client requires bag valve mask ventilations?

A

clients breathing less than ten times a minute with shallow respirations. It is also used to provide oxygen to the lower airways prior to suctioning or endotracheal intubation.

38
Q

How are in hospital cardiac arrests avoidable?

A

There are often clear physiological warning signs that begin appearing several hours before an arrest situation – cardiac or respiratory

need early interventions at first sign of decline - trend vitals

39
Q

What should you do if you notice a deterioration in vital signs?

A

Go up the chain, start with other nurse -> provider -> RRT

40
Q

What are the criteria for activating the rapid response team?

A

Heartrate over 140 or less than 40
Respiratory rate over 28 or less than 8
Systolic blood pressure greater than 180 or less than 90
Oxygen saturation less than 90% despite supplementation – or a significant increase in oxygen demands
Acute change in mental status
Urine output less than 50mL over 4 hours
Nurse, staff member, family or patient have a significant concern about the patient condition
Additional criteria may include: chest pain, threatened loss of airway, seizures, stroke, or sepsis.

41
Q

What decisions does the Rapid Response team make?

A

Whether the pt can stay on that floor with further interventions or if they need a higher level of care

42
Q

Who may be included on a code team?

A

Charge RN – Usually ICU Charge nurse
Respiratory Therapist
MD(s): anesthesiologist, pulmonary MD, critical care MD
ICU or unit nurses
CPR Compressors

43
Q

What should you do if your client is unresponsive?

A

Sternal rub, check pulse/breathing

44
Q

When do you push a code blue button?

A

Unresponsive w/ no pulse and not breathing

45
Q

Describe the various roles of the code team members.

A

Team Leader
Airway
Recorder
Compressors – CPR
Monitor
IV/Medications

46
Q

What is closed loop communication?

A

Repeat order to confirm heard/understand
Confirm order has been carried out/completed
Helps to reduce/eliminate errors
Concise and clear language -> Calm, controlled, confident

Foundations (8 decks)

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