Adult Health 1 Respiratory System

Adult Health 1 Respiratory System List four common symptoms of pneumonia a nurse might note on physical examination Tachypnea Fever with chills Productive cough Bronchial breath sounds State four nursing interventions for assisting a patient to cough productively Encourage deep breathing Increase fluid intake to 3L/day Use humidity to loosen secretions Suction airway to stimulate coughing What symptoms would you expect to see in an older adult with pneumonia? Lethargy Confusion anorexia rapid respiratory rate What should the O2 flow rate be for the client with COPD? Between 1-2L per nasal cannula; too much O2 may eliminate the COPD patient's stimulus to breathe. A COPD client has a hypoxic drive to breathe. How does the nurse prevent hypoxia during suctioning? Delivering 100% O2 (hyperinflating) before and after each endotracheal suctioning. During mechanical ventilation, what are three major nursing interventions? Monitor client's respiratory status & secure connections Establish a communication mechanism w/the client Keep airway clear by coughing and suctioning When examining a client with emphysema, what physical findings is the nurse likely to see? Barrel chest cough (dry or productive) decreased breath sounds dyspnea crackles in lung fields What is the most common risk factor associated with lung cancer? smoking Describe the preoperative nursing care for a client undergoing a laryngectomy. -Involve family and client in teaching on tracheostomy equipment -plan acceptable means of communication methods -refer to speech pathologist -discuss rehabilitation List 5 nursing interventions after a chest tube is inserted -Maintain dry, occlusive dressing over chest tube at insertion site -Keep all connections tight and taped -Encourage client to deep breathe periodically -Monitor fluid drainage amounts; mark time of measurement and the fluid level. What immediate actions should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus? Place end of tube in a container of sterile water at a 2 cm level What immediate actions should the nurse take when a chest tube becomes accidentally removed from the client's body? Place occlusive dressing over opening Notify doctor ASAP What instructions should be given to a client following radiation therapy? -Do not wash off lines drawn by physician -Wear comfortable cotton clothing -Avoid the use of powders or creams on radiation site What precautions are required for clients with TB? -Private room -A mask worn by anyone entering the room -Client must wear a mask if leaving his/her room List four components of teaching for the client with TB -Cough into a tissue and dispose of either by flushing down toilet or in specially provided bags -Need for long term daily medications -Good handwashing technique -Report any signs of worsening conditions