Health Assessment (Lecture)

    Cards (29)

    • Respiration is the process by which the body takes in and uses oxygen and removes carbon dioxide.
    • Respiration requires ventilation by the lungs (inspiration and expiration), gas exchange across alveolar membrane (diffusion, Fick’s law), transport of gases by blood (hemoglobin), and uptake of oxygen and release of carbon dioxide by tissues (diffusion).
    • There are two types of respiration: internal and external respiration (inhalation and exhalation).
    • Systemic circulation is the movement of blood between the heart and the rest of the body.
    • Pulmonary circulation is the movement of blood between the heart and the lungs.
    • Other functions of the respiration system include behavioral (talking, laughing, singing, reading), defense, secretions, metabolic (forms angiotensin II, prostacyclin, bradykinin, serotonin, histamine), and acid-base balance (changes in ventilation, such as acute acidosis of exercise or alkalosis).
    • Parts of the respiration system include the larynx (opening of nose), pharynx (oropharynx, nasopharynx, laryngopharynx), true and false vocal cords, trachea (16-20 C-shaped cartilages, trachealis muscle), conducting airways (trachea -> terminal bronchioles), right and left mainstem bronchi, right main bronchus, right lung (divided into upper, middle and lower lobes), left lung (upper and lower lobes), pleural sac (surroundings of lungs), ribs and costal cartilages (12 pairs, 7 pairs of true ribs, 5 pairs of false ribs, 11-12th ribs are floating ribs), sternum (breastbone, manubrium, body, xip
    • Blood vessels of the lung include the pulmonary artery (deoxygenated (venous) cardiac output), pulmonary capillaries (extremely dense, underground parking garage), and pulmonary veins.
    • Pleural Sac - surroundings of lungs
      -visceral pleura - inner layer that covers the lungs, blood vessels, nerves, and bronchi
      -parietal pleura - outer layer that attaches to the chest wall 
      -pleural cavity - space between the visceral and parietal pleura
      -pleural fluid - lubricates the surface of the pleura
    • Upper respiratory tract consists of: nasal cavity, pharynx (throat), external nose
      Lower respiratory tract consists of: larynx, trachea, bronchi, lungs
    • Ribs and Costal Cartilages
      -12 pairs of ribs
      -7 pairs of true ribs (attached directly to sternum by costal cartilage)
      -5 pairs of false ribs 
      -11-12th ribs are floating ribs 
    • Sternum
      -breastbone (manubrium, body, xiphoid process)
    • Jugular notch - depression at the superior end, located between the ends of clavicle where they articulate with sternum
    • Sternal angle - elevation, found at the junction of the manubrium and body of sternum, landmark for second rib 
    • Bronchoscopy: - diagnostic and therapeutic procedure
    • Actual nursing diagnosis indicates that a problem exists.
    • Risk nursing diagnosis indicates that specific risk factors are present.
    • Wellness nursing diagnosis is a client's statement of desire to attain a higher level of wellness in some area of function.
    • Planning and outcome identification is the third step in the nursing process.
    • Plans to implement establishing guidelines for the proposed course of nursing action and developing the client’s plan of care.
    • In the planning phases of the nursing process, initial planning is a preliminary plan, ongoing planning is updating a plan, and discharge planning is anticipating and planning for after discharge from the hospital.
    • Nursing interventions can be categorized as independent, which are initiated by the nurse and do not require an order, interdependent, which are implemented in a collaborative manner by the nurse in conjunction with other health care professionals, or dependent, which require an order.
    • A nursing care plan is a written guide or strategies to be implemented, beginning on the day of admission and continuing until discharge.
    • Nursing care plans include specific orders for individual clients, standing orders for standardized used in predictable cases, and protocols for generalized guidelines, series of standing orders/procedures.
    • Evaluation is the fifth stage in the nursing process, determining if goals are met, partially, or not met.
    • Reliability, validity, sensitivity, and specificity are principles of test selection and use.
    • Planning in the nursing process involves prioritizing the nursing diagnoses, identifying and writing client-centered long and short term goals and outcomes, and identifying specific nursing interventions.
    • The entire nurse plan in the nursing process is recorded, including expected outcomes based on goals, describing methods to be used to achieve goals, and specifying nursing care and teaching.
    • Nursing implementation/intervention is the fourth step in the nursing process, involving the performance of interventions, which are actions performed by the nurse and refer directly to the related factors or the risk factors, are stated in specific terms, and may change.