test one. Flashcards
ventilation
the exchange of gases in and out of the lungs
perfusion
the distribution of RBCs to and from pulmonary capillaries
compliance
the ability of the lungs to distend or expand in response to increased intra-aveolar
pressure; decreased in diseases such as pulmonary edema, interstitial and pleura fibrosis, and
congenital or traumatic structural abnormalities such as kyphosis or fractured ribs
resistance
pressure difference between the mouth and the alveoli in relation to the rate of flow of
inspired gas. Airway resistance is increased with illnesses such as asthma and tracheal edema
tidal volume:
typical amount of air that can be inhaled by forcible inspiration after completion of a
normal inspiration
inspiratory reserve volume:
amount of air that can be forcibly expelled from the lungs after
breathing in as deeply as possible
expiratory reserve volume
air remaining in the lungs after the most complete expiration possible; it
is elevated in diffuse obstructive emphysema and during an attack of asthma. Also known as
residual air.
vital capacity:
the maximal volume of air that can be forcefully exhaled after taking the deepest
breath
residual volume:
the amount of gas remaining in the lung at the end of a maximal exhalation
total lung capacity
the maximal volume to which the lungs can be expanded with the greatest
possible inspiratory effort; it is equal to vital capacity plus the residual volume and is approx. 5800
mL
eupnea
the normal rate and depth of ventilation
bradypnea
rate of breathing is regular but abnormally slow (less than 12 breaths per minute)
tachypnea:
te of breathing is regular but abnormally rapid (greater than 20 breaths per minute)
hyperventilation
rate and depth of respirations increase; hypocarbia may occur
hypoventilation
respiratory rate is abnormally low and depth of ventilation may be depressed;
hypercarbia may occur
apnea
respirations cease for several seconds; persistent cessation results in respiratory arrest
dyspnea
cal sign of hypoxia and manifests as breathlessness; sometimes related to exercise;
associated with pulmonary diseases, cardiovascular diseases, neuromuscular conditions & anemia
orthopnea
abnormal condition in which the person must use multiple pillows when lying down or
must sit with the arms elevated and leaning forward to breathe
cheyne-stokes respiration
pattern of breathing where increasingly longer and more frequent
periods of apnea alternates with hyperpnea;
biot’s respiration
respirations are abnormally shallow for two to three breaths, followed by regular
period of apnea
adventitious breath sounds
abnormal breath sounds
crackles
discontinuous, explosive, “popping” sounds that originate within the airways. Heard more
commonly during inspirations than expiration. Significant as they imply either accumulation of fluid
secretions or exudate within airways or inflammation and edema in the pulmonary tissue
wheeze
continuous musical tones that are most commonly heard at the end of inspiration or early
expiration
stridor
abnormal, high-pitched, musical breathing sound caused by a blockage in the throat or voice box (larynx). Usually heard when taking a breath
stertor:
heavy snoring sound in respiration
pleural friction rub
dry, rubbing or grating sound, usually caused by inflammation of pleural
surfaces; heard during inspiration or expiration; loudest over lower lateral anterior surface
cyanosis
blue discolouration of the skin and mucous membranes caused by the presence of
desaturated hemoglobin in capillaries, is a late sign of hypoxia
hemoptysis
bloody sputum
hypoxia
decrease in the amount of arterial oxygen
hypoxemia
inadequate concentration of oxygen in arterial blood
barrel chest
permanently rounded chest commonly found in people with emphysema, due to
trapped air in the lungs causing the rib cage to remain partially expanded
kyphosis
increased convexity in curvature of thoracic spine
clubbing
rounded and bulbous, the angle of the nail bed
NARRATIVE
chronological order of events that occur
story format
includes gathering information
sentence structure is preferred, although columns are sometimes used
traditional method of recording care
legibility is very important
disadvantages:
the tendency to have repetitious information
time consuming to complete
requires reader to sort through much of the information to locate desired data
SOAP
SOAP (subjective-objective-assessment-plan) charting:
1st progress note method
similar to nursing process to collect data about the client’s problems, draw
conclusions and develop plan of care
charting involves:
subjective data (verbalizations of the client)
objective data (data measured and observed)
assessment (diagnosis based on data)
plan (what the caregiver plans to do)
PIE
(problem-intervention-evaluation) format – SOAPIE
2nd progress note method
problem-oriented nature
different from SOAP method
PIE charting originated in nursing practice
SOAP originated from medical records
P - problem: knowledge deficit regarding surgery related to inexperience
I - intervention: explain to client normal preoperative preparations for surgery (deep
breathing & coughing), provided booklet to client on post-operative nursing care
E - evaluation: client demonstrates (deep breathing & coughing) exercises correctly;
needs review of post-operative care
DAR
(data-action-response)
3rd progress note format
includes both subjective and objective data, action or nursing intervention, and the
response of the client
address client’s concerns: a sign or symptom, a condition, a nursing diagnosis, a
behaviour, a significant event, or a change in client’s condition
PROBLEM-ORIENTED MEDICAL RECORDS (POMR)
method of documentation that emphasizes client’s problem
SOAP
ACUITY CHARTING
provides a method of determining the hours of care and staff required for a given group of
clients
FOCUS CHARTING
movement away from charting only problems which has a negative connotation
DAR
CHARTING BY EXCEPTION (CBE)
only significant findings or exceptions to standards or norms of care are recorded
flow sheets or charts
* indicates explanation
Kardex (client care summary)
What we use to look up or patient in clinical
Nursing flow sheet
document routine nursing procedures
designed to free the nurse from writing procedures that are done repeatedly
vital signs including pulse, respiration, blood pressure, and temperature are shown
graphically on a flow sheet
fluid intake and outtake, dressing changes, meals taken, and breath sounds
routine repetitive care actions (hygiene, ambulation, meals, weights and
safety/restraint checks)
Discharge Instruction
started at the time the patient is admitted, and is completed at discharge
lists the discharge planning and teaching that took place since the patient was admitted,
and documents the patient’s condition at the time of discharge.
also lists instructions concerning care after discharge
acute care
Maintaining elimination habits Medications Briefs/Incontinent protection Urethral catheterization Alternatives to urethral catheterization: suprapubic catheters, condom catheters Maintenance of skin integrity Promotion of comfort
restorative care
Lifestyle modification Strengthening pelvic floor muscles Bladder training Habit retraining and prompted voiding Self-catheterization
