Chapter 41: Oxygenation Part 2 (Nursing Process) Flashcards

1
Q

During assessment gather a

A

complete history

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2
Q

History of Respiratory Function

A
  • presence of cough: productive/nonproductive, hemoptysis
  • dyspnea (asthma, bronchitis, pneumonia)
  • pain: rule out chest pain
  • environmental exposure/allergies
  • frequency of respiratory tract infections: +TB, HIV
  • pulmonary risk factors
  • past respiratory problems
  • current medications
  • smoking history and/or secondhand smoke exposure
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3
Q

Types of Chest Pain

A
  1. pleuritic chest pain
  2. pericardial chest pain
  3. musculoskeletal pain
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4
Q

pleuritic chest pain

A

radiates to scapular regions

coughing and inspiration worsen pain.

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5
Q

pericardial chest pain

A

results from inflammation of the pericardia sac.

occurs on inspiration, does not usually radiate

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6
Q

musculoskeletal pain

A

usually following exercise, rib trauma, prolonged coughing episodes

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7
Q

Breathing Patterns include

A
  1. Kussmaul Respirations
  2. Cheyne-Stokes
  3. Apnea
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8
Q

Kussmaul Respirations

A

increased rate and depth in response to decreased pH

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9
Q

Cheyne-Stokes

A

due to decreased blood flow or injury the the brainstem.

deep breaths mixed with shallow breaths mixed with apnea.

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10
Q

apnea

A

absence of respirations for a period of time

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11
Q

During assessment, the nurse needs to

A
  • inspect chest wall movement (retraction, use of accessory muscles)
  • palpate peripheral pulses, capillary refill
  • auscultate: normal/abnormal lung and/or heart sounds
  • review diagnostic tests
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12
Q

Nursing Diagnosis RT Oxygenation

A
  • Decreased CO
  • Fatigue
  • Activity Intolerance
  • Impaired Gas Exchange
  • Ineffective Airway Clearance
  • Ineffective Breathing Pattern
  • Risk for Aspiration
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13
Q

Implementations RT Oxygenation

A
  • health promotion
  • airway maintenance
  • mobilization of pulmonary secretions
  • suctioning
  • artificial airways
  • maintenance and promotion of lung expansion
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14
Q

Health promotion includes

A
  • vaccinations: pneumococcal, influenza
  • healthy lifestyle: low-fat, high-fiber diet, maintain body weight, exercise
  • environmental pollutants: smoke/secondhand smoke, chemicals
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15
Q

hydration

A

fluid intake of 1500-2500/day unless contraindicated

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16
Q

humidification

A

keeps airways moist and loosens pulmonary secretions. Necessary for patients receiving > or equal to 4 L of O2/NP

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17
Q

Nebulization

A

adds moisture to medication-enhances mucociliary clearance

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18
Q

Chest physiotherapy (CPT)

A
  1. postural drainage
  2. chest percussion
  3. vibration
19
Q

Mobilization of Pulmonary Secretions include

A
  • hydration
  • humidification
  • nebulization
  • coughing and deep breathing
  • chest physiotherapy
20
Q

Suctioning Techniques

A

process no longer than 15 sec.

includes oro and naso pharyngeal; oro and naso tracheal

21
Q

Oro and Naso pharyngeal

A

patient able to cough but can not expectorate the secretions

22
Q

Oro and Naso tracheal

A

sterile technique

unable to manage by coughing

23
Q

Artificial Airways

A

places patient at high risk for infection.

includes oral, endotracheal and tracheal airways

24
Q

Oral airway

A

maintains the tongue in the normal position

25
endotracheal airway
through the mouth past the vocal cords into the trachea
26
tracheal airway
surgical incision into the trachea
27
Noninvasive maintenance and promotion of lung expansion
- ambulation - positioning - incentive spirometry - noninvasive ventilation
28
How does ambulation help promote lung expansion?
decreases atelectasis, decreases VAP and decreases functional limitations
29
How does positioning promote lung expansion?
45 degree semi fowlers promotes lung expansion
30
How does incentive spirometry promote lung expansion?
encourages deep breathing (visual)
31
What are the noninvasive ventilations?
1. CPAP - Continuous Positive Airway Pressure 2. BiPAP - bi-level positive airway pressure-provides both inspiratory positive pressure and a lesser expiratory airway pressure (PEEP)
32
Invasive maintenance and promotion of lung expansion
-chest tube insertion
33
Chest tube insertion
restoring lung expansion. | removes air and/or fluid from the pleural space
34
2 Types of Pneumothorax
1. primary | 2. secondary
35
primary pneumothorax
genetic condition: "bleb" on lung; occurs unexpectedly
36
secondary pneumothorax
result of chest trauma (stabbing, rib fractures), lung diseases (emphysema), invasive procedures (surgery, placement of subclavian IV line), mechanical ventilation
37
Hemothorax
accumulation of blood and fluid in the pleural cavity
38
Methods of Oxygen Delivery
1. nasal cannula | 2. masks: simple face mask, partial non-rebreather, non-rebreather, and venturi mask
39
Restorative and Continuing Care include
- CPR - Respiratory Muscle Training - Breathing Exercises
40
Respiratory Muscle Training
incentive spirometer
41
Breathing Exercises
- Coughing and Deep Breathing Exercises - Pursed Lip Breathing - Diaphragmatic Breathing
42
Pursed-Lip Breathing
deep inspiration and prolonged expiration with pursed lips
43
Diaphragmatic Breathing
helps expel trapped air; often used in conjunction with pursed-lip breathing