Term
| O2 cansiter: precautions (3) |
|
Definition
- no smoking
- non-sparking wrench
- protect from being knocked over
|
|
|
Term
| supplies to keep available for tracheostomy patient (2) |
|
Definition
-emergency resuscitation supplies
-suction |
|
|
Term
| Oxygen delivery types (4): setup for each (equipment) |
|
Definition
-Cannula: for breathing through nose
-Simple mask: covers mouth and nose
-Partial rebreather: includes a reservoir to capture some exhaled gas for rebreathing
-Nonrebreather: includes reservoire for oxygen, and vents to prohibit rebreathing |
|
|
Term
| high-flow oxygen: complications for newborns |
|
Definition
|
|
Term
| Why use hydrogen peroxide on chest tubes |
|
Definition
|
|
Term
| PEEP on ventilator: what does it do? |
|
Definition
| Forces air into the lungs to keep them open. |
|
|
Term
| oxygen concentrators (3)- liter flow they can provide, how to use |
|
Definition
Cannula: 1-5L/min
Mask: 6-10 L/min
Ambu-bag: up to 15 L/min
|
|
|
Term
| Positioning to improve perfusion of a healthy lung |
|
Definition
|
|
Term
| Priority of responses (2) to patient with pulse ox <95% |
|
Definition
- Get order for oxygen (probably cannula first)
- Fowler's position |
|
|
Term
|
Definition
| - Positive end-expiratory pressure - keeps airway open, to increase the amount of oxygen remaining in the alveoli |
|
|
Term
| Coarse rales: indications (3) |
|
Definition
- Pulmonary edema
- bronchitis
- pneumonia |
|
|
Term
|
Definition
- grating sound, similar to what is heard from joints grinding together in osteoarthritis
- may indicate broken rib
|
|
|
Term
Nursing Dx: Ineffective airway clearance related to excessive secretions
Interventions (5)? |
|
Definition
- assess lung sounds q4h
- monitor sputum (color & consistency)
- fluids
- turning, ambulation, etc.
- coughing/deep breathing |
|
|
Term
|
Definition
|
|
Term
| Signs that non-breather mask is working properly |
|
Definition
- bag is inflated
- vents are closed |
|
|
Term
| Nursing interventions (4): when pulse ox is low |
|
Definition
- quit smoking
- breathing exercises
- relaxation exercises
- upright positioning |
|
|
Term
| pleur-evac chambers: name, purpose, and what you should see |
|
Definition
- collection chamber
* drainage is collected
* flow that gradually diminishes over time
- water seal chamber
* prevents backflow of air into chest
* water level tides in sync with breathing
- suction control chamber
* controls strength of suction
* gentle bubbling |
|
|
Term
|
Definition
| - deep and labored breathing pattern - often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) - also indicates possible renal failure |
|
|
Term
| Symptoms to report if noted during O2 administration |
|
Definition
- dry cough
- chest pain
- numbness in extremities
- lethargy
- nausea
- PaO2 > 100 |
|
|
Term
| Thoracentesis nursing interventions (6) |
|
Definition
- ensure patient understanding of procedure
- witness written consent
- have patient void
- obtain procedure tray
- sit patient bending over bedside table or side-lying
- assess vital signs, breath sounds |
|
|
Term
|
Definition
| - eupnea: - 12-20 breaths/min |
|
|
Term
|
Definition
| - first chamber in the system - may be divided into three sub/chambers to facilitate measurement of drainage |
|
|
Term
| tracheostomy care schedule |
|
Definition
- first time: 2 days after installation
- subsequent cleanings: tid or every shift |
|
|
Term
| suction control chamber (3) |
|
Definition
| - gentle bubbling normally occurs - last chamber in the system - excessive bubbling will evaporate water and defeat the purpose |
|
|
Term
| fine crackles: indications |
|
Definition
- heart failure
- atelectasis |
|
|
Term
|
Definition
| - high pitched, whistling or sibilant sounds. - caused by airway narrowing, secretions. |
|
|
Term
| Tracheostomy suctioning procedure |
|
Definition
| - insert suction catheter until resistance or patient coughs - withdraw cath, suctioning intermittently while rotating cath |
|
|
Term
| Post-bronchoscopy nursing interventions (3) |
|
Definition
- keep patient NPO until gag reflex noted.
- look for s/sx pneumothorax
- look for s/sx airway swelling (hoarse voice) |
|
|
Term
| Pleural friction rub: indications |
|
Definition
- pleurisy
- lung cancer
- pneumonia
- pleural irritation |
|
|
Term
| lung sounds absent: indications |
|
Definition
- pneumothorax
- pneumectomy |
|
|
Term
|
Definition
| - second chamber in the system - tidaling indicates normal operation - bubbling indicates a leak |
|
|
Term
|
Definition
- suction machine with tubing
- suction catheter
- sterile container
- sterile water or saline
- sterile gloves |
|
|
Term
|
Definition
- suction
- T-tube
- cleaning materials
- dressing
- normal saline |
|
|
Term
| High-pressure alarm: 5 causes |
|
Definition
1- blockage (secretions)
2- cough
3- attempting to talk
4- kinks or obstructions in tubing
5- decreased lung compliance (sign of worsening respiratory disease) |
|
|
Term
| Low-pressure alarm: 4 causes |
|
Definition
1- disconnected tubing
2- leaks
3- underinflated cuff
4- patient attempts to remove the tube |
|
|
Term
|
Definition
1. Assemble equipment
2. Explain
3. Suction inner cannula if necessary.
4. prepare the kit.
5. Don clean gloves.
6. Remove old tracheostomy dressing.
7. Remove inner cannula and place it in peroxide solution.
8. suction if necessary.
9. Don sterile gloves.
10. Clean inner cannula.
11. Clean around tracheostomy site.
12. Replace ties.
13. Apply sterile tracheostomy dressing |
|
|
Term
| Limits on suctioning time |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| What is the normal lung pH? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| How does surfactant prevent the alveolar walls from collapsing? |
|
Definition
| A mixture of phospholipids (ie, lecithin & sphingomyelin). Acts to break up surface tension in pulmonary fluids to reduce friction |
|
|
Term
| What does a low PCO2 indicate |
|
Definition
| Alkaline environment in the lung. Breathing will be fast. |
|
|
Term
| Placement of Pleur-Evac device |
|
Definition
| Below chest (ie, on the floor) |
|
|
Term
| Respiratory alkalosis symptom |
|
Definition
| Breathing faster than normal |
|
|
Term
|
Definition
| Breathing: faster and deeper than normal |
|
|
Term
|
Definition
| Breathing: gradually increases, then decreases, periodically stopping |
|
|
Term
|
Definition
| Breathing: normal rate, deeper-than-normal breaths |
|
|
Term
|
Definition
|
|
Term
| Factor that controls breathing rate |
|
Definition
|
|
Term
| You walk into a patient's room and hear the vent high alarm. What do you do first? |
|
Definition
|
|
Term
| A patient's ventilator low alarm is sounding. What do you do first? |
|
Definition
|
|
Term
| Breathing: gradually increases, then decreases, periodically stopping |
|
Definition
|
|
Term
| What are the protective respiratory reflexes |
|
Definition
| Coughing, sneezing, yawning |
|
|
Term
| lung sounds that indicate possible pulmonary edema |
|
Definition
| Rales that don't clear after a cough |
|
|
Term
Asthma patient has diminished lung sounds, no wheezing.
indication? |
|
Definition
|
|
Term
|
Definition
| Effect of low oxygen saturation |
|
|
Term
| What is found in alveoli? |
|
Definition
| Epithelial cells that produce surfactant. |
|
|
Term
| normal respiration, 12-20 RPM |
|
Definition
|
|
Term
| What is ciliated epithelium and what does it do? |
|
Definition
| Hairlike tissue. It assists in removing dust particles and other unwanted foreign bodies that have entered the air passages. |
|
|
Term
| How is the trachea kept open? |
|
Definition
| Horseshoe-shaped cartilaginous rings, known as the tracheal windpipe. |
|
|
Term
| Cause of respiratory alkalosis |
|
Definition
| Hyperventilation, excessively rapid deep breathing. |
|
|
Term
| medication that can help reduce pulmonary edema and acts as a vasodilator |
|
Definition
|
|
Term
| How can the patient assist in your better hearing lung sounds |
|
Definition
| Inhale through nose, exhale through mouth. |
|
|
Term
| What does hydrogen peroxide do to facilitate tube cleaning. |
|
Definition
| It breaks down the protein |
|
|
Term
|
Definition
| It extends from the epiglottis to the openings of the larynx and esophagus Separates passageways for food and air. |
|
|
Term
|
Definition
| It reacts with water to form carbonic acid. This acid breaks down into H+ and HCO3-, which buffer the system and maintain pH levels. |
|
|
Term
| Breathing: faster and deeper than normal |
|
Definition
|
|
Term
- deep and labored breathing pattern
- often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA)
- also indicates possible renal failure |
|
Definition
|
|
Term
| Where and what are the palatine tonsils |
|
Definition
| Located posterially on each side of the oral cavity. Destroys foreign substances that are inhaled or ingested. Commonly removed in a tonsillectomy |
|
|
Term
| On the ventrolateral surface of the medulla. |
|
Definition
| Location of chemo-receptors |
|
|
Term
| Location of respiratory control center |
|
Definition
|
|
Term
| Major portion of the brain controlling respiration |
|
Definition
| Medulla (specifically the pons) |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Note about venturi oxygen supply |
|
Definition
|
|
Term
|
Definition
| Obstruction from tumor or foreign body |
|
|
Term
| Location of chemo-receptors |
|
Definition
| On the ventrolateral surface of the medulla. |
|
|
Term
| How do we exchange CO2 and O2 |
|
Definition
| Oxygenated blood passes through the walls of the alveoli into lung capillaries, where the exchange occurs. |
|
|
Term
| sac of serous membrane lining the chest cavity |
|
Definition
|
|
Term
| conducts the breathing impulses. |
|
Definition
|
|
Term
| Result of air pressure building in the chest (AKA pneumothorax) |
|
Definition
| Possible cause of lung collapse |
|
|
Term
| This may happen because surfactant does not form until after the seventh month of gestation. |
|
Definition
| Premature newborns may suffer from respiratory distress syndrome for this reason. |
|
|
Term
| What prevents friction in pleural membrane? |
|
Definition
| Serous lubricating fluid, is excreted by the pleura |
|
|
Term
| parietal pleura and visceral pleura |
|
Definition
| Serous membranes that cover lung |
|
|
Term
| Nursing intervention when patient is on nonbreather mask. |
|
Definition
| Stay with the patient the whole time. |
|
|
Term
| located in the posterior wall of the nasopharynx and, along with the tonsils, assist the body in its immune response to foreign invaders |
|
Definition
|
|
Term
| from the eyes, open into the upper nasal cavities, thereby causing the “runny nose” that often accompanies crying. |
|
Definition
| The nasolacrimal ducts, or tear ducts |
|
|
Term
| pleural cavity or pleural space |
|
Definition
| The space between the two layers of the pleura |
|
|
Term
| Reason that on the floor, cannulas are used. |
|
Definition
| Normal administration is 2 L/min. Any higher risks interference with the hypoxic drive. |
|
|
Term
| Premature newborns may suffer from respiratory distress syndrome for this reason. |
|
Definition
| This may happen because surfactant does not form until after the seventh month of gestation. |
|
|
Term
|
Definition
| Three small bones that increase the nasal mucosa surface area |
|
|
Term
| volume of air inhaled and exhaled with each breath |
|
Definition
|
|
Term
| Why do we give oxygen therapy? |
|
Definition
| To assist patients who cannot maintain oxygenation |
|
|
Term
| Where do most foreign substances aspirate? |
|
Definition
|
|
Term
| volume of air in lungs after a maximum inspiration |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Where is air moistened and warmed? |
|
Definition
|
|
Term
| most accurate oxygen delivery system |
|
Definition
|
|
Term
- second chamber in the system
- tidaling indicates normal operation
- bubbling indicates a leak |
|
Definition
|
|
Term
| a substance secreted by the great alveolar cells |
|
Definition
|
|
Term
|
Definition
| When swallowing, it covers the entrance to the larynx to prevent food and drink from entering the windpipe. |
|
|
Term
correct instructions for using an MDI:
a. “Inhale deeply, place canister in mouth, depress top of canister, exhale.”
b. “Exhale, place canister in mouth, depress canister and inhale at the same time.”
c. “Cough, place canister in mouth, inhale deeply, cough again.”
d. “Exhale, depress canister, place in mouth, inhale deeply.” |
|
Definition
| b. “Exhale, place canister in mouth, depress canister and inhale at the same time.” |
|
|
Term
|
Definition
| a smooth double-layered sac of serous membrane in the lower respiratory tract |
|
|
Term
|
Definition
| a structure consisting of bone and cartilage, divides the internal nose into two sides or cavities. |
|
|
Term
|
Definition
| a substance secreted by the great alveolar cells |
|
|
Term
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 |
|
Definition
| a. Carbon dioxide excretion |
|
|
Term
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 intercostal muscles move up. |
|
Definition
|
|
Term
| intervention for reducing incisional pain while breathing |
|
Definition
|
|
Term
|
Definition
|
|
Term
| What does a high PCO2 indicate |
|
Definition
| acid environment in the lung. Breathing will be slow. |
|
|
Term
| At what point in the suctioning procedure should the suction be applied? |
|
Definition
| after beginning to withdraw suction catheter |
|
|
Term
|
Definition
| air that remains in the lungs after exhaling. |
|
|
Term
| These microscopic “balloons” give the lungs their spongy appearance |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| wheezing - probable cause? |
|
Definition
|
|
Term
| Peak flow meter device: purpose |
|
Definition
| to measure the maximum volume rate of air someone can blow during the first second or so of expiration. |
|
|
Term
Which of the following terms is used to describe violinlike
sounds heard on chest auscultation?
a. Crackles
b. Wheezes
c. Friction rub
d. Stridor |
|
Definition
|
|
Term
| What helps in warming the air |
|
Definition
| blood vessels in the nasal cavity |
|
|
Term
| respiratory rate under 12/min |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| breathing: increased rate |
|
|
Term
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 suction.
d. Clamp the chest tube. |
|
Definition
| c. Reduce the level of wall suction. |
|
|
Term
Deteriorating cilia in the respiratory tract predispose the
elderly to which of the following?
a. Chronic hypoxia
b. Pulmonary hypertension
c. Respiratory infection
d. Decreased ventilation |
|
Definition
|
|
Term
| If lung sounds from one side appear adventitious, what do you do? |
|
Definition
| check the other side for comparison |
|
|
Term
| tiny hair-like projections on the membranes |
|
Definition
|
|
Term
|
Definition
| coarse rales (aka crackles) |
|
|
Term
|
Definition
| conducts the breathing impulses. |
|
|
Term
- grating sound, similar to that of joints grinding together in osteoarthritis
- may indicate broken rib |
|
Definition
|
|
Term
Which of the following is a normal value for oxygen
saturation?
a. Less than 60 percent
b. 61 to 85 percent
c. 86 to 95 percent
d. More than 95 percent |
|
Definition
|
|
Term
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 |
|
Definition
|
|
Term
| possible complication of administering more than 2L/min oxygen |
|
Definition
|
|
Term
| dome-shaped muscle separating the thoracic and abdominal cavities |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| dome-shaped muscle separating the thoracic and abdominal cavities |
|
|
Term
|
Definition
|
|
Term
| Causes of respiratory acidosis |
|
Definition
| emphysema, severe pneumonia, asthma, pulmonary edema. |
|
|
Term
| What guards the larynx opening |
|
Definition
|
|
Term
| Protective mechanisms of upper airway |
|
Definition
|
|
Term
| transports food from the pharynx to the stomach |
|
Definition
|
|
Term
|
Definition
| extends from the nares to uvula. Passageway for air only. |
|
|
Term
| The nasolacrimal ducts, or tear ducts |
|
Definition
| from the eyes, open into the upper nasal cavities, thereby causing the “runny nose” that often accompanies crying. |
|
|
Term
|
Definition
| frontal sinus, maxillary sinus, ethmoidal sinus, sphenoidal sinus |
|
|
Term
|
Definition
| gas exchange at the lung level |
|
|
Term
| Cellular (internal) respiration |
|
Definition
| gas exchange within the cells |
|
|
Term
| What to do before giving oxygen |
|
Definition
|
|
Term
| Surfactant: What is its function |
|
Definition
| helps prevent the alveolar walls from collapsing between breaths |
|
|
Term
| method of oxygen transportation in the body |
|
Definition
|
|
Term
| which method provides oxygen at most accurate rate, and which at highest rate. |
|
Definition
- highest: nonrebreather mask
- most accurate: venturi mask |
|
|
Term
| Breathing: normal rate, deeper-than-normal breaths |
|
Definition
|
|
Term
| Effect of low oxygen saturation |
|
Definition
|
|
Term
| Device used to promote breathing post-op |
|
Definition
|
|
Term
|
Definition
| lack of oxygen (or accumulation of CO2). Equalizes pressure between middle and outside atmosphere, to help maintain balance. |
|
|
Term
|
Definition
| located in the posterior wall of the nasopharynx and, along with the tonsils, assist the body in its immune response to foreign invaders |
|
|
Term
| What can cause decreased residual lung capacity? |
|
Definition
| lung effect of ARDS - Acute Respiratory Distress Syndrome. |
|
|
Term
| rales that don't clear after a cough: indication? |
|
Definition
|
|
Term
| one piece of equipment needed for suctioning procedure on trach patient but not for oropharyngeal or nasopharyngeal suctioning |
|
Definition
|
|
Term
| What can cause decreased vital lung capacity? |
|
Definition
| may be found in neuromuscular disease, generalized fatigue, pulmonary edema, COPD, atelectasis. |
|
|
Term
| the area lying between the lungs in the thorax |
|
Definition
|
|
Term
| Thoracentesis: nursing intervention (3) |
|
Definition
-monitor closely for s/sx of fluid leakage or infection.
- watch for pneumothorax
- watch for respiratory depression |
|
|
Term
| difficulty breathing - external s/sx |
|
Definition
|
|
Term
| Know parts of pharynx (especially food-related) |
|
Definition
| nasal pharynx, oral pharynx, laryngeal pharynx. |
|
|
Term
|
Definition
- normal respiration,
- 12-20 RPM |
|
|
Term
|
Definition
|
|
Term
| Serous membranes that covers lung |
|
Definition
| parietal pleura and visceral pleura |
|
|
Term
|
Definition
| part of the pharynx extending from the uvula to the epiglottis. Also known as the throat. |
|
|
Term
| sign that patient understands teaching of nebulizer use |
|
Definition
| patient demonstrates proper use |
|
|
Term
| a smooth double-layered sac of serous membrane in the lower respiratory tract |
|
Definition
|
|
Term
| The space between the two layers of the pleura |
|
Definition
| pleural cavity or pleural space |
|
|
Term
| May cause decreased total lung capacity |
|
Definition
| possible lung effect of atelectasis, pneumonia. |
|
|
Term
| non-invasive method of determining lung saturation/functionality |
|
Definition
|
|
Term
| non-rebreather masks usually not used on the floor. Reason? |
|
Definition
| requires constant monitoring |
|
|
Term
| air that remains in the lungs after exhaling. |
|
Definition
|
|
Term
| Respiratory acidosis symptom |
|
Definition
| respiration slower than normal |
|
|
Term
|
Definition
| respiratory rate over 20/min |
|
|
Term
|
Definition
| respiratory rate under 12/min |
|
|
Term
|
Definition
| sac of serous membrane covering the lungs |
|
|
Term
|
Definition
| sac of serous membrane lining the chest cavity |
|
|
Term
| Why are alveoli and pulmonary capillaries made of squamous epithelium? |
|
Definition
| squamous alveolar cells are responsible for gas exchange in the alveoli |
|
|
Term
- last chamber in the system
- gentle bubbling normally occurs
- excessive bubbling will evaporate water and defeat the purpose |
|
Definition
|
|
Term
| respiratory rate over 20/min |
|
Definition
|
|
Term
| breathing: increased rate |
|
Definition
|
|
Term
|
Definition
| the area lying between the lungs in the thorax |
|
|
Term
| How many lobes of each lung |
|
Definition
| three in right, two in left |
|
|
Term
|
Definition
| tiny hair-like projections) on the membranes |
|
|
Term
|
Definition
| transports food from the pharynx to the stomach |
|
|
Term
|
Definition
| treatment for dyspnea: acts as vasodilator and reduces pulmonary edema |
|
|
Term
| Three small bones that increase the nasal mucosa surface area |
|
Definition
|
|
Term
| oxygen supply that is not humidified |
|
Definition
|
|
Term
| Name the serous membrane covering the lung tissue |
|
Definition
|
|
Term
| sac of serous membrane covering the lungs |
|
Definition
|
|
Term
|
Definition
| volume of air in lungs after a maximum inspiration |
|
|
Term
|
Definition
| volume of air inhaled and exhaled with each breath |
|
|
Term
| functional residual capacity |
|
Definition
| volume of air remaining after a normal breath |
|
|
Term
- high pitched, whistling or sibilant sounds.
- caused by airway narrowing, secretions. |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
Nursing dx: Impaired gas exchange related to decreased ventilation or perfusion
Intervention? |
|
Definition
• Assess lung sounds, respiratory
rate and effort, use of accessory
muscles.
• Observe skin and mucous membranes
for cyanosis.
• Assess degree of dyspnea on a
scale of 0 to 10, 0 no dyspnea,
10 worst dyspnea.
• Monitor for confusion or
changes in mental status.
• Monitor arterial blood gas values
and pulse oximetry as ordered.
• Elevate head of bed or help patient
to lean on overbed table.
• Position with good lung dependent
(“good lung down”).
• Administer supplemental oxygen
at 2 L/min unless ordered
otherwise.
• Teach patient relaxation exercises.
• Teach patient diaphragmatic
and pursed-lip breathing. (See
Chapter 26.)
• Encourage patient to stop smoking
if patient is a current
smoker.
• For severe dyspnea, ask physician
about an order for intravenous
morphine sulfate. |
|
|
Term
Nursing Dx: Ineffective breathing pattern related to anxiety or pain.
Interventions (5)? |
|
Definition
• Assess respiratory rate, depth,
and effort q4h and prn.
• Monitor blood gas and oxygen
saturation values.
• Determine and treat the cause
of ineffective breathing pattern.
• Fowler’s or semi-Fowler’s position.
• Teach patient to use diaphragmatic
breathing, with a regular 2
second in, 4 second out pattern. |
|
|
