NUR 227 MS TEST 1 – OXYGENATION REVIEW QUESTIONS AND CORRECT ANSWERS

Patients who could have problems with oxygenation 1. COPD 2. Emphysema 3. Pneumonia 4. Cystic fibrosis 5. Recovering from lung surgery 6. CHF 7. Pneumothorax 8. Head/neck cancer 9. Trauma 10. Pregnant woman 11. Multiple Sclerosis S&S of Oxygen problem 1. Restlessness & anxiety (early) 2. Tachycardia 3. Increased BP 4. Dysrhythmias 5. Diaphoresis 6. SOB 7. Confusion 8. Dyspnea 9. Labored breathing 10. Decreased O2-Sat 11. Cyanosis 12. Stridor -AUSCULTATE LUNGS -HOB elevated immediately -Supplemental O2 -S&S of pnemonia Objective S&s of decreased oxygen 1. Cyanosis 2. Pallor 3. Clubbing 4. Decreased O2-sat 5. ABG's Subjective S&S of decreased oxygen 1. Pt reports SOB 2. Pt reports chest tightness 3. Pt. reports fatigue 4. Pt reports dizziness/headache Patients who may need chest tube Lung cancer Post-op lung surgery CHF Trauma Pneumothorax Hemothorax Pleural effusion Empyema Post-op cardiac surgery Traditional water seal chest drainage system has 3 chambers -collection chamber -water seal chamber - 2 mm sterile water -we suction control chamber - 20 mm sterile water intermittent bubbling = system is functioning properly positive and negative pressure-release valves can connect to suction source Dry Suction Water Seal 3 Chambers -collection chamber -water seal chamber - 2 cm sterile water -wet suction control chamber - does not require water set suction pressure with regulator positive and negative pressure release valves indicator to signify adequate suction pressure Dry suction one-way valve system one-way mechanical valve = allows air to leave chest; prevents air from moving back into chest suction chamber does not require fluids ideal for quick and emergency set-up good for ambulatory pt; works even if knocked over Energy conservation to promote oxygen 1. Cluster care (do as much as possible at one time to keep from disturbing the patient) 2. allow breaks between activities 3. keep frequently used items close by 4. rest periods