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Respiratory
Respiratory - major interventions
| Question | Answer |
|---|---|
| What are indications for spirometry? | asymetric chest wall movement, increased resp. rate, increased production of sputum, diminished lung expansion postoperatively |
| How is called procedure in which a device (spirometer) is used at the bedside at regular intervals to encourage the patient to breath deeply? | Incentive spirometry |
| On what base the RT will calculate maximum inspiratory capacity? | Height, age, sex, and type of surgery performed |
| How many ml is tidal capacity of inspired air at rest? | 500 ml |
| What is usual rate per hour during waking hours for incentive spirometry? | 8-10 breaths |
| What are the purposes of incentive spirometry? | to prevent or treat atelectasis, to imporve ling expansion, to imporove oxygenation, to prevent post - operative pneumonia |
| Flow - oriented inspiratory spirometer | inexpensive, measures inspiration but not volume, has 1-more clear plastic cylinder chambers that has movable, plastic colored balls. |
| Volume oriented spirometer | Maintains know volume of inspiration |
| What are the nursing intervention for using spirometers? | Preop. introduction and assist pt to practice, after spirmeter exercise pt should practice cough control techniques, have pt. perform return demonstration of correct procedure, administer before meals to prevent nausea and vomiting. |
| How to use spirometer? | cover mouthpiece with lips and inhale slowly until max. inspiration is reached and hold for 2-3 seconds and slowly exhale. Relax and breath normally for a short time.Gradually increase depth of inspiration. |
| What are the best way to evaluate the effectiveness of postural drainage? | Auscultation of lungs |
| How are called specific positions used so the force of gravity can assist in the removal of bronchial secretions to central airways by means of coughing or suctioning? | Postural drainage |
| How is determined positioning for postural drainage | by the location, severity and duration of mucous obstruction. |
| When and how often is usually postural drainage performed? | 2-4 times, before meals and at bedtime. Each position is held 3-15 minutes. |
| When u will discontinue postural drainage? | tachycardia, dyspnea, chest pain, hemoptysis |
| What u should administer before postural drainage? | bronchodilators, mucolytic agents, water, saline. |
| With what is postural drainage contraindicated? | head injury, increased ICP, glaucoma |
| What are the assemble equipment for suctioning? | Suction catheter, gloves, suction kit, basin or cup, tap water, sterile water, or normal saline, towel, connecting tubing, face shield, portable or wall suction. |
| Important steps for suctioning | suction 10-15 sec., do not suction while inserting catheter, suctioning is sterile technique, hyperoxigen pt before procedure |
| How u recognize need for suctioning? | gurgling respirations, restlessness, vomitus in mouth, drooling |
| What position will be unconscious patient for suctioning? | Side-lying position facing the nurse |
| Position of pt for suctioning is? | Semi-fowlers with head to one side. |
| What is the appropriate suction pressure for adult? | 110 - 150 mmHg |
| What size of catheter is needed for adult suctioning | 12-16 French |
| How would you measure correct length of catheter for nosopharyngeal suctioning? | Place nasal catheter near patients earlobe to tip of the nose to mark catheter for correct length - adults 16 cm, older children 8-12cm, infants/young children 4-8cm |
| with what will you lubricate nosopharingel suctioning cath? | water soluble jelly |
| How will you measure correct length of catheter for nosotracheal suctioning? | Measure from earlobe to tip of nose and extend to trachea |
| How will you guide nosotracheal catheter into trachea? | stimulate cough reflex or ask pt to caugh |
| how long is resting time for nosotracheal suctioning if needed repetation? | 1-2 minutes |
| what will u document after suctioning? | date, time. method, amt and consistency of secretion, resp. assessment, pt response, pt teaching. |
| What is expected during inserting of suctioning cath.? | Sneezing , coughing or gaging |
| If coughing reflex cannot be stimulated or pt cannot cough to help cath. to guide into trachea, how will you insert the cath? | when patient inhales |
| How is correct way to remove suctioning cath.? | rotate cath. gently as it is withdrawn. |
| What is tracheostomy? | Is an artificial opening made by surgical incision into the trachea |
| what is tracheostomy care? | cleansing of the inner cannula of the trachostomy tube, the incisional area and the anterior portion of the neck. |
| Most important steps for trach. | 1. Hyperoxigenate, 2. lubricate (NS), 3. insert with no suction on, 4. suction intermittently, 5. withdraw while still suctioning |
| why physician orders a cuffed tracheostomy? | is used initially until the healing process of the tracheal stoma is complete. The cuffed tube prevents slipping during special treatments, eating and taking meds. |
| What for is IPPB machine? | helps pt to get more air |
| What are the parts of trachostomy set? | external canula - maintains opening/stoma; internal cannula - collects secretions; obturator- used as a guide during insertion |
| What is the difference between inner and outer cannula | outer cannula is held in place by ties around the neck; the inner cannula is locked into the outer cannula |
| why pt with artificial airway require constant humidification? | because the insertion of the airway bypasses the normal filtering and humidification process of the nose and the mouth |
| What is the usual flow rate for trach. collar and T- piece | 10/L min. |
| What is purpose for oxygen therapy? | to prevent or relieve hypoxia |
| What is truth about oxygen therapy? | is expensive and has dangerous side effects, dosage and concentration should be ordered and closely monitored, use 5 rights, safety precautions, no smoking, wear fire resistant clothes, no use of el. razors and heating pads |
| what will promote mobilization of secretions? | ambulations or position changes |
| what will facilitate air exchange? | practice deep breathing and coughing techniques |
| what will help liquefy secretions? | fluid intake |
| what should be avoided? | drinks high in sugar and caffeine, dairy products |
| what is correct position for oxygen administration | fowlers or semi fowlers |
| with what should be filled humidifier? | sterile water |
| what for is humidifier? | provide moisture to prevent drying of the nasoorpharyngeal mucosa |
| what kind of concentration of O2 delivers nasal canula | low |
| How will you adjust flowmeter to flush tubing and prongs with O2 to check patency and microscopic particles removal? | 6-10L |
| What is usual physician order for flow of nasal canula | 2L/min |
| what are the types of O2 face masks? | Venturis mask, partial rebreather mask, non-rebreathing mask, simple face mask |
| What is usual physician order for flow rate of O2 mask | 6-10L/min. |
| Partial rebreather mask | no one way valve |
| non-breating mask | with valve |
| What CPAP mask do? | the flow of air creates enough pressure when you inhale to keep your airway open. It does NOT breathe for you |
| when is used humidifier solution? | infants; O2 rate 3-6L/min.; |
| what kind of water is used for humidifier? | sterile |
| What is the purpose of chest tubes and water seal drainage? | continuous drainage and medication instillation |
| What is normal condition of lungs? | intrapleural pressure is bellow atmospheric pressure |
| what kind of system is used to prevent lungs from collapsing? | closed- maintain the lung cavitys normal negative pressure |
| When will lungs collapse | when intrapleurel pressure becomes equal to atmospheric pressure |
| What pressure will reestablish the chest tubes? | negative (normal intrapleural pressure) |
| How is called cath. inserted through a stab wound in the anterior chest wall and what is its purpose? | anterior tube - used to remove AIR from the pleural space |
| How is called tube inserted through a stab wound in posterior chest and what is its purpose? | posterior tube - drainage of serosangionous fluid or purulent exudate; is larger in diameter to avoid becoming occluded with exudates or clots |
| what is Pleur-Evac? | a disposable, commercial chest drainage system |
| how big glass bottles are used for water seal drainage | 1,2 and 3 Liters |
| How much should be filled glass and why? | 300 ml of sterile water or enough so glass rod is under water; to maintain water-seal drainage and prevent air from entering the pleural cavity |
| What should and should not do water in water-sealed chamber? | Should fluctuating, should not continuously bubling |
| What indicates bubbling in water-sealed chamger? | air leak |
| What indicates absence of fluctuating in water-sealed chamber? | clot or lung reexpansion |
| What may indicate infection? | increase in WBC, elevated temperature, presence of purulent drainage |
| When tube in place, how should nurse position the patient and why? | on the unaffected side to keep the tube from becoming kinked |
| Why should water seal bottle remain bellow the level of chest? | to prevent fluid from draining back into the pleural cavity |
| How often should be coughing and deep breathing facilitated? | At least every 2 hours |
| What should u write on the container so that the drainage amt can be easily determined? | Date and hour |
| What should be always close by? | Hemostat or clamp |
| The tubes should be always: | straight as possible; do not let patient lie on it; never be placed over the side rails |
| What are concerns for maintaining chest tubes and closed chest drainage bottles? | Proper system function; potential atelactasis resulting from hypoventilation; increased air in the pleaural spac; complication of infection |
Created by:
Lidunka25
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