F & E
Lung sounds associated with fluid overload?
→ Crackles or rales
Key findings in Asthma
Wheezing, Shortness of breath (dyspnea),
Chest tightness, Coughing (especially at night or early morning), increased respiratory rate (tachypnea), Use of accessory muscles to breathe,
Anxiety and restlessness, decreased oxygen saturation, diminished or absent breath sounds in severe cases ("silent chest")
Nursing interventions that improve oxygenation in a client with COPD?
Positioning the high Fowler’s; Encouraging pursed-lip breathing; Administering low-flow oxygen as/if prescribed; promoting effective coughing, encouraging fluid intake, administering bronchodilators, teaching energy conservation, and high protein meals.
Why might an expectorant be prescribed for a client with pneumonia?
To promote cough production by increasing and thinning mucus secretions, helping the client clear chest congestion by coughing out secretions.
What causes sickle cell crises?
Hypoxia, dehydration, infection, or stress
Key assessment findings of fluid volume deficit?
Hypotension, tachycardia, dry mucous membranes, poor skin turgor, decreased urine output, weight loss, orthostatic hypotension
The device that helps monitor asthma control.
Peak Flow Meter
What diet modification is recommended for COPD?
Small, frequent meals high in calories and protein
What diagnostic test confirms pneumonia?
Chest X-ray
What is the hallmark symptom of a sickle cell crisis?
Severe pain due to vaso-occlusion
Key assessment findings of hypervolemia
What are Bounding pulse; Hypertension; Jugular vein distention (JVD); Edema; Crackles in lungs / pulmonary congestion; Dyspnea, tachypnea;
Weight gain; Decreased hematocrit and BUN (due to hemodilution)
Albuterol Inhaler Client Education
Rescue inhaler (acute symptoms), always carry, proper inhaler technique, possible SE (increased heart rate (tachycardia), tremors, nervousness, or headache), monitor frequency of use. Room temp storage, check expiration date.
Expected Findings in a client with COPD
Chronic cough; Dyspnea on exertion; Barrel-shaped chest; Use of accessory muscles to breathe;
Diminished breath sounds or wheezing; Clubbing of the fingers; Prolonged expiration
Expected findings in PNA
Cough (productive or dry); Fever and chills;
Shortness of breath; Crackles or decreased breath sounds; Tachypnea; Pleuritic chest pain;
Fatigue
What is the priority nursing intervention during a crisis?
Hydration/Fluids, oxygen, and pain control
Key Findings if K⁺ < 3.5 mEq/L
Muscle weakness or cramps,
Decreased deep tendon reflexes (DTRs),
Constipation or paralytic ileus, Flattened T waves on ECG, Irregular pulse or dysrhythmias, Shallow respirations
Health Promotion - Client with Asthma
Stop smoking; vaccinate; avoid triggers; administer meds correctly; monitor disease; early infection treatment, use inhaler prior to exercise, wash linens in hot water for dust mites.
Sitting upright, leaning forward, and supporting the upper body with the arms, often by resting the elbows on the knees or a table.
What is the tripod position? Tripod position can help clients with COPD by giving their lungs more space to expand and letting more air in
Administer prescribed antibiotics, encourage coughing and deep breathing, Position in semi-Fowler’s or high Fowler’s to promote lung expansion, monitor oxygen saturation, administer antipyretics, encourage fluid intake, and provide oxygen therapy as prescribed.
Expected findings during vaso-occlusive crisis in Sickle Cell Disease
Pain: severe, common in joints, abdominal pain, chest. Skin changes: pallor, cyanosis, jaundice (RBC destruction and bilirubin release), ulcers; Acute chest syndrome: pulmonary infiltrates. accounts for 25% of deaths of people with SCD. Can lead to respiratory failure and death.
Key findings if Na⁺ < 135 mEq/L
Headache, Confusion, Seizures (especially if severe or rapid onset), Muscle weakness or cramps, Nausea and vomiting, Fatigue or lethargy, Decreased deep tendon reflexes (DTRs), Coma (in severe cases)
What important step should clients take after using an inhaled glucocorticoid to prevent oral complications?
What is rinsing the mouth with water to prevent oral thrush (candidiasis)?
Complications of COPD
Hypoxemia; Acidosis; Respiratory Infection; Cardiac Failure; Dysrhythmias; Respiratory Failure
What is the underlying pathophysiology of pneumonia?
An infection that causes inflammation and accumulation of fluid and exudate in the alveoli, impairing gas exchange and leading to hypoxia.
What medication helps reduce the frequency of sickle cell crises?
Hydroxyurea: May reduce the number of sickling and pain episodes by stimulating the production of fetal hgb. suppresses bone marrow function (risk of infection), teratogen (can cause birth defects)