Adv Pt Assess Flashcards
what are the key concepts of pt assessment
collect info analyze info identify current status provide interventions evaluate outcome
what are the 2 main critical thinking skills
analysis - breaking stuff down into components
synthesis - putting the components back together
why do we need to know about diagnostic tests
review test results
advise the pt - alleviate concern
give pt prep
tell them where to find more info
define pulmonary ventilation
movement of air between atmosphere and alveoli
diffusion of oxygen and carbon dioxide occurs between …
alveoli and capillaries
breathing centre location
medulla oblongata
define pulmonary edema
fluid in interstitial spaces and alveoli causes decreased lymphatic drainage, cardiac diseases, pneumonia, SIS, SOB, cough, tachypnea, substernal pain **can be fatal
define emphysema
pathological extension of interstitial/spaces by air loss for of COPD, increased long size, obstruction, decrease surface area, alveoli cant recoil SIS, decrease lung sounds,
define pneumonitis
inflam of the lungs due to super sensitivity causes …, aspiration, virus, autoimmune, lupus, SIS fever congestion, pan, cough, fibrosis
define pneumothorax
collection, air loss in pleural cavity caused by perforation through chest wall (trauma) or plura (superficial lung ) SIS, sudden onset, side pain, dyspnea, asymmetric chest wall movement
what are some cardiovascular conditions that may effect oxygenation
anemia
vascular disease - obstruction
heart damage and muscle changes - infarction
damage to electrical conduction system - pacemaker
what is a pulse oximeter
non-invasive device which can be attached to a finger, earlobe, toe, etc. to measure the amount of oxygenated hemoglobin in arterial blood.
what is the normal range of oxygen saturation
when is low enough to be life threatening
90-100%
if less than 80 life threatening
if less than 90% need to alert nurse
what are some diagnostic tests that assess function of respiratory system
- chest imaging
- bronchyscopy/laryngoscopy
- sputum sample, CBC, biochem, blood gases
- pulmonary function tests
what are early signs of hypoxia
- increased pulse -tachycardia
- increased resp, decreased BP (go together)
- cyanosis -> dis
- anxiety/restlessness
- dyspnea, diaphoresis -increased sweating
- headache/agitation
what are late signs of hypoxia
- pulse <60/min (brachycardia)
- cough, frothy/bloody sputum
- decreased resp, increased bp (go together)
- cyanosis
- fatigue, restlessness
- clubbing of fingers
what are some things to keep in mind when you have a pt who depends on oxygen therapy
correct rate of oxygenation
enough tubing/long enough
colour of pt
try not to dislodge or kink tubing when moving pt
people with COPD rely on what stimulus to breathe
why is this dangerous with oxygen therapy
CO2 levels
if there is too much oxygen administered this stimulus is gone and they stop breathing
what is important to ensure due to oxygen’s combustive tendancies
no smoking in the area
should materials that may generate static electricity or short circuit sparks (wool)
describe oropharyngeal/nasopharyngeal artificial airways
- maintain upper air passages
- easy to insert
- low risk of complications
- triggers gag reflex so ideal for non conscious pt
describe oropharyngeal/nasopharyngeal artificial airways
- maintain upper air passages
- easy to insert
- low risk of complications
- triggers gag reflex so ideal for non conscious pt
describe endotracheal tubes
- commonly for pts under general anesthesia or emergency situations
- tube terminates at bifurcation of the trachea
- pt will not be able to speak, need alternate means of communication
- oral care required
describe tracheostomy
- surgical incision in trachea just below the larynx (usually between 2nd and 3rd cartilage)
- tracheostomy tube inserted through stoma and into trachea
- air needs to be humidified cuz it no longer goes through upper respiratory tract
- when stoma heels the pt will likely not need tube in place
what are some vital signs
body temp heart rate or pulse respiratory rate blood pressure pain - not officially considered
