Influenza
While assessing a patient with a "Main One" symptom of severe muscle aches and high fever , the nurse notes a respiratory rate of 28 and pink skin. Based on the nursing diagnosis of Fluid Volume Deficit, what is the nurse's priority physical assessment to determine the severity of this deficit?
What is Peripheral Pulse, Skin Temperature, and Color?
A patient with suspected bacterial pneumonia has an elevated WBC count. However, the nurse recognizes that in the gerontological population, this classic sign may be absent, and the primary assessment finding may instead be this neurological change.
What is Altered Mental Status (Confusion)?
A patient is admitted with night sweats and a "rusty-colored" sputum. Which Priority Intervention must the nurse perform before any other care to satisfy the "Chain of Infection" requirements?
What is Instituting Airborne/Environmental Isolation?
The nurse is assessing a patient with Emphysema and notes a "Barrel Chest" and the use of "Accessory Muscles". Which specific physical finding explains the nursing diagnosis of Impaired Gas Exchange in this patient?
What is Alveolar Destruction?
A patient arrives in the ER with an asthma attack. The nurse notes the patient is "unable to speak in full sentences". This is a red-flag assessment finding for which potential complication?
What is Severe Respiratory Distress (Status Asthmaticus)?
A patient presents with nasal congestion, cough, and a "sore throat". To prevent the Potential Complication of Viral Pneumonia , what is the most important prophylactic intervention the nurse should teach the patient for future seasons?
What is getting the Flu Vaccination?
While assessing a patient with pneumonia, the nurse notes pleuritic chest pain and a collection of pus in the pleural space. Beyond calling the provider for a suspected Empyema, what is the priority nursing diagnosis for the pain associated with this inflammatory process?
What is Ineffective Breathing Pattern
A patient is diagnosed with Ineffective Coping. The nurse recognizes this is not due to the disease itself, but rather these two secondary factors associated with the treatment plan.
What are Isolation and Long-term Therapy?
A patient with Chronic Bronchitis has a diagnosis of Ineffective Airway Clearance. This is directly related to which "Definition" criteria found in your notes?
What is the Presence of a Productive Cough for at least 3 months?
The nurse identifies the nursing diagnosis Impaired Gas Exchange related to "Airway Obstruction". According to the notes, what are the three physiological reasons for this obstruction?
What are Inflammation, Mucus Production, and Tightening of the Muscle (Bronchospasm)?
An older adult patient is admitted with Influenza and is struggling with "Decreased Activity Tolerance". According to your notes, which medical intervention must be administered within a strict 24–48 hour window to be effective?
What are Antivirals?
A nurse is caring for a patient with Impaired Peripheral Perfusion where oxygen is not adequately reaching the tissues. Before the nurse implements the medical order for a broad-spectrum antibiotic, which Diagnostic/Assessment action must be completed first?
What is Sputum/Blood Culture collection?
During the physical assessment of a patient with active TB, the nurse notes "Pleuritic Chest Pain". What specific nursing diagnosis should the nurse prioritize to address this discomfort?
What is Alteration in Comfort/Pain related to pleurisy?
A COPD patient is experiencing an exacerbation with increased SOB and "fatigue". Beyond oxygen, which Nursing Intervention should the nurse perform to assist with the clearance of thick secretions?
What is teaching Huff Coughing?
During an acute asthma exacerbation, the nurse's Priority Intervention is the administration of this class of medication to "open the airways."
What are Bronchodilators?
A nurse identifies the diagnosis Ineffective Breathing Pattern related to lung inflammation. Which specific position should the nurse implement immediately to optimize chest expansion?
What is Semi-to-High Fowler’s?
To address the nursing diagnosis of Ineffective Airway Clearance, the nurse plans to utilize gravity to assist in removing bronchial secretions. What is the name of this specific intervention mentioned in your notes?
What is Postural Drainage?
The nurse is preparing a discharge plan for a patient on TB "RIPE" therapy. What is the most critical teaching point regarding the duration of medical interventions to prevent Drug-Resistant TB?
What is the importance of Completing the full 6–12 month course of medications?
When planning care for a patient with COPD, the nurse understands that O2 administration must be handled carefully to avoid CO2 narcosis. What is the target SaO2 range the nurse should aim to maintain?
What is 88% to 92%?
To prevent future exacerbations, the nurse teaches the patient to use a Peak Flow Meter. This helps the patient and nurse develop what specific medical intervention document?
What is an Individual Written Asthma Action Plan?
The nurse is evaluating the "Effectiveness" of the care plan for a flu patient. Which finding indicates the patient has successfully met the primary goal of treatment?
What is a Return to Baseline Oxygenation?
The nurse is evaluating a patient’s readiness for discharge. According to your "Evaluation of Effectiveness" criteria, which three specific physiological clusters must return to baseline to indicate the treatment plan was successful?
What are Stable Vital Signs, Clear Chest (on X-ray/CT), and Improved Energy/Activity Tolerance?
To confirm a patient is no longer infectious and can be removed from airborne precautions, the nurse evaluates the results of this specific diagnostic test.
What are Negative Sputum Cultures?
A nurse is assessing for Right-Sided Heart Failure, a potential complication of COPD. Which specific physical assessment finding would indicate this complication is occurring?
What is Peripheral Edema (or JVD/stress on the heart)?
The nurse is evaluating the effectiveness of a Rescue Inhaler (Albuterol). Which assessment finding indicates the medication has worked effectively?
What is Minimized Symptoms (decreased wheezing, improved SOB)?