ADVANCED MED SURG: WEEK 4

hypoxemia

low oxygen in the blood

hypoxia

low oxygen out to tissues/organs

S/S of hypoxia

ALOC, restlessness, and organ failure

always start low with oxygen and go slow. True or false?

true (to prevent oxygen toxicity)

signs of oxygen toxicity

substernal discomfort, numbness, dyspnea, restlessness, fatigue, and atelectasis

(same signs as low oxygen)

how can a nurse prevent oxygen toxicity?

-use the lowest effective level of oxygen possible

-PEEP or CPAP to prevent atelectasis

_________ is the best intervention to treat atelectasis

incentive spirometry

(no order needed--> patient should perform 10x per hour while awake)

-have patient cough/deep breathe if no spirometer available

goals of chest physiotherapy (CPT)

-removes secretions

-improves ventilation

-increases efficiency of respiratory muscles

________ allows force of gravity to assist in removal of bronchial secretions

postural drainage

home oxygen patient education:

-no smoking

-compressed oxygen needs continuous energy (make sure they are somewhere they can have electricity always)

-teach patient about humidifying their oxygen

emergency airway management:

Partial obstruction --> encourage coughing/stay with patient (patient able to cough or make noises)

Complete obstruction --> BLS interventions

Endotracheal intubation

WHAT: places a tube through the nose/mouth and into the trachea (temporary intervention)

-provides patient airway/removes secretions

-used for 7-10 days ideally

Tracheostomy

WHAT: an opening made into the trachea (permanent)

-can have indefinitely/long-term

-can be reversed/closed if no longer needed

MANAGEMENT: continuous monitoring, maintain patency by suctioning PRN, semi-fowler's, provide effective means of communication (white board etc.)

suctioning is a clean procedure. True or false?

false (sterile)

Suctioning a tracheostomy:

-pass suction through 2-3x MAX

-suction on way OUT

-suction no more than 10 seconds

-hyperoxygenate patient before (b/c suctioning causes oxygen to be taken out)

how can a nurse help a patient prevent the development of ventilator acquired pneumonia?

perform oral care every 2-4 hours

noninvasive pressure ventilator

WHAT: a type of breathing support that helps a patient move air in and out of the lungs without the need for an invasive artificial airway (like an endotracheal or tracheostomy tube)

CONTRAINDICATIONS: respiratory arrest, dysrhythmias, cognitive impairment, and facial/head trauma

INTERVENTIONS: enhance gas exchange, promote effective airway clearance, prevent trauma/infection, and promote optimal level of mobility, communication, and coping ability

if a chest tube gets accidentally removed, how would a nurse cover the hole?

with a 3 sided occlusive dressing

Weaning from the ventilator:

1) check patients wakefulness (how sedated are they)

2) Oxygen (needs to be 60% FIO2 before removing)

3) wean from the ventilator respiratory rate (slowly; no massive changes)