Flashcards in Respiratory System Deck (31)
Fever can cause dehydration because of excessive fluid loss due to
diaphoresis. Increased temperature also increases metabolism and the demand for O2
What clients are at risk for pneumonia?
-Altered level of consciousness
-Depressed or absent gag and cough reflexes
-Susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals
Bronchial breath sounds are heard over
areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue
What does hydration due?
1) Thins out the mucus trapped in the bronchioles and alveoli, facilitating expectoration
2) Is essential for client experiencing fever
3) Is important because 300-400mL of fluid is lost daily by the lungs through evaporation
Irritability and restlessness are early signs of
Exposure of tobacco smoke is the primary cause of
What is a pink puffer
Barrel chest in indicative of emphysema and is caused by use of accessory muscles to breathe. The person works harder to breathe, but the amount of O2 taken in is adequate to oxygenate the tissues.
What is a blue bloater?
Insufficient oxygenation occurs with chronic bronchitis and lead to generalized cyanosis and often right sided heart failure/ cor pulmonale
If breath sounds are clear but the client is cyanotic and lethargic,
adequate oxygenation is not occurring
With cancer of the larynx, the tongue and mouth appear
white, gray, dark brown, or black and appear patchy
Tracheostomy care involves
cleaning the inner cannula, suctioning, and applying clean dressings.
The difference between a laryngectomy tube and tracheostomy tube
Laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks in the first 24 hours
glottal stop technique for fear of choking in laryngectomy clients.
Take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube.
Reduced effectiveness of oral contraceptives; client should use other birth control methods during treatment. Gives body fluids orange tinge, stains soft contact lenses.
Increased phenytoin, Dilantin, levels
Vision check before starting therapy and monthly there after. May have to take for 1-2 years
Some tumors are so large that they fill entire lobes of the lung. When removed large spaces are left. Chest tubes
are not usually used with these clients because it is helpful if the mediastinal cavity where the lung used to be fills up with fluid. This fluid helps to prevent the shift of the remaining chest organs to fill the empty space.
Occlusive dressing prevents
A tension pneumothorax
List four common symptoms of pneumonia the nurse might note on a physical exam?
Fever with chills
Bronchial breath sounds
State four nursing interventions for assisting the client to cough productively
-Encourage to deep breath
-Increased fluid intake to 3L/day
-Use humidity to loosen secretions
-Suction airway to stimulate coughing
What symptoms of pneumonia might the nurse expect to see in an older client?
-Rapid Respiration Rate
How dose the nurse prevent hypoxia during suctioning/?
Deliver 100% O2 (hyperinflating) before and after each endotracheal suctioning.
During mechanical ventilation, What are three major nursing interventions?
-Monitor clients respiratory status and secure connections
-Establish a communication mechanism with the client
-Keep airway clean with coughing and suctioning
When examining a client with emphysema, What physical findings is the nurse likely to see?
-dry or productive cough
-Decreased breath sounds
-Crackles in lung field
-Works really hard to breathe
What is the most common risk factor associated with lung cancer?
Describe the preoperative nursing care for a client undergoing a laryngectomy?
-Involve the family and client in manipulation of the tracheostomy equipment before surgery
-Establish a communication mechanism
-Refer to a speech therapist
-Discuss rehabilitation programs
List 5 nursing intervention after chest tube insertion?
-Maintain a dry occlusive dressing
-Keep all tubing connections tight and taped
-Monitor clients clinical status
-Encourage client to take deep breaths
-Monitor fluid drainage; mark time and fluid level
What immediate action should the nurse take when a chest tube becomes disconnected?
Place the end of the tube in a sterile water container at a 2 cm level. Apply an occlusive dressing, and notify the health care team
What instructions should be give to a client following radiation therapy?
-Do not wash off lines
-Wear soft cotton garments
-Avoid the use of powders/creams on radiation sites