Oxygenation
What is the meaning of the pulse oximetry reading?
% of red blood cells saturated with oxygen
What do the nasolabial folds allow the nurse to assess best?
Facial Symmetry
Name 2 expected findings for respiratory assessment in a geriatric patient
•Increased respiratory rate (compensation for age related changes)
Loss of lung elasticity, less effective cough, diminished breath sounds
Name three safety measures when oxygen is in use in the home
Signs, no smoking, no open flame, water soluble lubricant for nares, monitor for tripping hazard
A nurse shines a light into a patient's pupils.
What is the expected
response?
The pupils should constrict
What is the nurse inspecting and palpating when assessing the respiratory system?
Inspect anterior, posterior and lateral thorax for: color, symmetry, downward rib slope, sternum shape, position of trachea, ICS, AP:T ratio, chest expansion, respiratory rate, depth and rhythm
Palpate for tenderness, pain or crepitus
What does it mean to titrate oxygen?
A doctor can order a 'range' of oxygen per liter to keep the patients oxygen saturation at a specific level. The nurse then has freedom to 'titrate' or 'adjust' the dose within that range
To assess an adult patient's eardrum with an otoscope, the nurse does what with the patient's ear to ensure a good view?
Pull the ear up, out and back
The nurse auscultates high pitched, short popping sounds often during inspiration that do not clear with coughing in both posterior bases. How does this get documented?
Fine crackles in posterior lung bases bilaterally
Name two nursing interventions when a client is receiving oxygen via mask at 6 liters
Monitor pulse oximetry readings, skin assessments every 2 hours, dry moisture from humidification every two hours, respiratory assessment as needed, head of bed elevated
What is one test that a nurse can perform to evaluate extraocular movements?
6 cardinal fields of vision
Use of accessory muscles, and nasal flaring, grunting is NOT normal in what patient population?
Pediatric
Describe the correct use and purpose of the Incentive Spirometer
Put lips around the tube and inhale slow and steady as long as possible. Remove tube from lips and exhale. It is a visual incentive to expand lungs and prevent atelectasis
Demonstrate the assessment for TMJ and state what an abnormal finding would be
Two fingers on the client jaw and ask them to open and close their jaw. They should not have pain or clicking sounds.
Name 3 open ended subjective questions that are important when assessing the respiratory system
Any shortness of breath at rest or with activity?
Any history of respiratory illness such as asthma, COPD?
Smoker?
Any cough? COLDSPA cough