Sputum
White or clear (serous) sputum indicates...?
Usually present in Viral infections like the common cold
High-pressure alarm indicates...? Name 3
-excess secretions, kinks in the tube, client biting the tube
-pulmonary edema, bronchospam, pneumothorax
-check causes before calling it RT. You mau just need to suction.
Fine crackles aka fine rales sounds like?
Described as rubbing hair together, present during inspiration
(fibrosis/bronchitis/Pneumonia/COPD)
Pleural friction rub
Described as grating or squeaking
-caused by inflammation of the pleural space
pneumonia, lung malignancy, pleurisy
Venturi mask flow
2-15 L/min Most accurate oxygen concentration, mostly used for COPD patients to prevent CO2 build up
Yellow or Green sputum indicates?
sign of infection
Low pressure alarms
-Usually caused by leaks in the cuff or disconnections
Coarse crackles
- Low pitched
-Described as coarse popping, like pouring out water of a bottle or opening velcro
-caused by fluid secretions
(COPD, Sputum in airway, pneumonia, CHF)
Absent
Bad signs cuz they deado
Prevents rebreathing C02 (one-way), best for pts with physical trauma, chronic airway limitation, cluster headache, smoke inhalation, and carbon monoxide poisoning, or any other patients who require high-concentration oxygen, but do not require breathing assistance.
oxygen concentration 90%
10L/min
Black Sputum
caused by smoke, coal dust inhalation, or soot inhalation
Pulmonary function test
-No smoking 6-8 hours before test,
-no inhalers 4-6 hours before test
Rhonchi
-Low pitched, Described as snoring
-caused by obstruction, sputum, or secretions in uppper airways
-may clear with suctioning
(Pneumonia/Bronchitis/Masses/Foreign body)
Interventions for HAP
ICOUGH- incentive spirometer, cough & deep breathe, oral care, understand icough, get out of bed (ambulate TID) HOB positioning
-Administer humidified oxygen as directed/meds, pulmonary hygiene, patient positioning, monitor intake/output
Bronchodialators & antibiotics
Partial rebreather mask
Resevoir bag must be filled with oxygen
8-10 L/mn
50-75%
Pink & frothy (serosanguineous)
associated with pulmonary edema
Tracheostomy care
-hyperoxygenate for 30 secs
-suctioning, replace inner cannula, clean stoma
-maintain sterile trach dressing care
-replace velcro trach holder if soiled
Wheezing
described as squeaky musical insturment
-caused by bronchoconstriction & inflammation
present during inspiration and or expiration
(asthma, COPD)
Nursing interventions O2
-Maintain HOB 30-45
-Clear airway secretions, daily readiness to wean assessment, deep vein thrombosis/peptic ulcer disease prophylaxis (prevention)
-Daily care with chlorhexidine
Simple face mask oxygen flow
6-12 L/min
Used for short term
Foul-smelling sputum
bacterial infection
Sepsis
LOW BP, High WBC count, Tachycardia, fever, decreased urinary output
Stridor
-High pitch sound
Caused by airway obstruction or spasms of the throat
-allergic reaction, epiglottis, laryngitis
6 feet away from heat; do not use flammable materials near the tank. Do not use petroleum jelly, rubbing alcohol, do not smoke near it. Clean
Use cotton, not wool.
Observe skin for any breakdown.
Use warm soapy water. (some ppl use vinegar)
Tracheostomy collar
Used for pts with tracheostomy
Needs humidified oxygen
Can deliver supplemental oxygen