Lung sounds
Name that lung sound:
•Cause- narrowed airways
•Fine high-pitched violin sound, mostly on expiration
Wheezes
Name an invasive lab test that can determine the effectiveness of gas exchange
ABG- Arterial blood gases
Name that mask......•5-10 L/min 40-60% O2 concentration
simple mask
What is the term used when instructing the patient to inhale slowly through the nose and exhale slowly with their lips poked out
pursed lip breathing
Nursing care for patient with chest tube. All are true except for....
A-Keep drainage system below the level of the patient's chest
B-Ensure there are no dependent loops of tubing
C-The chest tube does not travel with the patient, it must stay hooked up in the room
D-Contact RN and HCP immediately if chest tube is accidentally pulled out before indicated
C-
Rationale- the drainage system is transported with the patient.
Name that lung sound:
•Cause- airway obstruction
•Loud crowing noise heard without stethoscope
Stridor
What invasive lab can check WBC which if elevated indicate infection
CBC- complete blood count
What is.....most common delivery tool for oxygen
patient must breathe through nose
may use humidifier
1-6L/min
Nasal cannula
Prevents atelectasis and pneumonia
Patient inhales deeply into device (do not blow into)
encourage to use 10 times every hour while awake
Incentive Spirometer (IS)
The patient has a chest tube in and the nurse notices tidaling and bubbling on inspiration. What should the nurse do?
Nothing
Tidaling- water in tube fluctuates up with inspiration and down with expiration; stops when lung fully reinflated
Upon initiation- bubbling occurs with each exhalation until lung is re-expanded. If constant bubbling present, immediately check for leak in the system
Name that lung sound:
•Cause- inflamed pleura rubbing together
•Sound of leather rubbing together; grating sound
Pleural friction rub
Which invasive lab if elevated indicates blood clot; can help diagnose the presence of a blood clot in in a vein or artery
D-dimer
name that mask...
•Vents on sides of mask allow room air to mix with O2
•50%+ O2 concentration
partial rebreather mask
Helps drain mucus from lungs
Assist pt into different positions to encourage mucous drainage
Percussion via cupping or clapping to help loosen pooled mucus or high frequency chest wall oscillation vest that vibrates patient's chest to loosen mucus
Chest physical therapy (CPT)
The nurse hears a continuous pulse ox alarm going off. She goes into the room to investigate, what does she check first?
The patient
Always check the patient first!
Name that lung sound:
•Cause- decreased air movement
•Faint lung sounds
Diminshed
Which invasive lab can determine which antibiotics are effective against the pathogen identified?
Culture and Sensitivity (C&S)
name that mask...
•1 or both vents on sides of mask closed to limit room air mixing with O2
•70-100% O2 concentration
Non rebreather mask
Needle inserted into pleural space to drain fluid
Assist with patient position
Assess vital signs, breath sounds, and the puncture site according to the HCP’s orders
Bedrest for 1 hour after the procedure
Postprocedure x-ray
Thoracentesis
Chest tube nursing care. All of the following are correct except....
A- the dressing over the insertion site is soiled, reinforce it and contact the RN or HCP
B- keep 2 padded clamps at bedside. You may clamp and disconnect the tube for patient to take a shower
C- Measure drainage level. Mark and time chamber every shift to monitor output
D- Notify HCP if drainage suddenly increases or becomes very bloody
E- If chamber full, change entire system
B- Keep 2 padded clamps at bedside ‒To clamp chest tube if becomes accidentally disconnected, for changing the drainage system, or for trial clamping period before removal of chest tube. Never clamp for more than a few seconds without HCP order! Can cause a tension pneumothorax.
Name that lung sound:
•moist bubbling on inspiration
coarse crackles
Which noninvasive measurement can measure the arterial oxygenation
Oxygen saturation (pulse ox)
name that mask...Delivers more precise % of O2
venturi mask
What are two types of medications that can be administered directly into the lungs
Nebulized mist treatments and Inhaler
If there you suspect an occlusion, you should strip the tube to remove the clot. True or false
FALSE-
Stripping- hold proximal end of tubing and squeeze tubing between two fingers while sliding fingers toward drainage system
‒Old practice. Should not be done! Can cause more damage.