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Quick Facts #1 - Respiratory

AB
Good way to determine severity of patient's dyspnea...scale of 0-10
Raising shoulders and pulling of neck muscles (chart this as...)use of accessory muscles
Cause of barrel-shaped chest...air trapping
If you hear an adventitious sound on the left, do this..listen on the right
Have the patient do this when breathing in and out while you listen...open mouth
Term meaning normal breathing...eupnea
Breathing has periods of fast, deep, then apnea...Cheyne-Stokes
RR of 32/min is termed...tachypnea
Moist, bubbling sounds in lungs...crackles (rales)
Sound made by airway obstruction...stridor
Sound associated with asthma...wheezing
Teach patient to do this before coughing to make it more effective...deep breaths
Do this before ABG's are drawn..Allen's test
Do this after ABG's are done...hold pressure for 5 minutes
PCO2 of 55 is...high
Describe oxygen saturation...% of hemoglobin saturated with oxygen
Pulse ox is 88% - what do you do?...place on 2L NC and obtain an order
Check gag reflex like this...touch back of throat with cotton tipped swab
Teach dyspneic patient this type of breathing...pursed lip
Best position for dyspneic patient to allow maximum lung expansion...Fowler's
Make sure of this concerning nonrebreathing mask...both side vents are closed and reservoir bag is inflated
Best way to determine whether or not a patient can administer neb treatments or MDI's...have them demonstrate the procedure
Tell patient to avoid this when using MDI's...taking more often than prescribed
Intervention to encourage deep breathing after surgery...Incentive Spirometer (IS)
Actions before a thoracentesis...teach relaxation techniques, assist patient to sit on side of bed or maintain a curved spine, have consent form signed prior to procedure
Best way to tell if thoracentesis was effective...patient staes his dyspnea has lessened
Remember this about the chest tube drainage system...always keep below chest level
Vigorous bubbling in chest tube system may indicate this...air leak in system
Fluctuation of water level in the water seal chamber means...Nothing. This is "tidaling" and is normal.
Trach patient has coarse crackles and is dyspneic. Have the patient do this to try to relieve the problem...take a deep breath and cough
Time for safe suctioning...15 seconds
Do this before the need for intubation arises...check advance directives
High pressure alarm on ventilator may mean the patient is coughing, or...needs suctioned
PEEP on a ventilator does this...provides positive pressure on expiration to keep alveoli open
First step to do when a ventilator alarm sounds...check the patient


School of Practical Nursing
James Rumsey Technical Institute
Martinsburg, WV

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