NURSING NUR 3227 Compiled study guide_ Already Graded A+

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Final Exam Study Guide Respiratory Normal values pH: 7.35-7.45 PCO2: 35-45 PO2: >80 mm Hg HCO3-: 22-26 mEq/L Assessing: 1. First note pH: 2. Determine primary cause of disturbance a. Alkalo ... sis b. Acidosis 3. Determine if compensation has begun Chest Tubes- 1. Procedure: a. Fill water-seal chamber with sterile water to the 2-cm level b. If suction is to be used, fill the suction control chamber with sterile water to the 20-cm level, or as ordered by the health care provider c. Encourage the client to change position frequently d. The drainage system must be maintained below the level of insertion e. Chest tubes are clamped only momentarily to check for air leaks and to change the drainage apparatus f. Observe for fluctuations of fluid in water-seal chamber g. Gently milk tubing in the direction of drainage as needed if agency policy allows h. When the health care provider removes the chest tubes, the nurse should instruct the client to do the Valsalva maneuver (forcibly bearing down while holding breath); the chest tube is clamped and quickly removed by the health care provider; an occlusive dressing is applied to the site 2. Complicaitons: a. Observe for constant bubbling in the water-seal chamber; this indicates a leak in the drainage system b. If the chest tube becomes dislodged, apply pressure over the insertion site with a dressing that is tented on one side to allow for escape of air c. If the tube becomes disconnected from the drainage system, cut the contaminated tip off the tubing, insert a sterile connector, reattach to the drainage system; or immerse the end of the chest tube in 2 cm of sterile water until the system can be reestablished Cystic Fibrosis-Hereditary dysfunction of exocrine glands, causing production of abnormally thick mucus secretions 1. Causes: sweat glands to dysfunction, respiratory dysfunction, GI dysfunction, 2. Diagnostic tests: a. Sweat chloride analysis-elevated levels of sodium and chloride b. GI enzyme evaluation-pancreatic enzyme deficiency 3. Nursing Management: a. Assess airway clearance b. Listen to breath sounds c. Assess vital signs d. Administer low-flow oxygen to prevent CO2 narcosis; monitor response to oxygen therapy e. Encourage fluids (6-8 glasses; 3,000 ml/24 h) f. Administer medications-bronchodialators, mucolytics, corticosteroids, anticholinergics, leukotriene inhibitors, influenza and pneumococcal vaccines g. Chest physiotherapy-to promote removal of secretions with a minimum expenditure or energy and to decrease need for deep thracheobronchial suctioning i. Breathing exercises: 1. Diaphragmatic or abdominal breathing a. Client positioned on back with knees bent b. Place hands on abdomen c. Breathe from abdomen and keep chest still 2. Pursed lip breathing a. Breathe in through nose b. Purse lips and breathe out through mouth c. Exhalation should be twice as long as inspiration 3. Coughing techniques a. Instruct client to lean slightly forward and take several slow, deep breaths through the nose, exhaling slowly through slightly parted or pursed lips b. Client should then take another deep breath and cough several times during expiration c. Client must be encouraged to cough from deep within the chest and to avoid nonproductive coughing that wastes energy 4. Postural drainage-uses gravity to facilitate removal of bronchial secretions a. Client is placed in a variety of positions to facilitate drainage into larger airway b. Secretions may be removed by coughing or suctioning 5. Percussion and vibration-usually performed during postural drainage to augment the effect of gravity drainage a. Percussion-rhythmic striking of chest wall with cupped hands over areas where secretions are retained b. Vibration-hand and arm muscles of person doing vibrations are tensed, and a vibrating pressure is applied to the chest as the client exhales 6. Incentive spirometer-used to maximize inspiration and mobilize secretions a. Set incentive spirometer to goal client is to reach or exceed (500 ml often used to start) [Show More]

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