Tracheostomy
Helps to moisten secretions
Humidity
Functions to warm, humidify and filter oxygen coming into the body.
What is the function of the Upper Respiratory System
Increase in both rate and depth, normally occurs with extreme exertion, fear, or anxiety.
What is hyperventilation
Done prior to suctioning a patient with a tracheostomy to prevent hypoxemia
What is preoxygenate the patient
Limb and joint movement the client can perform independently
Active Range of Motion
A change in pupil size as an item moves closer
What is the accommodation?
4th or 5th interspace, medial to the midclavicular line
What is the apical pulse?
Equipment used to oxygenate after suctioning
What is Ambu-Bag/oxygen?
Term for decreased oxygen in the blood
What is hypoxemia
An abnormal loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and in early expiration.
What is Coarse Crackles
This nursing skill will need to be performed for no more than 15 seconds.
What is Suctioning
Moving a body part toward the midline of the body
Adduction
20/60
What is visual acuity. A person with normal vision can read the line at 60 feet that this patient can only read at 20 feet.
Leg in dependent position has rubor and pallor when elevated.
What is arterial disease
The number and size of trachs to be kept at the bedside
What is same size trach and one size smaller?
I am 21%
What is oxygen content of atmospheric oxygen (room air)
Low-pitched, musical snoring, moaning sounds. Heard throughout the cycle, although more prominent on expiration.
What is a wheeze
A test for dysphagia is done when
What is when trouble swallowing is present or suspected
The foot is bent with toes pointed away from the leg
Plantar Flexion
Fine oscillating movement of the eyes.
What is nystagmus?
Radial pulse is bounding.
What is 3+?
The amount of space between skin and trach ties
What is 1-2 finger?
Head of bed at 45 degrees?
What is Semi-Fowler's.
Caused by closure of the AV valves
What is S1
Components of the Glascow Coma Scale
What are Eye Opening
Best Verbal Response
Best Motor Response
Feet together, arms at side, eyes closed.
What is the Romberg Test?
Use to elicit muscle weakness in the eyes.
What is the 6 cardinal field of gaze?
Just lateral to and parallel with the extensor tendon.
What is the dorsalis Pedis Pulse?
This tracheostomy tool comes packaged with a new tracheostomy. It is used for non-traumatic insertion of the tracheostomy. It should be kept in a sterile container at the bedside in case of emergency.
What is Obturator
Term for blood tinged sputum
What is hemoptysis?
A palpable vibration across the chest.
What is a thrill
Dorsal side of hand against skin.
What is checking skin temperature?
Active motion against some resistance (Slight Weakness)
What is 4? Muscle Strength.
2 syllable word or stating 3 items from behind
What is the whisper test?
Position the patient at a 45 degree angle in bed to perform this assessment
What is Jugular Vein Distention