part 2 Flashcards
Crackles (rales):
Crackles (or rales) are caused by fluid in the small airways or atelectasis. They are referred to as discontinuous sounds; they are intermittent, nonmusical and brief. Can be heard on inspiration or expiration.
Rhonchi
Rhonchi (plural of the word rhonchus) are continuous, low-pitched sounds that are best heard when you’re breathing out (also called “expiration”).
Sputum
A mixture of saliva and mucus coughed up from the respiratory tract, typically as a result of infection or other disease and often examined microscopically to aid medical diagnosis.
B/P:
Blood pressure is the pressure of blood pushing against the walls of your arteries. Arteries carry blood from your heart to other parts of your body
SOB:
to cry or weep with convulsive catching of the breath
SpO2:
Oxygen saturation (SpO2) is a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry.
IV:
An intravenous line (IV) is a soft, flexible tube placed inside a vein, usually in the hand or arm.
CXR:
A chest X-ray is an imaging test that uses X-rays to look at the structures and organs in your chest.
Hypoxemia:
Hypoxemia is when oxygen levels in the blood are lower than normal.
Cue recognition: Based on the expected VS for a client of this age, how would you interpret Lily’s most recent VS on Tuesday morning?
I would be concerned about Lily’s VS on Tuesday. Her body temperature of 103 degrees is very high, her pulse is slightly higher than I would expect, her respiration rate is extremely fast, however her blood pressure is just fine.
Hypotheses generation: What factors may have altered Lily’s vital signs?
For Lily’s vital signs to change, her condition must be getting worse. Her immune system is getting weaker therefore the illness is growing stronger. It would make sense that as her temperature/fever grew higher, her respiration and heart rate would get faster because the illness makes it harder for her body to function properly.
Cue recognition: What assessment data (cues) indicate a deterioration in Lily’s status at this point?
Her vital signs are the indicator that Lily’s getting worse. Without keeping track of that data we wouldn’t know if her condition is getting better or worse.
Hypotheses generation: What information is a priority at this point?
Lily’s temperature and her SpO2 levels should be taken as the biggest priority. She has a fever and has too little oxygen getting to her blood.
Hypotheses evaluation: What assessment data would indicate an improvement in status?
We would know that Lily’s status is improving once her vital signs return to normal levels. Her heart and respiration rate should slow down, her temperature should get lower, and her SpO2 levels should raise to over 95%.
