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36 Cards in this Set

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*HEMOGLOBLIN VALUE*
PROVIDES INFORMATION ABOUT OXYGEN CARRYING CAPACITY OF BLOOD
*PROCESS OF BREATHING IS CONTROLLED BY CNS*
*PROCESS OF BREATHING IS CONTROLLED BY CNS*
BEFORE YOU INTERVENE YOU NEED TO DO AN ASSESSMENT
BEFORE YOU INTERVENE YOU NEED TO DO AN ASSESSMENT
HYPOXIA: EARLY SIGN
RESTLESSNESS
HYPOXIA: LATE SIGN
CYANOSIS
SYSTOLIC BLOOD PRESSURE
MAX AMT. OF PRESSURE BEING EXERTED AGAINST ARTERIAL WALLS DURING VENTRICULAR CONTRACTION
DIASTOLIC BLOOD PRESSURE
MIN. AMT. OF PRESSURE WITHIN ARTERIES, WHEN VENTRICLES RELAX
PULSE OXIMETRY
USED TO DETERMINE ARTERIAL BLOOD SATURATION
Briefly describe the structure and function of the respiratory system.
chemoreceptors in the medulla, carotid arteries and the aorta detect changes in the blood pH, oxygen levels and CO2 levels
ventilation (breathing- rate and depth, compliance, elastic recoil, airway resistance, accessory muscles)
Describe the processes involved in ventilation
rate and depth of breathing, compliance, elastic recoil, airway resistance, accessory muscles
Describe the processes involved in perfusion
circulation of blood to and from the surface of the alveoli for gas exchange. Dependent on right ventricle for pulmonary circulation and systemic blood pressure for venous return
Describe the processes involved in exchange of respiratory gases.
Exchange occurs at alveoli and capillaries of body tissue. Method of transport is simple diffusion
Describe the processes involved in ventilation, perfusion, and exchange of respiratory gases.
Clients health (obesity, allergies), age (premature infants, elderly), environment (altitude, temperature), lifestyle (stress, smoking), physiological (COPD), decreased inspried O2 concentration (Ariway obstructions, hypovolemia-shock, severe dehydration, increases O2 demand), increased metabolic rate
hyperventilation
ventilation, greater than that which is required to eliminate normal CO2 level
causes of hyperventilation
anxiety, panic, high altitude, infection, asthma, drugs, heat
effects of hyperventilation
excessive intake of O2 and elimination of CO2 -> dizziness, faintness, numbness of fingers and toes, syncope, psycho motor impairment
hypoventilation
ventilation inadequate to meet O2 demands or eliminate sufficient CO2
causes of hypoventilation
bronchitis, obesity, neuromuscular or skeletal disease affecting the thorax, decreased response of the respiratory center to CO2, decreased functional lung tissue as in atelectasis or COPD
effects of hypoventilation
hypoxia, hypercapnia (low level of dissolved CO2 in blood due to hyperventilation), respiratory acidosis
treatment for hyperventilation
reassurance from family or friend to help relax breathing, breathing thru pursed lips, exercise regulalry
treatment for hypoventilation
weight reduction, artificial respiration, and possible tracheostomy
hypoxemia
abnormal defficiency of oxygen in arterial blood; most reliable method of measuring blood in gas analysis. Determines the partial pressure of O2 in arterial blood
EARLY SIGN OF BODY ADAPTING
INCREASED HEART RATE
Develop nursing diagnoses related to oxygenation, breathing, circulation and gas exchange
airway clearance, ineffective
activity intolerance
tissue perfusion, inadequate
nursing interventions to maintain or promote lung expansion
positioning, semi-fowlers is best, incentive spirometry, chest physiotherapy (percussion, postural drainage), chest tubes (pneumothorax, hemothorax)
nursing interventions to promote mobilization of respiratory secretions
hydration, humidification, nebulization
nursing interventions to maintain a patent airway
deep breathing and coughing, suctioning, artificial airways
nursing interventions to promote oxygenation
nasal canula, nasal catheter, oxygen mask, transtrachael
nursing interventions to restore cardiopulmonary function
Digoxin, Lidocaine, Nitroglycerin, Albuterol, Terbutaline
Accessory muscles
not efficient way of breathing; muscles in back neck and abdomen (can lead to barrel chest look)
COPD
chronic obstructive pulmonary disease
Tachycardia
HR > 100 BPM;
normal: fever, exercise, excitement abnormal: CHF, shock, anemia
Bradycardia
HR<60 BPM;
normal: well developed athlete
abnormal: brain tumor, drug toxicity, medications
Premature beats
Heart beat comes too soon early in cardiac cycle; incomplete emptying of heart
Blocked beats
delayed beats
Dysrhythmias
deviation from normal sinus heart rhythm. electrical impulses that do not result from the SA node