Term
| What does a pulse oximeter measure? |
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Definition
| Arterial oxygen saturation via a wave of infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood |
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Term
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Definition
Below 91% requires interventions to help client regain acceptable levels (using lowest amount possible)
Below 90% indicates hypoxemia
Below 86% is an emergency
Below 80% is life threatening
Lower the level, the less accurate the value |
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Term
| Order of what to do if SaO2 is below 90% |
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Definition
This indicates hypoxemia
-Confirm that sensor prove is properly placed
-Confirm that oxygen delivery system is functioning and that client is receiving prescribed levels
-Place client in Semi-Fowlers or Fowlers
-Encourage deep breathing
-Report significant findings
-Remain with client and provide emotional support to decrease anxiety |
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Term
| Early/late signs of hypoxemia |
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Definition
Early: tachypnea, tachycardia, restlessness, pale skin and mucous membranes. elevated BP, symptoms of respiratory distress
Late: confusion and stupor, cyanotic skin and mucous membranes, bradypnea, bradycardia, hypotension, cardiac dysrhythmias |
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Term
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Definition
| Nasal Cannula: FiO2 24-44% at 1-6 L/min; client is able to eat, talk and ambulate, watch for skin breakdown and dry mucous membranes and easy dislodging; use water soluble gel to prevent dry nares and provide humidification for flow rates above 4 L/min |
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Term
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Definition
Covers the clients nose and mouth
FiO2 of 40-60%; 5-8 L/min
Easy to apply, more comfortable than nasalC, simple delivery
-5 L/min or lower may cause Co2 rebreathing
-Poorly tolerated with claustrophobia/anxiety
-Caution with high risk aspiration or airway obstruction
-Secure fit and wear NC during meals |
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Term
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Definition
covers nose and mouth
FiO2 of 60-75%, rate 6-11 L/min
-Mask has a reservoir bag with no valve; client rebreathes up to 1/3 exhaled air together with room air
-Complete deflation causes Co2 buildup
-NC during meals; secure fit
-Caution: aspiration or airway obstruction risk patients |
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Term
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Definition
FiO2 of 80-95% at 10-15 L/min to keep bag 2/3 full during I and E
Delivers highest O2 concentration possible without intubation
-one way valve allows client to inhale max O2 from bag, two E flaps cover to prevent room air from entering
-Caution: clients with high aspiration/obstruction risk, NC during meals
-Perform hourly assessment of valve and flap |
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Term
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Definition
FiO2 of 24-55% at 2-10 L/min via different size adaptors
Delivers most precise oxygen concentration
-No humidification required
-best for clients with chronic lung disease
-expensive
-assess flow rate frequently and make sure tubing is free of kinks |
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Term
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Definition
Face tent-fits loosely around the face and neck, and tracheostomy collar-small mask that covers surgical opening of trachea
FiO2 of 24-100% at at least 10L/min
Humidification is provided
-Use with clients who cant tolerate masks well; clients with facial trauma, burns and thick secretions
-Frequent monitoring due to high humidification; ensure adequate water in canister
-Empty condensation
-Make sure tubing does not pull on tracheostomy |
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Term
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Definition
s.s.: nonproductive cough, substernal pain, nasal stuffiness, n/v, fatigue, headache, sore throat, hypoventilation
-Use lowest level of oxygen to maintain sats
-Monitor ABGs and notify if Sats are outside range
-Use o2 mask with: CPAP-continous positive airway pressure, BiPAP-bilevel positive airway pressure, or PEEP-positive end=expiratory pressure
-Reduce FiO2 as soon as condition permits |
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Term
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Definition
Rely on low levels of arterial oxygen as their primary drive. It is a chronic condition of hypoxemia and hypercapnia. High levels of oxygen can decrease or eliminate respiratory drive
-Monitor RR and pattern, LOC, and SaO2
-Lowest liter flow; a venturi mask if tolerated for precision
-Notify provider of resp depression (low RR or LOC) |
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Term
| Combustion Actions for Oxygen |
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Definition
-Post No Smoking, Oxygen in Use signs
-Know where extinguisher is
-Educate about fire hazard of smoking with oxygen
-Have client wear cotton gown; synthetic or wool generate static electricity
-Ensure all electric devices work properly and machinery is grounded
-Do not use volatile, flammable materials near client (alcohol, acetone) |
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Term
| Indications of Respiratory sputum specimen collection |
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Definition
-For cytology to identify aberrent cells or cancer
-For culture and sensitivity to grow and identify micro-organisms and the antibiotics effective against them
-To identify acid fast bacillua (AFB) to diagnose TB (three consecutive morning samples) |
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Term
| Sputum specimen nursing actions |
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Definition
Check prescription, wait 1-2 after client eats in the early morning, perform chest physiotherapy to mobolize secretions, use sterile specimen container for culture/AFB and container with preservatives for cytology and biohazard bag (possible mask/goggles with gloves)
-Fowlers position
-Rinse mouth of oral contaminant then check ability to cough (otherwise endotracheal order with sputum trap)
-Have client breathe deeply 2-4 times then cough deeply
-Expectorate 1-2tsp into sterile cup, redo if not enough
-Maintain sterility, place lid, lavel, put in biohazard bag and deliver to lab within 30m
-Document |
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Term
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Definition
set of techniques to loosen respiratory secretions and move them into central airways to be removed by coughing or suctioning
Percussion: cupped hands; clap rhythmically on chest to break up secretions
Vibrations: use of shaking movement applied during E to help remove secretions
Postural drainage-9 positions to allow secretions to drain by gravity |
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Term
| Chest Physiotherapy indications and preprocedure |
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Definition
-For clients with thick secretions, unable to clear airway
-Contraindicated: pregnant, rib/chest/neck/head injury, intracranial pressure, recent abdominal surgery, pulmonary embolism
-must maintain patent airway and SaO2 of 95-100%
Nursing Actions:
-Schedule: 1hr before meal, 2hr after and before bed-reduce vomiting/aspiration risk
-Administer bronchodilator or nebulizer treatment 30m-1hr before
-Offer emesis basin and facial tissues |
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Term
| Chest Physiotherapy Procedure |
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Definition
-Proper positioning: apical section of upper lobes-Fowlers; posterior section of upper-Side-lying; Right lobe-on left side with pillow under chest; left lobe-Trendelenburg
-Apply manual percussion with cupped hands/device
-Cough after each set of vibrations-tense hand/arm; moving heel of hand
-Each position for 10-15m
-Discontinue with faintness/dizziness/dyspnea-hypoxia
-After: lung auscultation ans assess amount, color and character of secretions
-Document and repeat 2-3 per day |
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Term
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Definition
-baseline assessment
-use yankauer or tonsil-tipped rigid suction catheter
After intraprocedure:
-Inset catheter in clients mouth and apply suction and move it around mouth, gum line and pharynx
-Clear catheter and tubing/repeat as needed |
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Term
| Intraprocedure to suctioning |
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Definition
Surgical asepsis: opening suction catheter kit/suctioning other than mouth
-Open sterile suction package and place drape on client chest
-Set up container, touch only outside and pout 100mL of sterile water or .9% NaCl
-Don sterile gloves
-nondominant holds tube; sterile holds sterile catheter
-Connect to tubing, set pressure no higher than 120 mmHg; test suction with sterile water
-Limit suction to 10-15s and 2-3 attempts; clear with sterile water when done
-Document: pre/post assessment, toleration, color/consistency |
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Term
| Nasopharyngeal/tracheal suctioning |
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Definition
-Hyperoxygenate with FiO2 of 100%, lubricate distal 6-8cm with a water-soluble
-Insert during inhalation but dont suction
-Follow natural naris course with slight slant downward (nose to earlobe)
-Apply suction intermittently by covering and releasing port with thumb for 10-15s while withdrawing and rotating with thumb and forefinger
-Allow 20-30s recovery between, repeat a/n; hyperoxygenating before each suctioning pass |
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Term
| Endotracheal suctioning ETS |
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Definition
Outer diameter of no more than 1cm of internal diameter of endo tube; hyperoxygenate with BVM or ventilator with FiO2 of 100%
-Remove BVM/V and insert catheter into lumen; advance till resistance then pull back 1cm
-Apply intermittent suctioning by covering/releasing port with thumb while withdrawing and rotating it with thumb/forefinger 10-15s
-Reattach BVM/V
-Clear catheter/tubing/allow time and repeat if necessary |
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Term
| Single Lumen and Double Lumen Cannula Tracheostomy |
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Definition
Single Lumen: long, single-cannula tube use for clients who have long or thin necks; do not use if have excessive secretions
Double Lumen: three parts
1. outer cannula fit into stoma to keep airway open
2. inner cannula snugly locked into outer cannula
3. Obturator: thin solid tube placed inside teach as guide for inserting outer cannula then removed
-Inner cannula can be removed, cleaned, reused or discarded and replaced
-Useful with excessive excretions |
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Term
| Cuffed versus cuffless tube trach |
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Definition
Cuffed tube: has balloon inflated around outside of distal segment of tube to protect the lower airway by producing a seal from upper airway
-permits mechanical ventilation but does not hold tube in place
-Unable to speak
-Measure pressures to prevent tissue necrosis
Cufflesstube: no balloon; used for clients with long term airway management that have low risk for aspiration
-Not used if on mechanical ventilation but can speak |
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Term
| Fenestrated tube with cuff versus without cuff |
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Definition
FT with cuff: One large or multiple openings in posterior wall with balloon around outside tube; has inner cannula
-allows for mechanical ventilation
-removing inner cannula allows fenestrations to permit air to flow through; client can speak
Without cuff: no balloon; still has inner cannula
-holes wean the client from the tracheostomy
-Removing inner cannula has fenestration permit air flow
-client can speak |
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Term
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Definition
-Explain procedure
-Place in semiF or F
-Keep material at bedside: two extra trach tubes (one client size and one smaller), obturator for existing tube, O2 source, suction catheters and source, manual resuscitation bag
-Provide with methods to communicate; emergency call system and call light |
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Term
| Some Tracheostomy Care Facts |
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Definition
-Provide adequate humidification and hydration to thin secretions and reduce risk of mucous plugs
-Do not suction routinely: PRN (bleeding, mucosal damage, bronchospasm)
-Oral care every 2 hours
-Trach care every 8 hours
-Change every 6-8 weeks
-Reposition every 2 hours to prevent atelectasis and pneumonia
-Eating: upright, chin tucked in to chest; watch aspiration
-Drugs: anti-inflammatory, antibiotic, aerosolized bronchodilater, mucus liquifier |
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Term
| Tracheostomy care every 8 hours |
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Definition
-Suction tube if necessary; sterile
-Remove soiled dressing and excess secretions
-Cotton tipped applicator and gauze pads to clean exporsed surface; hydrogen peroxide then .9% NaCl in circular motion from stoma out
-Clean inner cannula sterily with half strength-fill hydrogen peroxide; rinse with sterile saline
-Clean stoma with half strength H peroxide then sterile saline
-4x4 dressing around trach
-Change ties if soiled, after placing new ones with visible square knot fitting 1-2 fingers
-Document |
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Term
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Definition
First 72: not matured: EMERGENCY
-Ventilate with manual resuscitation bag and call for assistance
-hyperextend neck with obturator inserted into tube; quickly and gently replace tube and remove obturator
-Secure and auscultate
Always keep trach obturator and 2 tubes at bedside
-If unable to replace, administer O2 through stoma. If unable through stoma; occlude stoma and administer through mouth/nose |
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Term
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Definition
wall necrosis: tissue damage that results when presure of inflated cuff impairs blood flow to tracheal wall
senosis: narrowing of tracheal lumen due to scar formation: resulting from irritation of mucosa fromtracheal tube cuff
-Keep pressure between 14-20mmHg
-Check pressure at least once/8hr
-Keep tube in midline position and prevent pulling or traction on tube |
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Term
| Nasogastric Intubation use |
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Definition
Decompressiong: removal of gases or stomach contents to relieve distention, nausea or vomiting (salem sump, Miller-Abbot, Levin)
Feeding: route of administering nutritional supplements when oral/esophageal passageways cant be used (Duo, Levin, Dobbhoff)
Lavage: Washing out the stomach to treat overdose or ingestion of poison (Ewalk, Levin, Salem sump)
Compression: Applied pressure using an internal balloon to prevent hemorrhage (Sengstaken-Blakemore) |
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Term
| Placement check for NG tube |
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Definition
-Ask client to talk
-Inspect posterior pharynx for coiling
-Aspirate gently to collect gastric content and observe the color
-Test pH (should be 4 or less)
-If prescribed: confirm with x-ray
-DO NOT Inject air into the tube then listen over the abdomen
If tube is not in stomach, advance 5cm and repeat tests |
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Term
| Documentation after removal/discontinuation of NG tube |
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Definition
-Tubing removal and condition
-Volume and description of drainage
-Abdominal assessment
-Last and next bowel movement
-Urine output |
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Term
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Definition
Excoriation of nares/stomach: apply lubricant as needed to nares; assess color of drainage and report coffee-ground, dark or blood-streaked drainage immediately to provider
Discomfort: Rinse mouth with water for dryness; throat lozenges; frequent oral hygiene
Occlusion leading to distention: irrigate tube per protocol to unclog blockages; tap water may be used with feeding; change position in case tube is against stomach wall |
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Term
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Definition
Polymeric: (1.0-2/0 kcal/mL) milk based, blenderized foods; only if GI tract can absorb whole nutrients
Modular formulas (3.8-4.0 kcal/mL): single macronutrient preperation; not nutritionally complete; added for supplmental nutrition
Elemental formula (1.0-3.0 kcal/mL): predigested nutrients; not nutritionally complete; easier to absorb
Specialty formula (1.0-2/0 kcal/mL): created to meet specific nutritional needs; not nutritionally complete; primarily for those with hepatic failure, respiratory disease or HIV |
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Term
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Definition
NG/NI: therapy shorter than 4 weeks; via nose
Gastrostomy or jejunostomy: therapy longer than 4 weeks; inserted surgically
Percutaneous endoscopic gastrostomy PEG or jejunostomy PEJ: therapy longer than 4 weeks; inserted endoscopically |
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Term
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Definition
-Fowelers; head of bed at least at 30d
-Monitor tube placement and residual (100mL gastric; 10mL intestinal)
-Flush 30-60mL tap water
-Administer feeding (60mL syringe filled with 40-50mL formula; hold tubing above instillation site; if feeding bag-fill with total amount and hang until empty-30m)
-Follow with 60-100mL tap to flush/prevent clog
-Monitor: I&O-24 hr totals, capillary blood glucose every 6hr till max rate is sustained for 24hrs, gastric residual every 4-8hrs)
-Infusion pump for intestinal feeding |
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Term
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Definition
-gastric residual over 100/10mL: Withhold feeding, notify provider; maintain semi-F; recheck in hour/prescribed
-Diarrhea 3+ times in 24hrs: Notify provider, confer with dietition; provide skin care/protection
-N/V: Withhold feeding; turn client to side; notify provider; check patency; aspirate for residual and auscultate bowels
-Aspiration of formula: Withhold feeding; notify; turn client to side; suction airway; monitor vitals for elevated temp; auscultate breath sounds for congestion; obtain chest x-ray; o2 as indicated
-Skin irritation around tubing: Provide skin barrier from drainage; monitor tube placement |
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Term
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Definition
Stage I: Intact skin with area of persistent, non blanchable redness; may feel warm/cool to touch. Tissue is swollen and congested with possible discomfort. Blue/purple in darker skin.
Stage II: Partial-thickness skin loss involving epidermis and dermis. Ulcer is visible and superficial and may appear as an abrasion, blister or shallow crater. Edema persists and the ulcer may become infected; possibly with pain and scant drainage.
Stage III: Full-thickness tissue loss; damage/necrosis of subQ tissue. May extend down to, but not through underlying fascia. Appears as a deep crater, no exposed muscle/bone. Drainage/infection are common
Stage IV: Full-thickness tissue loss with destruction, necrosis, or damage to muscle, bone, or supporting structures. May be sinus tracts, deep pockets of infection, tunneling, eschar or slough.
Unstageable: not determinable due to eschar/slough obscuring wound |
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Term
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Definition
-Inflammatory: first 3 days after trauma; attempts to control bleeding with clot formation; deliver oxygen, WBCs, and nutrients to area via blood
-Proliferative: 3-24 days: replacing lost tissue with connective/granulated tissue; contracting wound edges; resurfacing new epithelial cells
-Maturation/Remodeling: can take more than a year: strengthening collagen scar and restoring normal appearance |
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Term
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Definition
Primary Intention: little/no tissue loss; edges are approximated, as with surgical incision: heals rapidly, low infection risk, no/minimal scarring
Secondary: loss of tissue, wound edges serparated widely (PU, stab): longer healing, increased infection risk, scarring
Tertiary: Widely separated; deep; spontaneous opening; risk of infection: extensive drainage and tissue debri, closed later, long healing time |
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Term
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Definition
normal result of healing process during inflammatory and proliferative phases
Character by consistency, color and odor:
-Serous: portion of blood that is watery and clear or slightly yellow in appearance
-Sanguineous: serum and RBC; thick and reddish
-Purulent: infection; thick; WBCs, tissue debri and bacteria; may have foul odor and color reflects organism (green=P.aeruginosa) |
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Term
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Definition
-Least contaminated toward most
-Gentle friction
-isotonic solutions are the preferred cleansing agent
-never use the same gauze to cleanse across incision/wound more than once
-irrigation with solution filled syringe help 1inch above the wound may be used |
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Term
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Definition
Woven gauze/sponge: absorbs exudate
Nonadherent: does not adhere to bed
Self-adhesive: temp second skin; ideal for small superficial wounds
Hydrocolliod: occlusive that swells in prescence of exudate; to maintain granulating wound bed up to 5 days
Hydrogel: infected, deep wounds; moist wound bed
Use neg pressure of a wound vacuum-assisted closure if prescribed |
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Term
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Definition
Dishicence: partial or total rupture of a sutured wound, usually with separation of underlying skin layers.
Evisceration: dehiscence that involves protrusion of visceral organs through opening usually due to increased serosanguineous flow 3-11 days postop
-call for help; stay with client
-cover wound/protruding organ with sterile towels or dressings that have been soaked in sterile normal saline
-Position supine with hips and knees bent
-Maintain calm environment and watch for signs of shock |
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Term
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Definition
Stage I: pressure relieving devices, such as an air-fluidized bed; pressure
Stage II: Maintain moist healing environment; promote natural healing; analgesics as prescribed
Stage III: Clean and/or debride; administer analgesics/antimicrobials as prescribed
Stage IV: clean and/or debride; perform nonadherent dressing changes every 12 hours; possible skin grafts; analgesics/antimicrobials as prescribed
Unstageable: debride as prescribed until it can be staged |
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