Medical Records
an electronic record of health-related information that can be created, gathered and managed by more than one healthcare organization
What are electronic health records (EHR)?
cost, access, quality
What are healthcare drivers?
a written explanation of the respiratory care that the patient is to receive
What is a respiratory care plan?
tachycardia, increased BP, tachypnea, hyperventilation, dyspnea
What are the initial signs of hypoxia?
involves the general appearance, mental state/level of consciousness, vitals, skin color, perfusion and capillary refill, presence of pursed lip breathing
What is the physical examination?
a type of record that focuses on problem-solving while providing complex care by encouraging ongoing assessments and care adjustments by the healthcare team
What is a problem-oriented medical record (POMR)?
in relation to personal health-related behaviors - heart disease, cancer, COPD, stroke, accidents
What are the top 5 leading causes of death in the US?
when used for extended periods of time, this can result in oxygen toxicity, absorption atelectasis, depression of ciliary and/or leukocytic function
What are high oxygen levels (50-60%)?
a sudden decrease in arterial blood oxygen levels with or without CO₂ retention
What is acute respiratory failure?
the only problem with this is that the delivered FiO₂ will vary with patient's ventilatory pattern and tidal volume
What is a nasal cannula?
part of the POMR that includes interviews from the patient/family, results of assessments & physical exams, and findings from laboratory & radiologic/imaging findings
What is a database?
individual genetic makeup, access to healthcare, environmental factors, personal health-related behaviors
What are health determinants?
improvement in oxygen & ventilation, work of breathing, breath sounds, pulmonary function & blood gases should be made note of during this
What is the assessment of a basic respiratory care plan?
the sudden rise in arterial CO₂ levels with a corresponding decrease in pH
What is acute ventilatory failure?
this method of oxygen delivery is considered in patients with a variable ventilatory pattern or with rapid, shallow breathing
What is a venturi mask?
this part of a SOAPIER note includes patient responses to interventions and medical treatments
What is evaluation?
decreased ability to take deep breaths
pneumonia, ARDS, ALI, pneumothorax
What is acute restrictive lung disease?
maintaining or improving oxygenation/ventilation, managing secretions, and treating/preventing bronchospasm, mucosal edema, atelectasis, pneumonia
What are goals of a respiratory care plan?
this is most commonly caused by severe COPD
What is chronic ventilatory failure?
MI, pulmonary embolus, aortic dissection, tension pneumothorax, esophageal rupture
What are potentially life-threatening causes of chest pain?
hematology, blood chemistry, microbiology, urinalysis, cytology, histology, and molecular techniques
What are laboratory studies?
much of what doctors learn about how to care for respiratory patients is not evidence-based
What is a reason for misallocation of care?
techniques to assess oxygenation, ventilation, acid-base balance, pulmonary function
What are diagnostic respiratory care procedures?
patient presents a PaO₂/FiO₂ ≤ 100 mmHg
with PEEP ≥ 5 cmH₂O
What is severe ALI, ARDS?
includes cardiac & hemodynamic monitoring, respiratory monitoring, intracranial pressure monitoring (ICP)
What is critical care monitoring?