Exam 1 Flashcards
Describe ISBAR
Identify - yourself, role, task; the patient, name, DOB, why admitted
Situation - what is going on, dx, symptoms
Background - previous dx, concerns
Assessment/Action: what you have determined, what needs to be intervened
Recommendations: interventions, transfers, etc.
Chronic Illness
Illness with symptoms that impede an individual’s daily life/QoL for more than 3 months
Chronic Illness Management
More symptom management, education, alleviate to improve QoL
Ageism
Nursing Processs
Critical thinking, decision making process
Assessment
Nursing Dx
Planning
Implementation
Evaluation
Objective Data
Signs; what the nurse observes
Vital signs
Diagnostic tests
Outward appearance of client
Physical Examination
- Inspection
- Auscultation
- Palpation
- Percussion
Subjective Data
Symptoms; what the client explicitly tells the nurse
Pain
Nausea
Tenderness
Told through physical exam (pain upon auscultation)
Health hx - fam/past/current
Medication use
Substance use
Nasal Cannula
Use when SpO2 slightly low but still okay
Can eat using this
Deliver <5L
Simple Face Mask
Use when need to deliver more O2 than nasal cannula
5-10L
Non-Rebreather Mask
Use when you need to deliver higher than 21% O2
Focused Assessment
Abbreviated health hx and physical exam when pt indicates pain/dysfunction in a particular system
ex. chest pain -> focused chest assessment
Comprehensive Assessment
Thorough documentation of health hx and physical examination of all systems
If issue arises, will continue on and perform a focused assessment
How to Assess Adequate Oxygenation
WoB - increased
Adventitious breath sounds
SpO2
ABGs
Cyanosis
Respiratory rate increased
Heart rate increased
Interventions for Inadequate Oxygenation
Administer oxygen
- higher flow/concentration
Determine what could be causing the impairment
- diffusion: pneumonia? COPD?
- airway bronchoconstriction/remodelling: COPD, asthma
Vital Signs
HR: 60-100 bpm
BP: 120/80 mmHg
RR: 12-20 br/min
SpO2: >95%
Temp: 36.6-37.5
Pain
Pneumonia - Manifestations (S/S)
Wheezing and crackling breath sounds
Fever
Increased respiratory rate
Increased heart rate
Productive cough
Decreased SpO2
Pneumonia - Nursing Assessments
SpO2
WoB
Adventitious breath sounds - auscultate
Equal chest expansion
RR/HR/Temp
Pneumonia - Nursing Interventions
Semi-fowler’s position
Productive coughing techniques
Incentive Spirometer
Antibiotics
Bronchodilator
Mucolytics
Pneumonia - Nursing Teaching
Tripod/Semi-Fowler’s position - helps with lung expansion
Incentive spirometer
Cough techniques
Mask wearing/hygiene
Pneumonia - Possible Complications
ARDs
Pleural effusion
Pneumothorax
Asthma - Manifestation (S/S)
Wheezing
WoB increased
Cough
Increased RR, prolonged expiration
Asthma Nursing Assessments
Dyspnea, WoB, accessory muscle use
Chest expansion
Decreased SpO2
Adventitious breath sounds - wheeze
Asthma - Nursing Management
Assessment: subjective - previous exacerbations, exposure to triggers, medications, vital signs
Nursing Dx: Ineffective airway clearance as a result of excess mucus production; Ineffective
Planning: goal - improve QoL, management of attack,
Implementation - asthma control plan
Asthma - Nursing Teaching
Health Promotion: fluid intake, exercise, anxiety control, trigger avoidance, nutrition
Device management - inhalers, medications, etc.
Education + resources
Asthma - Possible Complications
Could evolve into severe obstruction which could totally impair gas exchange
Untreated/uncontrolled could lead to airway remodelling and chronic inflammation
Hypoxemia, poor organ perfusion
ARDS
COPD - Manifestations (S/S)
Chronic, persistent dry cough for >3 months in two years
Mucus/sputum production
Dynamic hyperinflation - barrel chest
Increased WoB
Pursed lip breathing
Dyspnea, SoB
Smoking/particulate matter exposure hx
Weight loss/anorexia
Prolonged expiratory, wheezes, decreased breath sounds
Tripod position
Accessory muscle use
Hypoxemia, cyanosis
COPD - Nursing Assessments
Subjective: respiratory infections/illnesses, medications, pack years & smoking hx, dyspnea, exhaustion, irritability, exposure to particulate matter, restlessness, unable to fully exhale, anorexia/weight loss/difficulty eating, dyspnea, fatigue
Objective: height/weight/BMI, anxiety, increased WoB, compensatory breathing mechanisms, depression/restlessness, cyanosis, peripheral edema, increased RR, prolonged expiration
Equal chest expansion/retraction; body composition - thin?
Adventitious breath sounds - wheeze, crackles
Productive cough - sputum produced
COPD - Nursing Teaching
Health Promotion: smoking cessation, exercise/walking, fluid & nutritional intake,
COPD - Possible Complications
Pulmonary hypertension, right heart hypertrophy, cor pulmonale
