Nur 235 Exam 3
Focused Respiratory Assessment - ANS•Chief complaint
•Visual inspection
•Auscultation
•Vital signs
•Pain
•Continuous pulse oximetry
•Blood gas
•Sputum and/or Culture
•X-ray
•Pulmonary function test
What are some nursing interventions/Considerations in pediatric respiratory patients? - ANSPositioning
Pulse Ox
Suction/CPT/Incentive spirometry
O2
Meds
Emergency Preparedness
What are some priority respiratory assessment points? - ANSSigns of distress? (tachypnea, accessory
muscles, chest rise, coloring?)
Expected vital sign ranges.
Signs/Symptoms related to a specific disorder.
Adventitious breathing sounds
,(What do they tell you?)
What oxygen saturation necessitates a nursing intervention? - ANS< 95% SPO2
What considerations are necessary when delivering cool mist in an acute care environment? - ANS-
Temp Checks for hypothermia
- Oxygen flow at 4-5L/Min
What are the priority actions to ensure airway patency and optimal lung expansion? - ANS- Clear
patients airway
- Elevate the HOB
What nursing interventions should be applied for any pediatric patient admitted with a respiratory
concern? - ANSContinuous Pulse Ox
What are the bacterial Respiratory conditions? - ANS-Acute Streptococcal Pharyngitis
-Bacterial epiglottitis
-Bacterial pneumonia
Bacterial Epiglottitis & SSx - ANSBacterial infection of the epiglottis that swells and blocks the airway
Drooling
Agitation
Muffled voice
No cough
Inspiratory Stridor
, What is the priority intervention for Bacterial Epiglottitis? - ANSAirway management
intubation
protect airway (NO tongue blades)
Continuous Pulse Ox
What is the recommended testing for Bacterial Epiglottitis? - ANSNeck radiograph
What is the initial medication/treatment for Bacterial Epiglottitis? - ANSO2
IV fluids
antibiotics
Education on immunization "Hib"
Why is Bacterial Epiglottitis considered a medical emergency? - ANS-Risk of airway compromise
-Immediate intervention!
What is acute streptococcal pharyngitis? - ANSStrep throat, bacterial infection of the upper airway
Pharyngitis, tonsillitis, fever, positive gabhs
What are some symptoms of Acute Streptococcal Pharyngitis? - ANS-Sore Throat
-difficulty swallowing
-mouth odor
-tonsillar exudate
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