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Module 3 (MedSurg 1) > Gas Exchange/Chest Tubes/Drains/Trachs > Flashcards

Gas Exchange/Chest Tubes/Drains/Trachs Flashcards

1
Q

Pulmonary disease is classified by

A

alteration in the lung or heart

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2
Q

Understanding the pathophysiology of common ____________ problems can greatly affect the outcome of each individuals during gas exchange.

A

respiratory

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3
Q

Lungs characteristics

A

large surface area constantly exposed to the external environment

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4
Q

Lung disease is greatly influenced by what a pt is exposed to

A

environmental, occupation, personal, social habits

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5
Q

S/S of pulmonary alterations

A

cough
dyspnea
chest pain
abnormal sputum
hemoptysis
altered breathing patterns
cyanosis
fever

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6
Q

Dyspnea is described as
with s/s

A

subjective sensation of uncomfortable breathing
the feeling of being unable to get enough air described as air hunger, sob, labored breathing- causes disturbance of gas exchange, increase work of breathing, dz that damages lung tissue, pulmonary congestion r/t heart dz
s/s of dyspnea nostril flaring accessory muscles use, retraction more common in children

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7
Q

Hemoptysis

A

coughing up blood or bloody secretions from lungs

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8
Q

Cyanosis

A

bluish discoloration of skin and mucous membranes

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9
Q

Cough

A

protective reflex cleanse the lower airways by an explosive expiration

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10
Q

Chest pain can be described as

A

sharp or stabbing when breathing could be pleural

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11
Q

What is a symptom of severe or later sign of hypoxia

A

cyanosis

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12
Q

Orthopnea

A

dyspnea when lying down often sleeps propped up

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13
Q

Hypoventilation

A

inadequate alveolar ventilation r/t metabolic demands

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14
Q

Hypercapnia

A

retaining CO2

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15
Q

Hyperventilation

A

alveolar ventilation exceeding metabolic demands

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16
Q

Hypocapnia

A

a state of reduced carbon dioxide in the blood

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17
Q

Hypercapnia

A

breathing may be the normal cause- decreased drive to breathe – drug, CNS ( brain spine) obstruction, increased work of breathing

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18
Q

Clubbing

A

bulbous enlargement of the end of a finger or toe

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19
Q

What sign is related to chronic hypoxemia?

A

clubbing

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20
Q

Hypoxemia

A

abnormally low concentration of oxygen in the blood

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21
Q

Hypoxia

A

deficiency in the amount of oxygen reaching the tissues

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22
Q

Aspiration

A

passage of fluid or solid particles into the lung

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23
Q

Atelectasis

A

collapse of alveoli

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24
Q

Hypoxia dx

A

ABGs
Pulmonary function
Hgb and Hct
Clinical S/S
Hx
Pulse Ox below 90%

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25
Q

Hypoxia Complications

A

cellular death in target tissue with body-wide effects
- heart and brain are most affected

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26
Q

Hypoxia Risk factors

A

Chronic or acute hypoxia
inflammation problems
immobility in elderly

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27
Q

Nursing Interventions for Hypoxia

A

maintain fluids, suction, TCDB
Position in semi to high fowlers
O2, expectorants, ambulation

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28
Q

Tracheostomy is a medical procedure that is permeant or temporary?

A

Both

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29
Q

Tracheostomy involves creating an opening into the

A

neck and place a tube in pt’s windpipe

30
Q

The incision is made into

A

the trachea below the larynx

31
Q

What is needed at the bedside if the trachea comes out?

A

Obfuscator and a smaller trach

32
Q

Why is a tracheostomy performed?

A
  • ventilation
  • airway obstruction or blockage
  • airway protection
  • secretions
33
Q

Risks associated with tracheostomy performed

A

thyroid gland damage
erosion of trachea
collapse lung
scar tissue in trachea

34
Q

JP Drains

A

used after surgery
- if blood clots, then okay to milk or strip
-compress with negative pressure for suction

35
Q

What type of fluid will appear in JP Drains?

A

serosanguinous

36
Q

What do you do if clots appear in the JP Drain tubes?

A

milk or strip

37
Q

When showering with a Drain, what should you do?

A

Hold or clip to an area to prevent falling out

38
Q

Colostomy

A

intestine (still living/pink) stoma
left side
stool hard
strangulation = med emergency
rash can form if in contact with poop

39
Q

Ileostomy

A

right-sided
a lot of fluid and gas (empty out more)
will look watery

40
Q

Reasons for a chest tube

A

Pneumothorax
Hemothorax

41
Q

Pneumothorax

A

air in pleural space
- keeps lungs from expanding

42
Q

Hemothorax

A

blood in the pleural space
- possible conjunction with pneumothorax

43
Q

Tension pneumothorax causes

A

tracheal deviation

44
Q

T/F: Never clamp the chest tube unless cracked or emergency.

A

True

45
Q

If there is more than _____ mL of liquid in an hour out of chest tubes.
- Then what should be the next step?

A

100 mL
call HCP

46
Q

If the chest tube comes out, then what should the nurse do?

A

Place a gauze pad and have it taped on 3 sides for air to escape and catch secretions

47
Q

If tube becomes detached from the drainage system, then

A

place in sterile water

48
Q

What should you never do with a chest tube?

A

strip or milk the line
avoid clamping or dependent loops

49
Q

What is the purpose of a chest tube?

A

restore negative pressure

50
Q

Air in pleural space chest tubes are located

A

top of the lungs

51
Q

Blood/fluid in pleural space chest tubes are located

A

bottom of the lungs

52
Q

If the patient has a pneumothorax, what side should they lay on?

A

lay on their good side

53
Q

If the patient has a hemothorax, what side should they lay on?

A

lay on their bad side

54
Q

Where should the drainage system of a chest tube be placed related to the patient?

A

below the pt

55
Q

Subcutaneous emphysema

A

swelling with air starts at the insertion site and spreads up to the face, neck, and chest which causes a crackling feeling under fingertips
- sounds like rice krispies

56
Q

What should the nurse encourage the patient to do if a patient has a chest tube? Select all that apply.
- TCDB
- ROM exercises
- ICS
- Milk and stretch-out tubing

A

TCDB
ROM exercises
ICS

57
Q

What position should a patient with a chest tube?

A

45 degree or semi-fowlers

58
Q

S/S of pneumothorax

A

P- pleuritic pain
T - Trachea deviation
H- hyper resonance
O-onset sudden
R- reduced breath sounds
A- absent fremitus
X- x-ray shows collapse

59
Q

The nurse is caring for a client with a chest tube. During report handoff, the incoming nurse notes that the fluid in the tube is moving up the tube with inspiration, and down the tube with expiration. Which of the following actions is most appropriate for the nurses in this situation?
A. Notify the provider
B. Continue with the report, as this is a normal finding
C. Increase the suction because it is too low to be effective
D. Place the chest tube on the bedside table in order to stop the fluid from moving up and down

A

B. Continue with report, as this is a normal finding
This finding is referred to as tidaling, and is a normal occurrence with a chest tube system with inspiration and expiration. If the nurse notes that there is no tidaling, then either the client’s lung has completely re-expanded, or there’s an occlusion in the tubing, such as a clot.

60
Q

The provider writes an order for a client to have a chest tube removed. Which of the following are appropriate reasons to discontinue a chest tube? Select all that apply.
A. Improved respiratory status
B. Symmetrical rise and fall of the chest
C. Bilateral breath sounds
D. Oxygen saturation above 90%

A

A. Improved respiratory status
Chest tubes may be removed when the client has an improvement in respiratory status, as this indicates that the reason for placing the chest tube has improved.
B. Symmetrical rise and fall of the chest
When the chest rises and falls symmetrically, this indicates that the hemothorax or pneumothorax has resolved.
C. Bilateral breath sounds
When breath sounds can be heard on both sides, the client’s lung has expanded on the affected side.

61
Q

A nurse is preparing for a focused assessment of the chest and lungs of a client. Which position is best for the nurse to place this client?
A. Sitting
B. Dorsal recumbent position
C. Sim’s position
D. Knee-chest position

A

A. Sitting
In order to have the most access to a client’s chest and lungs when performing a focused respiratory assessment, the nurse should assist the client to a sitting position if the client is able. All other positions listed may still allow the nurse to assess the chest, but the best access is the sitting position.

62
Q

The nurse is assessing a client’s thorax and lungs and lightly palpates the skin over the anterior chest. Which of the following conditions, if present, will the nurse discover with this assessment?
A. Subcutaneous emphysema
B. Pneumonia
C. Cystic fibrosis
D. Status asthmatica

A

A. Subcutaneous emphysema
When a client has a tension pneumothorax, air becomes trapped in the tissues. This is called subcutaneous emphysema or crepitus and feels like “rice crispies” under the skin. This is felt by lightly palpating the chest with two fingers.

63
Q

A patient has developed a pneumothorax and requires a chest tube. The nurse knows that the chest tube will be inserted where?
A. 8th or 9th intercostal space
B. 2nd intercostal space
C. In conjunction with the endotracheal tube
D. At the sternoclavicular junction

A

B. 2nd intercostal space
When a client has air in the pleural space, the chest tube is placed in the 2nd intercostal space.

64
Q

A patient has had a chest tube for three days. The nurse assesses the client’s respiratory status and chest tube unit during shift assessment. Which of the following would indicate that the client is ready to have the chest tube removed?
A. There is little to no drainage
B. The client has only mild respiratory distress
C. The water seal has fluctuations
D. There is a minimal air leak

A

A. There is little to no drainage
Certain criteria must be met before a client’s chest tube can be removed. Criteria include little to no drainage from the tube, absence of respiratory distress, bilateral breath sounds, no fluctuations in the water seal, and no air leak.

65
Q

What color should a stoma be?

A

pink/red

66
Q

If a stoma is purple, what is happening?

A

strangulation

67
Q

What discharge teaching is needed for ileostomy?

A

record mL (gas and liquid) emptied and keep more fluids going

68
Q

Tracheostomy needs to happen with the cuff/balloon

A

deflated to prevent erosion usually when doing care

69
Q

Can a tracheotomy be performed at the bedside?

A

yes

70
Q

What keeps air from going up into the chest tube?

A

Closed water seal in the chamber

Module 3 (MedSurg 1) (12 decks)

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