Quiz 2 fund
study guide
Nursing Process
1. ASSESS/ ANALYZE
2. DIAGNOSE
3. PLANNING
4. IMPLEMENTATION
5. EVALUATION
Pain Assessment
❖ Pain
➢ P: provocative: what do you do to cause the main or make it worse?
➢ Q: quality: dull, sharp, shocking
➢ R: radiate: where does it radiate to
➢ S: scale 1-10
➢ T: time: the time the pain occurs
Pain Management
❖ Acute Pain
➢ Protective, temporary usually self limiting, has direct cause, and resolves with
tissue healing
➢ Physiological responses (sympathetic nervous system) are fight or flight
response
■ Tachycardia
■ Hypertension
■ Anxiety
■ Diaphoresis
➢ Behavioral response
■ Grimacing
■ Moaning
■ Flinching
■ Guarding
■ Interventions include treatment of the underlying problem
■ Can lead to chronic pain if unrelieved
❖ Chronic pain
➢ Not protective, ongoing, occurs frequently and last longer than 6 months
persisting beyond tissue healing
➢ Does not alter vital signs
➢ Can lead to
■ Depression
■ Fatigue
■ Decreased level of function
■ Not usually life threatening
➢ Pain does not always respond to interventions
➢ Can be categorized as cancer pain or noncancer pain
➢ Idiopathic pain:
■ Chronic pain without a known cause
■ Exceeds typical pain levels associated with client condition
, Airway/ Respiratory
Oxygen
➢ Oxygenation:
○ Mechanism facilitate or impair body’s ability to supply oxygen to cells
➢ Ventilation
○ ACTUAL exchange of oxygen and carbon dioxide
○ Required for respiration to take place (move air in and out of the lungs)
○ Breathing in inhale and exhale
○ Achieved by lungs and diaphragm
○ Breathing in, diaphragm relaxes
○ Breathe out, diaphragm contracts
➢ Respiration
○ Act of inhaling and exhaling air to transport O2 to alveoli
■ O2 exchanged for CO2
■ CO2 expelled from body
○ Alveoli (air sacs) inflated, plump
■ Where oxygen and carbon dioxide takes place
○ Cannot happen without ventilation
○ surfactant
○ Always have patient turn
○ Cough
○ Breath in, deep breathes
Upper respiratory tract: nose to pharynx
Lower respiratory tract: Epiglottis to alveoli
➢ Expected Findings:
○ Normal: 95%-100%
○ Acceptable: 91%-100%
○ Some illness can allow: 85%-89%
○ Less than 90% = hypoxia
○ Values can be slightly lower for older adult clients and clients who have dark skin
➢ Hypoxemia:
○ Low levels of arterial oxygen
○ Oxygen less than 90%
○ Considerations:
■ Confirm probe placement
■ Confirm oxygen delivery system functioning
■ Client is receiving prescribed oxygen levels
■ Place client in semi fowler/ fowler position to promote chest expansion
and maximize ventilation
, ■ Encourage deep breathing
■ Remain with client and provide emotional support to decrease anxiety
○ Manifestations
■ Early
● Tachypnea
● Tachycardia
● Restlessness, anxiety, confusion
● Pale, skin, mucous membranes
● Elevated BP
● Use of accessory muscles, nasal flaring, tracheal tugging
● Adventitious lung sounds
■ Late
● Stupor
● Cyanotic skin, mucous membranes
● Bradypnea
● Bradycardia
● Hypotension
● Cardiac dysrhythmias
○ Nursing Actions:
■ Monitor respiratory rate patterns
■ Level of consciousness
■ Arterial blood gas
■ Provide oxygen therapy at lowest lifter flow that will correct hypoxemia
■ Oxygen is therapeutic gas treats hypoxemia (low levels of arterial oxygen)
administering and adjusting it requires a prescription
■ Make sure mask creates secure seal over nose and mouth
■ assess/ monitor hypoxemia and hypercarbia (elevated CO2)
■ Auscultate lungs for crackles, wheezes. Adventitious breath sounds
■ Promote oral hygiene
■ ENCOURAGE TURNING, COUCHING, DEEP BREATHING, AND
ARTERIAL BLOOD GASSES
■ Assess nutritional status
■ Provide emotional support
■ Assess skin integrity
● Provide moisture and pressure relief device
■ assess/ document response of oxygen therapy
➢ Oxygen toxicity:
○ Result in high concentration of oxygen (50%)
○ Long durations of oxygen therapy (usually more than 24 hrs) and severity of lung
disease
○ Manifestations:
■ Non productive cough
■ Substernal pain
■ Nausea
■ Vomiting
■ Fatigue
■ Dyspnea
■ Restlessness
, ■ Paresthesia
○
Nursing actions:
■ Use lowest level of oxygen necessary to maintain adequate SpO2
■ Monitor ABGs, and notify provider if SpO2 levels are outside expected
range
■ Decrease FiO2 if Spo2 increases
➢ COMBUSTION:
○ Oxygen is combustible
○ Nursing actions:
■ Post “No smoking” or “oxygen in use” signs to alert others of the fire
hazard
■ Know where to find closest fire distinguisher
■ Educate about fire hazard of smoking with oxygen use
■ HAVE CLIENT WEAR COTTON GOWN BECAUSE SYNTHETIC OR
WOOL FABRICS CAN CAUSE STATIC ELECTRICITY
■ Ensure all electric devices (razors, hearing aids, radios) working well
■ Make sure all electric machinery (monitors, suction machines) is
grounded
■ Do not use volatile, flammable materials (alcohol, acetone) near pt
receiving oxygen
Oxygen Equipment
LOW FLOW OXYGEN DELIVERY SYSTEMS
➢ Nasal Cannula
○ Tubing with 2 small prongs inserted to nose nares
○ Flow rate: 1-6 L/min
○ FiO2: 24-44%
○ Used: non acute situations
○ Patients:
■ Respiratory failure
■ Asthma
■ Bronchitis
■ emphysema
○ Advantages:
■ Safe and easy, and comfortable
■ Patient is able to eat, talk, and ambulate
○ Disadvantages:
■ FiO2 varies flow rate, and rate and depth of pt breathing
■ Extended use lead to skin breakdown and dry mucous membranes
■ Tubing can be easily tangled (dislodged)
○ Nursing action:
■ Assess patency to nares
■ Ensure prongs fit in nares properly
■ Use water soluble gel to prevent dry nares
study guide
Nursing Process
1. ASSESS/ ANALYZE
2. DIAGNOSE
3. PLANNING
4. IMPLEMENTATION
5. EVALUATION
Pain Assessment
❖ Pain
➢ P: provocative: what do you do to cause the main or make it worse?
➢ Q: quality: dull, sharp, shocking
➢ R: radiate: where does it radiate to
➢ S: scale 1-10
➢ T: time: the time the pain occurs
Pain Management
❖ Acute Pain
➢ Protective, temporary usually self limiting, has direct cause, and resolves with
tissue healing
➢ Physiological responses (sympathetic nervous system) are fight or flight
response
■ Tachycardia
■ Hypertension
■ Anxiety
■ Diaphoresis
➢ Behavioral response
■ Grimacing
■ Moaning
■ Flinching
■ Guarding
■ Interventions include treatment of the underlying problem
■ Can lead to chronic pain if unrelieved
❖ Chronic pain
➢ Not protective, ongoing, occurs frequently and last longer than 6 months
persisting beyond tissue healing
➢ Does not alter vital signs
➢ Can lead to
■ Depression
■ Fatigue
■ Decreased level of function
■ Not usually life threatening
➢ Pain does not always respond to interventions
➢ Can be categorized as cancer pain or noncancer pain
➢ Idiopathic pain:
■ Chronic pain without a known cause
■ Exceeds typical pain levels associated with client condition
, Airway/ Respiratory
Oxygen
➢ Oxygenation:
○ Mechanism facilitate or impair body’s ability to supply oxygen to cells
➢ Ventilation
○ ACTUAL exchange of oxygen and carbon dioxide
○ Required for respiration to take place (move air in and out of the lungs)
○ Breathing in inhale and exhale
○ Achieved by lungs and diaphragm
○ Breathing in, diaphragm relaxes
○ Breathe out, diaphragm contracts
➢ Respiration
○ Act of inhaling and exhaling air to transport O2 to alveoli
■ O2 exchanged for CO2
■ CO2 expelled from body
○ Alveoli (air sacs) inflated, plump
■ Where oxygen and carbon dioxide takes place
○ Cannot happen without ventilation
○ surfactant
○ Always have patient turn
○ Cough
○ Breath in, deep breathes
Upper respiratory tract: nose to pharynx
Lower respiratory tract: Epiglottis to alveoli
➢ Expected Findings:
○ Normal: 95%-100%
○ Acceptable: 91%-100%
○ Some illness can allow: 85%-89%
○ Less than 90% = hypoxia
○ Values can be slightly lower for older adult clients and clients who have dark skin
➢ Hypoxemia:
○ Low levels of arterial oxygen
○ Oxygen less than 90%
○ Considerations:
■ Confirm probe placement
■ Confirm oxygen delivery system functioning
■ Client is receiving prescribed oxygen levels
■ Place client in semi fowler/ fowler position to promote chest expansion
and maximize ventilation
, ■ Encourage deep breathing
■ Remain with client and provide emotional support to decrease anxiety
○ Manifestations
■ Early
● Tachypnea
● Tachycardia
● Restlessness, anxiety, confusion
● Pale, skin, mucous membranes
● Elevated BP
● Use of accessory muscles, nasal flaring, tracheal tugging
● Adventitious lung sounds
■ Late
● Stupor
● Cyanotic skin, mucous membranes
● Bradypnea
● Bradycardia
● Hypotension
● Cardiac dysrhythmias
○ Nursing Actions:
■ Monitor respiratory rate patterns
■ Level of consciousness
■ Arterial blood gas
■ Provide oxygen therapy at lowest lifter flow that will correct hypoxemia
■ Oxygen is therapeutic gas treats hypoxemia (low levels of arterial oxygen)
administering and adjusting it requires a prescription
■ Make sure mask creates secure seal over nose and mouth
■ assess/ monitor hypoxemia and hypercarbia (elevated CO2)
■ Auscultate lungs for crackles, wheezes. Adventitious breath sounds
■ Promote oral hygiene
■ ENCOURAGE TURNING, COUCHING, DEEP BREATHING, AND
ARTERIAL BLOOD GASSES
■ Assess nutritional status
■ Provide emotional support
■ Assess skin integrity
● Provide moisture and pressure relief device
■ assess/ document response of oxygen therapy
➢ Oxygen toxicity:
○ Result in high concentration of oxygen (50%)
○ Long durations of oxygen therapy (usually more than 24 hrs) and severity of lung
disease
○ Manifestations:
■ Non productive cough
■ Substernal pain
■ Nausea
■ Vomiting
■ Fatigue
■ Dyspnea
■ Restlessness
, ■ Paresthesia
○
Nursing actions:
■ Use lowest level of oxygen necessary to maintain adequate SpO2
■ Monitor ABGs, and notify provider if SpO2 levels are outside expected
range
■ Decrease FiO2 if Spo2 increases
➢ COMBUSTION:
○ Oxygen is combustible
○ Nursing actions:
■ Post “No smoking” or “oxygen in use” signs to alert others of the fire
hazard
■ Know where to find closest fire distinguisher
■ Educate about fire hazard of smoking with oxygen use
■ HAVE CLIENT WEAR COTTON GOWN BECAUSE SYNTHETIC OR
WOOL FABRICS CAN CAUSE STATIC ELECTRICITY
■ Ensure all electric devices (razors, hearing aids, radios) working well
■ Make sure all electric machinery (monitors, suction machines) is
grounded
■ Do not use volatile, flammable materials (alcohol, acetone) near pt
receiving oxygen
Oxygen Equipment
LOW FLOW OXYGEN DELIVERY SYSTEMS
➢ Nasal Cannula
○ Tubing with 2 small prongs inserted to nose nares
○ Flow rate: 1-6 L/min
○ FiO2: 24-44%
○ Used: non acute situations
○ Patients:
■ Respiratory failure
■ Asthma
■ Bronchitis
■ emphysema
○ Advantages:
■ Safe and easy, and comfortable
■ Patient is able to eat, talk, and ambulate
○ Disadvantages:
■ FiO2 varies flow rate, and rate and depth of pt breathing
■ Extended use lead to skin breakdown and dry mucous membranes
■ Tubing can be easily tangled (dislodged)
○ Nursing action:
■ Assess patency to nares
■ Ensure prongs fit in nares properly
■ Use water soluble gel to prevent dry nares
