Oxygenation
The expected O2 saturation level range.
What is between 95-100%?
Perfusion is defined as this.
What is the flow of Red Blood Cells (RBCs) to and from the pulmonary capillaries (lungs)?
True of False
Infection control technique is used when performing trach suction.
What is true?
Trach suction requires sterile technique procedure.
Rationale: There is a direct contact with the patient's airway which bypasses the body's natural defenses.
Critical thinking is relation to patient care is.
What is evaluating the effectiveness or ineffectiveness of a given treatment?
Following a process or pattern and not jumping to conclusions. Using reason to back up your decisions.
The #1 priority with every patient is this.
What is safety?
The six types of oxygen delivery systems are these?
What are nasal Canula, Simple Face Mask, Partial Rebreather, Non-Rebreather, Venturi Mask, and Arisol Mask or Face Tent?
Perfusion is measured by this.
What is pulse oximeter?
A nurse should allow this much time in between suction.
What is at least one minute in between suction for ventilation and oxygenation. (Let them catch their breath.)
The three levels of critical thinking are these.
What are:
Basic: Trusts experts and bases thinking upon rules.
Complex: Analyzing and examining data to determine the best alternative.
Commitment: Expect to make decisions without expecting help from others and takes accountability for those choices.
Advancement is based on knowledge and experience.
Safety education for an elderly patient returning to their home who is a fall risk.
What are 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 in case of falls?
The late signs and symptoms of hypoxia are these.
What are cyanosis in extremities, Bradycardia, Hypotension, Cardiac Dysrhythmias, and Stupor (hard to wake)?
True or False
A person who is newly diagnosed with COPD will have an oxygenation issue.
What is true?
This person with Chronic Obstructive Pulmonary Disorder (COPD) will have 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.
The nurse should perform this before each suction.
What is hyperoxygenate the patient?
The five critical thinking skills are.
What are
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 this.
What is Personal Healthcare Information
(HIPPA)?
Early signs and symptoms of hypoxia are these.
What are tachypnea, Tachycardia, Restlessness/Anxiety, Pale Skin, Elevated Blood Pressure, and Nasal Flaring?
True or False
Perfusion plays an a role in selecting a site for medication administration.
What is true?
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)
The proper technique for suctioning a patient with a tracheostomy tube are these.
What are
1. Hyperoxygenate the patient.
2. Insert catheter into the trach.
3. Advance catheter until resistance is met.
4. Pull the catheter back 1 cm (1/2 in) before beginning suction.
5. Apply intermittent or continuous suction by covering and uncovering the suction port with your thumb, suction no more than 10-15 seconds.
Critical thinking can be applied in ATI by?
What is asking yourself what is being asked and look for distractors.
Measures that must be taken to ensure patient information are these. 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
The flow rates for the six different types of oxygen delivery systems are these.
Nasal Canula: 1-6 L/min
What are:
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?
Factors that promote wound healing in relation to perfusions. Name three
What are oxygen, WBC, proteins, potential medication side/adverse effects?
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy suction? (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.
What are 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.
The patient's safety supersede the safety of the nurse.
There is no right answer! ¯\_(ツ)_/¯
Follow facility protocols.
Document everything