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Med-Surg Chap 30
Ignativicius, med-surg
| Question | Answer |
|---|---|
| What three systems work together to ensure sufficient tissue perfusion with oxygen for cell survival | Respiratory system, cardiovascular system, and the hematologic system |
| What happens when respiratory problems interfere with adequate oxygenation | The cardiac system and the hematologic system compensate and work harder to restore balance |
| Name two interventions that can help improve oxygenation and tissue perfusion (and at the same time reduce the burden on the cardiovascular and hematologic system) | Oxygen therapy and the use of a tracheostomy |
| Oxygen is used as a drug for relief of what | Hypoxemia |
| What is hypoxemia | Low levels of oxygen in the blood |
| One of hypoxia | Decreased tissue oxygenation |
| When is oxygen therapy prescribed | When the oxygen needs of the patient cannot be met by room air alone |
| Name some non-respiratory conditions that can affect oxygenation | Heart failure, sepsis, fever, some poisons, and decreased hemoglobin levels |
| How do the nonrespiratory conditions affect oxygenation | They Increase oxygen demand, Decrease oxygen-carrying capability of the blood |
| What is the purpose of oxygen therapy | To use the lowest fraction of inspired oxygen to have an acceptable blood oxygen level without causing harmful side effects |
| What is hypercarbia | Increased partial pressure of arterial carbon dioxide levels |
| What is the best measure for determining the need for oxygen therapy | ABGs - arterial blood gas |
| Name some hazards and complications of oxygen therapy | Combustion, oxygen induced hypoventilation, oxygen toxicity, absorption atelectasis, drying of the mucous membranes, infection |
| What precautions should be used to prevent combustion during oxygen therapy | Open fires should not be in the same room during oxygen therapy (candles, cigarettes)post a sign on patients room that smoking is prohibited, flammable solutions (containing high concentrations of alcohol or oil) are not used in rooms which oxygen is in u |
| What is oxygen induced hypoventilation | Occurs in patients whose main respiratory drive is hypoxia (hypoxic Drive) e.g. The patient with chronic lung disease, who also has carbon dioxide retention (hypercarbia) |
| What is the loss of sensitivity to high levels of arterial carbon dioxide called | CO2 narcosis |
| What happens to the patient with hypoxic drive, when given oxygen | PaO2 level increases, removing the trigger for breathing and the patient has respiratory depression |
| What patient is not at risk for this complication | Patient being ventilated mechanically |
| How is oxygen therapy prescribed | The lowest liter flow needed to manage hypoxemia |
| When are manifestations of hyperventilation seen. | During the first 30 minutes of oxygen therapy |
| What should be monitored for the patient at risk for oxygen induced hypoventilation, apnea, or respiratory arrest | Carefully monitor the LOC, respiratory pattern and weight, pulse oximetry |
| Which is a greater threat to life - oxygen induced hypoventilation, or inadequately treated hypoxemia | Hypoxemia is a greater threat to life |
| How can oxygen damage the lungs | Oxygen toxicity can damage the lungs, oxygen level greater than 50%. Given continuously for more than 24 to 48 hours |
| What are some symptoms of oxygen toxicity | Dyspnea, nonproductive cough, chest pain beneath the sternal and G.I. upset |
| What happens as exposure to high levels of oxygen continues | Symptoms become more severe with decreased to vital capacity, decreased compliance, crackles and hypoxemia- Eventually atelectasis, pulmonary edema, hemorrhage, and hyaline membrane formation results |
| At what levels should healthcare provider be notified | PaO2 levels greater than 90 mm HG |
| What does nitrogen in the air do | Helps maintain patent Airways and alveoli |
| What percentage of room air does nitrogen make | 79% |
| What happens to nitrogen when high oxygen levels are delivered | Nitrogen is diluted, oxygen diffuses from the alveoli into the circulation and the alveoli collapse |
| What does collapsed alveoli cause | Atelectasis |
| How do you detect Atelectasis | By auscultation, you will hear crackles, and decreased breath sounds |
| How often should you monitor the patient receiving high levels of oxygen | Every 1 to 2 hours when oxygen therapy is started |
| when should you humidify the delivery system | When the flow rate Is higher than 4 L per minute |
| What nursing interventions should take place with humidified oxygen | Remove condensation as it collects By disconnecting the tubing and emptying the water |
| Name one way to prevent bacterial contamination of the oxygen delivery system | Never drain the fluid from the water trap back into the humidifier or nebulizer |
| How often should you change equipment to avoid infection | Per policy or protocol, which ranges from every 24 hours for humidification systems to every 7 days or whenever necessary for cannulas and Masks |
| The type of delivery system used in oxygen therapy depends on what | Concentration required by the patient- concentration achieved by delivery system - of accuracy control of O2 concentration - patient comfort - expense to the patient - importance of humidity - patient mobility |
| Name two classifications of 02 delivery systems | Low flow system, high flow system |
| Explain low-flow systems | They do not provide enough flow of oxygen to meet the total need and air volume of the patient. Part of tidal volume is supplied by breathing room air |
| Explain high- flow systems | high-flow systems meets the entire oxygen need and tidal volume regardless of the patient's breathing pattern. These are used for critically ill patients and when delivery of precise levels are needed |
| What interventions can be used if the patient needs a mask but is able to eat | request a prescription for nasal cannula to be used for meal times only. Reapply mask when meal is complete. |
| What can be used to increase mobility | Up to 50 feet of connecting tubing can be used with connecting pieces |
| Low flow delivery systems include what | Nasal cannula, simple facemask, partial rebreather mask, and non-rebreather mask |
| What are the benefits of the low-flow oxygen delivery system | They are inexpensive, easy-to-use and fairly comfortable |
| What are the disadvantages of low flow system | Amount of oxygen delivered varies, depends on the patient's breathing pattern, oxygen is diluted with room air, which lowers the amount of oxygen actually inspired |
| How much oxygen is in room air | 21% oxygen |
| What flow rates our nasal cannula is used at | 1 to 6 L/min (oxygen concentrations of 24% to 44%) |
| Why are flow rates greater than 6 L per minute not usedwith nasal cannulas | It does not increase oxygenation, because of anatomic dead space and high flow rates increase mucosal irritation |
| What is anatomic dead space | Places where air flows but the structures are too thick for gas exchange |
| Nasal cannulas are often used for chronic lung disease and patients needing long-term oxygen therapy, why | The patient who retains carbon dioxide is rarely prescribed to receive oxygen at a rate higher than 2 to 3 L/min because of the risk for losing the drive to breathe thereby increasing the risk for apnea or respiratory arrest |
| What oxygen concentration does a simple facemask deliver | 40 to 60% |
| What are simple facemasks used for | Short-term oxygen therapy or emergency |
| What is the minimum flow rate needed and why | 5 liters/min - - to prevent rebreathing exhaled air |
| What concentrations of oxygen do partial rebreather mask's deliver | 60% to 75% with flow rates of 6-11 L/min |
| How does a rebreather work | The patient rebreathes one third of the exhaled tidal volume which is high and oxygen, and provides a higher fraction of inspired oxygen |
| What happens if the bag on a rebreather does not remain slightly inflated at the end of inspiration | The desired amount of oxygen is not delivered |
| What percentage of oxygen is delivered with a non-rebreather mask | 80 to 95% |
| What type of patient uses a non-rebreather mask | One who's respiratory status is unstable and may require intubation |
| What is the flow rate in a non-rebreather mask | 10 to 15 L/min |
| Why is the flow rate High on a non-rebreather mask | To keep the bag inflated during inhalation |
| How often should you assess that the bag is inflated during inhalation | At least hourly |
| Why is it important that the valve and flaps on a non-rebreather mask are intact and functioning during each breath | If the oxygen source should fail or be depleted when both flaps are closed the patient would not be able to inhale room air, suffocation could occur |
| What nursing interventions should be used with the nasal cannula | Ensure prongs are in the nares properly - apply water-soluble jelly to mayors as needed - assess the patency of the nostrils - assess the patient for changes in respiratory rate and depth |
| Why should the prongs be of the nares properly | Poorly fitting nasal cannula leads to hypoxemia and skin breakdown |
| Why should you use water-soluble jelly in the nares | Prevents mucosal irritation related to the drying effect of oxygen, promotes comfort (petroleum jelly should not be used due to possibility of burns) |
| Why should you assess the patency of the nostrils | Congestion or a deviated septum prevents effective delivery of oxygen |
| What nursing interventions should be used with a simple facemask | Ensure mask fit securely over nose and mouth - assess skin and provide skin care to the area covered by the mask - monitor for risk of aspiration - provide emotional support for feelings of claustrophobia - suggested that healthcare provider to switch pat |
| Why should the mask fit securely | Poorly fitting mask reduces the inspired oxygen delivered |
| Why should you assess the skin | Pressure and moisture under the mask may cause skin breakdown |
| Why should you monitor for risk of aspiration | The mask limits the patient's ability to clear their mouth, especially if vomiting occurs |
| What does emotional support do | Decreases anxiety, ( which may contribute to a claustrophobic feeling) |
| What interventions should be used for the partial rebreather mask- Adjust flow rate to keep reservoir bag inflated | Make sure the reservoir does not twist or kink |
| What happens if the reservoir bag does twist or kink | It can result in a deflated bag, deflation results in decreased oxygen delivered, and rebreathing of exhaled air |
| Why should you just the flow rate | The flow rate is adjusted to meet the pattern of the patient |
| What interventions should be used with the non-rebreather mask | Make sure reservoir does not twist or kink - adjust the flow rate - monitor closely - make sure the valves and rubber flaps are patent, functional and not stuck. Remove mucus or saliva - closely assess the patient |
| Why is close monitoring required | Ensures proper functioning and prevents harm |
| What should you see if the non-rebreather mask is functioning correctly | Valves should open during expiration and close during inhalation to prevent dramatic decrease in inspired oxygen |
| Why should you closely assess the patient | The only way to provide more precise inspired oxygen is to intubate; patient may need intubation |
| Name some high-flow oxygen delivery systems | Venturi mask, aerosol mask, face tent, tracheostomy collar, and T-piece |
| What concentrations and at what rate do high- flow systems deliver oxygen | 24% - 100% at 8 to 15 L/min |
| Which high flow oxygen delivery system delivers the most accurate oxygen concentration without intubation | Venturi masks |
| What kind patient is the Venturi mask best for | Chronic lung disease because it delivers a more precise oxygen concentration |
| A face tent system is useful for what type of patient | Patients with facial trauma or burns |
| When is an aerosol mask used | When high humidity is needed after extubation or upper airway surgery or thick secretions |
| When is a tracheostomy collar used | To deliver high humidity and the desired oxygen to the patient with a tracheostomy |
| When is a T-piece used | To deliver any desired fraction of inspired oxygen to the patient with a tracheostomy, laryngectomy, or endotracheal tube |
| What nursing interventions should be used with the ventii mask | Constantly survey to ensure accurate flow rate - keep orifice for Venturi adapter open and uncovered - provide mask that fits snugly and tubing that is free of kinks - assess for dry, mucous membranes - change to nasal cannula during mealtime |
| Why should you constantly survey for accurate flow rate | Accurate flow rate insurers fraction of inspired oxygen delivered |
| Why should the orifice be kept open and uncovered | If orifice is covered, adapter does not function and oxygen delivery varies |
| Why should the mask fit snugly and the tubing be free of kinks | Fraction of inspired oxygen is altered if kinking occurs or mask fits poorly |
| Why should you assess the patient for dry, mucous membranes | Comfort measures may be indicated |
| Why should you change to nasal cannula during mealtime | Oxygen is a drug that needs to be given continuously |
| What nursing interventions need to be used for the aerosol mask, face tent, tracheostomy collar | Assess that aerosol mist escapes from the vents during inspiration and expiration - empty condensation from tubing - change aerosol water container as needed |
| Why should you assess that aerosol mist is escaping | Humidification should be delivered to the patient |
| Why should you empty condensation from the tubing | Emptying prevents patient from being revised with water, promotes an adequate flow rate, and ensures continued prescribed FiO2 |
| Why should you change the aerosol water container | Adequate humidification is insured only when there is sufficient water in the canister |
| What interventions are needed for the T-piece | Empty condensation from tubing - keep exhalation Port open and uncovered - position T-piece, so it does not pull on tracheostomy or endotracheal tube - make sure humidifier creates enough mist (mist should be seen during inspiration and expiration) |
| Why should you empty the condensation from the tubing of a T-piece | Condensation interferes with flow rate delivery, and may drain into the tracheostomy if not emptied |
| Why should the exhalation port be open and uncovered | If port is occluded, the patient can suffocate |
| Why is the positioning of the T-piece important | If the weight of the T-piece pulls on the tracheostomy it can cause pain or erosion of skin at insertion site |
| Why should mist be seen during inspiration and expiration | And adequate flow rate is needed to meet the effort of the patient, if not patient will be<br> "air-hungry" |
| What is noninvasive positive pressure ventilation | A technique using positive pressure to keep alveoli open and improve gas exchange |
| What is noninvasive positive pressure ventilation used for | Manage dyspnea, hypercarbia, and acute exacerbations of COPD, cardiogenic pulmonary edema, and acute asthma attacks |
| What are some risks and complications associated with noninvasive positive pressure ventilation | Skin breakdown can occur due to tightfitting masks (needed in order to form a proper seal), leaks can cause uncomfortable pressure around the eyes, and gastric insulation can lead to vomiting and the potential for aspiration |
| What type of patients should use noninvasive positive pressure ventilation | Those patients with an intact mental status and the ability to protect their airway |
| What does a CPAP do | Delivers a set positive airway pressure throughout each cycle of inhalation and exhalation |
| What does a BiPAP do | Cycles different pressures at inspiration and expiration. Together, these two pressures improve tidal volume, can reduce respiratory rate, and may relieve dyspnea |
| Why is a CPAP used | To open collapsed alveoli |
| What patients may benefit from using a CPAP | Those with atelectasis after surgery or cardiac induced pulmonary edema, or those with COPD |
| What are some safety precautions when using oxygen at home | Tanks must always be in a stand or rack (one that is accidentally knocked over, could suddenly decompress and move around in an uncontrolled manner), patient should not smoke when using oxygen, smoking materials, candles, gas burners and fireplaces should |
| What is a tracheotomy | Surgical incision into the trachea to create an airway |
| What is a tracheostomy | the stoma, or opening that results from the tracheotomy |
| What are some indications for a tracheostomy | Acute airway obstruction, need for airway protection, laryngeal trauma and airway involvement during head or neck surgery |
| What are some priority problems for patients requiring a tracheostomy | Reduced oxygenation R/T weak chest muscles, obstruction, or other physical problems - inadequate communication - inadequate nutrition - potential for infection R/T invasive procedures - damaged oral mucosa R/T mechanical factors |
| What type of postoperative care is indicated after a tracheotomy | Focus care on ensuring a patent airway - confirmed the presence of bilateral breath sounds - perform respiratory assessment at least every two hours - assess for complications from procedure |
| What are some complications that can occur after tracheotomy surgery | Tube obstruction - tube dislodgment - pneumothorax - subcutaneous emphysema - bleeding - infection |
| What could cause tube obstruction | Secretions, cuff displacement |
| What indicates an obstruction | Difficulty breathing - noisy respirations - difficulty inserting a suction catheter - thick, dry, secretions |
| What interventions should be used regarding tube obstruction | Assess patient hourly for tube patency, help patient cough and deep breathe, provide inner cannula care, humidify oxygen source, and suction |
| What should be known about tube dislodgment | Considered an emergency in the first 72 hours after surgery- tube may end up in the subcutaneous tissue instead of in the trachea |
| What should we do if the tube is dislodged | Ventilated patient. Using manual resuscitation bag and facemask while another nurse calls the rapid response team |
| What is a pneumothorax,How does it occur And how do we assess for one | Air in the chest cavity,If the chest cavity is entered during a tracheotomy (usually at the apex of the lung)Use chest x-ray after placement |
| How does subcutaneous emphysema occur | When air escapes into fresh tissue planes of the neck from an opening or tear in the trachea (it can also progress throughout the chest and other tissues into the face) |
| How do you assess for subcutaneous emphysema | Inspect and palpate for air under the skin around the new tracheostomy |
| What does subcutaneous emphysema feel like and what should you do about it | The skin will be puffy and you can feel crackling sensation when pressing on the skin, notify physician immediately |
| What should we do about bleeding from the tracheotomy incision | wrap gauze around tube and pack gently into the wound to apply pressure to the bleeding sites |
| How can we prevent infection from occurring | Use sterile technique during suctioning and tracheostomy care, change, tracheostomy dressings often because moist dressings provide a medium for bacterial growth |
| In regards to infection what and when should you assess | Assess at least once per shift for purulent drainage, redness, pain, or swelling |
| What can you do if tracheostomy dressings are unavailable (what should you not do) | Fold standard sterile 4 x 4 to fit around tube (do NOT cut the gauze because small bits could be aspirated through the tube) |
| What are complications of having a tracheostomy | Tracheomalacia-tracheal stenosis - tracheoesophageal fistula - trachea-innominate artery fistula |
| What is tracheomalacia | Tracheal dilation and erosion of cartilage caused by constant pressure exerted by the cuff |
| What are the manifestations of tracheomalacia | Increased amount of air is required in cuff to maintain seal<br>larger tracheostomy tube is required to prevent an air leak at stoma<br>food particles are seen and tracheal secretions<br>patient does not receive set tidal volume on the ventilator |
| How do you manage and prevent tracheomalacia | No special management is needed, unless bleeding occurs<br>to prevent use and on cuff tube as soon as possible, monitor cuff pressure and air volumes closely and detect changes |
| What is tracheal stenosis | Narrowed tracheal lumen due to scar formation from irritation of tracheal mucosa by the cuff |
| How does tracheal stenosis manifest | Patient has increased coughing, inability to expect during secretions, difficulty in breathing, or talking (usually seen after the cuff is deflated or the tracheostomy tube is removed) |
| How do you manage tracheal stenosis | Tracheal dilation or surgical intervention is used |
| How can you prevent tracheal stenosis | Prevent pulling up and traction on tracheostomy tube<br>properly secure tube in midline position<br>maintain proper cuff pressure<br>minimize oronasal intubation time |
| What is a tracheoesophageal fistula | A hole created between the trachea and the anterior esophagus when excessive cuff pressure causes erosion of the posterior wall of the trachea |
| What are the manifestations of TEF | Food particles are seen in tracheal secretions<br>increased air in cuff is needed to achieve a seal<br>patient has increased coughing and choking while eating<br>patient does not receive set tidal volume on the ventilator |
| How is TEF managed | Manually administer oxygen by mask to prevent hypoxemia,use a small soft feeding tube instead of a nasogastric tube for tube feedings (a gastrostomy or jejunostomy may be performed by the physician, monitor patients with nasogastric tube closely assess fo |
| How can TEF be prevented | Maintain cuff pressure<br>monitor amount of air needed for inflation and detect changes<br>progress to a deflated cuff or couples tube ASAP |
| What is trachea - innominate artery fistula | Necrosis and erosion of the innominate artery caused by continued pressure of a malpositioned tube with the distal tip, pushing against the lateral wall of the tracheostomy |
| How is a trachea-innominate artery fistula different from other complications | It is a life-threatening complication that is considered a medical emergency |
| How is the trachea - innominate artery fistula manifested | The tracheostomy tube pulsates in synchrony with the heartbeat<br>heavy bleeding from the stoma |
| How is the trachea - innominate artery fistula managed | Remove tracheostomy tube immediately<br>apply direct pressure to the innominate artery at the stoma site<br>prepare patient for immediate repair surgery |
| How can a trachea - innominate artery fistula be prevented | Correct the tube size, length and midline position<br>prevent pulling or tugging on the tracheostomy tube<br>immediately notify the physician of the pulsating tube |
| What temperature should the air entering a tracheostomy be kept at | Between 98.6° and 100.4°F (never exceed 104°F) |
| What can happen if humidification and warming of the air is not adequate | Tracheal damage can occur<br>thick, dried secretions can occlude the Airways |
| What can suctioning cause | Hypoxia - tissue trauma - infection - vagal stimulation - bronchospasm and cardiac dysrhythmias |
| What factors in the patient with a tracheostomy can cause hypoxia | Ineffective oxygenation before, during, and after suctioning<br>use of catheter that is too large for artificial airway<br>prolonged suctioning time<br>excessive suction pressure<br>too frequent suctioning |
| How can you prevent hypoxia while suctioning | Hyperoxygenating patient with 100% oxygen,monitor heart rate or use pulse oximeter, while suctioning to assess tolerance of procedure, assess for hypoxia (e.g., increased heart rate and blood pressure, oxygen desaturation, cyanosis, restlessness, anxiety, |
| What should be done if hypoxemia occurs | Stop the suctioning procedure, re-oxygenate patient with 100% oxygen until baseline parameters return |
| What results from vagal stimulation | Severe bradycardia, Hypotension, heart block, ventricular tachycardia, asystole or other dysrhythmias<br> |
| How can you prevent accidental decannulation during tracheostomy care | Keep the old ties or holder on the tube while applying new ties or by keeping hand on the tube until it is securely stable |
| How should you assess the patient with a tracheostomy | Note the quality pattern and rate of breathing (tachypnea can indicate hypoxia, dyspnea can indicate secretions in the airway, assess for cyanosis, especially around the lips could indicate hypoxia, check pulse oximetry reading, check oxygen prescription |
| When assessing the tracheostomy site... | Note color, consistency, amount of secretions in tube or externally if sutured - any redness, swelling, or drainage from suture sites if secured with ties - condition of ties (moist with secretion or perspiration? Dried secretions? Are ties secured condit |
| How to prevent aspiration during swallowing | Avoid meals when patient is tired - provide smaller and more frequent meals - provide adequate time - close supervision with self-feeding - keep emergency suctioning equipment on and ready - avoid thin liquids - thicken all liquids (including water) - avo |
| 10 steps for tracheostomy care | 1. Assemble necessary equipment 2. Wash hands, maintain standard precautions 3. Suction tracheostomy tube if necessary 4. Remove all dressings and excess secretions 5. Set up sterile field 6. Remove and clean the inner cannula (half strength hydrogen pero |
| How is a patient weaned from a tracheostomy tube | Gradually decrease the tube in size, until it can be removed. The tube can be removed after patient tolerates more than 24 hours of capping. |
| What considerations should be taken for older adults who are self managing tracheostomy care | Older patients have vision problems or difficulty with upper arm movement - teach them to use magnifying lenses or glasses to ensure the proper setting on the oxygen gauge. Assess their ability to reach and manipulate the tracheostomy. If possible encoura |
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