What does an ABG measure?
The amount of oxygen available in the blood stream.
What does the hemoglobin lab value indicate?
What does the pulse oximetry value indicate?
What does the respiratory rate indicate?
Client has thick secretions. Would patient teaching could the nurse provide?
Increase fluid intake, high-fowler position, deep cough, use of expectorant medication, use of humidifer
Signs and symptoms of hypoxia
Altered mental status, discoloration of skin (cyanosis), shortness of breath (dyspnea), tachycardia (body is trying to compensate)
What if chest tube accidentally gets pulled out of patient?
Cover insertion site. Tape dressing on 3 sides. Call RRT. Prepare new chest tube supplies.
What is ventilation?
The process of moving air into and out of the lungs.
What is diffusion?
What is perfusion?
What factors determine cardiac output?
Stroke volume (how much blood gets ejected from left ventricle)
Heart rate (how often does blood get ejected)
SV x HR = Cardiac Output
What would the client look like if they had low cardiac output?
Who needs to have an EKG?
Client with chest pain, shortness of breath, dizziness, abnormal vital signs.
Conditions that would make the SpO2 inaccurate or poor reading
Poor circulation, cold environment, nail polish, artificial nails, anemia/low hemoglobin, carbon monoxide poisoning
Considerations for home oxygen use.
Fire safety, portable oxygen cylinder safety.
Client has heart failure. What breath sounds do you anticipate?
Crackles in the lower bases.
What if chest tube drainage system is inoperable?
Disconnect chest tube from drainage system. Temporarily insert tip of exposed chest tube into vial of sterile water to recreate water seal.
What during a respiratory assessment would make you concerned?
Retractions, shallow effort, discoloration of skin or mucus membranes, asymmetrical chest rise, abnormal respiratory rate.
What's the natural pacemaker of the heart?
Sinoatrial (SA) node.
Where does the electricity go next? And after that, where the does the electricity travel to?
What is an adequate amount of urine for an adult?
Most references say 0.5 to 1 mL/kg per hour indicates the kidneys are well perfused.
In a client with shock, one of the first organs to show a problem will be the kidneys. In order to save our life, our body shunts blood away from the kidneys to preserve heart/brain function. So a client experiencing shock will start to have decreased urine output and changes in kidney function lab tests.
Who knew pee was so important : )
End-tidal CO2 of 50 indicates
An etCO2 level of 50 indicates hypoventilation.
What does etCO2 measure? End-tidal CO2 (etCO2) measures exhaled carbon dioxide with each breath.
What does SpO2 measure?
What condition/situation would your client need a nonrebreather mask?
Respiratory distress, need to hyper-oxygenate prior to a procedure.
Keep in mind that with this type of mask the client still has to have the effort and rate to bring the 100% oxygen into the lungs.
What about an AMBU bag, when would you use it?
What causes wheezing in the lungs?
Narrowed airways.
Caused by inflammation, bronchoconstriction, mucus, obstructions (tumors/foreign objects).
What if you see continuous bubbling in water seal chamber?
This may indicate an air leak. Check all connections between patient and chest tube drainage system.
What does no bubbling at all indicate?
Measured from the tip of the earlobe to the nose.
Nasopharyngeal Airway (NPA)
How do you measure for an OPA?
What's the purpose of either of these adjuncts?
EKG strip - What happens during the T wave?
The ventricles relax/repolarize.
What happens during the P wave?
What happens during the QRS complex?
Client is having sudden severe chest pain. What labs does the nurse anticipate?
Troponin, Creatine Kinase
Why do these labs have to be repeated?
pH 7.32
pCO2 36
HCO3 18
Interpret this ABG result
Metabolic acidosis
Low pH = acidosis
Low HCO3 = metabolic
What's the purpose of the incentive spirometer?
The I.S. acts as a visual aid during deep breathing exercises. These exercises help to prevent atelectasis by promoting deep inflation the lungs.
What's the purpose of humidified air?
What's the purpose of expectorants?
What causes stridor?
Upper airway obstruction. More common in children.
Use the internet to look up what stridor sounds like. Once you hear it you'll never forget it!
Pleural effusion, hemothorax, pneumothorax.
Indications for a chest tube.
Endotracheal tube (ETT) assessment
Once the ETT is inserted, the client technical has 2 airways, 1 natural, 1 artificial. A top priority is ensuring the ETT is actually where it's suppose to be (in the trachea). To do this we can measure exhaled carbon dioxide (etCO2). We can also listen to breath sounds as air is forced into the lungs using the AMBU bag and also watch for chest rise with each breath. We can also visually look at the markings on the tube (22 cm at the patient's gum line).
30 compressions: 2 breaths
100 to 120 compressions per minute
At least 2 inches deep
Adult CPR guidelines.
What's the order of skills done during cardiac arrest? ABC or CAB?
How do you know someone's in cardiac arrest?
What's the purpose of a thoracentesis?
Remove extra fluid from pleural space (called a pleural effusion).
What assessment should the nurse do before, during, after this procedure?
What would make you stop suctioning a client?
Hmmmm.... let me think???
What's the technique for providing suctioning?
What would cause absent breath sounds on one side of the chest?
Pneumothorax, Hemothorax (think the lung can't expand with air in that specific area), section of lung removal (if it's not there, you can't listen to it), Obstruction (something in the bronchi is blocking the airflow)
What do you do before administering abdominal thrusts to a client?
Ask them if they are choking. Tell them you are going to help. We don't want to startle them or have them fight us. We also want to ensure abdominal thrusts are warranted.
How long do you perform abdominal thrusts for?
What if the patient become unconscious?