foundations exam

nursing process

adopie

adopie

assessment, diagnosis, planning, implement, evaluation

smart

specific, measurable, attainable, relevant, time-bound

abc

airway breathing circulation

maslows hierarchy

Physiological, afety, love and belonging, esteem, self actualization

verbal orders

given directly by provider to RN, recorded in med record as verbal, read back to verify accuracy, name of provider for emergencies only

ISBARR

identify/intro, situation, background, Assessment, recs, read back of orders/provider response

upper respiratory

nose pharynx larynx epiglottis

lower respiratory

trachea R&L main stem bronchi, segmental bronchi, terminal bronchioles

alveoli

site of gas exchange

parietal pleura

line thoracic cavity

viseral pleura

serous membrane that lines lungs

pleural space

holds lungs in place, acts as a lubricant

gas exchange

intake of oxygen and release of co2

respiration

gas exchange between atmospheric air in the alveoli and blood in capillaries via diffusion

perfusion

oxygenated capillary blood passes through body tissues

inspiration

diaphragm contracts and descends to lengthen thoracic cavity

emphysema

reduce the ability to transfer o2 bc alveoli are damaged/ruptured

retraction

using abdomen, neck and back to help breathe

surfactant

reduces the surface tension between alveoli preventing their collapse

medulla oblongata in brainstem

regulates respiratory by chemoreceptors in aortic arch and carotid bodies and receptors in muscles and joints

respiratory system and brain

MO sends signal to spinal cord to inhale/exhale and diaphragm to contract

hemoglobin

carries co2 in carboxyhemoglobin

ventilation

air isnt moving adequately

ventilation cues

low RR and depth, shallow breathing

diffusion

o2 isnt crossing effectively

diffusion cues

asthma, dyspnea, low Spo2

transport

blood cant carry enough o2

transport cues

sickle cell, low hemoglobin(anemia), issues with RBC, fatigue, pallor

pallor

lack of color of skin and mucous membranes bc of low o2

cyanosis

bluish or coolness or decreased temp bc of low blood flow or poor blood oxygenation

edema

result of overhydration, heart failure, kidney failure, trauma or PVD

dyspnea

difficulty breathing

tachypnea

rapid breathing

bradypnea

slow breathing

apnea

no breathing

orthopnea

difficulty breathing when flat

hypoxia

low o2 available to cells

spo2

95-100, chronic lung disease 88-92

crackles

fluid in lower lungs

rhonchi

Louder snoring, thick secretions trying to get in/out

wheezing

air trying to get out of a narrow airway

heart faillure

cant pump/fill enough to meet bodys need

systolic HF

ventricles cant pump hard enough

diastolic HF

stiff heart muscles

stridor

harsh high pitched upper airway soun

nasal cannula

low-flow o2, 1-6 L/m

venturi mask

precise oxygen concentration 24-50 % o2, fio2

nonrebreather

needed for a high concentration of o2, 10-15 L/m, reservoir bag is partially inflated

incentive spirometry

promote deep breathing and prevent/treat atelectasis

shock

inadequate tissue perfusion

right

Receive deoxygenated blood and refill o2

left

get oxygenated blood to launch out of body

arteries

away

veins

toward the heart

PICOT

population, intervention, comparison, outcome, time

dysphagia

Difficulty breathing

dysrhythmia/arrhythmia

abnormal HR or rhythm

dysrhythmia/arrhythmia effect on perfusion

ineffective pumping can decrease cardiac output

dysrhythmia/arrhythmia cues

palpitations, dizzy, syncope hypertension

myocardial ischemia

heart muscle isnt getting enough blood/o2

myocardial ischemia effect on perfusion

low o2 delivery to myocardium

myocardial ischemia cues

chest discomfort, angina

angina

temporary myocardial ischemia

angina effect on perfusion

o2 supply doesnt meet myocardial demand

angina cues

chest pain/pressure, sob, nausea

myocardial infarction

prolonged lack of blood/o2 causes death of H tissue

myocardial infarction effect on perfusion

damaged myocardium impairs cardiac function

myocardial infarction cues

chest pain/pressure, sob, nausea, diaphoresis

HF effect on perfusion

low cardiac output so low tissue perfusion, blood may backup so congestion

HF cues

fatigue, sob, edema, activity intolerance