1
NR224 i Final i Exam i Test
i MapiDistribution iof i Questions:
Main iFocus iTopics i: iOxygenation, iBowel/ Nutrit ion, iMedications
Delegation: i For i all i topics , i pleas e ik now i what i the i nurs e i can i and i cannot i deleg ate i related
itoithe i patient’s i care.
Oxygenation
Basic iA i& iP
• Ventilation i- ithe imovement iof iair ibetween ithe iatmosphere iand ithe ialveoli iof ithe ilungs ias
weiinhale iand iexhale
i
• Diffusion i- igas iexchange iwhich iinvolves iCO2 ibetween ithe ialveoli iand ithe ipulmonary icapillaries
• Transportation i- itransport iof ioxygen ifrom ithe ilungs ito ithe itissues iand itransport iof icarbon
idioxide ifrom ithe itissues ito ithe ilungs
Respiratory i assessment/Priorities iof i care/s/s i of irespiratory i abnormalities i and i RN
iResponse
• Assessment iincludes ipain, idyspnea, iwheezing, irespiratory iinfections, ihealth irisks,
smoking,icough, ienvironmental iexposures, iallergies, iand imedications iused.
i
• Alterations iin iRespiratory iFunctioning
• Hyperventilation i- iventilation i in iexcess iof ithat irequired ito ieliminate icarbon idioxide iproduced
ibyic ellular imetabolism
• Hypoventilaiton i- ialveolar iventilation iinadequate ito imeet ithe ibody’s ioxygen idemand ior ito
ieliminate isufficient icarbon idioxide
• Hypoxia i- iinadequate itissue ioxygenation iat ithe icellular ilevel
• Cyanosis i- iblue idiscoloration iof ithe iskin iand imucous imembranes
• Interventions
, 2
• Position ithe iclient ito iallow ifor imaximal ichest iexpansion
• Encourage ior iassist iclient iwith ifrequent ichanges iin iposition,every i2 ihours
• Encourage ideep ibreathing iand icoughing
• Encourage iambulation
• Promote icomfort iso iclient ican itolerate ithe iabove iactivities
• increased ifluids
• suctioning
, 3
Delivery isystems
• Oxygen iis ia imedication, iit imust ibe iadministered ias iprescribed.
• The idose ior i concentration iof ithe ioxygen ishould ibe icontinuously imonitored
• Humidification iis inecessary ifor iclients ireceiving iO2 itherapy i>4L/min
• If iyou ihave ia iclient ireceiving ioxygen iyou imust icheck iit iwhen iyou iassess ithe iclient
• If iclient iis itransported imake isure iportable itank ihas ienough ioxygen iin itank
• Initiating ithe iadm iof ioxygen iis iconsidered isimilar ito iadministering ia imedication iand iis
inotidelegated ito iUAP
• UAP imay ireapply ithe ioxygen idelivery idevice
• Nasal iCannula
• Most icommonly iused ioxygen idevice ibecause iof iconvenience iand iclient icomfort
• Delivered ioxygen iconcentration ican ivary iwith iclient ibreathing ipattern
• Nasal ipassages imust ibe ipatent ifor iclient ito ireceive iO2
• Can icause iskin ibreakdown iover ithe iears iand iin ithe inares
• Face iMask
• FaceiMasks icover ithe iclient’s inose iand imouth
, 4
• To iavoid irebreathing iCO2 iwhile iwearing ia imask,a iminimum iof i5L/min ioxygen iflow irate
iisirequired
• Exhalation iPorts ion ithe isides iof ithe imask iallow iexhaled icarbon idioxide ito iescape
• Remember ito ifind ian iappropriate imask isize ifor ithe iclient
• Limitations: ihard ito iachieve ia iproper ifit iand ipoor itolerance
• 40-60% iwhen ioperated iat i6-10L
• Most icommon imidrange iO2 idelivery idevice
• Minimum iof i5L/min iO2 irequired ito iprevent iclient ifrom ire-breathing iexhaled icarbon idioxide
• As iwith icannula, iactual idelivered iO2 iconcentration ivaries iwith ibreathing ipattern
• Face iMask iis icontraindicated ifor iclients iwith iCO2 iretention ibecause iit ican iworsen
• Face iMasks iwith iReservior iBags
• Provide ia ihigher ioxygen iconcentration ito ithe iclient
• Portion iof iclient’s iexpired iair iis idirected ito ithe ibag
• Its ioxygen iconcentration iremains ithe isame ias ithe iinspired iair
• Partial iRebreather
• Delivers ioxygen iconcentrations iof i60-90% iat iliter iflows iof i6-10 iL iper iminute
• O2 ireservoir ibag iallows iclient ito irebreathe ifirst ithird iof iexhaled iair iin iconjunction iwith iO2
• Do inot iallow ibag ito ideflate iduring iinspiration ito iavoid iCO2 ibuildup(increase iliter iof iflow
iifineeded)
• Non-rebreathing iFace iMask iwith iReservior iBag
• Nonrebreather idelivers ithe ihighest ioxygen iconcentration ipossible i95-100% iat iliter iflows iof i10-
i15L/min
• One-way ivalves ion ithe imask iand ibetween ithe ireservoir ibag iand imask iprevent iroom iair iand
iclient’s ie xhaled iair ifrom ientering ithe ibag iso ionly iO2 iin ibag iis iinspired
• To iprevent iCO2 ibuildup,the inonrebreather ibag imust inot ideflate
• Used ifor icritically iill iclients
• FaceiTent
• Face iTents ican ibe iused iwhen imasks iare inot itolerated
• Provide i30-50% iconcentrations iof iO2 iat i4-8L/m
• Keep iskin idry
NR224 i Final i Exam i Test
i MapiDistribution iof i Questions:
Main iFocus iTopics i: iOxygenation, iBowel/ Nutrit ion, iMedications
Delegation: i For i all i topics , i pleas e ik now i what i the i nurs e i can i and i cannot i deleg ate i related
itoithe i patient’s i care.
Oxygenation
Basic iA i& iP
• Ventilation i- ithe imovement iof iair ibetween ithe iatmosphere iand ithe ialveoli iof ithe ilungs ias
weiinhale iand iexhale
i
• Diffusion i- igas iexchange iwhich iinvolves iCO2 ibetween ithe ialveoli iand ithe ipulmonary icapillaries
• Transportation i- itransport iof ioxygen ifrom ithe ilungs ito ithe itissues iand itransport iof icarbon
idioxide ifrom ithe itissues ito ithe ilungs
Respiratory i assessment/Priorities iof i care/s/s i of irespiratory i abnormalities i and i RN
iResponse
• Assessment iincludes ipain, idyspnea, iwheezing, irespiratory iinfections, ihealth irisks,
smoking,icough, ienvironmental iexposures, iallergies, iand imedications iused.
i
• Alterations iin iRespiratory iFunctioning
• Hyperventilation i- iventilation i in iexcess iof ithat irequired ito ieliminate icarbon idioxide iproduced
ibyic ellular imetabolism
• Hypoventilaiton i- ialveolar iventilation iinadequate ito imeet ithe ibody’s ioxygen idemand ior ito
ieliminate isufficient icarbon idioxide
• Hypoxia i- iinadequate itissue ioxygenation iat ithe icellular ilevel
• Cyanosis i- iblue idiscoloration iof ithe iskin iand imucous imembranes
• Interventions
, 2
• Position ithe iclient ito iallow ifor imaximal ichest iexpansion
• Encourage ior iassist iclient iwith ifrequent ichanges iin iposition,every i2 ihours
• Encourage ideep ibreathing iand icoughing
• Encourage iambulation
• Promote icomfort iso iclient ican itolerate ithe iabove iactivities
• increased ifluids
• suctioning
, 3
Delivery isystems
• Oxygen iis ia imedication, iit imust ibe iadministered ias iprescribed.
• The idose ior i concentration iof ithe ioxygen ishould ibe icontinuously imonitored
• Humidification iis inecessary ifor iclients ireceiving iO2 itherapy i>4L/min
• If iyou ihave ia iclient ireceiving ioxygen iyou imust icheck iit iwhen iyou iassess ithe iclient
• If iclient iis itransported imake isure iportable itank ihas ienough ioxygen iin itank
• Initiating ithe iadm iof ioxygen iis iconsidered isimilar ito iadministering ia imedication iand iis
inotidelegated ito iUAP
• UAP imay ireapply ithe ioxygen idelivery idevice
• Nasal iCannula
• Most icommonly iused ioxygen idevice ibecause iof iconvenience iand iclient icomfort
• Delivered ioxygen iconcentration ican ivary iwith iclient ibreathing ipattern
• Nasal ipassages imust ibe ipatent ifor iclient ito ireceive iO2
• Can icause iskin ibreakdown iover ithe iears iand iin ithe inares
• Face iMask
• FaceiMasks icover ithe iclient’s inose iand imouth
, 4
• To iavoid irebreathing iCO2 iwhile iwearing ia imask,a iminimum iof i5L/min ioxygen iflow irate
iisirequired
• Exhalation iPorts ion ithe isides iof ithe imask iallow iexhaled icarbon idioxide ito iescape
• Remember ito ifind ian iappropriate imask isize ifor ithe iclient
• Limitations: ihard ito iachieve ia iproper ifit iand ipoor itolerance
• 40-60% iwhen ioperated iat i6-10L
• Most icommon imidrange iO2 idelivery idevice
• Minimum iof i5L/min iO2 irequired ito iprevent iclient ifrom ire-breathing iexhaled icarbon idioxide
• As iwith icannula, iactual idelivered iO2 iconcentration ivaries iwith ibreathing ipattern
• Face iMask iis icontraindicated ifor iclients iwith iCO2 iretention ibecause iit ican iworsen
• Face iMasks iwith iReservior iBags
• Provide ia ihigher ioxygen iconcentration ito ithe iclient
• Portion iof iclient’s iexpired iair iis idirected ito ithe ibag
• Its ioxygen iconcentration iremains ithe isame ias ithe iinspired iair
• Partial iRebreather
• Delivers ioxygen iconcentrations iof i60-90% iat iliter iflows iof i6-10 iL iper iminute
• O2 ireservoir ibag iallows iclient ito irebreathe ifirst ithird iof iexhaled iair iin iconjunction iwith iO2
• Do inot iallow ibag ito ideflate iduring iinspiration ito iavoid iCO2 ibuildup(increase iliter iof iflow
iifineeded)
• Non-rebreathing iFace iMask iwith iReservior iBag
• Nonrebreather idelivers ithe ihighest ioxygen iconcentration ipossible i95-100% iat iliter iflows iof i10-
i15L/min
• One-way ivalves ion ithe imask iand ibetween ithe ireservoir ibag iand imask iprevent iroom iair iand
iclient’s ie xhaled iair ifrom ientering ithe ibag iso ionly iO2 iin ibag iis iinspired
• To iprevent iCO2 ibuildup,the inonrebreather ibag imust inot ideflate
• Used ifor icritically iill iclients
• FaceiTent
• Face iTents ican ibe iused iwhen imasks iare inot itolerated
• Provide i30-50% iconcentrations iof iO2 iat i4-8L/m
• Keep iskin idry
