What is the proper way to assess respiratory status?
Have patient sit up. Inspection: normally the thorax is symmetrical and the anterior posterior diameter is less than the transverse diameter, respirations should be even, unlabored, at a rate of 12 to 20 bpm, inspiration is normally half as long as expiration and chest expansion should be symmetrical. If patient appears anxious, has nasal flaring, cyanosis of the lips/mouth, intercostal retractions, or use of accessory muscles he/she may be in respiratory distress. Start on back check for symmetric lung expansion by noting that thumbs move apart symmetrically, feel for fremitis (say 99 to generate vibrations, examine for crepitus (a course crackling sensation when palpating skin), measure diaphragmatic excursion (distance between marks to determine-normally 5-6 cm in adults). Auscultate his lung sounds starting at C7 down to T10, percuss anterior and lateral chest (dullness over diaphragm, liver, or other organs is normal, but over lungs may indicate a mass or consolidation.
What is the normal range for pH? Lower than normal? Higher than normal?
7.35-7.45. <7.35= acidosis, >7.45= alkalosis
What is the normal range for CO2? Lower than normal? Higher than normal?
35-45. < 35= alkaline, >45=acidosis (respiratory)
What is the normal range for HC03? Lower than normal? Higher than normal?
22-26. <22=acidodic, >26=alkalosis (metabolic)
What should you do if your patient's C02 is less than 35?
They need more C02 so breath into bag and suck in more C02 (NO O2).
What should you do if your patient's C02 is greater than 45?
Need less C02 so have them cough out or slow/deep breathing (pursed lip breathing).
Who is metabolic alkalosis common in?
Prolonged vomiting, hypovolemia, diuretic use, and hypokalemia.
What are the criteria for home O2 use? (select all that apply)
1. PaO2 <55 torr & SaO2 <88% on RA, 2. PaO2 <56 torr & SaO2 <89% w/cor pulmonale/CHF/or HCT >56%, 3. SaO2 <88% w/activity.
What needs to be included in home O2 teaching? (check all that apply or when to intervene)
INCREASES FIRE HAZARD, NO SMOKING ANYWHERE IN THE HOUSE, AVOID ELECTRICAL SPARKS (USE STRAIGHT EDGE RAZOR VS. ELECTRICAL), BE CONCERNED IF BLACK AROUND ELECTRICAL OUTLETS, HUMIDIFY HOUSE TO MINIMIZE STATIC ELECTRICITY, KEEP O2 >6FEET FROM FLAMES/ FIREPLACE/ CIGARETTE LIGHTER, O2 TANKS STORED/SECURED UPRIGHT, CHECK TANKS/FLOW DAILY AND HAVE BACKUP TANK, LIQUID O2 BURNS SKIN.
What is important to remember about administering O2 via a mask?
Don't place a mask with a reservoir over pts mouth and nose without first allowing the bag to fill with O2 (KEEP BAG INFLATED!!!) and turn on O2 to prescribed liter flow, typically 5 liters or more except COPD= 2L O2.
What are the symptoms of hypoxia in children?
FINES= FEEDING DIFFICULTY, INSPIRATORY STRIDOR, NARES FLARE, EXPIRATORY GRUNTING, AND STERNAL RETRACTIONS.
How should you correctly apply a pulse oximeter to a patient?
Choose an application site (finger, toe, nose, forehead, or ear) with adequate circulation, remove polish or artificial fingernails, make sure the high and low SPO2 and pulse alarms are set appropriately (NEVER DISARM AN ALARM), DON'T APPLY PULSE OX SENSOR TO AN EXTREMITY WITH AN AUTOMATIC BLOOD PRESSURE CUFF, AND DON'T APPLY TO THE INDEX FINGER ON THE PATIENTS DOMINANT HAND.
Where should you apply a pulse ox sensor for a COPD patient?
On an earlobe because they have sausage fingers and their reading won't be accurate.
What is thoracentesis?
A sterile procedure performed by a Dr. where a needle is inserted to remove excess fluid from the pleural space.
What is the nurses responsibility for assisting with thoracentesis?
Help position the patient, support them, and assess for complications. Make sure informed consent, assess for allergies, perform baseline assessment, MUST STAY STILL DURING PROCEDURE (PNEUMOTHORAX= POSSIBLE)- FEET SHOULD BE PLANTED ON THE GROUND, monitor VS and S&S of pneumothorax (dyspnea, tachycardia, chest pain).
What is capnography?
A noninvasive technique to alert you to hypoventilation even when your patient's pulse ox reading are fine. Carbon dioxide is the most significant factor in monitoring ventilation. Capnography measures the CO2 in every breath to monitor air exchange in the patient's alveoli.
What should you do if your patients capnograph wave shows apnea (one wave then nothing)?
Shake the patient and hope come back to normal.
What should you do if your patients capnograph wave shows shallow hypoventilation (shallow/low waves)?
If they have a pillow under there neck and their chin is to their chest it means their airway is closed off so need to REMOVE PILLOW.
Is a patient who pulls out their endotracheal tube with a balloon attached a priority patient?
No because they will breath just fine (28 days can stay in).
Can an NA feed a pt post laryngectomy?
Yes! Air from the nose and mouth doesn't go to lungs anymore because not connected. There is no risk for aspiration so an NA can feed them. Breathing will occur through stoma in neck.
What are the proper steps for suctioning? (Sequential order)
Turn on suctioning device, attach tubing, sterile gloves, 100 ml NS into device, attach suction catheter, HYPEROXYGENATE WITH 100% FIO2 FOR 30 SECONDS, take thumb off suction control and insert into airway until resistance then cover suction with thumb and withdrawal APPLYING INTERMITTENT SUCTION AS YOU WITHDRAW, APPLY SUCTION FOR NO MORE THAN 10 SECONDS AT A TIME, AND NO MORE THAN 3 CONSECUTIVE PASSES ARE RECOMMENDED, HYPEROXYGENATE INBETWEEN EACH PASS. (10-15 LITERS O2).
What are the proper steps for suctioning a tracheostomy tube?
Put on sterile gloves, HAVE A COLLEAGUE SET THE NEGATIVE PRESSURE TO 80 TO 130 MMHG, HAVE OTHER NURSE DELIVER 3 HYPERINFLATION BREATHS MANUALLY OR RESUSCITATION BAG CONNECTED TO 10 TO 15 L OF O2/MIN, without suction insert catheter into trach tube until resistance or patient coughs then withdraw 1 cm, apply suction intermittently ROTATING THE CATHETER WHILE WITHDRAWING IT, ADMINISTER 3 HYPERINFLATION BREATHS, AND RE-SUCTION IF NEEDED. Wait 15 seconds between suctioning and don't suction for more than 10 seconds/pass.
What is important to remember with a cuff trach?
5 cc of air should be put into it to inflate cuff before eat or drink anything. Also, if the trach is capped bc not in use YOU MUST MAKE SURE THE CUFF IS DEFLATED OTHERWISE THEY ARE ONLY BREATHING THROUGH THE TRACH (AND ITS CAPPED!).
What type of trach is used in pediatrics?
Opterator= trach that is all rubber but firm for placement. (nurses don't do trachs on nclex)
What should be done if you are trying to suction someone but the trach is occluded and won't facilitate suctioning?
Pull inner cannula out and clean.
Is suctioning in home care sterile? Hospital?
Suctioning in home care is clean. In the hospital it's sterile.
HOW SHOULD A TRACHEOSTOMY CANNULA BE CLEANED?
WITH EQUAL PARTS H202 AND NACL (DENTURES AND EYEBALLS ALSO).
What are the steps for providing tracheostomy care?
HYPEROXYGENATE BEFORE AND AFTER SUCTIONING, STABILIZE NECK FLANGES AND REMOVE INNER CANNULA, CLEAN WITH EQUAL PARTS H202 AND NACL WEARING STERILE GLOVES, REINSERT AND SECURELY LOCK, SECURE NEW TIES TO TRACHEOSTOMY BEFORE REMOVING OLD ONES (BC IF COUGH OUT NEW TRACH WILL CLOSE).
What should not be done during tracheostomy care?
DONT CUT GAUZE AND PLACE UNDER THE TRACH TUBE FLANGES BC FIBERS/STRING CAN BE INHALED INTO THE TRACH.
What is the only way to get a sterile sputum sample from a trach?
You need a line connecter with a T attachment to connect the suction catheter to a collection container. The secretions must be wet for testing!
What should be taught to a pt about cancer of the larynx? (select all that apply)
It can be caused by smoking, tx is removal of the larynx and permanent stoma placement, you are at risk of lung pollutants (avoid baby powder or aerosol sprays), artificial saliva may be needed, NO SWIMMING, Have carbon monoxide/smoke detectors, gulping air while eating=modified valsalva, talking while burping= esophageal speech.
What is a lung, bone, or ventilation perfusion scan? Teaching?
The pt is injected with radioisotope and placed under a scanner (any type of scan). The patient must void before the test and lie still during.
What should be taught to a patient about strep throat? (select all that apply)
It is a beta strep organism, it is contagious so the pt needs to be in a private room with droplet precautions, S&S include fever, chills, and sore throat, bright red/white pustules may be present, increased in WBC is expected, culture 1st then antibiotics given q6 hrs around the clock, and complications w/o tx include rheumatic/scarlet fever, mitral valve disease (vegitation/growth), or glomerulonephritis (peds).
What occurs in the event of inadvertent tracheal decannulation? What should you do?
Most likely the stoma will close and the patient will become tachypneic, signs of respiratory distress will arise, and oxygen sat will fall. You should call the emergency response team to attempt and reinsert (nurses don't reinsert trachs), use a bag-valve mask device to ventilate (ventilate gently) and place the pt in semi fowlers.
What are the possible causes of a low pressure alarm on a ventilator? Interventions?
Tube disconnected from ventilator (reconnect) or ventilator malfunction (disconnect patient ventilate manually if necessary and obtain another vent).
What are the possible causes of high pressure alarms? Interventions?
Patient is biting of ET tube (insert bite block if needed), secretions in the airway (suction patient or have him cough), condensate in large bore tubing (check and remove any fluid), or patient attempting to talk (sedative or neuromuscular blocking agent).
What are bronchial breath sounds?
Loud, harsh, high pitched. Heard over the trachea, bronchi, and main bronchus.
What are bronchovesicular breath sounds?
Blowing sounds, moderate intensity and pitch. Heard over large airways, on either side of the sternum, at the angle of louis, and between the scapulae.
What are vesicular breath sounds?
Soft, breezy quality, low pitched. Heard over the peripheral lung areas, heard best at base of the lungs.
What are crackles? With what lung problems would you hear this?
Popping, crackling, bubbling, moist sounds on inspiration. Common with pneumonia, pulmonary edema, and pulmonary fibrosis.
What is rhonchi? With what lung problems would you hear this?
Rumbling sound on expiration. Common with pneumonia, emphysema, bronchitis, or bronchiectasis.
What are wheezes? With what lung problems would you here this?
High pitched musical sounds during inspiration and expiration (louder). Common in emphysema, asthma, and foreign body obstruction.
If there is a child in the ER that is wheezing. You noticed previously that he was eating grapes and peanuts. What would you suspect?
What are the S&S of acute respiratory distress syndrome (ARDS)? Check all that apply
Tachypnea, Dyspnea, retractions, hypoxia, tachycardia, crackles, grunting, and use of accessory muscles.
What are the causes of ARDS?
It is a medical emergency caused by massive trauma, severe respiratory disorder, prolonged mechanical ventilation, hemorrhagic shock, fat emboli, and septic condition.
What is the treatment for ARDS?
PEEP (positive end expiratory pressure keeps air in the alveoli- complication= pneumothorax).
What effect does carbon monoxide have on O2?
It is a colorless, odorless gas that bind tightly to hemoglobin and crowds out oxygen.
What are normal carboxyhemoglobin levels?
0-8%, 10-20% could cause HA (mild toxicity), over 40%=severe/seizures.
What does the patient with carbon monoxide poisoning need immediately?
O2 (high concentrations-possible hyperbaric oxygenation in chamber). Initiate seizure precautions and have crash cart available.
Will pulse ox work for someone with carbon monoxide poisoning?
NO because it reads red blood cells not substance attached to.
What are the S&S of COPD?
Easily fatigued, frequent respiratory infections, use of accessory muscles, orthopneic, dyspnea, pursed lip breathing, nonproductive cough, BARREL CHEST, wheezing, prolonged expiratory time, DIGITAL CLUBBING (no pulse ox on finger just earlobe), COR PULMONALE (LATE IN DISEASE-JVD AND CAN ONLY BREATH SITTING UP), thin in appearance, and pulse ox in the 80's.
What should be taught to a COPDer about vaccines?
They should get the flu vaccine q year and pneumonia q 5 yrs (can get same day but different sites).
What classes of medications are used for COPD?
Beta 2 antagonists, anticholinergics, glucocorticoids, methylxanthine, and expectorants.
What are examples of short acting beta 2 antagonists used for COPD? Things to look out for?
Albuterol (proventil, ventolin) or terbutaline (brethine, brethaire). Look for NERVOUSNESS, HA ,dizziness, or FAST HEARTBEAT.
What is an example of a glucocorticoid used for COPD? What should you look out for?
Fluticasone (flovent). Look for mouth infections (use nonsteroid inhaler first if using both steroid and nonsteroid), always rinse mouth out with water after using steroid inhaler to prevent mouth infections.
What are examples of methylxanthines used for COPD? What should you look out for?
Aminophylline, theophylline. Look out for NERVOUSNESS, FAST HEARTBEAT, and restlessness.
What should you do to treat chronic bronchitis?
Increase hydration (avoid milk), hot coffee or shower to break up thin secretions, chest physiotherapy (NEVER after they eat), avoid cough suppressants, and avoid inhaling cold air.
What should you tell a mother who is calling about her child with chronic bronchitis and want to know what she can do to help at home?
Have her sit her child in a warm shower.
What are they S&S of pulmonary emphysema? (Select all that apply)
"PINK PUFFERS". INCREASED CO2 RETENTION, PURSE LIP BREATHING, INCREASED MUCOUS, BARREL CHEST, SPEAKS IN SHORT JERKY SENTENCES, DIGITAL CLUBBING, no cyanosis, orthopneic, SOB, easily fatigues, wheezing, anxious, and thin appearance.
What is a complication of pulmonary emphysema?
Polycythemia- increased RBCs d/t decreased O2 (increased bruising tx: increased fluids)
What treatment helps a pt. with pulmonary emphysema breath at night?
(Ask if wake with dry mouth from open when snoring) CPAP- keep airway open (decreased snoring and sleep apnea=more alert next day).
What should you teach a person about nutrition post bronchoscopy?
Can't eat or drink until their gag reflex comes back (if someone wants to leave immediately= concern bc risk for aspiration).
What complications should you watch for with bronchoscopy?
Make sure to check lung sounds and watch for hypoxemia, pneumothorax, laryngospasm, bronchospasm, bleeding, aspiration, and infection.
What are the S&S of asthma?
RETRACTIONS, HYPOXIA, ANXIOUS, RESTLESS, FAMILIAL TENDENCY, EXPIRATORY WHEEZE, increased occurrence in males, onset before age 12, tachycardia, cough, SOB, and chest tightness.
When should a person with asthma seek medical attention?
If symptoms don't respond to usual tx in 30 mins (AKA status asthmaticus= life threatening).
What is asthma?
When the airways in your lungs swell and get narrow so that getting air in and out if difficult.
If you are taking a bronchodilator and a steroid for asthma which should you take first?
Bronchodilator then steroid
Most people with asthma have 2 types of inhalers. What are they?
Everyday inhaler to prevent problems and a rescuer inhaler for use only during an emergency/asthma attack.
What are the steps for using an inhaler? (sequential order)
Take off cap and shake inhaler, breathe out all the way, place in mouth (if steroid 1-2 inches from mouth), press down on inhaler and breath in slowly through the mouth as deeply as possible (if spacer wait 5 sec before breathing), hold breath and count to 10, breath out, wait 1 minute between puffs.
When should someone with asthma take a walk or exercise outside?
In the am bc the dew holds pollen on the ground and not in the air.
What are the steps for using a peak flow meter? (sequential order)
Marker to bottom of scale, stand or sit up straight, deep breath fill lungs all the way, hold breath while place mouthpiece in mouth blow out as hard and fast as you can, repeat steps 2 more times and take the highest of the 3 #s.
What are asthma triggers?
Smoking, dirty/dusty house, odors/sprays, furred or feathered pets, cover nose w/scarf on cold windy days, and avoid pollen/mold.
What are types of long term asthma medications?
Steroids (flovent-use 15 mins after other inhalers), cromolyn (intal), leukotriene modifiers (accolate and montauks/singulair), long acting beta 2 antagonists (serevent and provent), and THEOPHYLLINE (SLO-BID AND THEO-DUR).
What are Quick relief asthma medications?
Short acting beta 2 antagonists (proventil and brethaire), anticholinergic (ipratropium/ atrovent), and steroids (medrol and prednisone).
What people are at risk for a respiratory death and could use a peak flow meter?
MS, asthma, ALS, Myasthenia Gravis, Gullian Barre syndrome (pig head), parkinsons, and scleroderma (harden to death).
In what positions should you place a patient so that postural drainage can be effective?
In positions where gravity can help remove the accumulated secretions. CONGESTED SIDE UP!
When is postural drainage usually done?
2-4 times a day, before meals (to prevent N&V), and at bedtime.
What is the proper way to percuss?
Form a hollow cup with your hand and lightly thump the chest wall in rapid rhythmic motion. (NO Slapping)
Where is percussion not recommended?
Over chest tubes, the sternum, the spine, the liver, the kidneys, the spleen, and the breasts.
When should chest physiotherapy be stopped?
If there is an increase in pain, a worsening of dyspnea, weakness, lightheadedness, or hemoptysis.
What is the purpose of pursed lip breathing?
To help the pt slow expiratory rate and help exhale retained carbon dioxide.
How should you teach pursed lip breathing to your patient? While walking?
Inhale through nose, exhale through pursed lips (like blowing candle flame but not out). While walking she should inhale while taking 2 steps, then exhale through pursed lips with taking the next four steps.
How should you make sure the patient understands the pursed lip breathing teaching?
How should you teach someone to use the incentive spirometer?
Exhale completely with mouth off spirometer, seal lips tightly around the mouthpiece, breath in as slowly and deeply as possible and note the highest level of the indicator, hold breath for at least 3 sec then exhale normally. It should be done every hour that your awake and should be done 5-10 consecutive times. Each session should be followed with a deep cough (splint incision if needed).
What should be done if a kid post op doesn't want to use the incentive spirometer?
Have him blow bubbles
What are the S&S of pneumothorax?
Dyspnea, tachycardia, anxiety, decreased breath sounds, asymmetrical chest expansion, pleural pain.
What are the causes of pneumothorax?
RUPTURED BLEB (COPD), THORACENTESIS, TRAUMA, SECONDARY INFECTION, OR PLACEMENT OF A CENTRAL LINE.
What should you not do if someone with a stab would has a knife in their chest and a potential pneumothorax?
Do not remove plug or air will enter the chest and crush the heart and lung, cause a deviated trach and mediostinal shift. Wait to remove until chest tube placed.
What are the three compartments to the pleurovac (chest tube drainage system)? Functions?
SUCTION CONTROL CATHETER (gentle continuous bubbling-if vigorous turn down if no then turn up), WATER SEAL CHAMBER (breath in H20 breath out bubbles intermittently- if continuous=leak- after 3 days should be no fluctuation- if leak then put vaseline gauze around incision, if still tape around junction, if still cracked so replace unit), and DRAINAGE COLLECTION CHAMBER (drainage accumulates here).
What is the max amount of bloody drainage that should be in a chest tube per hour in an adult? Child?
100 cc/hr in an adult, in a child 30 cc/hr. Make sure to assess the patient 1st if greater than these values.
What is there is no change in drainage in the chest tube?
Check for kink or obstruction by clot and make sure drainage has completely ceased.
What if there is no fluctuations or bubbling in the water seal chamber?
The lung may have re-expanded if gradual stop along with clear lung sounds and easy respirations-document. If not check for tubing obstructions.
What is the best way to see if the lung is expanded?
Chest x-ray and nurses listen to all lung fields.
What is a thoracotomy? Complications?
Incision from sternum to back. Frozen shoulder may occur-hand exercises for circulation (wall walking with hands).
What in pneumectomy? Post op?
Lung removal. Patient lays on surgical side with pillows for positioning bc want good lung to expand and plug up area of concern.
What is Tuberculosis (Acid Fast Bacillus-AFB)?
An airborne infection that requires isolation in a negative pressure room (filter air 6x/hr) and must be reported to the health department?
What are the S&S of TB?
Fatigue, malaise, anorexia, wt. loss, CHRONIC COUGH (PRODUCTIVE), NIGHT SWEATS, HEMOPTYSIS, AND LOW GRADE TEMP (LATE IN AFTERNOON).
What should you do if a pt with TB has a cloth hanky? Kleenex?
Throw it away (traps bacteria) and if use kleenex goes in toilet.
What are the steps for a nurse entering a negative pressure room to see someone with TB?
The door is closed, put mask on in clean hallway, open door, close door, see pt, open door, close door, and take off mask.
What is the treatment for TB?
TB medications 18-24 months, bedrest until no symptoms, resp isolation x2weeks or negative sputum, and frequent out patient services.
What is the proper way to perform an intradermal injection?
Stretch skin downward towards patients hand, insert needle at 15 degree angle to patients arm, bevel up, stopping when needle bevel tip is under the skin, DON'T RUB OR MASSAGE INJECTION SITE, slowly inject observing for bleb formation (if no bleb do other arm), circle injection sites.
When must a PPD be checked? What is being documented?
48-72 hours after. The amount of induration is being documented (swelling not redness).
What is a positive result for resident of long term care facilities and those with chronic illnesses?
What is a positive result for immunocompromised patients (HIV, CA, radiation, steroids, addisons, organ transplant, and cushings)?
What is the PPD is positive? Tx?
It means you have been exposed at some point and have antibodies. You must get a chest xray to determine if active disease (+ chest xray is active). Tx: 1 year of medications. If the PPD and the chest xray are positive it means active disease. Tx: isolation for 2 weeks and medications x 2 years and monthly sputum cultures.
What are the drugs to help mycobacterium tuberculosis RISE out of a patients body?
RISE= RIFAMPIN (hepatitis may be a complication, take on empty stomach, No BC pills, urine may be orange, ISONIAZID (INH) primary med (pretreat with vitamin B6 to prevent peripheral neuropathies and take once daily on an empty stomach), STREPTOMYCIN (ototoxicity and nephrotoxicity are complication and the med can't be given PO), and ETHAMBUTOL (once daily with food to decrease irritation).