Oxygenation
What is the expected O2 saturation level range?
95-100%
What is the definition of perfusion?
The flow of Red Blood Cells (RBCs) to and from the pulmonary capillaries (lungs).
What infection control technique is used when performing trach care?
Surgical Asepsis
Rationale: There is direct contact with the patient's airway which bypasses the body's natural defenses.
What is critical thinking in relation to nursing applications?
Thinking about why something is effective or ineffective.
Following a process or pattern and not jumping to conclusions. Using reason to back up your decisions.
What is your #1 priority with every patient.
Safety
What are the six types of oxygen delivery systems?
Nasal Canula, Simple Face Mask, Partial Rebreather, Non-Rebreather, Venturi Mask, and Arisol Mask or Face Tent.
How is perfusion measured?
The pulse oximeter is used to test perfusion. The higher the O2 saturation, the better the perfusion of the individual.
How much time should the patient be given between passes with suction?
Allow at least one minute between passes for ventilation and oxygenation. (Let them catch their breath.)
What are the three levels of critical thinking?
Basic: Trusts experts and bases thinking upon rules.
Complex: Analyzing and examining data to determine the best alternative.
Commitment: Expects to make decisions without expecting help from others and takes accountability for those choices.
Advancement is based on knowledge and experience.
What safety education might need to be provided to an elderly patient returning to their home but is a fall risk?
Get rid of rugs, Avoid having any loose cords, Be careful with any steps, Stand and sit slowly, and Keep your phone on your person incase of falls.
What are the late signs and symptoms of hypoxia?
Cyanosis in extremities, Bradycardia, Hypotension, Cardiac Dysrhythmias, and Stupor (hard to wake)
A person is newly diagnosed with COPD, do they have an issue with perfusion or oxygenation?
This person has Chronic Obstructive Pulmonary Disorder (COPD), this is an issue with oxygenation because they cannot get sufficient oxygen delivered to the lungs.
Perfusion Issues: Insufficient O2 distribution.
Oxygenation Issues: Insufficient delivery of O2 to the lungs.
What preparatory task must be performed before doing the first pass of suction?
You must hyper oxygenate the patient to help ensure they do not low stat during the procedure.
What are the five critical thinking skills?
1. Observe
2. Use correct data collecting technique.
3. Differentiate between relevant and irrelevant data.
4. Organize and validate data.
5. Interpret assessment data and draw a conclusion.
We as healthcare professionals are responsible for the SECURITY of what?
Personal Healthcare Information
(HIPPA)
What are the early signs and symptoms of hypoxia?
Tachypnea, Tachycardia, Restlessness/Anxiety, Pale Skin, Elevated Blood Pressure, and Nasal Flaring
What factor does perfusion play in determining the site of administration for a given medication?
Administration sites with high blood perfusion have rapid absorption. (Major muscle groups and the lungs)
Administration sites with low blood perfusion have slow absorption. (Adipose tissue and topical/transdermal medications)
What is the proper technique for suctioning a patient with a tracheostomy tube?
1. Remove bag or ventilator from tube.
2. Insert catheter into airway.
3. Advance catheter until resistance is met.
4. Pull the catheter back 1 cm before beginning suction.
5. Apply intermittent suction by covering and uncovering the suction port with your thumb, pass should last 10-15 seconds.
How do you apply critical thinking to ATI?
Ask yourself what section they may be asking you about. Look for distractors in the question, they are there more often than not.
What measures must be taken to ensure patient information is secure? Name three!
-Log off any work station if you leave it
-Never share your Username or Password
-Never leave any kind of printed or written records where others can access them
-Shred any printed or written client information used for reporting or client care after use
What are the flow rates for the six different types of oxygen delivery systems?
Nasal Canula: 1-6 L/min
Simple Face Mask: 6-12 L/min
Partial Rebreather Mask: 6-11 L/min
Non-Rebreather Mask: 10-15 L/min
Venturi Mask: 4-12 L/min
Aerosol Mask/Face Tent: 10 or More L/min
What is carried in the blood that makes perfusion so important in wound healing? Name three!
Oxygen, WBC, Proteins, Potential medications introduced into the blood.
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.)
A. Apply the oxygen source loosely if the SPO2 decreases during the procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer cannula surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.
A, B, and C
A. Apply the oxygen source loosely if the SPO2 decreases during the procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer cannula surfaces in a circular motion from the stoma site outward.
A very clumsy patient stepped off their deck and sprained their right ankle while holding a steak knife, and during the fall they stabbed their left thigh. Using her knowledge of perfusion, the charge nurse instructs the patient to elevate their right ankle but keep their left thigh at heart level or lower. Why?
The sprained ankle will be prone to swelling, so it will be helpful to decrease perfusion to the area by elevating the ankle above the heart.
The stab wound to the thigh runs a risk of infection and will need to rebuild tissue. To best heal this injury the patient will want to increase perfusion to the area. This will bring WBCs to defend against infection and needed proteins to make new tissue.
Does the patient's safety supersede the safety of the nurse?
There is no right answer! ¯\_(ツ)_/¯
Follow facility protocols.
Document everything!
Cover your a**!