Nursing Assessment
These little sacs in the lungs are responsible for carrying out gas exchange. Extra points for naming the gases that are exchanged :)
What are the alveoli?
Oxygen and Carbon Dioxide
This disease is characterized by trapping of air within the alveoli.
What is COPD?
This medical term is used to describe shortness of breath.
What is dyspnea?
This intervention would be included in the plan for care for a patient with a history of smoking who is at risk of developing pneumonia.
What is Incentive Spirometry every hour?
The nurse will describe this procedure to the patient as a scope that goes down the throat that is used to examine the inside of the lungs and obtain biopsies if needed.
What is a bronchoscopy?
This is a classic sign of chronic hypoxemia, common in patients with a significant history of smoking.
What is clubbing of the nail beds?
Often diagnosed in childhood, this condition is characterized by narrowing of the airways usually brought on by exposure to a certain trigger, like dust, pollen, or even cold air.
What is asthma?
This term describes the inadequate supply of oxygen to the tissues.
What is hypoxia?
This is a priority action when your patient who is lying in bed is experiencing dyspnea.
What is sit the patient up into High-Fowler's position?
This assessment finding is characterized by a high-pitched sound created when air passes through narrowed or tight airways.
What is a wheeze?
Skin is normal for ethnicity, cap refill is <3 seconds, respiratory rate is 18 with no reports of dyspnea and chest is symmetrical.
What are normal assessment findings in a respiratory assessment?
You explain your patient's diagnosis as a condition where the air sacs in the lungs are filled with fluid, causing inflammation that reduces respiratory function. What diagnosis is this?
What is Pneumonia?
The nurse knows that he can remove a nasal cannula and instead apply this to a patient who requires 6-10L of oxygen per minute.
What is a simple face mask?
Vaccinations, bronchodilators, oxygen therapy, suctioning, and steroids.
What are dependent (collaborative) nursing interventions for a patient who is at risk of developing a respiratory complication?
The nurse knows that he should stop suctioning the oral cavity of a patient when this happens.
What is the oxygen level drops below 90%?
The nurse includes a goal to maintain skin integrity for a patient who is placed on a nasal cannula. This is an appropriate nursing assessment to include in the plan of care:
What is assess skin around nares, cheeks and ears every shift?
The nurse will monitor this lab to determine if iron deficiency anemia is a contributing factor in the patient's respiratory dysfunction.
What is the hemoglobin level?
A nurse is caring for a patient with COPD. When she brings in the meal tray she notices several bloody tissues on the overbed table, the patient coughs and the patient fills another tissue with blood. She reports this assessment finding to the provider as:
What is hemoptysis?
The nurse attaches this to the oxygen delivery valve when the patient using a nasal cannula reports sore, dry nares.
What is humidification?
The nurse expects the pulmonary doctor to order this procedure, which is used to drain fluid that accumulates around the lung (pleural effusion).
What is a Thoracentesis?
These assessment findings can be seen during inspection of the chest in a patient with late onset hypoxia who is struggling to breathe.
What is use of accessory muscles and retractions of the intercostal muscles?
This medical term can be described to a patient as a collapsed lung, where the space around the lung fills with air and reduces the lung's ability to carry out gas exchange.
What is a pneumothorax?
This term describes the flow of blood through the tissues, a measure of how well the blood is supplied with oxygen and nutrients.
What is tissue perfusion?
Ambulation, position changes, adequate hydration, breathing exercises, incentive spirometry and relaxation techniques.
What are independent nursing interventions for a patient who is at risk of developing a respiratory complication?
This assessment finding may be common in a patient with severe hyperglycemia (DKA), characterized by deep rapid breaths.
What is Kussmaul's breathing?