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203 terms

Ch. 40 Nursing Test 4

how much oxygen is in the air we breathe
cardiopulmonary system delivers what
oxygen to tissues and removes carbon dioxide. plays important part in acid base balance in our bodies
muscles working. diaphram contracts (descends) causes negative pleural pressure
positive pressure in lungs. lets air go out
approximately 30 million alveoli. looks like grapes. covered with veins, arteries, capillaries. vascular network. surfactant is the chemical in them to keep them from collapsing
oxygen (O2) in (how lungs function)
-oxygen inhaled from environment
-upper airway (mouth)
-trachea, bronchi
-bronchioles, alveoli
-pulmonary capillaries
-pulmonary vein
-left heart -> body tissues
carbon dioxide (CO2) out (how lungs function)
-body tissues -> right heart
-right ventricle
-pulmonary artery
-pulmonary arterioles to capillaries
-exhaled to environment
oxygenated blood (how heart functions)
is O2 rich.
-from lungs
-left atrium
-mitral valve
-left ventricle
-aortic valve
-aortic arch
-arteries, arterioles
-capillaries -> tissues
deoxygenated blood (how heart functions)
CO2 rich.
-from tissues
-venules, veins
-vena cavas
-right atrium
-tricuspid valve
-right ventricle
-to lungs
cardiac output
the amount of blood ejected from the left ventricle each minute. average is 6 liters per minute. to calculate: stroke volume x heartrate. Ex- stroke volume is 75 ml, heart rate is 72 bpm, cardiac output is 75 x 72 = 5400 ml which equals 5.4 liters.
stroke volume
amount of blood ejected with each heartbeat. average is 75 ml.
circulation of blood supplying tissues with O2 nutrients
basic components of the cardiovascular system
-adequate pump (heart)
-adequate transport system (blood vessels)
-adequate supply of circulation (of blood)
how long does it take to recirculate the blood in your body
1 minute
desired pump characteristics
-adequate stroke volume
-competent valves (good valves that don't leak)
-adequate heart rate: high enough to supply nutrients but not to high
-myocardial (heart muscle) blood flow
-effective electrical conduction system
-adequate chemical and neural controls: neural controls is the sympathetic and parasympathetic nervous system
right side of heart
has deoxyginated blood that goes to the lungs
left side of heart
has oxygenated blood that goes to the body
carry oxygenated blood
carry deoxygenated blood
pulmonary arteries
carry deoxygenated blood from heart
pulmonary veins
carry oxygenated blood to heart
vena cava
major vessel that brings blood back to the heart
coronary veins
drain directly into left side of heart
adequate blood vessel system
-patent: no obstructions, no clots, no plaque in arteries, no narrowing
-various vessel types: each has own structure and function
-elastic, able to constrict and dilate
-able to respond to chemical and neural stimulation
adequate blood and blood components
-adequate volume: maintain circulation, maintain blood pressure
-hemoglobin to carry oxygen: hemoglobin is oxygen carrier within blood stream to body
-plasma to maintain volume: plasma is noncellular portion of blood
-clotting factors to retain viscosity
carbon dioxide
is also carried by hemoglobin to get rid of it
process of moving air and gases in and out of lungs (inspiration and expiration). breathing.
the molecular exchange of O2 and CO2 within tissue of the body. Gas exchange in the body. (tissue level)
movement of particles (gases) from area of higher concentration to lower across alveolar and capillary membranes. red blood cells in hemoglobin carry oxygen
actual work of respiration/gas exchange is done at
the alveolar level in the lungs. at the capillary cell level in the body
sign of distress
clavical muscles contract (accessory muscles)
medulla oblongata
respiratory system
if not doing a good job it will use accessory muscles
needed for ventilation and gas exchange
-adequate muscles of respiration
-adequate chemical and neural controls
-adequate pulmonary circulation (to ventilate and exchange gases)
-adequate negative pressure in the pleural space (pressure lower than atmosphere)
-adequate airway
-adequate lung volume and lung compliance
-adequate alveoli
basic components needed for ventilation and gas exchange
-adequate nervous system
-adequate musculoskeletal system
-adequate pulmonary system
is reversable. insufficient blood supply to meet bodies demands
(pectoris). chest pain from ischemia
not reversable. cell (tissue) death from insufficient blood supply (ischemia)
can lead to cardiac arythmias or death of not treated. inadequate tissue oxygenation due to respiratory or cardiovascular. signs and symptoms: apprehension, restlessness, decreased level of consciousness, decreased pulse and respirations. cyanosis is a late sign
-mia refers to blood. inadequate oxygen in blood. usually a respiratory issue. measure-O2 saturation.
leaking mitral valve, cardiac arythmia, heart failure
severe enemia, hemorrhage
blood vessels
hypertension, arteriosclerosis
negative pleural pressure
open chest injury
lung volume
shallow respirations
chemical/neural control
brain injury
pulmonary circulation
pulmonary embolism
lung disease affecting surfactant
inadequate air intake and alveolar gas exchange to meet metabolic needs causing the body to retain CO2
airless/collapsed lung or part of lung resulting from collapsed alveoli. common in obstructive lung disease
elevated level of CO2 in blood. can lead to acidosis
pleural/pericardial effusion
accumulation of fluid around heart or lungs (in pleural or pericardial space)
anemia and low hemoglobin
spinal cord injury trouble with oxygenation
weak or ineffective muscles of respiration
could you have hypoxemia without having hypoxia?
no. if adequate oxygen is not diffused into blood stream there won't be enough to perfuse the tissues
could you have hypoxia without hypoxemia?
yes. the lungs could be exchanging gas well but the circulatory system might not be perfussing the tissues
which would be more serious: ischemia or infarction
infarction because it is irreversable. ischemia is reversable
which patient would be more likely to have hypercapnia? one hyperventilating or hypoventilating?
hypoventilating. you would be retaining CO2. with hypercapnia you have elevated CO2 levels in blood
congestive heart failure (retaining all the fluid, starts in right side of heart)
acute myocardial infarction (death of a muscle, heart attack)
pulmonary embolism (blood clot)
unstable angina (chest pain)
coronary artery disease
cerebral vascular accident (stroke)
peripheral vascular disease (not getting enough profussion to the extremities)
hypertension (high blood pressure)
chest pain
shortness of air (breath)
normal sinus rhythm (normal heart beat)
exudate in the lungs
pneumonia (respiratory disorder)
inflammation of lungs. usually due to infection with pathogenic organisms
bronchitis (respiratory disorder)
inflammation of bronchial airways by infection or irritation. characterized by airway edema, coughing, and sputum production
asthma (respiratory disorder)
increased airway responsiveness to stimuli resulting in airway narrowing and inflammation
lung cancer (respiratory disorder)
malignant growth causing lung obstruction
COPD chronic obstructive pulmonary disease
progressive disease with increased resistance to air movement and loss of lung compliance resulting in chronic hypoxemia. emphysema is a common type of COPD
angina (pectoris): common cardiovascular disorder
USA: unstable angina (chest pain). pain from myocardial ischemia. sharp, burning, aching, tingling pain. < 15 min. usually relieved by rest or coronary vasodilator (nitroglycerine)
MI (myocardial infarction): common cardiovascular disorder
death of a muscle, heart attack. pain with irreversible heart damage. crushing, squeezing, stabbing pain. > 30 min. not relieved by rest or coronary vasodilator (nitroglycerine)
heart failure: common cardiovascular disorder
CHF (congestive heart failure). failure of heart to pump adequately -> decreased cardiac output and can back up into lungs and systemic circulation
CAD (coronary artery disease): common cardiovascular disorder
narrowing of coronary arteries, usually due to atherosclerosis
HTN (hypertension): common cardiovascular disorder
High blood pressure. often silent without signs and symptoms. headache, nausea, blurred vision, kidney damage, high risk for stroke. diagnosis of HTN-blood pressure
A person who starts smoking in adolescence and continues to smoke into middle age
Has an increased risk for cardiopulmonary disease and lung cancer. The risk of lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Cigarette smoking worsens peripheral vascular and coronary artery disease. Inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood pressure and decreasing blood flow to peripheral vessels.
Carbon monoxide (CO) is a toxic inhalant that decreases the oxygen-carrying capacity of blood by:
Forming a strong bond with hemoglobin. CO is the most common toxic inhalant and decreases the oxygen-carrying capacity of blood. In CO toxicity, hemoglobin strongly binds with carbon monoxide, creating a functional anemia. Because of the strength of the bond, carbon monoxide does not easily dissociate from hemoglobin, which makes hemoglobin unavailable for oxygen transport.
Conditions such as shock and severe dehydration resulting from extracellular fluid loss cause:
Hypovolemia. Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume (hypovolemia).
Fever increases the tissues' need for oxygen, and as a result:
Carbon dioxide production increases. Fever increases the tissues' need for oxygen, and as a result, carbon dioxide production increases. When fever persists, the metabolic rate remains high and the body begins to break down protein stores, which results in muscle wasting and decreased muscle mass.
Left-sided heart failure is characterized by:
Decreased functioning of the left ventricle. Left-sided heart failure is an abnormal condition characterized by decreased functioning of the left ventricle. If left ventricular failure is significant, the amount of blood ejected from the left ventricle drops greatly, which results in decreased cardiac output.
Cyanosis, the blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is:
A late sign of hypoxia. Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of cyanosis is not a reliable measure of oxygen status.
A simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion is:
Frequent change of position. Changing the client's position frequently is a simple and cost-effective method for reducing the risk of pneumonia associated with stasis of pulmonary secretions and decreased chest wall expansion. Oxygen humidification, chest physiotherapy, and use of antiinfectives are all helpful, but are not cost effective.
The nurse is concerned when a client's heart rate, which is normally 95 beats per minute, rises to 220 beats per minute, because a rate this high will:
Reduce coronary artery perfusion. Coronary arteries fill and perfuse the myocardium (heart muscle) during diastole. When the heart rate is elevated, more time is spent in systole and less in diastole; hence, the myocardium may not be perfused adequately. The client may be exhausted, but the primary concern is myocardial perfusion. Major organs will adjust to increased blood flow. This is usually not a problem. With a heart rate this high, metabolic rate will be increased, not decreased.
A client is admitted to the emergency department with a suspected cervical spine fracture at the C3 level. The nurse is most concerned about the client's ability to:
Breathe. Spinal cord injury at the level of C5 or above often results in damage to the phrenic nerve, which innervates the diaphragm and permits breathing. Cardiac output is not usually affected by spinal cord injury; however, cardiac output may be reduced as a result of trauma and blood loss. It is too early to be concerned with ambulation. Life-threatening problems take priority. Level of consciousness is certainly an important consideration, because this client most likely sustained a head injury. However, this is not a certainty given the data provided.
When suctioning secretions that are collecting in an endotracheal tube, the nurse does not apply suction for longer than:
15 seconds. Applying suction for too long can result in complications such as hypoxemia and cardiac dysrhythmias. Thus the nurse is always aware of the length of time that suctioning is applied to an airway. If the suctioning time is too short, the suction catheter may not remove the secretions. If the suctioning time is too long, hypoxemia and/or cardiac dysrhythmias could result.
The nurse is caring for a client with a chest tube in the right thorax. On first assessment the nurse notes that there is bubbling in the water-seal chamber. This client is scheduled to undergo a chest x-ray examination, and the transporters have arrived to take him by wheelchair to the radiology department. The nurse considers whether the chest tube should be clamped or not during the trip to the radiology department. The nurse makes the which correct decision?
Do not clamp the chest tube and disconnect it from the wall suction. A bubbling chest tube (in the water-seal portion) should never be clamped because it provides the only exit for air accumulating in the pleural space. If the tube is clamped, tension pneumothorax could occur, which could be fatal. There is no advantage to clamping the chest tube but venting the system. Clamping of the chest tube prevents communication of the chest tube with the venting system or with the wall suction. There is no such thing as "temporary suction" for a chest tube system.
A client is receiving oxygen via a nonrebreathing mask. A crucial nursing assessment the nurse performs is to be sure that:
The bag attached to the mask is inflated at all times. If the bag attached to a nonrebreathing mask is deflated, the client is at risk for breathing in large amounts of exhaled carbon dioxide. The bag should be maximally inflated at all times. Checking the straps to make sure they are not causing skin ulcers is important but not crucial. For a nonrebreathing mask 2 L/min is far too low a flow setting. The oxygen flow should be set at 10 L/min or more. Otherwise, the bag will collapse. Heating the fluid used to increase humidity is not essential.
A client with known chronic obstructive pulmonary disease (COPD) is admitted to the emergency department with multiple minor injuries following an automobile accident. To ensure adequate ventilation the nurse applies a nasal cannula providing oxygen at what rate and for what reason?
2 L/min to prevent elevating the arterial oxygen tension (PaO2), which would suppress the hypoxic drive. Clients without COPD rely on low PaO2 as a stimulus to breathe. Thus, increasing the PaO2 would stop the client from breathing. Low oxygen therapy is recommended for clients with COPD who are severely hypoxic. Options 1 and 2 give the client too much oxygen and might suppress the client's breathing. Because the client experienced only minor injuries, the client presumably is still breathing on his or her own; therefore, option 3 is incorrect because artificial ventilation is not necessary.
The nurse is caring for a client who has undergone cardiac catheterization. The client says to the nurse, "The doctor said my cardiac output was 5.5 L/min. What is normal cardiac output?" Which of the following is the nurse's best response?
"The normal cardiac output for an adult is 4 to 6 L/min." The client asked a direct question that the nurse should be able to answer. Normal cardiac output for an adult is 4 to 6 L/min. Questions regarding diagnosis and prognosis may be referred to physicians. There is no harm in answering this question. When using therapeutic communication, the nurse should never ask a client to justify his or her feelings by inquiring why a question was asked. There is no evidence that this client is upset
A client asks why smoking is a major risk factor for heart disease. In formulating a response, the nurse incorporates the understanding that nicotine:
Causes vasoconstriction. Nicotine causes vasoconstriction, which restricts blood flow to the heart and peripheral tissues and increases the risk of hypertension and subsequently heart disease as a complicating factor. Nicotine does not cause vasodilation. Nicotine decreases the oxygen-carrying capacity of hemoglobin. Nicotine decreases the level of high-density lipoproteins and elevates the level of harmful low-density lipoproteins, which leads to atherosclerosis.
Symptoms associated with anemia include which of the following? (Select all that apply.)
Increased breathlessness and Decreased activity tolerance. Clients with anemia have fatigue, decreased activity tolerance, and increased breathlessness, as well as pallor (especially seen in the conjunctiva of the eye) and an increased heart rate.
Which of the following assessment data indicate that the client's airway needs suctioning? (Select all that apply.)
Drooling, Decreased coughing ability, and Abnormal lung sounds only in left lower lobe. Suctioning is necessary when the client is unable to clear respiratory secretions from the airways. Signs that a client's airway needs suctioning include a change in respiratory rate or adventitious sounds, nasal secretions, gurgling, drooling, restlessness, gastric secretions or vomitus in the mouth, and coughing without clearance of secretions from the airway.
The nurse suspects left-sided heart failure in a newly admitted client when the nurse notes which of the following symptoms? (Select all that apply.)
Bilateral crackles in the lungs and Shortness of breath, especially at night. Left-sided heart failure results in ineffective ejection of blood from the left ventricle. This causes a backup of blood into the lungs. Thus, symptoms of left-sided heart failure are usually related to the lungs.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and anxiety. The nurse helps the client to breathe better by doing which of the following? (Select all that apply.)
Instructing the client to perform pursed-lip breathing and Elevating the head of the bed to semi-Fowler's or Fowler's position. Elevating the head of the bed to Fowler's position (45-degree angle) or semi-Fowler's position (30- to 45-degree angle) causes the diaphragm to lower from gravity and thus increases the space for lung expansion. Pursed-lip breathing prolongs exhalation and maintains the alveoli open longer, thus extending the period of oxygen and carbon dioxide exchange. Too high an elevation of the head of the bed could force the diaphragm into the thorax and reduce lung expansion. Fluids could help liquify the pulmonary secretions in the future, but right now the client needs more acute care. Guided imagery may help in the future, but now is not the time to implement this intervention.
this primary muscle is needed for ventilation and gas exchange
acessory muscles
sternocleidomastoid, scaleni, and intercostals
what provides the drive for respirations
CO2 (also O2 and H)
what provides voluntary control
cerebral cortex
what regulates rate and depth
what is the rhythm
automatic / involuntary
gases move in and out of lungs through
pressure change: low pressure in lungs allows air to enter
what keeps the alveoli from collapsing
surfactant. adequate # for adequate surface area
untreated HTN (hypertension) leads to an increased chance of
CVAs (cerebral vascular accident - stroke)
physiological factors impacting oxygenation
-damaged/diseased cardiopulmonary structures
-decreased O2 carrying capacity
-increased metabolic rate (causes: fever, tissue healing, pregnancy, obesity, exercise)
-conditions affecting thoracic (chest wall) movement: will impact respiration and ventilation. COPD, open heart surgery, multiple sclerosis, aging
effects of aging
-decreased lung compliance: lung can't expand, move, to take in air
-decreased alveolar area: alveoli shrink
-decreased airway clearance
-decreased cough reflex: can't clear airway well
-decreased immune functioning: increased risk of pulmonary infections. TB skin testing (antigen/antibody response)
-thickening of heart valves/walls
-conduction system ages: greater numbers of elderly with cardiac arrythmias
-calcification of vessels
-vessels less elastic: don't respond as well
negative environmental factors
-air pollution
-environmental allergens
-occupational pollutants: coal dust, asbestos, fungi, chemicals
-high altitudes (over 10,000 feet): air is thinner and has less oxygen. RBC count could be elevated
what is a snack that promotes cardiovascular health
fruit and low fat yogurt
Nursing Oxygenation Assessment: History
risk factors-medical history-smoking-medications-pain-fatigue-dyspnea (difficulty breathing)-cough-constipation
Nursing Oxygenation Assessment: Inspect
LOC-skin color (cyanosis)-respirations & thorax (barrel chest shape or use of accessory muscles)-sputum-edema-clubbing-neck vein distention-urine output (kidneys will slow down without oxygen)
Nursing Oxygenation Assessment: Palpate & Grade
pulses-pitting edema-abdominal distention
Nursing Oxygenation Assessment: Auscultate
apical pulse and heart sounds-lungs (adventitious lung sounds)-blood pressure-bowel sounds
dependent edema
in hands, feet, ankles, related to cardiovascular system
dyspnea means
bad breathing. dys=bad. pnea=breathing
-subjective sensation of difficult or uncomfortable breathing
-can have respiratory, cardiovascular, neuromuscular, or hematological origin
-often used to describe SOA (shortness of air)
-can be rated as with pain and fatigue
-can only occur with exertion (when at rest they are fine)
brady=low. pnea=breathing. RR < 10. (RR=rate of respirations)
tacy=fast. pnea=breathing. RR > 35. (RR=rate of respirations)
no respirations
HR <60 (HR=heart rate)
HR > 100 at rest (HR=heart rate)
respiratory distress
showing signs having difficulty breathing
labored breathing when in a flat position but improves when upright
orthostatic hypotension
blood pressure falls in erect position
respiratory distress
-use of accessory muscles
-nasal flaring (sign of air hunger)
-rate alterations (significant ones)
-stridor (harsh, loud, noisy sound on inspiration, in upper airway)
-pursed lip breathing
-leaning forward and mouth breathing
-interrupt talking to breathe (at rest). ex-asthma patients sometimes
negative lifestyle and environmental factors
-pack years = packs per day x years smoked
-malnutrition (anemia, muscle waisting, decreased immune functioning)
-diets high in saturated fats, cholesterol, and sodium (could lead to cardiovascular disease)
-lack of exercise (strengthen cardiovascular system)
-substance abuse
-chronic stress and anxiety
check the consistency, amount, and color
green/yellow, purulent sputum
pusey, associated with infection. ex-pneumonia
blood streaked sputum
airway irritation, ruptured capillaries in throat
pink, watery, frothy sputum
pulmonary edema
bloody (hemoptysis) sputum
trauma, TB, lung cancer
rusty (old blood) sputum
certain types of pneumonia
thick, tenacious sputum
dehydration, COPD
watery, clear runny nose, can impact oxygenation
why would you want to assess bowel sounds, abdominal distention, and bowel movement status in patients with an oxygenation problem
-bowel sounds-with major hypoxemia, non vital body systems will slow down or stop.
-abdominal distention-mouth breathing often occurs with significant dyspnea: swallowed air leads to distention. a lot of distention leads to decreased lung expansion
-bowl movement-constipation leads to increased cardiac strain during defecation
when a nurse asks a client how many pillows they use at night she is assessing what
degree of orthopnea
charting thoughts-a client with asthma c/o SOA and labored breathing. what else should be included in the charting note?
-vital statistics with O2 sat
-any specific signs of respiratory distress (identify them)
-lung sounds (abnormal sounds/inflation)
-mucus membranes, skin color
-coughing, sputum
what are diagnostic tests used for
to identify oxygenation dysfunction
what 3 things tell you something about the oxygen carrying capacity of the blood
RBC, Hgb, Hct
normal RBC
4.2 - 6.1 x 10
normal Hgb
12-18 g/dl
normal Hct
37-52 %
normal WBC
5,000-10,000 / mm3
cardiac enzymes (creatine, kinase, troponins)
can be elevated when patient has a myocardial infarction
cholesterol and triglycerides
if high they have an increased risk factor for CVD (cerebral vascular disease or stroke)
normal cholesterol
<200 mg/dl
are also fats
HDLs (high density lipoproteins)
Are good. (remember H for healthy)
LDLs (low density lipoproteins)
are bad. (remember L for lethal)
normal electrolytes (K+)
electrical conduction for heart - 3.5 - 5 mEq/L
arterial blood gases. sample of blood drawn from artery so you have oxygenated blood
Diagnostic Tests: TB Skin Testing
-intradermal injection: antigen/antibody response
-mycobacterium tuberculosis
-o.1 mL tuberculin purified protein derivative (PPD)
-read 48-72 hours later
-positive: palpable raised and red area measured in mm
Diagnostic Tests: ECG (electrocardiogram)
record of electrical activity of heart. also called EKG occassionaly
Diagnostic Tests: Stress Test
also called ECG exercise stress test. monitoring ECG to see what exertion does
Diagnostic Tests: Thallium stress test
inject a form of thallium into IV while doing stress test. higher level than regular stress test
Diagnostic Tests: Echocardiogram
Measures cardio output. done at bedside. pic of heart beating and moving, checking chambers and valves
Diagnostic Tests: Transesophageal Echocardiogram (TEE)
super echocardiogram. small scope in esophogus to get as close to heart as possible
Diagnostic Tests: Cardiac Catheterization
common procedure. surgical. IV sedation. insert catheter through artery and go to aorta and into heart and they inject dye and observe. can detect blockages. make sure that patient is not allergic to components of dye
Diagnostic Studies: Pulmonary function tests
can diagnose COPD or anything affecting function of lung. residual volume. volume of air patient can inspire. rates of airflow
Diagnostic Studies: Bronchoscopy
insert scope through mouth, down trachea. IV sedation
Diagnostic Studies: Lund Scan
inject dye (IV). looking for lesions, spots for lung cancer
Diagnostic Studies: Chest X ray (CXR)
looking for pneumonia
Diagnostic Studies: Pulse oximetry (O2 sat)
Diagnostic Studies: Thoracentesis
large syringe inserted through chest wall to remove fluid
Diagnostic Studies: Sputum specimens
check in the morning time.
Diagnostic Studies: C & S
culture and sensitivity
Diagnostic Studies: acid fast bacillus
AFB. if they suspect TB
Diagnostic Studies: Cytology
to see what kind of cells are in there
Major nursing diagnoses
-impaired gas exchange: an excess or deficit of oxygenation
-ineffective airway clearance: unable to clear secretions or obstructions from respiratory tract
-ineffective breathing pattern: inspiration/expiration not providing adequate ventilation
-decreased cardia output: relates more directly to the heart
-decreased tissue perfusion: relates more directly to the heart. decrease in oxygen resulting in failure to nurture ? at cellular level
-activity intolerance
additional nursing diagnosis
-risk for fluid imbalance (overload/deficit)
-alteration in nutrition (less than body requirements, no energy to eat)
-risk for infection
-risk for aspiration
-ineffective health maintenance (any chronic disease)
-social isolation (ex- related to not being able to get out of home)
client goals and outcomes "the client will"
-lungs clear to ascultation
-bilateral lung expansion
-no cough/ productive cough
-sputum thin and clear/absent
-No/decreased c/o SOA, dyspnea, pain (SOA=shortness of air)
-O2 sat > or = 95
-vital signs within acceptable limits
-understands self-care/need for follow up
what kind of info do cardiac enzymes show the nurse
presence or absence of myocardial damage
what test do you use for gas exchange in the patient
arterial blood gas
crackles and rhonchi
ineffective airway clearance
systemic blood pressure is falling
decreased cardiac output
O2 sats are dropping
impaired gas exchange
exertional dyspnea
activity intolerance
shallow breathing
ineffective breathing pattern
coughing and sputum
ineffective airway clearance
decreased mental status
decreased tissue perfusion to brain
ineffective airway clearance
color is dusky (darkish color)
impaired gas exchange
impaired gas exchange
significant increase in pulse and respirations after ambulation
activity intolerance
severe enemia
decreased tissue perfusion
necrotic toe
decreased tissue perfusion
where everything takes place, where perfusion takes place
right heart-right ventricle
goes to lungs
right side of heart
goes to lungs (deoxygenated)
left side of heart
goes systematic (throughout the body) has thickest muscles cause going to whole body
away from heart is always an
artery (deoxyginated)
stroke volume =
1 beat
sympathetic nervous system
fight or flight, heart rate increases
parasympathetic nervous system
body calms down to state of normal. heart rate decreases
exhalation (expiration)
passive response
inhalation (inspiration)
active response