Unit 8: Basic Nursing Interventions Related to Oxygenation

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The stimulus to breathe
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CO2
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Patients with chronic lung disease stimulus to breathe
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lack of O2
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Hypoxia
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insufficient oxygen to tissues related to ventilation, diffusion of gases, and transport of gases by blood
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Signs and symptoms of Hypoxia
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tachycardia, rapid and shallow respiration (dyspnea), increased restlessness and anxiety, light-headedness, nasal flaring, sub-sternal or intercostal retraction, cyanosis
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Hypoxemia
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reduced oxygen in the blood related to low partial pressure of O2 in arterial blood or a low hemoglobin saturation
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Signs and symptoms of Hypoxemia
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dyspnea, tachypnea, tachycardia
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What come before or leads to hypoxia?
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hypoxemia
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Problems related to hypoxemia
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smoking
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Subjective history
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patient, family, self-care behaviors (exams)
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Physical Assessment
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lung sounds, respiratory assessment (warm hands, start with the back of the chest)
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Diagnostic Tests
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labs, arterial blood gases (ABG’s)
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(2) types of labs for diagnostic testing
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1. hemoglobin 2. sputum cultures
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Best time to collect a sputum culture
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morning
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What to inspect in a sputum culture
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color, consistency, odor, blood, acid fast bacillus (AFB)
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This needs to be cultured before giving an antibiotic
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cytology
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Arterial Blood Gases (ABG’s)
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checking for gases in the blood, measures pH, PCO2, PO2, O2 saturation, and bicarbonate levels
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Most accurate measure of hypoxemia
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arterial blood gases (ABG’s)
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Procedure to collect arterial blood gases (ABG’s)
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direct stick of the arterial line (radial side of hand)
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Test that is done prior to collection of arterial blood gases (ABG’s)
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Allen’s Test
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Allen’s Test
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checks for radial/ulnar circulation
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Most accurate type of imaging
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MRI
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Pulse Oximetry
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non-invasive, indirect device that estimates the % of oxygenated hemoglobin (hgb)
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Each hemoglobin carries this many oxygen molecules
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4
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Pulse Oximetry is a concern if less than ______%
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94
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Pulse Oximetry sensor can be placed at these locations
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finger, forehead, nose, earlobe
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Pulse Oximetry can detect _________ before signs and symptoms
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hypoxia
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Patient can be anemic even if they have 100% SPO2 – what would you do clinically
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look at the patient
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Nursing Diagnosis – Problems with ventilation or gas exchange
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ineffective airway clearance, ineffective breathing pattern, impaired gas exchange
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Ineffective Airway Clearance related to
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blockages, mucous, inflammation
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Ineffective Breathing Pattern related to
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drugs (tachypnea, bradypnea) and pain
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Impaired Gas Exchange related to
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verified by ABG’s and O2 saturation, pneumonia, inflammation
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Implementation of Nursing Care
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health promotion, vaccination, healthy lifestyle
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Health Promotion
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TB skin testing, allergy testing
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TB Testing
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attenuated TB, done by intra-dermal injection to see if a patient has an antigen/antibody response, should be read in 48-72 hours and measure induration
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Positive TB Test
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red/raised area on the skin
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Healthy Lifestyle Choices
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not smoking, exercise, nutrition, decrease obesity, occupation hazards, no substance abuse
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Oxygen
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colorless, odorless, tasteless drug
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Physicians Order for Oxygen
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method of delivery, concentration, flow rate
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Safety Issues for Oxygen
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supports combustion, avoid static electricity, no smoking, avoid oils and greases, ground all electrical equipment, secure cylinders
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Oxygen Toxicity
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more than 50% O2 concentration for longer than 48-72 hours
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Surfactant Production during Oxygen Toxicity
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decreases which leads to alveolar collapse and reduced lung elasticity
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Oxygen Considerations
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wall outlet systems, oxygen tanks, flow meter (liters/minute), very drying, monitor system, monitor the patient
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Oxygen Wall Outlet Systems
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read the meter at the middle of the ball and make sure there are no hissing sounds
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Oxygen Tanks
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these must be secured or can become a missile if cap come off
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Oxygen Flow Meter is measured in
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liters/minute
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When oxygen becomes drying
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add humidifier bottle if more than 2-4 L/min and do frequent oronasal care
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Monitor the Oxygen System when
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oxygen is connected to the wall or patient, make sure it isn’t kinked/coiled on bed rails
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Monitor Patient on Oxygen
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take vital signs, visible signs and symptoms of hypoxia or hypoxemia, note any chronic lung history
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Too much oxygen
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knocks out the patients stimulus to breathe
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Too much use of the humidifier
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can drown the patient
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Methods of Oxygen Administration
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nasal cannula, face mask, face tent, trans-tracheal, home oxygen
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Nasal Cannula
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common, inexpensive, easy to apply, well tolerated, low flow system
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Nasal Cannula Considerations
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make sure both tubes are in the patients nostrils, make sure drawstring isn’t choking the patient and is behind their ears
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Nasal Cannula Flow Rate
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24-44% O2 at 1-6 L/min
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Limitations to Nasal Cannula
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low O2 concentration, very drying, pressure areas (nasal septum and behind the ears)
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(4) types of Face Masks
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1. simple face mask 2. non-rebreather 3. partial rebreather 4. venturi mask
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Most Precise Face Mask
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venturi mask
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Simple Face Mask Flow Rate
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40-60% O2 at 5-10 L/min
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Non-Rebreather
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reservoir has a bag with one way valve so CO2 exits and always have the bag inflated or the patient will suffocate
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Non-Rebreather Flow Rate
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70-100% O2 at 6-15 L/min
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The face mask that has the highest concentration of oxygen
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non-rebreather
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Partial Rebreather
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reservoir bag captures some exhaled CO2
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Partial Rebreather Flow Rate
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50-90% O2 at 6-15 L/min
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Venturi Mask
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uses color coded jet tubing
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Venturi Mask Flow Rate
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24-50% O2 at 4-10 L/min
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Face Tent
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open from the nose up and used if mask is not tolerated
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Face Tent Flow Rate
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30-55% O2 at 8-12 L/min
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Nursing Consideration when use a Face Tent
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skin care
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Trans-tracheal
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tube inserted right into the trachea where oxygen can be humidified – patient can drown, trach mask
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Trans-tracheal Flow Rate
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24-100% at 4-10 L/min
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Home Oxygen
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concentrator that removes nitrogen from the air and concentrates oxygen, expensive, noisy, and non portable
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Home Oxygen Flow Rate
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delivers flow up to 4 L/min
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Liquid Oxygen
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small and portable, can always take an extra one with you
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Liquid Oxygen Flow Rate
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delivers flow up to 6 L/min
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Liquid Oxygen Reservoir Flow Rate
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40 Liters
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Mask Considerations
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proper fit (size and nasal bridge), no smothering or hot feeling, skin care, removal for talking , eating, or drinking
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Chest Physiotherapy
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helps mobilize secretions to be expectorated
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Manual Chest Physiotherapies
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manual PVD and mechanical PVD
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PVD
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percussion, vibration, drainage
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Manual PVD
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a manual machine placed on the patient’s chest wall
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Mechanical PVD
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vests (vibrates patient), hand held devices, beds (rotochrome bed)
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PVD Pre – Procedure
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doctor ordered, position patient for drainage (gravity), check patients’ tolerance
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PVD Procedure
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cup hands, clap chest wall 1-2 mins (manual percussion) vibrate on exhalation with tense hands, and encourage patient to expectorate, post assessment evaluation
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When the PVD Procedure should be done
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before meals
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Deep Breathing
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breathe in for 2 seconds then blow out for 4 seconds
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Diaphragmatic Breathing
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breathe in through the nose for more volume and less work “smell the flowers”
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Pursed – Lip Breathing
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breathe out through the mouth for positive expiratory pressure “blow out the candles”
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Huff Cough
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forceful expiration to open the epiglottis, say the word “huff”
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Positioning
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comfort, elevation, flat, physiologic effects
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Physiologic Effects for Comfort
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draining the lungs
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Flat Positioning can lead to
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orthopnea where the patient can’t breathe when they lie flat
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Positioning Elevation
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Semi-Fowler’s to facilitate maximum lung expansion
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Ambulation
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helps ventilation, helps mobilize secretions, and exercise
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Incentive Spirometry
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a hand held device used as a visual incentive to deep breathe, measures airflow, improves gas exchange, loosens secretions, expands collapsed alveoli
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Incentive Spirometry is used
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device used after surgery
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Teaching a patient to use Incentive Spirometry
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inhale slowly and deeply every 1-2 hours 10 times
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Hydration
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iv, oral fluids, humidify environment
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Humidify O2 delivery system with a flow rate over
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2-4 L/min
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BEWARE of during humidifying systems
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pseudomonas aeruginosa
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Decreased sensation in the elderly
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thirst, use a hypotonic solution
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Medications to Open and Clear the airways
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steroids, bronchodilators, expectorants, anti-inflammatory
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Artificial Airways
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are inserted to patent (open) air passage
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Types of Artificial Airways
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1. oropharyngeal 2. nasopharyngeal 3. nasotracheal 4. endotracheal 5. tracheal
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Oropharyngeal
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used only if altered LOC (gags)
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Nasopharyngeal
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limits the trauma of suctioning, trumpet
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Nasotracheal
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advanced tube into the trachea during inspiration, always insert during inspiration when the lungs and trachea are open
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Endotracheal
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direct path into the trachea via the mouth
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Tracheal
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air filtration is bypassed, sizes range from cuffed (balloon) vs. uncured, cannula (outer and inner), and obturator (plastic tip)
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Suctioning
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removes secretions, facilitates ventilations, physician ordered
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Suctioning is this type of technique
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sterile technique
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Assess for need during suctioning
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signs and symptoms of hypoxia, adventitious lung sounds
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Suctioning Procedure
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pre-oxygenate the patient, suction pressure 80-120 mmhg, lubricate catheter in sterile saline or water soluble gel, insert catheter without suction until patient coughs, retract, then suction with finger and swirl catheter on the way out, post assessment
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Suction is limited to what time
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15 seconds
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Standard Precautions for Suctioning
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sterile gloves, mask, goggles
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Suctioning Complications
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bradycardia related to vagal nerve stimulation, trauma to the tissue, aspiration due to the dangling of the catheter, hypoxia
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Tracheostomy Care
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suction before care starts, humidification/O2 in between, protective mechanisms (cough) bypassed, stoma care to prevent bacteria
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Respiratory Therapy
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health team, initiate and maintain ordered therapy, O2 treatment of aerosol/intermittent positive pressure, incentives, PVD, suction, ABG’s, ventilators/respirators, inhalers
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Delegation of Oxygen
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should be done by RN or trained LPN, initiated by RN or respiratory therapy, nurse’s aid may reapply O2 without change in liters and my obtain pulse ox, the RN monitors and evaluates response
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Documentation
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assessment done, implementation of specific procedure, patients’ response/tolerance, patient teaching
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Community Resources
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Cardiopulmonary Rehab, American Lung Association, American Cancer Society, American Thoracic Society

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