Nursing Care Plan
Respiratory
Abdomen
Review of Systems/Head to Toe assessment
Urinary
100

What are the definitions of clinical reasoning and clinical judgement

  • Clinical reasoning: the processes by which nurses make judgments, including generating alternatives, weighing them against evidence, choosing the most appropriate. Also involves recognizing patterns, using intuition, and tacit knowledge.
  • Clinical judgment: an interpretation or conclusion about a patient’s needs, concerns or health problems, and/or the decision to take action (or not), use or modify standard approaches, or develop new ones as deemed appropriate by the patient’s response.
100

What is the main drive to breath and control respiration through inspiration and expiration. 

o    Main drive to breath is hypercapnia, NOT low O2 levels

o    Inspiration-active movement: Diaphragm movement, elevation of ribs

o    Expiration-passive recoil of lungs, abdomen, thorax


100

What are the organs in the hollow viscera? 

  • Stomach
  • Gallbladder
  • Small intestine
  • Colon
  • Bladder
100
For are the topic for questions asked for Mouth and Thorat? 
  • Bleeding gums
  • Toothache
  • Altered taste
  • Dysphagia
100
What are the difference between intracellular fluid and extracellular and what are the 3 forms of extracellular? 
  • Intracellular fluid (ICF)-fluids within cells- 60% of total body fluids
  • Extracellular fluid (ECF)-fluid outside of cells
  • types of extracellular: 
  • Interstitial: fluid between cells in the tissue
  • Intravascular: blood and plasma
  • Transcellular: fluid separated by epithelium
200
What are the type of data by source and what do they include? 
  • Primary-Client
  • Secondary-Family and significant others, Health Care team, Medical records
  • Tertiary-Literature, Nurses experience
200

What are the developmental considerations for older adults? 

  • Lungs more rigid & harder to inflate
  • Decrease in vital capacity
  • Increase in residual volume
  • Decrease in number of alveoli
  • Increased shortness of breath on exertion
  • Above changes mean increased risk for postoperative respiratory complications
200

What the developmental considerations for pregnant women? 

  • Morning sickness
  • Heartburn
  • Constipation and decreased bowel sounds
  • Hemorrhoids
  • Diminished bowel sounds
  • Intestines pushed upward and posteriorly
200

What are questions asked about peripheral vascular 

  • Any coldness, numbness, tingling,
  • Varicose veins,
  • Thrombophlebitis,
  • Ulcers?
200

What is Osmosis and Osmotic Pressure? 

Osmosis: Movement of water through a semipermeable membrane from an area of lesser solute concentration to one of greater concentration

Osmotic Pressure: 

  • Pressure needed to counter the movement of water across a semipermeable membrane from an area of low solute concentration to an area of high concentration
  • A solution with a high solute concentration: high osmotic pressure; draws water into itself
300

What is the nursing diagnosis? 

A nursing diagnosis is a clinical judgment about

  • individual,
  • family,
  • or community responses to actual or potential health problems within the domain of nursing
  • “A nursing diagnosis focuses on a client’s actual or potential response to a health problem rather than on the physiological event, complication or disease.
300

What are the components of anterior chest inspection? 

  • Shape & configuration of chest wall-Downward sloping ribs, costal angle <90
  • Facial expression
  • Level of consciousness
  • Skin colour & condition
  • Quality of respirations, RR, pattern-Include pulse oximetry/O2 saturation
  • Accessory muscles: interspaces/intercostals, subcostal, tracheal tug, neck, substernal
300

What do you look for in inspection? 

  • Skin colour, striae, moles, lesions, hair distribution, scars
  • Pulsation or movement
  • Contour
  • Symmetry
  • Umbilicus
  • Demeanor & facial expression
300

What questions asked about neurological 

  • Seizures, strokes,
  • Numbness, tingling
  • Coordination etc.
  • Ask about Mental Health
300

What are the components of Fluid intake regulation and what is the minimum obligatory water loss per day 

  • Thirst mechanism
  • Osmoreceptors in hypothalamus stimulated when serum osmolality increases or blood volume decreases
  • Hormonal control: ADH and aldosterone
  • Obligatory water loss-500 mL per day
400
What are the components of a Nursing Diagnosis? 

Diagnostic label: (Problem)

Related to-The etiology identified from the patient’s database

Defining characteristics (clustering cues)


400

What is done for percussion of the posterior chest? 

  • Resonance is predominant note over lung fields
  • Start above scapula
  • Percuss at 5cm intervals
  • Compare side to side
  • Resonance: clear, hollow, low pitched
400
What to do in Auscultation of Bowel Sounds? 
  • Use a diaphragm, press lightly
  • Start in RLQ and listen in all 4 quadrants, zigzag across the abdomen
  • Note character & frequency-High pitched, gurgling, irregular 5-30 times per minute
400

Before you enter the room what do you see? 

First, stop at the door: Do you see

• Isolation precautions?

• Allergies?

• Fall precautions?

• Other relevant information?

400
What is positive and negative fluid balance? 
  • Positive fluid balance-Assess patient for signs of fluid overload, Look at trends, Consider patient context & condition
  • Negative fluid balance-Assess patient for signs of dehydration, Look at trends, Consider patient context and condition
500
What are the types of Nursing Diagnosis? 
Actual client problem, Health Risk, Health Promotion Challenge and Wellness 
500

What are the developmental considerations for infant & Children?  

  • Flexibility in sequence of the exam
  • Thoracic cage soft and flexible, rounded shape 
  • Diaphragm main respiratory muscle, will see abdomen move with respirations
  • Sternal or intercostal retractions indicates distress
  • Respiratory rate & pattern may be irregular (count 60 secs); infants are nose-breathers until 3 months
  • On auscultation, localization of breath sounds more difficult
  • Percussion of limited use in newborns: hyperresonance
500

What are developmental considerations for older adults? 

  • Increased fat deposits on abdomen and hips
  • Thinner abdominal musculature
  • Organs easier to palpate
500

What are the component of a general survey 

  • Appearance
  • Body Structure
  • Mobility
  • Behavior
500
What are factors influencing Urination? 
  • Psychological factors: anxiety and stress
  • Sociocultural factors: cultural, gender, and religious practices
  • Fluid balance: caffeine, alcohol
  • Diagnostic examination
  • Surgical procedures: anaesthesia
  • Pathological conditions: neurological disease, altered mobility, renal disease
  • Medications: diuretics
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