Nursing Care: Upper Respiratory Tract Disorders
Type of Oxygen mask used to deliver precise concentrations of oxygen.
Venturi Mask
Common position to help with ventilation
Redness and swelling at site, possible exudate are signs of this type of IV therapy complication
Local Infection
Single most effective way to prevent and control the spread of infections
Handwashing
Nutrient to promote wound healing
What is Protein
Steps to collect sputum
Collect early in the morning
Tachycardia
Risk factors for dehydration
Elderly
Confused
NPO
Causes of Respiratory alkalosis
Hyperventilation (anxiety, fear) Mechanical ventilation, overactive thyroid
When caregivers are required to provide 24-hour care for a patient, may experience burn out. This type of care may be offered?
Respite Care
Nursing Care for a patient having difficulty with expectorating secretions
Turn patient every 2 hours or encourage ambulation
Encourage oral fluids
Cool steam humidifier
Encourage deep breathe every hour or prn
Administer expectorants or mucolytics
Suction if ordered
Obtain order for chest physiotherapy (CPT)
Medical term for Nose Bleed
Epistaxis
This is required for an LPN/LVN to increase oxygen flow rates?
Physician order
An Alternative option for administration of medications or fluids is subcutaneous infusion , also known as?
Hypodermoclysis
Droplet PPE for patients with Infectious non-COVID 19
Surgical Mask
Face Shield or googles
Gloves
Standard Precautions such as a gown
What are the 6 processes to Clinical Decision Making in the Clinical Judgment Model?
Recognize Cues
Analyze Cues
Prioritize Hypotheses
Generate Solutions
Take Action
Evaluate Outcomes
Administer bronchodilator
Educate about triggers
Peak flow meter daily
Patient is at risk for _____ related to decreased level of consciousness, depressed gag reflex and facial, neck or oral surgery
Aspiration
Risk factors for fluid volume overload
Heart failure, kidney failure, increased fluid intake, IV fluid
Causes of Respiratory Acidosis
Decreased Respiratory Stimuli, Hypoventilation, Anesthesia, Drug Overdose, COPD, Pneumonia, Head Injuries
Common signs/symptoms at end of life
Activity level decreases
Interest in surroundings fades
Desire for food and drink ceases
Constipation
Decreased urinary output
Methods to improve airway clearance
Encourage turning, coughing and deep breathing
Offering analgesics for a client with an upper respiratory infection is focused on providing what?
Comfort
Nurse is called into a room for a respiratory emergency with a patient. What should they do first?
Assess the patient
Signs and Symptoms of Sepsis
Shiver, fever or very cold
Extreme pain and discomfort
Clammy or sweaty skin
Confusion or disorientation
SOB
High HR
When to reassess pain interventions?
What is 30 mins - 1 hour after administration of pain meds.
Nursing care for patients on oxygen
What is a sudden bursting open of a wound's edges?
Bonus: term associated when viscera spills out of the abdomen.
Dehiscence
Evisceration
Nursing interventions for fluid imbalances
Fluid overload: monitor I & O, monitor VS, monitor electrolytes, monitor respiratory status. Restrict fluid
Fluid deficiency: monitor I & O, VS, electrolytes, encourage fluid, monitor for fluid overload
pH 7.22
HCO3 12
CO2 36
Metabolic Acidosis
Most common form of non-small cell lung cancer
Squamous cell Carcinoma
Brand name for a balloon catheter inserted for epistaxis
Rapid Rhino
Variation of Diaphragmatic Breathing technique with patient breathing in the nose and out of the mouth
Pursed-lip breathing
Signs and symptoms of Localized infection
Pain
Redness
Swelling
Warmth at the site
Presented on most test, prominent on the NCLEX and vital to daily success during medication administration.
Med Math!!!
Practice your med math!!!
Types/purposes of oxygen delivery devices
Nasal Cannula - 1-6L/min--Most Common--Lowest Concentration
Simple face mask - 5-10L/min--40-60% oxygen
Nonrebreathing mask - 6-15 L/min - provides 100% oxgen - should not be given to COPD
Venturi mask - 24-80% FiO2 - Precise Percentage of oxygen, good for COPD patients
Emergency--Immediate surgery needed to save life or limb without delay (Ruptured aortic aneurysm)
Urgent-- Surgery needed within 24-30 hours (Fracture repair, infected gallbladder)
Elective-- Planned/scheduled, with no time requirements (Joint replacement)
Optional--Surgery requested by patient (cosmetic)
Clinical manifestations for fluid volume deficit & fluid volume overload
Fluid volume deficit - dry skin, sunken eyes, low BP, tachycardia, poor skin tugor
Fluid volume overload - BP elevated, Jugular vein distention, respiratory distress, edema
PH 7.29
CO2 59
HCO3 25
Respiratory Acidosis
Non-common signs of infection in aging adults
Behavioral Changes: Pacing or irritability or new onset confusion
Nonpharmacologic interventions for pain
What is:
Guided imagery, heat/cold packs, quiet/dark environment, massage
Nursing interventions for COPD
Encourage fluid intake
Encourage cough & deep breath
Position in high-Fowler's
O2 sat between 88 - 91%
Stop smoking
Malignant Hyperthermia
Complications of hyponatremia (serum sodium less than 135 mEq/L)
Seizures
Respiratory arrest
coma that can lead to death
pH - 7.50
CO2 - 41
HCO3 - 32
Metabolic Alkalosis
Albuterol
(Considering payment for services): LPN/LVN priority when patient being admitted to the hospital for stroke, arrives to the ER with an Indwelling Foley catheter with signs of infection.
Thorough Data Collection and Documentation of patient conditions POA (Present on Admission).
Chart details showing condition occurred prior to hospitalization
Passive, soft, flat drains usually presenting with moderate, pink serosanguineous (consisting of blood and serous fluid) drainage?
Penrose drains
Nursing Care Plan for the Postoperative Patient should include?
Monitor Breath sounds--Crackles or wheezing can indicate retained secretions
Encourage Deep Breathing-Coughing
Ensure adequate Hydration
Monitor Pain
Monitor Cognitive Status
Observe Incision and dressings--Surgical wound dressing starts sanguineous (red), progresses to serosanguineous (pink) and then (pale yellow) after a few hours to days.
Monitor for low-grade temperature
Normal lab values for:
Potassium?
Calcium?
Sodium?
Potassium: 3.5 to 5.3 mEq/L
Calcium: 8.2 to 10.2 mg/dL
Sodium: 135 to 145 mEq/L
Normal Lab Values: PH, Pco2, HCO3, PaO2
PH: 7.35 to 7.45
Pco2: 32-45 mm Hg
HCO3: 20-26 mEq/L
PaO2: 75 to 100 mmHg