NUR 105 Respiratory Exam
- Carries oxygen
Answer Hemoglobin
- Normal hemoglobin range
Answer 12-18g/dL
- Why do we need oxygen?
Answer Provides adequate tissue perfusion to the body
- Signs of respiratory distress
Answer Dyspnea
Nasal flaring- mostly in infants, MAJOR distress sign for adults Use of accessory muscles- shoulder shrugs, retractions Decreased endurance- tripod position on toilet Skin- dry mucous membrane, cyanotic, poor capillary refill Long term respiratory disease- clubbing, barrel chest
- Respiratory Assessment
Answer Nasal patency- alignment, pen light to check for ob- struction
Pharynx, trachea, larynx- midline, not deviated Lungs and thorax- movement, even unlabored breath sounds, use of accessory muscles General appearance- enlarged muscles, neck, shoulders, barrel chest (indicates long term) Oral mucosa for dryness, skin pallor, no cracks present
- If a pt is now confused after being AO all day, what should you do? 1 / 4
Answer Check oxygen level for hypoxia- brain tissue death
- Most precise route to check the need for oxygen therapy
Answer ABG
- 2nd most precise route to check for oxygen therapy
- pH range PCO2 range PO3 range HCO3 range
Answer O2 SAT and physical assessment
O2 range Answer
7.35-7.45
35-45
80-100
22-26
95-100%
- What is the purpose of oxygen therapy?
Answer To relieve hypoxemia
- How to check for hypoxemia?
Answer Check Hgb levels
- What do we want to do when we start to administer oxygen therapy? 2 / 4
Ad- minister the lowest amount possible to achieve goal
- Combustion education for O2 therapy
- No smoking- post signs
Answer
-Avoid flammables hairspray, heaters, nail polish, cleaning products
-Grounded plugs, cords not frayed -Avoid solutions containing alcohol or oil- WATER BASED ONLY
- How does oxygen toxicity occur
Answer 1- extent of lung disease
2- concentration of oxygen 3- Duration of oxygen use
- Signs of oxygen toxicity
Answer NEW onset of respiratory symptoms- will not be something they already have
-Dyspnea -Nonproductive cough -Chest pain beneath sternum -GI upset -Crackles on auscultation -Atelectasis
- What can you do to prevent oxygen toxicity 3 / 4
Monitor ABGs, then O2, then physically assess pt
- new onset of crackles/decreased breath sounds
Answer Absorption atelectasis
- What do you hear if a pt has atelectasis?
Answer Crackles
- What should you do if a pt is on more than 4 L of oxygen?
Answer Humidify oxygen
- What can a pt with oxygen have if they are non compliant?
Answer Sores
- What do we want to educate our pts with oxygen on?
- What do the alveoli do?
Answer Risk for infection- If you humidify oxygen- pathogens grow- clean and change out If tubing is on ground, clean or change out tubing
Answer Increase gas exchange
- Incision to create stoma for trach
- / 4
Answer Tracheotomy