Funds ch 27
Terms
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- What's the difference between hypoxia and hypoxemia?
- Hypoxia is low level of O2 in tissues: Hypoxemia is low level of O2 in blood
- What is the first sign of hypoxia?
- Confusion
- What are retractions?
- Muscles move upward upon inspiration
- Some patients with neuromuscular diseases develoop hypoxemia because of:
- Weak respiratory muscles
- In an unconscious patient what's the most common cause of airway obstruction?
- Tongue
- What is normal SaO2?
- 95-99 percent
- In using a pulse oximeter how often do you rotate the sites?
- Clip on every 4 hours; disposable probes every 24 hours
- In administering the heimlich maneuver, where do you put your hands?
- 1/2 way between the xiphoid process and the umbilicus with the thumb of fist inward.
- If you're doing the heimlich on an unconscious person, how many abdominal thrusts do you do?
- 5, then check the Jaw to see if there's a foreign body
- If the choking victim is very obese or pregnant, what do you do?
- Chest thrusts rather than abdominal thrusts.
- Single rescuer rescue breathing is how often
- 12 X a minute
- For postural drainage, how much should the patient drink?
- 1500-2000 CCs
- To drain the apical segment of the upper lobe, what position do you have the patient in?
- High Fowlers
- How often should a patient deep breathe after surgery?
- 5-10 deep breaths every 2 hours
- When are the best results from postural drainage?
- In the AM and 45 to 60 mins before a meal
- How much O2 can a nurse administer w/o dr involvement?
- 2 liters
- What is the venturi mask?
- Delivers O2 - most accurate - must be removed for eating and meds
- What is the advantage of the non rebreathing mask?
- Highest O2 delivery
- The patient with COPD has what abmormality?
- Decreased elasticity of the lung tissue.
- In general, a safe level of O2 for someone with normal lungs is:
- 3 - 5 liters per minute
- If the patient is showing restlessness and irritability, the nurse should:
- TCDB
- If a patient is undergoing O2 therapy, what must the nurse do?
- Mouth care
- If there is continuous bubbling in a water seal drainage system that is not hooked up to suction, the nurse knows that:
- There's an air leak in the system
- Many elderly pts have trouble breathing deep enough because of:
- Arthritis of the rib cage
- How often are the settings on respiratory support equipment checked?
- Once a shift (at least)
- When deep breathing, how long should they hold it?
- at least 3 seconds
- How does the incentive spirometer work
- The pt takes a deep breath and the ball moves upward. Should do 10 X hour
- Pts with difficulty breathing are in what position usually?
- High fowlers
- What is the orthopenic position?
- Hunched over a table with 2 or 3 pillows
- When O2 is in use, give oral hygiene how often
- Every 3 to 4 hours
- What is the obturator?
- Guide for the tracheostomy tube to be inserted, then it is removed
- When taking care of chest tubes, you should report drainage in excess of what?
- 100 ml per hour
- Wall suction unit pressure is set to ??
- 80 to 120 mm HG
- How is oxygen delivered?
- Flowmeter
- How often must a tracheostomy tube be deflated?
- every 8 hours
- Where is the chest drainage tube placed?
- Intrapleural space
- Pertinent nursing diagnoses are:
-
Ineffective airway clearance
Impaired gas exchange
Risk for infection
Knowledge deficit
Risk for injury - What is another name for COPD?
- CAL (Chronic airflow limitation)
- Evaluation is based on what?
- Pulse OX, ABG, assessment findings
- It is important to relieve anxiety in a patient with impaired lung function because:
- tense muscles need more oxygen
- For a disposable chest drainage unit, you know there has to be what?
- Continuous bubbling in the suction chamber
- Elderly more prone to problems because:
- reduced elasticity of lung tissues
- One nursing measure that can prevent respiratory insufficiency is to:
- administer lo flow O2 constantly
- What is a tension pneumothorax?
- Air that enters the pleural space and is trapped there