N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 70 of 160 avoided so as not to induce reflux or vomiting. Prior to respiratory treatment, the nurse assesses the upper and lower lobes. After treatment, the nurse auscultates the lobes again to compare and evaluate the effectiveness of treatment. o Percussion and vibration (cupping and clapping) is a dependent nursing function that is performed by cupping the hands and striking the client’s chest in an attempt to dislodge secretions. Vibration is performed by lying flat hands on the chest and vigorously quivering the hand in movements designed to increase air turbulence in the lung, thus loosening secretions. Both methods are usually performed together after postural drainage. • Ethical and legal implications : Use of ventilators, protocols for blood administration, and the institution of life support measures can cause cultural and religious concerns for some patients. • Metered Dose Inhaler (MDI): a hand held nebulizer that contains pressurized medication for delivery through the mouth/oropharyngeal route (via an extender or spacer for children) o Inhale/exhale several breaths slowly and deeply through the nose o Inhale slowly/deeply thru the mouth while pressing down once on the canister and continue to inhale 2-3 seconds o Hold breath for 5-10 seconds o Exhale slowly through pursed lips o If another puff is prescribed, wait 1-3 minutes o Rinse mouth with tap water and blow nose to remove remaining medication o Clean the mouthpiece after each use o Disinfect weekly using water/vinegar solution o Store at room temp o Report adverse reactions such as restlessness, palpitation, nervousness or rash after use 3.3 Pulmonary Physiology The cough reflex is triggered by irritants in the larynx, trachea or bronchi. This reflex prevents aspiration of fluids and keeps the airways open by expelling foreign matter and pathogens. The cough reflex is initiated as the vagus nerve triggers the medulla and a large amount of air is quickly inhaled. With the help of the abdominal muscles and internal intercostal muscles, a strong contraction raises the lungs’ internal intercostal muscles, forcing a sudden opening of the epiglottis and glottis. During the explosive rush of air, mucous and foreign matter is dislodged from the lower respiratory tract for propulsion outward. The alveolar and capillary walls form the respiratory membrane. Pulmonary ventilation is the ventilation of the lungs through the act of breathing. Inspirations (Inhalation) is when air flows into the lungs. Expirations (exhalation) is when air moves out of the lungs.