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Flashcards in oxygenation Deck (31)
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1

respiratory system includes

upper airways, lungs, lower airways, and alveolar air sacs (base of lungs)

2

the lungs aid the body

in oxygenation and tissue perfusion

3

noninvasive procesures

- chest x-ray (CXR): use lead sheild for adults who are childbearing age
- pulse oximetry
- pulmonary function tests
- sputum culture
- ct scan
- mri

4

hypoxemia

when there is a limited amount of oxyegen in the blood

5

retractions

- when the muscles are pulled inward and occur between the ribs when inspiration occurs
- intercostal retractions are a sign that the airway is blocked

6

Hypoxia

lack of oxygen at the cellular level

7

clinical manifestation of hypoxia and hypoemia

tachypnea
tachycardia
restlessness
pale skin and mucous membranes
elevated blood pressure
use of accessory muscles, nasal flaring, adventitious lung sounds

8

nursing actions for hypoxia and hypoxemia

- monitor respiratory rate and pattern, level of consciousness
- provide oxygen therapy at the lowest liter flow that will correct hypoxia
- make sure the mask creates a secure seal over the nose and mouth
- assess/monitor restlessness, hypertension, and headache
- wheezing because of inflammation on inhaling or exhale
- auscultate the lungs for breath sounds and adventitious sounds (crackles and wheezes)
- assess/ monitor oxygenation status with pulse oximetry
- promote oral hygiene
- encourage turning, coughing, deep breathing, and the use of incentive spirometry and suctioning
- promote rest and decrease environmental stimuli

9

oxygen therapy

- a therapeutic gas that treats hypoxemia (low levels of arterial oxygen)
- administering and adjusting oxygen requires a prescription

10

oxygen delivery devices

- nasal cannula
- simple face mask
- partial rebreather mask
- non-rebreather mask
- venturi mask
- aerosol mask, face tent
- t-piece

11

nasal cannula

tubing with two small prongs for insertion into the nares
- fraction of inspired oxygen: delivers an Fio2 of 24% to 44% at a flow rate of 1-6 l/min

12

nasal cannula advantages

- safe, simple, easy to apply method
- cannula is comfortable and well tolerates
- client is able to eat, talk, and ambulate

13

nasal cannula disadvantages

- FiO2 varies with flow rate, and the rate and depth of the clients breathing
- extended use can lead to skin breakdown and dry mucous membranes
- tuning is easily dislodged

14

nasal cannula nursing actions

- assess the patency of the nares
- ensure that the prongs fit in the nares properly
- use water-soluble gel to prevent dry nares
- provider humidication for flow rates of 4l/min and greater ****

15

simple face mask

- covers the client's nose and mouth
- delivers an Fi02 of 35% to 50% at flow rates of 6 to 12 l/min
- minimum flow rate is 6l/min to ensure flushing of CO2 from the mask

16

simple face mask advantages

- face mask is easy to apply and can be more comfortable than a nsal cannula
- provides humidified oxygen

17

simple face mask disadvantages

- flow rates less than 6L/min can result in rebreathing of co2
- clients who have anixety or claustrophobia do not tolerate it well
- eating, drinking, and talking are impaires. mositure and pressure can collect under mask and cause skin breakdown
- face mask pose a greater risk of aspiration

18

simple face mask nursing actions

- assess proper fit to ensure a secure seal over the nose and mouth
- make sure the client wears a nasal cannula during meals
- use with caution for clients who have a high risk of aspiration or airway obsutrction
- monitor for skin breakdown

19

non-rebreather mask fraction of inspired oxygen

- delivers an FiO2 of 80% to 95% at flow rates of 10-15 l/min to keep the reservoir bag 2/3 full during inspiration and expiration

20

non-rebreather mask advantages

- it delivers the highest 02 concentration possible
- a one-way valve situated between the mask and reservoir allows the client to inhale maximum 02 from the reservoir bag
- the two exhalation ports have flaps covering them that prevent room air from entering the mask

21

non-rebreather mask disadvantage

- the valve and flap on the mask must be intact and functional during each breath
- it is poorly tolerated by clients who have anxiety or claustrophobia
- eating drinking and talking are impaired
- use with caution for clients who have high risk of aspiration or airway obstruction

22

non-rebreather mask nursing actions

- perform and hourly assessment of the valve and flap
- assess proper fit to ensure a secure seal over the nose and mouth
- assess for skin breakdown beneath the edges of the mask and bride of the nose. make sure the client uses a nasal cannula during meals

23

oxygen complications

- oxygen toxicity can result from high concentrations of oxygen (typically greater than 50%)
- long duration of oxygen therapy (typically more than 24 to 48 hours) and the severity of lung disease

24

oxygen toxicity manifsations

- nonproductive cough
- substernal pain
- nausea
- vomiting
- fatigue
- dyspnea
- restlessness
- paresthesias

25

oxygen toxicity nursing actions

- use the lowest level of oxygen necessay to maintain an adequate spo2
- monitor abg and notify the provider if sp02 levels are outside the expected reference range
- decrease the fio2 as the clients spo2 imrpoves

26

combustion nursing actions

- post "no smoking" or "oxygen in use" signs to alert others of the fire hazard. known where to find the closest fire extinguisher
- educate about the fire hazard of smoking with oxygen use
- have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity

27

combustion

- ensure that all electric devices (razors, hearing aids, radios) are working well
- make sure all electric machinery (monitors, suction machines is grounded
- do not sure volatile, flammable materials (alcohol, acetone) near clients receiving oxygen

28

specimen collection and airway clearance

- mucoasl secretion buildup or aspiration of emeis can obstruct a clients airway
- adequate hydration and coughing help the client maintain airway patency
- these interventions promote adequate gas exchange and lung expansion

29

specimen collection and airway clearance nursing actions that mobilize secretions and maintain airway patency include:

- assistance with coughing
- hydration
- positioning
- humidification
- nebulizer therapy
- chest phsiotherapy
- suctioning

30

suctioning

don the required personal protective equitment
- assist the client to high-fowelers or fowlers position for suctioning if possible
- encourage the client to breathe deeply and cough in a an attempt to clear secretions without artifical suction