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Understanding Medical Surgical Nursing Ch 26


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During inhalation, which of the following muscle contractions takes place to enlarge the chest cavity from top to bottom?
a. Diaphragm moves down.
b. External intercostal muscles move down.
c. Diaphragm moves up.
d. Internal intercost
a. Diaphragm moves down.
Deteriorating cilia in the respiratory tract predispose the elderly to which of the following?
a. Chronic hypoxia
b. Pulmonary hyptertension
c. Respiratory infection
d. Decreased ventilation
c. Respiratory infection
Which of the following terms is used to describe violinlike sounds heard on chest auscultation?
a. Crackles
b. Wheezes
c. Friction rub
d. Stridor
b. Wheezes
Which of the following is a normal value for oxygen saturation?
a. Less than 60%
b. 61 to 85%
c. 86 to 95%
d. More than 95%
d. More than 95%
the purpose of pursed-lip breathing is to promote which of the following?
a. Carbon dioxide excretion
b. Carbon dioxide retention
c. Oxygen excretion
d. Oxygen retention
a. Carbon dioxide excretion
Which of the following instructions is correct when teaching a patient how to use a metered dose inhaler?
a. "Inhale deeply, place canister in mouth, depress top of canister, exhale."
b. "Exhale, place canister in mouth, depress
b. "Exhale, place canister in mouth, depress canister and inhale at the same time."
Which of the following actions by the nurse is appropriate when vigorous bubbling is noted in the suction control chamber of a chest drainage system?
a. Check the tubing for leaks.
b. Notify the physician.
c. Reduce the level of wall sucti
c. Reduce the level of wall suction.
You hear a high-pressure alarm sounding on a mechanically ventilated patient. Which of the following should you check first?
a. Tubing
b. Power to the ventilator
c. Ventilator settings
d. The patient
d. The patient
The respiratory system consists of:
1. nose
2. nasal cavities
3. pharynx
4. larynx
5. trachea
6. broncial tree
7. lungs
8. respiratory muscles
The nasal mucosa is 1_____ 1_____ that is highly vascular; it 2_____ and 3_____ inhaled air. Dust and microorganisms are trapped on mucus produced by 4_____ 4_____ and swept backward and down to the 5_____ by the cilia.
1 ciliated epithilium
2 warms
3 moistens
4 goblet cells
5 pharynx
What are the three parts of the pharynx?
1. nasopharynx (air passage above soft palate)
2. oropharynx (behind oral cavity)
3. laryngopharynx (air and food passage)
voice box

airway between pharynx & trachea

made of nine pieces of cartilage that keep airway open (lined w/ciliated epithilium)
trachea and bronchial tree
4 to 5 inch tube from larynx to primary bronchi

mucosa is ciliated epithilium
fill chest cavity

from clavicles to diaphragm

functional units are millions of alveoli (simple squamous epithelium)
pleural membranes
serous membranes of thoracic cavity

includes visceral pleura (covers lungs) and parietal pleura (lines chest cavity)
movement of air into & out of alveoli

moves from high-pressure to low-pressure areas (pressure gradients)
The respiratory centers are in the 1_____ and 2_____. The main respiratory muscles are the 3_____ below the lungs and the external and internal 4_____ 4_____between the ribs.
1 medulla
2 pons
3 diaphragm
4 intercostal muscles
Pressures important to breathing include:
1. atmospheric pressure
(air around us)
2. intrapleural pressure
(in potential pleural space between pleural membranes)
3. intrapulmonic pressure
(inside alveoli and bronchial tree)
Oxygen is carried in the blood by 1_____ in the 2_____ (Hgb) of RBCs. The iron-oxygen bond is formed in the 3_____, where the 4_____ 4_____ of oxygen (PO2) is high. In tissues where the PO2 is low, 5_____ releases much of its oxygen.
1 iron
2 hemoglobin
3 lungs
4 partial pressure
5 Hgb
_____ _____ is usually the major regulator of respiration because even small changes in its blood level change the pH.
Carbon dioxide
occurs when air leaks into subcutaneous tissues due to pneumothorax or leaking chest tube

feels like Rice Krispies under skin when felt w/fingers
abnormal extra sounds
normal respiratory rate & rhythm
increased respiratory rate
decreased respiratory rate
absence of breathing (may be periodic)
deeper respirations - normal rate
respirations that gradually become faster & deeper than normal, then slower

alternates w/periods of apnea
Biot's respirations
faster & deeper respirations than normal, with abrupt pauses between them

breaths have equal depth
Kussmaul's respirations
faster & deeper respirations w/o pauses
prolonged, gasping inspiration followed by extremely short, inefficient expiration
arterial blood gases (ABGs)
measure effectiveness of gas exchange
pulse oximetry
measures percentage of Hgb that is saturated w/oxygen

AKA O2 sat & SaO2
ventilation-perfusion scan
radioactive substance is injected IV & scan done to view blood flow to lungs (perfusion)

another radioactive substance is inhaled - scanning shows how well oxygen is distributed into lungs (ventilation)
pulmonary angiography
x-ray exam of pulmonary vessels after IV administration of radiopaque dye

helps dx pulmonary embolism or other pulmonary vessel disorders

pt NPO for 4-8 hrs prior to procedure

pt lays flat for 3-8 hrs post procedure
diaphragmatic breathing
can be relaxing & conserves energy

-one hand on abdomen & other on chest

-concentrate on pushing out abdomen during inspiration & relaxing abdomen on expiration (chest should move very little)
pursed-lip breathing
for pt feeling SOB

helps keep airways open during exhalation

-inhale slowly through nose to count of 2
-exhale slowly through pursed lips to count of 4
"good lung down"
placing patients w/unilateral lung disease lying on side w/healthy lung in dependent position to increase oxygenation
low-flow oxygen devices
-nasal cannula
(simple - partial rebreather - nonrebreather)
high-flow oxygen device
venturi mask
insertion of needle into pleural space

done to aspirate fluid in pts w/pleural effusion
chronic airflow limitation (CAL)
pt has chronically high PaCO2 levels

depend on low PaO2 levels to stimulate breathing

high supplemental oxygen flow rates can depress respirations
When are chest tubes used?
chest tubes used when fluid/air has collected in pleural space

can occur w/a pneumothorax, pleural effusion, or penetrating chest injury
water seal chamber
chest drainage system

pt exhales

air trapped in pleural space travels through chest tube to water seal chamber, under water, then bubbles up & out of chamber

water acts as a seal allowing air to escape & preventing air from returning during negative pressure of inspiration
water in tube goes up w/inspiration & down w/expiration (as much as 5-10cm)
surgical opening through base of neck into trachea
permanent opening into trachea

tube inserted to maintain patency
What are the three parts of a tracheostomy tube?
1. outer cannula (in place at all times - secured by ties)

2. inner cannula (removed for cleaning)

3. obturator (guide only used during insertion of tube)
fenestrated tracheostomy tubes
tubes w/openings (fenestra) in the cannula to allow air flow up to larynx for speaking
Risk for Ineffective Airway Clearance Related to Increase in Secretions

- assess lung sounds every 4 hrs & prn

- encourage deep breathing & coughing

- encourage fluids

- encourage ambulation or turn every 2 hours

- suction pt w/sterile technique prn
Risk for Infection Related to Bypass of Normal Respiratory Defense Mechanisms

- good hand washing practice

- monitor & report s/s of fever

- protect trach opening from foreign material

- sterile technique for all trach care

- prevent aspiration
Impaired Verbal Communication Related to Presence of Tracheostomy Tube

- allow pt to communicate needs

- watch for nonverbal cues

- offer writing materials

- use picture board for communication

- teach pt w/fenestrated tube how to cover opening to talk

- consult w/speech therapist
Disturbed Body Image Related to Presence of Tracheostomy

- assess pt feelings re: trach

- positive attitude

- allow pt to express concers

- refer pt to support group

- help pt find ways to conceal trach tube if desired
Deficient Knowledge Related to Care of New Tracheostomy

- assess pt knowledge of selfcare

- teach trach cleaning, deep breathing & coughing, suctioning, infection prevention

- provide follow-up home health nurse post dc
endotracheal tube (ET)
used for pts unable to breathe effectively due to airway obstruction or respiratory failure

inserted via nose or mouth & into trachea

most mechanically ventilated also
ventilator alarms
- low-pressure: reduced pressure in system due to dc tube, tube leaking, etc.

- high-pressure: higher-than-normal resistance to air flow due to tube kinked, need suctioning, decreased lung compliance, etc.

- loss of power: power failure or disconnected plug

- vol & frequency: tidal vol or breaths per min fall
When a ventilator alarm sounds, the priorities are:
1. check pt FIRST

2. if pt stable, check machine

3. if unable to correct machine, dc pt & get help - **use manual resusciation bag until and RT arrives**
Noninvasive Positive-Pressure Ventilation
uses external masklike device to aide in ventilation

alternative to intubation & mechanical ventilation for pts able to breathe on own but unable to maintain normal blood gases
continuouspositive airway pressure
type of NIPPV

same amount of positive pressure maintained throughout inspiration & expiration

prevents airway collapse
bilevel positive airway pressure
type of NIPPV

different level of positive pressure used on inspiration & expiration

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