Exam 2 Flashcards
Nursing Assessment
assessing is the systematic and continuous collection, analysis, validation, and communication of patient data, or information. Assessment is the first of six nursing standards; collecting patient data is a vital step in the nursing process because the remaining steps depend on purposeful, prioritized, complete, systematic, accurate, and relevant data.
Nursing Diagnosis
the second step in the nursing process. The purposes of diagnosing are to identify how a person, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths that the person, group or community can draw on to prevent or resolve problems.
Nursing Implementation
During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. Nursing intervention as “any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes”. Direct and indirect care.
Nursing Evaluation
The fifth step of the nursing process, evaluating, the nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care.
Full Health Assessment
Involves gathering information about the health status of the patient. The nurse plans appropriate nursing interventions based on this data and evaluates patient outcomes to deliver the best possible care for each patient.
NANDA - North American Nursing Diagnosis Association
- Gather information and disseminate it through the Clearinghouse for Nursing Diagnosis
- Encourage educational activities at regional and state levels to promote the implementation of nursing diagnosis
- Promote and organize activities to continue the development, classification, and scientific testing of nursing diagnosis.
Importance of Coughing and deep breathing
- A cough is a cleansing mechanism of the body. It is a means of healping to keep the airway clear of secretions and other debris. A cough that is dry is termed a non-productive cough. A cough that produces respiratory secretions is termed a productive cough.
- Deep-breathing exercises can be used to overcome hypoventilation. Instruct the patient to make each breath deep enough to move the bottom ribs.
Pursed-lip Breathing
- Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing.
- Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration.
Crackles
intermittent sounds occurring when air moves through airways that contain fluid. Classified as fine, medium or coarse.
Rhonchi
Sonorous or coarse; snoring quality, low-pitched, continuous sounds, auscultated during inspiration and expiration, coughing may clear the sound somewhat, and air passing through or around secretions.
Wheezing (musical sounds)
continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors. Classified as sibilant or sonorous.
Gas exchange and CO2 within respiratory system
- Oxygen is carried in the body via plasma and red blood cells
- Most oxygen is carried by RBCs in the form of oxyhemoglobin
- Hemoglobin also carries carbon dioxide in the form of carboxyhemoglobin.
- Internal respiration between the circulating blood and tissue cells must occur
Normal values for Respirations
under normal conditions Respirations should be 12-20 breaths a minute
Normal Pulse Oximeter Levels
95-100% SpO2
S&S Respiratory Distress
- Rapid, Shallow breathing
- Sharp pulling in of the chest below and between the ribs with each breath
- Grunting sounds
- Flaring of the nostrils
Cyanosis
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood
Dyspnea
difficulty breathing or labored breathing
Anemia
condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness.
Pallor
an unhealthy pale appearance
Apnea
temporary cessation of breathing, especially during sleep
Tachypnea
abnormally rapid breathing
Bradypnea
decrease in respiratory rate
Nursing diagnosis’s for various respiratory conditions
Impaired gas exchange, ineffective airway clearance, risk for deficient fluid volume, risk for decreased cardiac output, anxiety and risk for injury.
S&S of hypoxia
hypoxia is a condition in which an inadequate amount of oxygen is available to cells, skin can turn blue to cherry red, confusion, cough, increase HR and Respirations, SOB, sweating and wheezing.
