DONE Respiratory Assessment, Upper Respiratory Disorders, and Acute (Influenza): 7 questions- Dr. Larkin

Question 1

Inadequate oxygenation

Respiratory

Early?
Late?

Answer 1

Early:
-Dyspnea on exertion
-Tachypnea

Late:
-Dyspnea on exertion
-Dyspnea at rest
-shortwords
-Use of accessory muscles

Question 2

Inadequate oxygenation

Cardiovascular

Early?
Late?

Answer 2

Early:
Dysrhythmias
Hypertension
Tachycardia

Late:
Cool, clammy skin
Cyanosis
Hypotension

Question 3

Inadequate oxygenation

CNS

Early?
Late?

will see mental changes first in elderly population

Answer 3

Early:
Apprehension
Confusion, lethargy
Restlessness, irritability
**will see mental changes first in elderly population

Late:
Combativeness
Coma

Question 4

Identifying age related (gerontologic) differences

Thoracic structures?
cough?

immunity in an adult client?

Answer 4

-Increased AP diameter
-Decreased chest wall compliance
-Chest wall stiffening, costal cartilage calcification
-Decreased elastic recoil
-Decreased functioning alveoli
-Decreased respiratory muscle strength

Cough isn’t as strong. Encourage client to cough to move mucus and to ↑ fluid intake

Cell-mediated immunity
↓ Cough force
↓ Cilia function

Question 5

Obtaining a sputum culture

Answer 5

During:
*Obtain specimen in early morning after mouth care because secretions collect during night.

*Have patient expectorate sputum (COUGH NOT SPIT) into container after coughing deeply. If unsuccessful, try increasing oral fluid intake unless fluids are restricted.

Can collect sputum in sterile container (sputum trap) during suctioning via endotracheal tube or by aspirating secretions from the trachea.

*If patient cannot produce specimen, they may need bronchoscopy

*After: Send specimen to laboratory promptly for analysis.

(BEFORE GIVING ANTIBIOTICS). YOU WANT TO PERFORM ORAL CARE, THEN HAVE PT COUGH AND IF CANT THEN INCREASE FLUID INTAKE AND THEN SUCTION THEN BRONCHOSCOPY

Question 6

Analyzing results from a Mantoux test

checked in 48-72 hours!!!

> / = 5 mm induration?
/ = 10 mm induration?
/ = 15 mm induration?

Answer 6

• > / = 5 mm induration
  HIV-infected people
  Recent exposure w/ a person w/ TB disease
  Immunosuppressed persons
• > /= 10 mm induration
  Recent immigrants from a country where TB is common
  Injected drug users
  Residents & employees of high-risk settings
  Mycobacteriology lab personnel
  People w/ clinical conditions (DM, ESRD) that place then at high risk
• > /= 15 mm induration
  o Any person; no risk factors

Question 7

Recognizing assessment cues in a client with a sinus infection (sinusitis)

BP increases from decongestants

Answer 7

• Purulent nasal drainage (yellow or green)
• Nasal obstruction
• Facial pain (over & around sinuses)
• Fatigue
• Fever
• Post-nasal drip
• Maxillary dental pain
• Cough
• Ear fullness

Question 8

Nursing actions for a client with influenza

Answer 8

• Initiate isolation precautions
• Administer humidified supplemental oxygen
• Semi to high Fowler’s
• Obtain cultures
• Administer medications as ordered
• Provide adequate fluid intake
• Provide nutritional intake