exam 2 study guide (Ch 19, Ch 14, Ch 57, Ch 49, Ch 2, Ch 38)

Oxygen Delivery Devices With Percentage of Oxygen Delivered - matching on exam

1. Nasal cannula

   1. 1–6 L/min = 24%–44% O2

2. Oxymizer

   1. 1–15 L/min = 29%–50% O2

3. Simple face mask

   1. 5–8 L/min = 35%–55% O2

4. Venturi mask

   1. 4–10 L/min = 24%–55% O2

5. Partial rebreather mask

   1. 6–12 L/min = 60%–90% O2

6. No rebreather mask

   1. 6–15 L/min = 70%–100% O2

fraction of inspired oxygen (FiO2)

1. percentage or concentration of oxygen delivered

nonrebreather mask

1. mask with a bag

2. Oxygen with mask goes up to 100%

3. when functioning properly, the reservoir fills on exhalation but never totally collapses on inhalation

tracheostomy suctioning (put in order)

1. Assemble equipment

   1. Sterile suction catheter kit

   2. Sterile water or normal saline if not contained in the kit

   3. Sterile gloves

   4. Clean gloves

   5. Clean, water-repellent gown, and mask with face shield (if indicated)

   6. Stethoscope

2. Check the patient’s tracheostomy for exudate, edema, and respiratory obstruction; check that the tracheostomy phalange is secure with the ties/strap. (Allows the nurse to identify the potential need for further nursing interventions.)

3. Position the patient in the semi-Fowler’s position. (Allows for optimal lung expansion; during suctioning, the patient may cough forcefully and dislodge the tracheostomy if it is not secure.)

4. Provide paper and pencil or a communication board for the patient. (Because the patient cannot speak, this offers a means of communication.)

5. Position self at the head of the bed facing the patient. Always face the patient while cleaning or suctioning a tracheostomy. (Enables close observation for respiratory difficulty and coughing, which could expel the tracheostomy cannula.)

6. Auscultate lung sounds. (Provides baseline information regarding airway for comparison after suctioning.)

7. Place towel or prepackaged drape under tracheostomy and across the chest. (Protects patient’s gown and the bed linens and provides a sterile field on the chest.)

8. Perform hand hygiene. Prepare equipment and supplies on the overbed table. (Organizes procedure.)

   1. Open suction catheter kit but maintain sterility of contents, leaving the catheter in its wrapper. (Maintains sterility.) The order of steps depends on how the equipment is placed in the kit and if there is a prefilled container of sterile saline or water. Don sterile gloves if there is a prefilled container of saline or water. Open the container. If there is only an empty basin for saline to be added, open the basin and remove the lid from the bottle of sterile saline or water outside of the kit, then don sterile gloves. Fanfold or wrap suction catheter around dominant hand. (Helps protect the sterility of the catheter tip.) Pick up tubing from the machine with the nondominant hand and attach the end of the suction catheter to the suction machine tubing. (This hand will no longer be sterile for the remainder of the procedure.)

   2. If sterile saline or water is to be added to an empty basin inside the suction kit, use the nondominant hand to pour the sterile saline or water into the basin. (Sterile saline or water is used to rinse the suction catheter. The nondominant hand is no longer sterile and can be used to pour solution.)

   3. Turn on the suction machine with the nondominant hand and check that suction is working by suctioning a small amount of the sterile saline or water. This is accomplished by covering the port on the suction tubing with the thumb of the nondominant hand.

9. Preoxygenate the patient by having the patient take several deep breaths by setting the ventilator to deliver 100% oxygen with sigh breaths, or by having an assistant use a resuscitator bag. If the patient is receiving oxygen, wait to remove the oxygen delivery system until just before suctioning. (Prevents oxygen depletion during the procedure.)

10. Suction tracheal cannula. (Aids in maintaining a patent airway.)

    1. Place thumb over suction control vent; place tip of the suction catheter in the container of sterile rinse solution. Withdraw sterile rinsing solution through the catheter by placing a thumb over the suction control. (Moistens catheter and clears any mucus from the catheter tip.)

    2. Remove the thumb from suction control; advance catheter gently through the tracheostomy while maintaining sterility until resistance is met, and then withdraw catheter approximately 1 cm. (Depth of the catheter approximately equals the length of the outer cannula, and the distal end of which protrudes from the opening approximately 1 to 2 inches.) (Keeping thumb off of suction vent prevents suctioning while inserting the catheter, which has the potential to damage the mucosa. Resistance is met when the catheter reaches the junction of the main bronchi.)

    3. Apply intermittent suction by placing a thumb on and off suction control and gently rotate the catheter as it is withdrawn. (Secretions are suctioned around the circumference of the trachea.)

    4. Suction for a maximum of 10 s at a time, never longer. (Prolonged suctioning depletes oxygen supply.)

    5. Rinse the catheter with a sterile solution by suctioning the sterile solution through it. Repeat Steps 11b through 11e if needed. Most facilities’ policies indicate no more than three suction attempts during the suctioning procedure.

    6. Allow the patient to rest between each suctioning effort. If the patient was receiving oxygen previously, reapply it at the prescribed rate between each suctioning episode. (Suctioning is often exhausting and frightening for the patient. Resting helps the patient regain depleted oxygen and decreases fear.)

    7. Turn off suction, and dispose of catheter appropriately by rolling the catheter up into one gloved hand and pulling the glove off over the catheter; then, place the glove with the catheter into the other hand and pull the glove off over the glove with the catheter.

    8. Perform hand hygiene.

    9. Auscultate lung sounds. (Evaluate the effectiveness of suctioning.)

type 1 alveolar cells

1. alveolar walls lined with a single layer of epithelial cells that provide structure

2. between the cells are thicker type 2 alveolar cells that produce surfactant (lipoprotein that coats the inner surface of alveoli to keep them open)

nursing intervention for giving nasal cannula

1. assess the nose

2. prevent skin breakdown behind the ears need to put padding

3. assess respiratory rate

4. A nasal cannula allows the patient to eat and talk normally, and its use is appropriate for all age groups.

   1. Attach nasal cannula tubing to the flowmeter. (Oxygen delivery system must be continuous to ensure adequate supply of oxygen.)

   2. Adjust flowmeter to 6–10 L/min to flush tubing and prongs with oxygen. Feel the oxygen on your skin to ensure flow. (Enables the nurse to determine patency and removes any microscopic particles possibly in the tubing.)

   3. Adjust the flow rate to a prescribed amount; 1–6 L/min may be ordered. (Ensures delivery of oxygen flow rate as directed by the health care provider.)

   4. Place a nasal prong into each nostril of the patient in the direction that the prongs are curved (see illustration). (Directs flow of oxygen into the patient’s upper respiratory tract.)

   5. Place cannula tubing over the patient’s ears and tighten under the chin. (Proper fit is snug and comfortable to prevent displacement of prongs.)

   6. Place padding between strap and ears if needed. Use lamb’s wool, gauze, or cotton balls. Some nasal cannula tubing already has protective devices in place. (Prevents skin irritation and breakdown.)

   7. Ensure that the cannula tubing is long enough to allow for patient movement. (Reduces the risk that one or both prongs will cause pressure on the nares, as well as the risk of displacement, as the patient moves or is repositioned.)

   8. Regularly evaluate equipment and patient’s respiratory status. (Ensures delivery of prescribed oxygen flow rate. Determines whether the patient needs further respiratory interventions.)

      1. Evaluate cannula frequently for possible obstruction.

      2. Observe external nasal area, nares, and superior surface of both ears for skin impairment every 6–8 h.

      3. Observe nares and cannula prongs at least once a shift for irritation or breakage. Cleanse skin with a cotton-tipped applicator as needed. (Prevents skin irritation or trauma to the nares from damaged cannula prongs.)

      4. Apply water-soluble lubricant to nares if needed. (Prevents drying and irritation of nares. Water-soluble lubricant will not occlude the nasal cannula.)

      5. Refer to health care provider’s orders for any prescribed changes in flow rate.

      6. Maintain solution in humidifier container, if used, at an appropriate level at all times. (Prevents inhalation of dehumidified oxygen.)

      7. Auscultate lung sounds. (Verifies adequate oxygenation and patency of the airway.)

      8. Consult with health care provider regarding need for pulse oximetry if the patient’s oxygen level is unstable. (Assists in determining oxygenation needs and helps prevent oxygen toxicity.)

      9. Oxymizer: the oxymizer is similar to the nasal cannula in delivery. The steps for initiating oxygen via this device are the same as a nasal cannula. The difference lies in the amount of oxygen delivered (FiO2). The reservoirs of the oxymizer collect and conserve oxygen, allowing a higher percentage of oxygen to be delivered. It is important to check the reservoirs to ensure that they do not deflate, as this would lower the percentage of oxygen delivered. When comparing the nasal cannula to the oxymizer, at 6 L/min, the oxymizer delivers 7% more FiO2 than the nasal cannula, and the oxymizer can be set as high as 15L/min.

signs and symptoms of hypoxia

1. Apprehension, anxiety, restlessness

2. Behavioral changes

3. Cardiac dysrhythmias

4. Cyanosis

5. Decreased ability to concentrate

6. Decreased level of consciousness

7. Digital clubbing (with chronic hypoxia)

8. Dyspnea

9. Elevated blood pressure

10. Increased fatigue

11. Increased pulse rate: As hypoxia advances, bradycardia results, which in turn results in decreased oxygen saturation

12. Increased rate and depth of respiration: As hypoxia progresses, respirations become shallow and slower, and apnea develops

13. Pallor

14. Vertigo

definition of gas exchange

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

safety precautions during oxygen use

1. Place “No Smoking” or “Oxygen in Use” signs, or both, in the patient’s room and where easily seen.

2. Instruct the patient, the family, and visitors that smoking is not permitted because oxygen supports combustion (burning).

3. Avoid the use of electrical appliances such as razors, blankets, and heating pads while oxygen is administered.

4. Avoid the use of petrolatum products such as petroleum jelly when oxygen is administered because of the combustibility of oxygen.

5. Secure portable oxygen delivery systems, such as cylinders or portable tanks, into proper portable oxygen-carrying equipment to prevent falling or tipping because these delivery devices can become projectiles.

6. Avoid placing oxygen cylinders near sources of heat, such as lamps or radiators.

7. Avoid clothing that is not fire resistant.

8. Ensure that all electrical equipment is functioning appropriately and is well grounded (three-prong plug). Avoid frayed, tangled, or cluttered cords, and do not overload circuits.

9. Know the facility’s fire procedure and the locations of fire extinguishers.

10. Administer oxygen by the method and rate ordered by the health care provider.

11. Ensure that the patient is aware if extension tubing is in use to prevent falls from tripping over the tubing.

inadequate gas exchange - matching question

1. ischemia

   1. refers to insufficient flow of oxygenated blood to tissues that may result in hypoxemia and subsequent cell injury or death

2. hypoxia

   1. is insufficient oxygen reaching cells

3. anoxia

   1. is the total lack of oxygen in body tissues

4. hypoxemia

   1. is reduced oxygenation of arterial blood

preventing postoperative pulmonary complications

1. After a surgical procedure

   1. encouraged to deep breathe

   2. cough at least every 2 hours

   3. use an incentive spirometer to prevent pneumonia and atelectasis

2. spirometer encourages deep breathing for patients and measures the air inhaled as an outcome indicator that is useful for nursing assessment

turning Celsius to Fahrenheit

1. C = (F - 32) / 1.8

health insurance portability and accountability act (HIPPA)

1. HIPAA of 1996 was enacted to provide individuals with preexisting medical conditions access to health insurance if they changed or lost their job

2. is to prevent healthcare fraud and abuse and promote medical liability reform

3. act also included a provision (known as the Privacy Rule) for health information privacy requirements for individually identifiable health information

4. Privacy Rule protects the confidentiality of health information relating to the provision or payment of health care for a past, present, or future physical or mental health condition but does permit the “minimum necessary” use and disclosure of protected health information without patient authorization for purposes of treatment, payment, and healthcare operations

HIPAA Patient Identifiers

1. HIPAA, Health Insurance Portability and Accountability Act of 1996.

2. Names

3. Geographic locations smaller than a state—includes zip code, city, county, precinct

4. Dates—includes admission date, discharge date, date of death, and all ages over 89

5. Phone numbers

6. Fax numbers

7. Electronic mail addresses

8. Social security numbers

9. Medical record number

10. Health plan beneficiary

11. Account numbers

12. Certificate/license numbers

13. Vehicle identifiers

14. Device identifiers and serial numbers

15. URLs

16. Internet protocol (IP) addresses

17. Biometric identifiers, including fingerprints and voice prints

18. Full face photographic images

19. Any other unique identifying number, characteristic, or code

consent for treatment

1. Healthcare practitioners are obligated to disclose and explain procedures and treatment (including the risks and benefits of the procedure and disclosures about alternatives to the proposed procedure) to a patient in language that they understand.

2. Consent must be given voluntarily in writing by the patient who has the requisite capacity to consent.

3. Prior to receiving healthcare services, it is a normal practice for a patient to sign paperwork consenting to receiving care that is generally provided in a particular setting.

4. Even with this general consent, a nurse should always alert a patient prior to touching; the nurse should explain what she/he is going to do and why.

5. If a patient refuses a specific treatment, the nurse should be respectful of the patient’s wishes and communicate with the patient what the risks are in refusing the treatment.

6. The nurse must notify the ordering practitioner of the patient’s refusal.

7. Additionally, the nurse should document the refusal (including the conversation with the patient about the risks of refusing the ordered treatment) and notification of the practitioner in the patient’s health record.

advance directives

1. Healthcare entities that receive federal funds are required to provide patients with written information about their rights to make their own healthcare decisions, including the right to execute written healthcare directives in advance, the right to refuse medical treatment, and to appoint a person or agent to speak and make decisions on their behalf if they become incapacitated.

2. The provider must ask patients if they have advance directives and document the patient’s response in the medical record.

3. The patient should be encouraged to provide these documents and they should be placed in the patient’s medical record.

4. A nurse should become familiar with the contents of a patient’s directives.

5. Providers are prohibited from discriminating against patients, based on whether they have advance directive.

6. All states have laws outlining the specific details of drafting and executing advance directives.

7. These laws encourage compliance with the patient’s directive by giving healthcare providers, who act in reliance on these documents, immunity from civil or criminal liability.

8. Some states impose criminal liability if a patient’s advance directives are not followed.

9. two basic types

   1. living wills

      1. written document that directs treatment in accordance with a patient’s wishes in the event of a terminal illness or condition

   2. durable powers

      1. health care designates an agent, surrogate, or proxy to make health care decisions on the patient’s behalf based on the patient’s wishes.

care coordination

1. is recognized as essential for organizing care and information around patients’ needs and preferences

2. is one of the six priorities identified by the National Quality Strategy (NQS) as needed to provide more affordable care, improved health for people and communities, and better patient-centered care.

ANA - American Nurses Association

1. published care coordination - a blueprint for action and analyzes the current landscape, and produced 6 actionable steps for nurses to consider in the advancement of care coordination initiatives

2. 6 actionable steps include:

   1. patient, family, and caregiver engagement

   2. competency and readiness

   3. teams and teamwork

   4. documentation and health information technology (HIT)

   5. quality and performance measurement

   6. payment

attributes and criteria for care coordination

1. Optimal care coordination features patient-centered, evidence-based care highlighted by efficiency which results in the achievement of the NQS goals for improved quality of health care; better health of individuals, communities, and populations; and delivery of health care that is affordable.

2. Additionally, care coordination efforts will demonstrate movement toward value-based care delivery and away from fee-for-service as a response to the goals of the ACA.

3. Efficiency is conceptualized broadly to include efficiency in communication among providers, consumption of medical treatment and associated costs, and a consideration of time as a resource.

nursing practice is dependent on evidence-based practice

2 domains within theoretical framework

1. continuity of patient care

   1. requires connected health care and should provide consistency for the patient and healthcare team

2. activities of the clinician

   1. include skilled interprofessional communication, covering provision of care during transitions, clearly delineating who on the team is accountable for aspects of the patient care, and connecting the patient to resources

confidentiality

1. Nurses have a duty to protect information about a patient regardless of how the information is kept.

2. Information should be accessed only on a need-to-know basis.

3. Failure to maintain patient confidentiality risks legal liability, and civil and criminal filings may result.

4. Securing the materials that contain confidential information is a responsibility of the nurse.

5. These materials include not only the physical chart forms but the technological resources as well.

6. When accessing computerized patient files, the nurse must ensure the appropriate log-out information is entered to prevent others from viewing the records.

7. Written notes and chart forms must be stored in restricted areas.

8. Information that can be used to identify a patient is considered protected health information (PHI)

9. These identifiers extend well beyond the patient’s name and include admission and discharge dates; social security number; photographs; addresses and phone numbers; and date of birth.

social media

1. Common Myths About the Use of Social Media for the Health Care Professional

   1. Posted communication is private between the individual posting it and the initial intended recipient.

   2. Content is deleted easily from a social media site.

   3. If transmitted information is shared with a few people and the patient does not find out, it is acceptable.

   4. If names are not used in posted communication, the patient’s privacy is protected and violations are avoided.

proper documentation - “care was not given if it was not charted”

code of ethics

1. to know and function within the scope of practice for a licensed LPN/LVN

2. to maintain patient confidences

3. to provide health care without discrimination

4. to maintain a high standard of professional and personal behavior

5. to take an active role in the development of the LPN/LVN profession

autonomy

1. it refers to freedom of personal choice, a right to be independent and make decisions freely

beneficence

1. means doing good or acting for someone’s good; this principle is of primary importance to nurses.

nonmaleficence

1. means to do no harm

justice

1. concept of what is fair.

respite care

1. provides short term relief for primary caregivers, allowing hem time to rest, travel, or spend time with others

2. care can last from a few hours to several weeks

3. can take place at home, in healthcare facility, or at an adult day care center

discharge for patient

1. process starts as soon as the patient is admitted

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