assessment
1) history
2) physical
3) hypoxia
what is the first thing we do if someone has low oxygen
give them oxygen
examples of implementation
1) dyspnea management
2) airway maintenance
3) mobilization of pulmonary secretions
4) hydration
5) humidification
6) coughing and deep breathing techniques
for oxygen therapy, when would you use it, and do you need an order
lower than 95% and yes
low flow: what is the nasal cannula amount and describe
1-6 L
can eat, drink, talk, light weight
for the physical assessment, what are you looking for
1) retractions
2) breathing rate
3) barrel chest (COPD)
4) skin
5) arterial O2 saturation
6) lung sounds
do you need an order for oxygen
yes
what can you do for dyspnea management
meds
oxygen
sit them up
whre do you get a supply of oxygen
tanks or on the wall (green tank)
low flow: what is the amount of a simple face mask
6-12 L
(short term)
what do you assess for the skin
cyanosis (blue lips and fingernails)
what are your priorities if someone is low on oxygen
ABS (airway, breathing, circulation)
what do you do for the mobilization of pulmonary secretions
SUCTION
reposition
what is the goal of oxygen therapy
relieve hypoxemia by delivering the lowest amount of oxygen possible to achieve good tissue oxygenation
low flow: what is the amount for non-partial and partial re-breathers (describe)
10-15 L
short term, increase FiO2 (inhaled oxygen)
what is the normal Sa2 saturation
95 (older adult)-100%
what else can we do for planning
SMART goals
teamwork
vaccines (flu and pneumococcal)
healthy lifestyle
environment
how do you maintain the airway
1) hydration
2) suctioning
3) chest physiotherapy
4) nebulizers
what are examples of breathing exercises
pursed lip breathing
diaphragmatic breathing
high flow: venturi mask how many liters and describe
24-50%
MOST PRECISE
what are the differences between late and early hypoxia (low oxygen)
early: apprehension, restlessness, elevated BP, unable to lie flat, fatigue, and agitated
late: cyanosis, decreased HR/BP/RR
what are SMART goals
s: specific
m: measurable
a: achievable/attainable
r: relevant
t: timing bound
who teaches the coughing and deep breathing techniques
the nurses (maintain clearance of airways)
what does pursed lip breathing do and what does diaphragmatic breathing do
pl: prevents alveolar collapse
db: increase tidal volume, decrease RR
high flow: what is the benefit of a high flow nasal cannula
humid
higher rate