Fundamentals Exam 3

oxygenation

oxygenation

the process of providing cells with oxygen through the respiratory system and is accomplished by pulmonary ventilation, respiration, and perfusion

gas exchange

process by which oxygen is transported to cells and carbon dioxide is transported from cells

factors affecting respiratory function

-body position -environment/weather -air pollution -pollens/allergens -heart failure -COPD -pregnancy -medications -anxiety/fear -airway obstruction

lifestyle: -smoking -alcohol -nutrition -drugs -obesity -exersize -occupational hazards

nursing respiratory function assessment

-respiratory rate -breathing pattern and effort -chest symmetry -auscultation of lung sounds -pulse oximetry -vital signs -skin color (cyanosis)

cyanosis

occurs when a person has unoxygenated hemoglobin in the arterial blood in body

central cyanosis

cyanosis of the lips, mucus membranes, and tongue; occurs when arterial blood's oxygen saturation falls below 85%

cyanosis on light skinned individuals

dark bluish tint to skin and mucus membranes reflecting the blue tint of unoxygenated hemoglobin

cyanosis of dark skinned individuals

gray or whitish skin tone; gray/white tint around the mouth and conjunctiva

cyanosis on yellowish toned individuals

grayish/green skin tone

respiratory nursing assessment

inspection: -skin color -use of accessory muscles -pt. positioning -respiratory rate -quality of respirations

auscultation: -listening for normal breath sounds -note any adventitious/abnormal breath sounds

patient teaching to support respiratory function

-smoking cessation -hydration -nutrition -reduce allergen exposure -exercise -flu, pneumonia, and covid vaccinations -weight loss -coughing and deep breathing exercised to move secretions

deep breathing

technique used for maximizing ventilation by taking in a large volume of air to improve gas exchange

pursed lip breathing

form of controlled ventilation to consciously prolong the expiration phase of breathing to improve gas exchange

diaphragmatic breathing

used to promote diaphragm use for breathing (instead of upper chest) and to increase volume of air exchange; decreases respiratory effort and relieves rapid ineffective breathing with hypertension

incentive spirometry

technique used to encourage deep breathing using a calibrated device to teach a goal-directed volume of inspired air -used every hour awake; 10 times an hour -insert the mouthpiece between lips, inhale slowly and deeply until the ball reaches predetermined goal

indications for incentive spirometry

-post-operative -chronic respiratory disease -pneumonia

oxygen saturation

pulse oximetry; a noninvasive measure of pulse saturation and direct oxygenation through blood gases

-normal: 95%-100% -low readings can be found with elderly, dark skinned pts, and COPD pts

COPD oxygen saturation

COPD pts are chronically hypoxic due to oxygen saturation being their drive to breathe, so a low O2 sat is maintained to maintain breathing

-healthy pt drive to breath is the build up of CO2

oxygen therapy

goal is to prevent or relieve hypoxia; oxygen is used as a drug where dose and concentration are continuously monitored

hypoxia

an inadequate amount of oxygen in the cells and tissues

early signs/symptoms of hypoxia

-tachypnea -tachycardia -restlessness, anxiety, confusion -pale skin -elevated blood pressure -use of accessory muscled, nasal flaring, adventitious lung sounds

late signs/symptoms of hypoxia

-stupor/dazed -cyanosis -bradypnea -bradycardia -hypotension -cardiac dysrhythmias

hypoxemia

insufficient oxygen in the arterial blood

dyspnea

difficulty breathing

nasal canula

simple comfortable device that delivers oxygen concentrations at: 24%-44% 2-6L/min

simple face mask

short term oxygen administration delivering oxygen concentrations at: 35%-60% 6-10L/min

venturi mask

delivers the most precise amount of oxygen @ 24%-55% 4-10L/min

-color coded valves

partial rebreather mask

works by allowing 2/3 of air to be exhaled to environment while 1/3 is exhaled to reservoir bag; delivers @ 70-90% 6-15L/min

nonrebreather mask

all air is exhaled into the environment and reservoir bag must be inflated at all times; delivers @ 60%-100% 6-15L/min

related oxygenation lab work

-sputum culture -peak flow -tuberculine testing -arterial blood gases

arterial blood gases (ABG)

blood from radial artery tested and used to measure the amounts of arterial gases (O2; CO2) in the arterial blood and blood pH

normal ABG testing results

-pH: 7.35-7.45 -PaO2: partial pressure of O2; 80-100 mm Hg -PaCO2: partial pressure of CO2; 35-45 mm Hg -SpO2: 95%-100% -FiO2: measures O2 delivery

abnormal ABG testing results

pH -less than 7.35 = acidosis -more than 7.45 = alkalosis

PaO2 -less than 80mm Hg = hypoxia

PaCO2: -either less than 35 or more than 45 = compromising respiratory issues -less than 35mm Hg = hyperventilation -more than 45mm Hg = hypoventilation; breathing depth and rate are insufficient

hand held device used to measure the highest flow during maximal expiration and indicated how rapidly and at what volume a patient can breath out -reading changes indicate changes in airway diameter -can prevent acute asthma attack -use the best (%) of 3 measured reading

chest physiotherapy

commonly prescribed to help clear excessive bronchial secretions from the airways -use cupped hand and clap on pt back in hollow sounding areas

elimination

the secretion and excretion of body wastes

urine specimen

collected urine samples used for laboratory tests to inspect urine

clean catch/midstream specimen

after perineum care, pt. catches urine sample mid-stream after urination begins -first voided amount is contaminated

sterile urine specimen

using asepsis, obtain a sterile specimen from a straight or indwelling catheter port

24 hour urine specimen

after discarding the first voiding of the day, collect urine output for 24 hours and refridgerate

urinalysis

diagnostic test used to analyze the physical, chemical, and microscopic components of a pt's urine and the presence of disease or substance use

urine culture and sensitivity

urine culture tested to detect and identify the bacteria/germ causing infection and which drug can be used to treat it

catheter

a flexible tube placed into the bladder (internal) or placed over the genitalia (external) to allow urine to drain

indwelling foley catheter

catheter placed into the urethra to the bladder for a specified amount of time to measure accurate output, unmanageable urinary retention, and incontinence

straight catheter

intermittent; used as needed to empty the bladder then removed and discarded when emptying is complete ur

urinary tract infection

infection of the urinary system caused by the introduction of bacteria to the tract

signs and symptoms of UTI

-urinalysis findings of RBCs, WBCs, bacteria, protein, and nitrites in urine sample -dysuria -increased frequency increased urgency cloudy urine -foul smelling urine -fever -confusion

nursing assessment of UTI

-typical voiding pattern -frequency -volume -color, odor, clarity -pain -distention

nursing education for UTIs

-female anatomy -hygiene -lifestyle (sexual intercourse)

CAUTI

catheter associated urinary tract infection

risk factors for CAUTI

-indwelling foley catheters -increased time of foley use -opening and placement of drainage system -changing and insertion of catheters

signs and symptoms of CAUTI

-increased frequency -increased urgency -nocturia -pain -hematuria -cloudy -foul smelling -fever -confusing -tachycardia -hypotension

prevention of CAUTI

-aseptic technique -prevent drainage system backflow perineum care

bladder retraining

retraining the bladder to increase the bladder's ability to hold urine and train a pt's ability to suppress urination incontinence

phenazopyridine

pyridium; used to treat manifestations/symptoms of UTI; doesn't treat infection but relieves bladder discomfort -changes urine orange

antibiotics

antimicrobial medications used to kill or inhibit bacterial growth

sulfamethoxazole and thrimethoprim

antibiotics used to treat UTI -take with water and avoid sun exposure

bowel retraining

training your bowels and body to return to or start a normal defecation pattern -used for pts who have the inability to control bowel movements, incomplete bowel emptying, or chronic constipation

bowel retraining assessment

-normal bowel function -nutrition and hydration -lifestyle -timing of bowel movements -consistency -use of enemas or laxitives (bulk builders)

bowels

small and large intestines responsible for physical and chemical digestion and absorption

small intestines

absorb nutrients and water from food

large intestine

compacting and removing waste products of food

factor affecting bowel function

-anatomy/length of intestines (increased length = increased risk for constipation) -activity/exercise -body positioning (on toilet) -ignoring impulse to defecate (increased time tim bowel = increased dryness) -lifestyle -pregnancy -medications (opioids decrease bowel function) -surgery -fecal diversion

bowel diversion

surgical procedure done to allow stool to safely leave the body when the large intestine is removed or needs to heal

ostomy

temporary or permenant opening (stoma) surgically created in the abdomen wall to allow fecal matter to pass; in either the small or large intestine

stoma

an artificial opening made into an organ from the surface of the body

ileostomy

ends in the ileum (last part of the small intestine) and produces fully liquid stool

colostomy

ostomy ending in the colon/large intestine -ascending = liquid stool -transverse = soft stool -descending = solid stool -sigmoid = solid stool

stoma assessmenT

-stoma should be pink/red, moist and shiny -surrounding skin should be intact and healthys

stoma care

-assess stoma when changing bag (less than 1/2-1/3 full) -use mild soap and water to cleanse area -measure stoma using template -irrigate when necessary -pt. acceptance -odor control -skin care -body dysmorphia

constipation

infrequent, sometimes painful passage of hard, dry stool causes: -frequency of laxitaves -age -inadequate hydration -inadequate fiber intake -immobiloty -pregnancy -opioid use

can cause bradypnea or hypotension

hemorroids

blood vessels in the rectal wall that are engorged and dilated due to difficult defecation, pregnancy, or heart failure; can be itchy, painful, and bloody

fissures

tearing at the lining of the anus due to hard or large stools

syncope due to vasovagal response

straining while defecating decreases blood volume that returns to the heart and output; pressure receptors detect the increase of pressure and trigger the heart to slow down and blood pressure drops, causing fainting

assessment and prevention of constipation

-normal bowel function -encourage physical activity -encourage toilet use at same time daily -assess complications -increase fiber and fluid intake -monitor bloating -monitor cramping -avoid straining while defecating

risk factors for the elderly (bowel function)

-increased risk for dehydration -general muscle weakness -decrease peristalsis -relaxation of sphincters -ignored sense of defecation and dehydration -medications

nutrition for bowel function

-daily fiber intake of 25g-30g -daily fluid intake of 2,000mL-3,000mL

pain assessment

-subjective -use of standardized scales depending on pt.

expected findings: -behavioral changes -facial expression -changes in vitals signs (for acute pain)

acute pain

pain lasting less than 6 months and is sudden and unusual -fight or flight response -direct cause resolved with healing

chronic pain

pain lasting more than 6 months that is ongoing or recurs

nociceptive pain

pain arising from damage to or inflammation of tissue -Triggers pain receptors called nociceptors and causes throbbing, aching, and localized pain -Responds to opioids and non-opioid medications

somatic (nociceptive) pain

localized pain originating in bone, skin, and soft tissue

visceral (nociceptive) pain

pain in internal organs as a result of stretching, distention, or inflammation -ex. period pain

neuropathic pain

pain arising from diseased or damaged nervous system pr spinal nerves; feels like tingling, electric, pins and needles -responds to adjuvant medications

verbal indicators of pain

-moaning -complaining -crying -screaming

nonverbal indicators of pain

-facial expressions -body movements -elevated blood pressure, respiration rate, and pulse

numeric pain scale

pain ratings from 1-10 1-3 = mild pain 4-6 = moderate pain 7-10 = severe pain

wong baker faces scale

used for pts who don't speak english and infants/children; series of faces ranging from 0 = no hurt to 10 = hurts worst

FLACC scale

scale used for nonverbal pts and infants; assesses face, legs, activity, cry, and consolability 0 = relaxed/comfortable 1-3 = mild discomfort 4-6 = moderate pain 7-10 = severe discomfort/pain

NIPS infant pain score

assessed 6 behavioral reactions to painful stimuli; 0-7

CRIES observer pain scale

assesses Crying, Requires oxygenation, Increased vitals, Expression, and Sleeplessness; 0-10

pharmacologic intervention

analgesic; pain relievers

nonopioids

treats mild to moderate pain (1-3) -acetimenophem -NSAID

opiods

appropriate for treating moderate tot severe pain (4-6) for post-op and cancer pain -morphine sulfate -dilauded -fentanyl (100x stronger than morphine) -codine

opioid adverse effects

-sedation -respiratory depression -orthostatic hypotention -urinary retention -nausea/vomiting -constipation -pruritus = itching

perioperative

begins with decision to have surgery until transfer to OR

intraperative

begins in OR intil transfer to PACU

post operative

lasts from PACU to follow up heath care provider visit

pre-operative nursing interventions

-establish theraputic relationship -listen to verbalized concerns -demonstrate empathy/caring -ensure tests are explained to pt. -collect appropriate specimen -report results -report any abnormalities

informed consent

signed consent given by the patient to the surgeon to perform the surgical proceedure -obtained by surgeon but a nurse but be physically present to witness signature of documents