Breathing Pattern Case Study – Flashcards
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The nurse assesses Josh's vital signs. His respirations are rapid and shallow What is the best technique for the nurse to use to assess Josh's respirations accurately?
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D) Place a hand on Josh's chest and count the hand motion This technique allows the nurse to observe and cont the chest movement, even when respirations are shallow
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Josh's respiratory rate is 36 How should the nurse describe Josh's respiratory pattern
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Tachypnea A rapid respiratory rate, which is consistent with Josh's rate of 36. Normal respiratory rate for a school-aged child is 16 to 30 breaths per minutes.
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Because of Josh's dyspnea, the nurse is concerned that he may need to receive oxygen To determine the need for the application of a nasal cannula which assessment is most important for the nurse to perform?
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Measure O2 Sat O2 Sat provides important data about the % of hgb that is saturated w/ O2- a valuable reflection of the client's overall oxygenation
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In assessing Josh's breath sounds, the nurse should ask him to perform which action?
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Breathe deeply through the mouth Josh should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds
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To measure cap refill, the nurse must first perform which action?
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Compress Josh's nailbed To measure cap refill, the nurse should first compress the client's nailbed and then observe the return of normal color to the nailbed
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The nurse plans to measure Josh's O2 sat w/ a spring-tension finger clip. While the nurse is explaining this procedure Josh asks if it will hurt Which response is best for the nurse to provide?
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"The clip feels like squeezing your finger with your other hand" This is an honest response to Josh's question regarding pain and one that places the sensation he will feel in a context he can understand.
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The nurse measures Josh's O2 sat at 88% and cap refill at 1 sec. Breath sounds are absent in the base and coarse bilaterally throughout the rest of the lung fields. The nurse applies a nasal cannula and administers O2 at 2 liters per minute. When applying a nasal cannula, it is most important for the nurse to provide which instructions?
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Remind client and family that O2 is combustible and must be kept 10 feet away from open flames O2 supports combustion and is essential to ensure client safety during O2 administration.
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Which nursing diagnosis is most relevant to Josh's current status?
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Impaired gas exchange Normal sat is 95-100%. Josh's O2 sat is well below normal, indicating that his gas exchange is impaired
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Which assessment finding further supports diagnosis?
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Restlessness & fatigue Restlessness and fatigue are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.
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After determining the priority nursing diagnoses, what step should the nurse take next in developing the plan of care?
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Establish goals and expected outcomes After analysis of the data to prioritize nursing diagnoses, the nurse should establish nursing care goals and expected outcomes
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Which outcome statement should the nurse use for Josh's plane of care?
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The client's O2 sat will be >95% on room air This client-centered outcome statement describes the desired outcome in measurable terms
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To achieve the desired outcome, the nurse has initiated the prescribed O2 therapy. After applying the nasal cannula, the nurse plans to attach a disposable sensor pad to measure the O2 sat continuously. What action should the nurse implement prior to applying the sensor?
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Determine if Josh has a latex allergy The disposable sensor pads may be made of latex. If they are , the nurse should confirm that the client does not have a latex sensitivity or allergy
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After receiving O2 for short while, Josh is much less dyspnenic. The nurse notes that the O2 sat reading is 97%. 15 minutes later, the O2 sat alarm indicates that the reading has changed to 80% What immediate action(s) should the nurse implement? (select all that apply)
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- Reposition the finger clip and obtain another reading Since Josh is not in any distress, the nurse should first reapply the clip and obtain another reading to confirm the sudden drop in O2 - Assess Josh for s&s of respiratory distress This is a priority - Encourage Josh to begin coughing and deep breathing Coughing helps to clear mucous from airway which will allow for optimal lung expansion
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After the nurse repositions the finger clip, the oxygen saturation reading returns to 97% despite the normal reading, josh's mom appears worried and states, "josh has never been sick. I am so scared." To encourage the mother to share more about her feelings, how should the nurse respond?
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"It sounds like this has been a very fighting experience for you" This open-ended statement acknowledges the difficult situation the mother is experiencing and encourages further discussion.
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After further conversation with josh's mom, the nurse needs to leave the room to assess another client. Which action be the nurse demonstrates the use of trust in the nurse-client relationship?
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returning to the room at the time promised Trust and rapport is important to develop during the orientation stage so the client has the most optimal outcome
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Upon returning to the room, the nurse assess Josh's cough. Which documentation is subjective data?
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Client reports that he is coughing a lot Subjective data is reported by the client
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Which documentation best reflects nurse's objective assessment?
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Frequent deep cough, producing SMALL amounts of PALE YELLOW sputum objective report-w/documentation of thorough description of the cough and sputum produced)
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Upon further observation the nurse describes Josh's sputum as "Tenacious." To what does this refer?
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Consistency sputum w/ thick consistency (sticking together TENACIOUSLY)
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Since Josh has a productive cough, HCP requests sputum specimen be obtained and sent to lab for culture and sensitivity. In assisting Josh to obtain a sputum specimen, what action should nurse take?
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Instruct Josh to cough deeply from chest and spit into specimen cup This technique is the least invasive and will provide sputum rather than mucus. Client who is alert, able to follow instructions and has productive cough can obtain a specimen without invasive catheter.
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The patient care technician is planning to transport sputum to the lab. What instructions should nurse provide?
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Place specimen cup in biohazard bag for transport This protects person transporting specimen, as well as the lab personnel receiving the specimen
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HCP determines Josh has respiratory tract infection and prescribes oral abx and oral liquid cough syrup. Josh's mother obtains meds at pharmacy and shows them to the nurse. The prescription for abx reads, "Take 2 pills for 1st dose, followed by 1 pill every 12 hours." The mother asks the nurse if this "seems right." How should the nurse respond?
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"A large first dose allows the medication to start working faster" A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream.
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The liquid cough syrup is labeled as an antitussive. The nurse explains this medication should have what effect?
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Reduce the frequency of the cough Antitussives are used to reduce the frequency of cough. This may be desirable for Josh at night, to allow him to sleep
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The med label states, "Take 2 tsp every 4hrs as needed." The nurse gives Josh some medication cups and teaches him and his mother how to pour medication into the cup. To what level should the medication be poured?
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10 ml Each teaspoon contains 5 ml. two teaspoons equals 10ml. 5ml x 2= 10ml
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Josh and his mother return to HCP office 1 week later, after Josh completed course of abx therapy. In assessing Josh's breath sounds, where should nurse listen first?
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Lung apices An accepted method for lung auscultation is to begin at the top of the chest, comparing one side of the chest to the other, moving downward in a systematic method finishing at the lung base
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Nurse auscultates vesicular breath sounds in the peripheral lung fields. What action should nurse take?
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Record presence of clear breath sounds vesicular breath sounds (NORMAL) in peripheral lung fields
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Which serum lab value confirms resolution of Josh's infection?
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WBC 6,000/mm(^3) Normal value for a child, confirming the resolution of the infection. Infection generally causes an elevation in the WBC.
