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Identify individual, environmental, & pathological factors that influence oxygenation
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describe a focused physical assessment in relation to oxygenation
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NUR 104 Chpt 35 & 36
Oxygentation- Respiratory & Cardiac
| Question | Answer |
|---|---|
| Identify individual, environmental, & pathological factors that influence oxygenation | air pollution pollens & allergens high blood pressure cigarette smoking obesity diabetes lack of exercise medications/drug use stress medical/family history smoking drugs & alcohol nutrition |
| describe a focused physical assessment in relation to oxygenation | observe & inspect skin for pallor, palpate lungs, ausculate breath sounds, observe rate & pattern of respiration, inspect the chest to detect obvious chest deformities , wounds or masses, percuss |
| describe a focused physical assessment in relation to breathing | observe the rate & pattern of respiration observe the assessory muscles palpate percuss auscultate |
| describe a focused physical assessment in relation to circulation | inspect skin for pallor, inspect for edema, capillary refill, palpate & check pulses on both sides, check for dorsi flexion, ausculate for heart sounds in aoric, pulmonic, tricuspid and mitral locations |
| describe a focused physical assessment in relation to gas exchange | |
| interpret diagnostic testing related to oxygentation | pulse oximetry-greater than 95% is normal, below 93% indicates a need for oxygen |
| interpret diagnostic testing related to breathing | Pulmonary function tests by use of tidal volume, vital capacity, forced expiratory volume Spirometry-gives graphic representation of lung volumes & flows |
| interpret diagnostic testing related to circulation | Complete Blood Count Blood Chemistry tests |
| interpret diagnostic testing related to gas exchange | arterial blood levels of O2, CO2, and pH PaO2 norm: 80-100 mm Hg PaCO2 norm: 35-45 mm Hg pH norm: 7.35-7.45 Hypoventilation-a PaCO2 lower than 35 Hyperventilation-a PaCO2 above 45 |
| develop a nursing diagnoses related to alteration in oxygentation | Ineffective airway clearance |
| develop a nursing diagnoses related to alteration in breathing | Ineffective breathing pattern |
| develop a nursing diagnoses related to alteration in circulation | Ineffective tissue perfusion |
| develop a nursing diagnoses related to alteration in gas exchange | Impaired gas exchange |
| plan outcomes and patient centered care for maintaing and improving oxygenation | Pt will demonstrate knowledge regarding prevention of respiratory dysfunction Pts tissues will have adequate oxygenation Pt will mobilize pulmonary secretions Pt will effectively cope with changes in self concept & lifestyle |
| identify nursing procedures that promote safety and involve other members of the health care team related to oxygenation, breathing, perfusion, & gas exchange. | Assess the pts response regularly assess the pts color, alertness, heart rate, breathing effort inform pt of the importance of the procedure |
| describe methods to evaluate adequacy of oxygenation, breathing, perfusion, & gas exhange | |
| modify outcomes based on patient centered care and safety related to oxygenation. | |
| Name 3 defenses of the respiritory system | nose, epiglottis, sneeze & cough reflex, |
| What is the normal respiritory range for a 25 year old? 85 year old? | 12-20 16-25 |
| What does Crepitus or subcutaneous emphasema sound/feel like? | crackles that sound like rice krispies |
| What are adventitious breath sounds? | abnormal breath sounds |
| When would you use CAB as compared to ABC? | CAB-unresponsive pt ABC-responsive pt |
| What is a syncopal expisode? | passing out |
| What is dyspnea? | labored breathing & breathlessness |
| What is Hemoptysis | coughing up blood |
| What is the purpose of a PFT? (pulmonary function test) | to measure the airway & amt of air you can get into your lungs |
| What does ABG monitoring do? | monitoring of acid base balance |
| Is a consent form needed for a bronchioscopy? | yes |
| What type of pt will use pursed lip breathing? | COPD |
| What is chest physiotherapy? | clears excessive secretions from airway by Percussion, Vibration, Drainage (postural) |
| What is the conduction system? | elecrical activity-SA node, bundle of HIS, etc |
| What are the pumping chambers? | atria, ventrical valves |
| What do the coronary arteries do? | carry oxygenated blood to heart lies outside the heart |
| What is an arrhytmia? | abnormal electrical activity of the heart |
| What are the normal ranges for Potassium? | 3.5-5mEq/L |
| What are the normal ranges for Sodium? | 135-145mEq/L |
| What are the normal ranges for hematocrit? | Male: 45-52% Female37-48% |
| What are the normal ranges for hemoglobin? | Male: 13-18 g/100ml Female: 12-16 g /100ml |
| What type of drug would you give to increase cardiac contractablility and decrease heartrate? | cardiac glycoside |
| What type of drug would you give to decrease blood pressure? | antihypertensive agents (beta blockers & ace inhibitors) |
| What type of drug would you give to increase blood pressure? | vasopressor |
| What type of drug would you give to regulate heart rhythm? | Antiarrythmic |
| What type of drug would you give to relive angina | nitrates |
| What type of drug would you give to decrease cholesterol levels | antilipid agents |
| What type of drug would you give to reduce edema and fluid volume by increasing urinary output? | diuretics |
| What type of drug would you give to decrease potential for clot formation? | anticoagulants |
| What is the normal range for PaO2? | 80-100 mm Hg |
| What is the normal range for PaCO2? | 35-45 mm Hg |
| What is the normal range for pH? | 7.35-7.45 |
| What is hypoventilation, in relation to ranges? | PaCO2 level is lower than 35 |
| What is hyperventilation, in relation to ranges? | PaCO2 level is higher than 45 |
| What is Cachectic? | deteriortion of muscles...looking flacid |
| What is angina? | chest pain |
Created by:
jessicaspring
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