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Midterm (Lab)
Oxygenation, Safety/Mobility, Abbreviations
| Question | Answer |
|---|---|
| Nasal Cannula FR | -1 to 6 L/min, -24–45% (FiO2) |
| Simple Mask FR | -5 to 8 L/min, -40–50% FiO2. |
| Non-rebreather Mask FR | -10–15 L/min. -95–100% FiO2 |
| Venturi Mask FR | - 4–10 L/min -24–50% FiO2 |
| Nasal cannula indication | -Used for patients requiring low-flow oxygen therapy -Suitable for stable patients with mild hypoxemia. |
| simple mask indication | -Used for moderate oxygen needs -Suitable for patients with moderate hypoxemia. |
| venturi mask indication | Ideal for patients with COPD who require controlled oxygen delivery to prevent CO2 retention -NEEDS DR ORDER PRIOR TO STARTING |
| non-rebreather indication | -Used for severe hypoxemia, delivering up to 100% oxygen. -Suitable for emergency situations |
| high flow nasal cannula indication | Used for patients with acute respiratory failure, |
| suction indications | -Audible secretions -Increased respiratory rate -Decreased O2 saturation -Inability to cough effectively -Signs of respiratory distress |
| Oropharyngeal Suctioning Procedure: | 1. HIPIE 2. Positioning pt 3. Equipment: Use a Yankauer suction tip or suction catheter. 4. Suctioning: Moisten the catheter, insert it without applying suction, and advance it along the side of the mouth to avoid the gag reflex. |
| Suctioning positioning (oro and naso) | -conscious patients: use the semi-Fowler position with the head turned to one side -unconscious patients: use the lateral position. |
| Nasopharyngeal Suctioning Procedure: | 1. sterile procedure 2. Position pt 3. Equipment: Use a sterile suction catheter and water-soluble lubricant. 4. Suctioning: Lubricate the catheter, insert it into the naris without applying suction, and advance it gently. |
| O2 safety considerations: | -perform regular assessments and monitor: vitals, O2 sat, and for signs of hypoxia - older pt are at high risk for O2 toxicity (esp w/ chronic lung conditions). lowest affective O2 is usually best -older pt are also at higher risk for pressure injuries |
| what is important to remember when a pt is on O2? | O2 can be drying. Humidifying can be used to ease this |
| cannula special considerations | -apply water-soluble jelly Q3-4 hrs -good mouth care |
| face mask special considerations | - wash, dry, and apply lotion to skin |
| tracheostomy (T-piece) FR | -8 to 10 LMP |
| Croupette/O2 hood (infants) | -8 to 10 LMP -needs temp monitoring |
| O2 hazards | -infection -drying of mucosa -resp depression -O2 toxicity -combustion |
| what is an incentive spirometer (IS) | a device that helps patients to take long, slow, deep breaths. It helps to prevent complications such as pneumonia |
| How long does a pt hold their breath while using IS | 6 secs |
| how many times should a pt use the IS | 10-12 times once every hour (unless pt is sleeping) |
| proper use of an IS | sitting upright, pt places their lips tightly around the mouthpiece and take in slow, deep breaths. -older pt w/ dentures or dry mouth might have trouble |
| what should a pt do after using the IS | Cough to facilitate removal of loose secretions and open alveoli |
| indications for IS use | - post-op pts. - Immobilized clients - Spinal cord injury - Lung disease |
| what does the IS do for a pt? | - Measures amt of air inhaled - Opens alveoli small airways - Maintains muscle strength |
| when should you check on a pt after starting O2 therapy | 15-30 mins after applying to ensure VS have stabilized |
| what should you check prior to starting a pt on O2 | their skin |
| each liter of O2 increases O2 delivery by what % | 3-4% (starting off of 21% RA) -ex. 1L = 24-25% |
| respiratory assessment steps | 1. inspect/palpate 2. auscultate 3. findings (normal vs abnormal) |
| what do you inspect during an assessment | -symmetry (obs rise and fall) -depth of breathing (shallow, even, or deep) -effort of breathing (labored/unlabored) -rate and rhythm (count and regular/irregular) |
| auscultation during resp assessment (w/ diaphragm) | -lister for cough -anterior thorax -posterior thorax |
| anterior thorax sites | - Above Clavicles (apices) - 2nd intercostal space (upper lobes) - 4th intercostal space (R mid/upper lobes) - 6th intercostal space (lower lobes) |
| posterior thorax sites | - AboveScapula (apices) - b/t scapulae @T3 (upper lobes) - Down to T7-T8 (lower lobes) - Lat. Chest & midaxillary line (RML and lingula) |
| normal resp assessment findings | clear breath sounds bilaterally |
| abnormal resp assessment findings | - Crackles (rales): fluid, atelectasis, Pneumonia -Wheezes: Asthma, copd, narrow airway -Rhonchi : Secretion in large airways -Stridor : upper airway obs. -Absent/diminished: effusion , pneumothorax , severe obs. |
| stridor | shrill and harsh during insp. |
| stertor | snoring |
| wheeze | high pitched whistling |
| rhonchi | gurgling sounds |
| intercostal retraction | indrawing b/t ribs |
| suprasternal retraction | indrawing beneath breastbone |
| suprasternal reaction | indrawing above clavicles |
| cheyne-strokes breathin | waxing and waning of resps. -deep to shallow and temp apnea |
| crackles | -high-pitched (fine crackles, like hair rubbed between fingers) -low-pitched (coarse crackles, like Velcro) -typically occur during inspiration |
| morse fall scale | -hx of falls (25) - secondary dx (15) -ambulatory aid use - furniture (30) -crutches, cane, walker (15) -IV/saline lock (20) -Gait/transfer -impaired (20) -weak (10) -mental stat (15) |
| risk level scores | -no risk (0-24) -low risk (25-50) -high risk (greater or equal to 51) |
| risk level actions | -no risk (0-24): basic care -low risk (25-50): standard fall preventions -high risk (greater or equal to 51): high risk fall preventions |
| mobility assistive devices | ●Gait/Transfer Belt ●Sliding Board ● Mechanical Lift ● Wheelchair |
| how can older adults improve mobility | ROM exercises |
| Fall preventions for older adults | ● Environmental Safety ● Exercise Programs ● Footwear (non-slip) ● Assistive Devices (walkers, canes) ● Medication Review ● Vision and Health Checks ● Clinical Setting Strategies |
| Standard Fall Precautions | -Includes removing obstacles from walking paths, ensuring rooms are well-lit, and keeping frequently used items within easy reach. -Patients are encouraged to wear shoes with adequate traction and use prescribed eyewear to improve vision. |
| High Risk Fall Precautions | -measures like bed alarms, electronic tracking devices, and color-coded armbands for easy identification. -Frequent safety rounds and assistance with toileting -review medication to mitigate risks associated with side effects like dizziness. |
| Prone Position | Patient lies on their stomach. It's used to improve respiratory function and prevent pressure ulcers on the back. |
| Supine Position | Patient lies flat on their back. It is often used for surgeries or when a neutral alignment is needed. |
| Lateral Position (Side-lying) | Patient rests on either side. This helps relieve pressure from the back and enhances ventilation. |
| Trendelenburg Position | Head of the bed is lowered while feet are elevated. Used to promote venous return and assist with certain medical procedures like percussion |
| Reverse Trendelenburg Position | Head of the bed raised while feet lowered. Ideal for patients with gastric conditions to prevent esophageal reflux. |
| Mechanical Lift | Ideal for patients who cannot assist in the transfer, this device uses a sling to lift and move the patient safely. |
| Gait/Transfer Belt | This belt is placed snugly around the patient's waist to provide support during the transfer. |
| Sliding Board | Useful for patients with upper body strength, it allows them to slide from bed to chair independently. |
| Wheelchair | Positioned close to the bed, it provides a stable destination for the patient during transfer. |
| Body mechanics | 1. Feet Positioning: stand w/ feet apart and 1 foot slightly forward 2. Bend at the Knees to lift 3. Use Large Muscles to lift 4. Close Proximity to pt or object 5. Avoid Twisting your back |
| mobility independent interventions | -education on body mechanics and posture -support devices to prevent injury (canes, walkers, etc) -exercise education and promotion |
| mobility collaborative interventions | -physical therapy: exercise and muscle strength -occupational therapy: helps to perform daily activities independently (usually with help of assistive devices) |
| types of restraints | -wrist/ankle restraints -vest restraints (bed or wheelchair) -mitts (children/infants) |
| CMS check requires | C: capillary refill, radial pulse M: mobility of fingers/toes (wiggle) S: sensory (light touch) |
| when should CMS be performed | before and after application of restraints |
| what important to assess using a vest restraint | respiratory (can the pt breath or is there any changes in respiration after application) |
| How often does the physician’s order need to be renewed for a client on restraints? | ● Non-behavioral health: Q 24 hrs ● Behavioral health: Q 2-4 hrs ● Children (12-17): Q 2 hours with a max duration of 24 hours |
| When initiating restraints without a physician’s order, what is the time frame in which the physician’s order needs to be signed? | Within 1 hour |
| How often do you release restraints on a client? | Every 2 hours to perform ROM exercises, check skin and circulation |
| What would you need to monitor on a client who is on restraints and how often would you do this? | ● Every 15 mins: check for signs of distress or complications ● Every 2 hours: to perform ROM exercises, check skin and circulation |
| i | one |
| ii | two |
| ∆ | change |
| ° | degrees or hours |
| ā | before |
| AAOx4 | awake, alert, and oriented X4 |
| abd | abdomen |
| ABG | arterial blood gas |
| AC | antecubital |
| a.c. | before meals |
| ADA | American Diabetes Association |
| ADL | activities of daily living |
| ad lib | as desired |
| AFA | appropriate for age |
| aka | also known as |
| AKA | above knee amputation |
| alb | albumin |
| ALOC | altered level of consciousness |
| AMA | against medical advice |
| amb | ambulate |
| amt | amount |
| ant | anterior |
| as tol | as tolerated |
| ASA | aspirin |
| ASHD | arteriosclerotic heart disease |
| Ax | axillary |
| bid | twice a day |
| BKA | below knee amputation |
| BLE | bilateral lower extremities |
| BM | bowel movement |
| BMP | basic metabolic panel |
| B/P or BP | blood pressure |
| BPH | benign prostatic hypertrophy |
| BR | bedrest |
| BRBPR | bright red blood per rectum |
| BRP | bathroom privileges |
| BS | bedside |
| DP | dorsalis pedis |
| drsg | dressing |
| DSD | dry sterile dressing |
| DVT | deep vein thrombosis |
| DX | diagnosis |
| ECF | extended care facility |
| ECG/EKG | electrocardiogram |
| ED | emergency department |
| EGD | esophagogastroduodenoscopy |
| ESRD | end stage renal disease |
| FA | forearm |
| FBS | fasting blood sugar |
| FC | foley catheter |
| FFP | fresh frozen plasma |
| F/U | follow up |
| FUO | fever of undetermined origin |
| FWB | full weight bearing |
| fx | fracture |
| GCS | Glasgow coma scale |
| GI | gastrointestinal |
| G-tube | gastrostomy tube |
| GU | genitourinary |
| HA | headache |
| Hct | hematocrit |
| HD | hemodialysis |
| Hgb | hemoglobin |
| H & H | hemoglobin and hematocrit |
| HOB | head of bed |
| HOH | hard of hearing |
| H&P | history and physical |
| HR | heart rate |
| hs | at bedtime |
| HTN | hypertension |
| I&D | incision and drainage |
| IDDM | insulin dependent diabetes mellitus |
| inc | incontinent |
| IM | intramuscular |
| I&O | intake and output |
| IS | incentive spirometer |
| IV | intravenous |
| J-tube | jejunostomy tube |
| JVD | jugular vein distention |
| pc | after meals |
| per | by, or through |
| PCN | Penicillin |
| PCXR | portable chest X-ray |
| PEG | percutaneous endoscopic gastrostomy |
| PERL | pupils equal and reactive to light |
| PERLA | pupils equal and reactive to light and accommodation |
| PERRLA | pupils equal, round,reactive to light and accommodation |
| PICC | peripherally inserted central catheter |
| PMH | past medical history |
| po | by mouth |
| POD | postoperative day |
| post | after |
| pre | before |
| PR | per rectum |
| PRN | as needed |
| Pt | patient |
| PT | physical therapy |
| PVD | peripheral vascular disease |
| PWB | partial weight bearing |
| q | h |
| R | right |
| R/O | rule out |
| RR | regular rhythm |
| RUL | right upper lobe (lung) |
| RUQ | right upper quadrant |
| Rx | prescription |
| s | without |
| sat | saturation |
| SL | sublingual |
| SNF | skilled nursing facility |
| SOB | shortness of breath |
| S/P | status post |
| spec | specimen |
| S/S | signs and symptoms |
| SSE | soap suds enema |
| SSRI | selective serotonin reuptake inhibitor |
| STAT | at once |
| SW | social worker |
| sx | symptom |
| TCDB | turn, cough, deep breathe |
| TDWB | touch down weight bearing |
| THA | total hip arthroplasty |
| THR | total hip replacement |
| TIA | transient ischemic attack |
| T.O | telephone order |
| tol | tolerated |
| TWE | tap water enema |
| TPN | total parentral nutrition |
| TSH | thyroid stimulating hormone |
| TURP | transurethral resection of the prostate |
| Tx | treatment |
| UA | urinalysis |
| UE | upper extremity |
| UGI | upper gastrointestinal |
| UO | urine output |
| URI | upper respiratory infection |
| US | ultrasound |
| UTI | urinary tract infection |
| VO | verbal order |
| VRE | vancomycin-resistant enterococcus |
| WBAT | weight bearing as tolerated |
| WBC | white blood cell |
| W/C | wheelchair |
| W&D | warm and dry |
| WNL | within normal limits |
| VS | vital signs |
| K | potassium |
| KCL | potassium chloride |
| KVO | keep vein open |
| KUB | kidneys, ureters, and bladder x-ray |
| L | left |
| LE | lower extremity |
| lg | large |
| LLL | left lower lobe (lung) |
| LLQ | left lower quadrant |
| LMP | last menstrual period |
| LUL | left upper lobe (lung) |
| LVN | licensed vocational nurse |
| MAE | moves all extremities |
| mg | milligrams |
| MOM | milk of magnesia |
| MRI | magnetic resonance imaging |
| MRSA | methicillin-resistant Staphylococcus aureus |
| MAR | medication administration records |
| ml | milliliter |
| MM | mucous membranes |
| MVA | motor vehicle accident |
| Na | sodium |
| NAD | no apparent distress |
| NCP | nursing care plan |
| NGT | nasogastric tube |
| NIDDM | non-insulin dependent diabetes mellitus |
| NKA | no known allergies |
| NS | normal saline |
| Nsg | nursing |
| NPO | nothing by mouth |
| N/V/D | nausea, vomiting, diarrhea |
| NWB | non-weight bearing |
| O2 | oxygen |
| OA | osteoarthritis |
| OBS | organic brain syndrome |
| OOB | out of bed |
| ORIF | open reduction and internal fixation |
| after | |
| BS | bowel sounds |
| BSC | bedside commode |
| BUN | blood urea nitrogen |
| BX | biopsy |
| ℅ | complains of,complaints of |
| c | with |
| Ca | calcium |
| CA | cancer |
| CABG | coronary artery bypass graft |
| CAD | coronary artery disease |
| cap | capsule |
| cath | catheter |
| CBC | complete blood count |
| CDB | cough and deep breath |
| C/D/I | clean, dry, intact |
| CHF | congestive heart failure |
| cm | centimeters |
| CMP | complete metabolic panel |
| CMS | circulation, movement,sensation |
| CNS | central nervous system |
| COPD | chronic obstructive pulmonary disease |
| CP | chest pain |
| CPM | continuous passive motion |
| C&S | culture and sensitivity |
| CT | computerized tomography |
| CTA | clear to auscultation |
| CVA | cerebrovascular accident |
| CVD | cardiovascular disease |
| CXR | chest X-ray |
| DAT | diet as tolerated |
| DJD | degenerative joint disease |
| DKA | diabetic ketoacidosis |
| DM | diabetes mellitus |
| DOB | date of birth |
| DOE | dyspnea on exertion |
| restraints are considered | last resort |
| where should you stand while using a gait belt | on the pt weak side |
| restraint scenario: pt suddenly quiet | assess immediately (risk for hard/LOC change) |
| fall prevention basics | Bed low/locked, nonskid socks, call light in reach, environment clear. |
Created by:
tabithaj23