Shared Flashcard Set


ATI Fundamentals Chpt 53-
ATI Fundamentals for Nursing test review
Undergraduate 2

Additional Nursing Flashcards




What does a pulse oximeter measure?
Arterial oxygen saturation via a wave of infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood
SaO2 Sat Levels
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
Order of what to do if SaO2 is below 90%
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
Early/late signs of hypoxemia
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
Nasal Cannula
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
Simple face mark
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
Partial rebreather
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
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
Venturi Mask
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
-assess flow rate frequently and make sure tubing is free of kinks
Aerosol mask
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
Oxygen Toxicity
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
COPD oxygen
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)
Combustion Actions for Oxygen
-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)
Indications of Respiratory sputum specimen collection
-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)
Sputum specimen nursing actions
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
Chest Physiotherapy
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
Chest Physiotherapy indications and preprocedure
-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
Chest Physiotherapy Procedure
-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
Oropharyngeal suctioning
-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
Intraprocedure to suctioning
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
Nasopharyngeal/tracheal suctioning
-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
Endotracheal suctioning ETS
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
Single Lumen and Double Lumen Cannula Tracheostomy
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
Cuffed versus cuffless tube trach
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
Fenestrated tube with cuff versus without cuff
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
Before tracheostomy care
-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
Some Tracheostomy Care Facts
-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
Tracheostomy care every 8 hours
-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
Accidental Decannulation
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
Damage to Trachea
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
Nasogastric Intubation use
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)
Placement check for NG tube
-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
Documentation after removal/discontinuation of NG tube
-Tubing removal and condition
-Volume and description of drainage
-Abdominal assessment
-Last and next bowel movement
-Urine output
NG complications
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
enteral formulas
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
Enteral access tubes
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
eneteral feeding
-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
NG/Enteral Complications
-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
Pressure Ulcer Staging
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
Stages of Wound Healing
-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
Healing Process
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
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)
Wound Cleansing
-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
Wound dressings
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
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
Stage extra treatment
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
Supporting users have an ad free experience!