N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 69 of 160 • Altered oxygen diffusion and transport : Blood alterations impact transport because the majority of O2 is carried with hemoglobin. Encourage dietary protein, iron, and vitamin C intake. Encourage increased exercise. Avoid constricting peripheral circulation by avoiding tight clothing, dressings and constricting positions. • Altered cellular demand for oxygen : Promote rest, reduce anxiety, encourage weight loss, prevent shivering, and teach controlled breathing and relaxation techniques. Interventions to Promote Oxygenation • Positioning: elevation of the extremities; place patient in high-fowler’s position • Activity and rest patterns: passive and active exercises and stress reduction • Dietary modifications: sodium restriction; increase fluids; caloric restriction; modifications to promote erythrogenesis (birth of RBC) • Administration of oxygen : o Cannula: most common and least expensive; provides low concentration of O2, 2-6 lpm o Masks: simple mask at 5-8 lpm; partial rebreather mask at 6-10 lpm; non-rebreather mask provides the highest oxygen concentration possible other than intubation and mechanical ventilation at 10-15 lpm; venturi mask provides flow and jet adapters to determine specific FiO2 24-50% • Administration of blood and blood products: identify packed cells, clotting factors, and blood typing; introduction of blood or blood components into the venous system is performed when it is necessary to restore the body’s ability to transport oxygen and expel carbon dioxide, to restore clotting factors, fight infection, and to keep extracellular fluid within the vascular system • Airway maintenance o Incentive spirometry is used to improve pulmonary ventilation and counteract the effects of anesthesia/hypoventilation. It is also used to loosen respiratory secretions, facilitate respiratory gaseous exchange, and to expand collapsed alveoli. o Suctioning is vacuuming secretions via the use of a catheter connected to a negative pressure vacuum. It can be performed via oral, oropharyngeal, or nasopharyngeal suctioning to remove secretions from the upper airway tract. Endotracheal suctioning can be used to suction the trachea and two main bronchi. o Pursed-lip breathing creates resistance to the air flowing out of the lungs, prolonging exhalation and preventing airway collapse. This exercise works by increasing intrapulmonary pressure (when the client exhales through pursed lips), and then, the increased pressure helps to force open the collapsed alveoli blocked by secretions. This exercise assists the client to achieve some control over breathing. The pursed lip breathing is done to a count of 6-7when exhaling. o Postural drainage is the use of gravity to drain secretions from lung segments. Position the patient to promote gravity drainage of secretions from the lung fields. This is best performed upon awakening, before meals, and before bedtime. Hours after meals are