ADULT HEALTH HESI STUDY GUIDE
Respiratory
system
Pathophysiology Nursing Assessment Analysis Plans Hints
Pneumonia: A. Impaired gas High risk for
A. Tachypnea: shallow exchange related A. Assess suptum pneumonia
Inflammation of respirations with to…
B. In e f f e ct i ve for volume, Any person who has an
lower respiratory use of accessory c a ie rlawr aayn c e r
e l a t ed color, altered level of
tract Caused by muscles. to… consistency consciousness, has
C. Activity intolerance
infectious agents B. Abrupt onset of related to… and clarity. depressed or absent gag
Organisms D. R isk for deficient
fever with shaking ed f B. Assist client to and cough reflexes or
reach the and chills (not lu id volume cough is susceptible to
lungs in 3 relat
to … . aspirating
reliable in O/A) productively
methods: C. Pr o du c t i v e E. Ineffectivepattern
1. Aspiration cw ou i thg h p l e u r it breathing
related to… by: orophayngeal
2. Inhalation ic p a in 1. deep secretions, including
3. Hematogeno D. R ap i d alcoholics,
pu l s e
bounding breathing
us spread care every 2 anesthesized, those
E. I o ld e r adults
Pneumonia is sxinc lu d e : hours (many with a brain injury and
1. Confusion
classified 2. Lethargy use those in a state of drug
3. Anorexia
according to incentive overdose and stroke
4. R a pid
causitive agent
1. B a ct e r ial
ra te
respiratory spiometer) victims are at high risk
p (o sama n d F. Pain and dullness 2. Using
When feeding-- raise
ne g) the head of the bed and
V ir
2. to percussion over humidity to
a l 3.n
Fu
the affected lung loosen position the client on
g al
4. Chemical area sevretions his or her side and not
Pneumonia B r o c hi al b
G.
on the back.
r so e au hnd t s /c ra c (may be
may be k l e s oxylgenera
community H. Chest radiography Bronchial brath
ted)
3. Suctioning
acquired or indication of airway if sounds are heard over
nosomcomial
H i g h r isk inflitrates with necessary areas of density or
in c lu d e consolidation or C. Assess lung
groups consolidation. Sound
1. Debilitated by sounds before
lung secretions I. pleural effusions
E l e v at e d w waves are easily
2. Cigarette and after
smokers bh il ote o d c e ll c transmitted over
3. Immoblie coughing
o u ng consolidated tissues.
4. Im J. ABG of hypoxemia D. Assess rate,
e d
unosuppress K. On pulse oximetry a Hydration
5. Expereincing
depth, and
drop in O2 pattern of Enables liquefication
a depressed satruation (> 90 and respirations of mucous trapped in
gag reflex ideally 95)
6. Sedated regularly the bronchioles and
7. Experiencin (normal adult alveoli, facilitating
g rate 16 to 20 expectoration Is
neuromuscl breaths/min) essential for client
ar disorders M
E. on it or A
(pO
bg 's 2 > 8 experiencing fever
0m m 2; Is important because
Pc o 2
< 4 5 mm hg) 300 to 400 mL of fluid
F. Monitor O2 is lost daily by the lugns
saturation with through evaporation.
pulse oximetry
(ideally > Irritably and restlessnes
95%) are early signs of
G. A s s e ss skin cerebral hypoxia; the
co l o r
H. Assess mental cleint's brain is not
status, recieiing enough of O2.
restlessness,
,
, and irritability
A d m i n is Pneumonia
I.
t pr er o2e as
sc r ib e Preventaives
J.
d Older adults: flue
M on i to r shots; pneumonia,
tem p e ra t immunizations;
ure avoiding soucres of
regularly
K. Provide
infection and indoor
adequate rest pollutants (dust,
periods, smoke and aerosols);
including no smoking.
uniterrupted Immunosuppressed
sleep. and debilitated
L. Encourage at
persons: infection
risk groups to avoidance, sensible
annual nutition, adequate
pneumonia and intake, balanced rest
influenza (flu) and activy.
Comatose and
immuniziations
immoblie persons:
.
elevetion of head of
bed to fed and for 2
hours after/ frequently
turning
Pathophysiology Nursing assessment Analysis Plans Hints
Chronic airflow Changes in Ineffective airway Teach client to Exposrue to tobacco
limitation
Description: breathing pattern clearance related sit upright and smoke is the primary
chonic lung (eg. An increase to Ineffective bend slightly cause of COPD in the
disease includes with rate iand depth) breathing pattern forward to United States.
chonic Use of accessory related to promote
bronchitis; breathing (barrel Impaired gas breathing Compensation occurs
pulmonary chest) Gernalized exchage related to 1. In bed teach over time in clients
emphysema and cyanosis of the lips, Activity related to client to sit over time in clients
asthma. mucous with arms with chonic lung
Emphysema and memrbanes, face, resting on disease, and ABG's are
chonic nail beds ("blue overbed table altered.
boronchitis bloaters) Cough (tripod As COPD worsens the
termed as chonic (dry
H iorg productive)
h e r Co2 position0 amount of O2 in the
av e r a g e 2. In chair teach blood decreases
obstructive than Low O2 as
pulmonary de t e rm in ed client to lean (hypoxemia) and the
by
o pulse
x i m eta ry forward with amount of carbon
disease (COPD) Decreased breath
sound elbows dioxide (Co2) in the
are characterized
Coarse crackles resting on blood increases
bronchospasm
in lung fields that knees (tripod (hypercarbia), causing
and dyspnea. The
tend disappear position) chonic repisratory
damage to the
after coughing, Teach acidosis (increased
lung is not
wheezing diaphragmatic arterial carbon dioxide
reversity and
increases in the Dyspnea, and pursed lip (paCo2), which results
severity. Asthma, orthopena rbeathing. Teach in metabolic a
P o o r n tonui t i (increased arterial
Unlike COPD, is A c ti v it y i n tol
erance prolonged
A n x i et y co
an intermittent br
n ce eatr hn ei ingn g expiratory phase bicarbonate) as
disease with m a n ic e st e d to clear trappped compensation.
by:
1. Anger Not all clients with
reversible airflow 2. Fear of being
air Administer
obstruction. alone O2 at 1 - 2 L per COPD are Co2
3. Far of not being
able to catch nasal canula. retainers, even when
breath
, Pase activities hypoxemia is present,
to conserve because Co2 diffuses
energy more easliy across
Maintain lung memebranes than
adequate O2.
dietary intake In advanced
1. S e l e c t emphysema, due to the
s mall,
n tfr e q u e
mealse alveoli bereing affected
2. Inscreased
hypercarbia is is a
calories and problem rather than
protein Select borchitis where the
foods that derive airway are affected.
their calories It is imparitive that
from high fat basline data be
rather than high obtained for the client.
carbohydrate
level because Productive cough and
Co2 that is a comfort can be
natrual end facilited by semi fower
product of or high power
carbohydrate position, which lessens
metablism and pressure on the
can elevate diaphragm by
PaCo2 levels abdominal organs.
3. Favorite
4. Gastric distention
D i e ta r y become a proity in
su p p l e m these cliente because it
ents elevates the idaphragm
For people and inhibits full lung
contiinuing to expansion.
smoke tobacco,
adiditional N ORMAldu l t ABG
A
values pH 7 . 35 -
vatamin C may 7.45
Pco2
be necessary. Po2 80 to- 45
35 100mmHG
mmhg
H c o 3 - 21 to 28
Magnesium and mEq/L Ch i l d
clacium, pH 7.36 - 7.44
because of their Same
role in muscle as
contraction and adult
relaxation, may Same
be important for as
people with adult
COPD. Same
Routine as
monitoring of adult
magnesium and
phosphorus levels Pink puffer: barrel chest
is important is indicative of
because of their emphysema and is
role related to caused by the use of
bone mineral accessory muscles to
density breathe. The person
(osteoprorisis). works harder to
breathe, but the amount
Provide an
of O2 taken is adequate
adequate fluid
intake
Respiratory
system
Pathophysiology Nursing Assessment Analysis Plans Hints
Pneumonia: A. Impaired gas High risk for
A. Tachypnea: shallow exchange related A. Assess suptum pneumonia
Inflammation of respirations with to…
B. In e f f e ct i ve for volume, Any person who has an
lower respiratory use of accessory c a ie rlawr aayn c e r
e l a t ed color, altered level of
tract Caused by muscles. to… consistency consciousness, has
C. Activity intolerance
infectious agents B. Abrupt onset of related to… and clarity. depressed or absent gag
Organisms D. R isk for deficient
fever with shaking ed f B. Assist client to and cough reflexes or
reach the and chills (not lu id volume cough is susceptible to
lungs in 3 relat
to … . aspirating
reliable in O/A) productively
methods: C. Pr o du c t i v e E. Ineffectivepattern
1. Aspiration cw ou i thg h p l e u r it breathing
related to… by: orophayngeal
2. Inhalation ic p a in 1. deep secretions, including
3. Hematogeno D. R ap i d alcoholics,
pu l s e
bounding breathing
us spread care every 2 anesthesized, those
E. I o ld e r adults
Pneumonia is sxinc lu d e : hours (many with a brain injury and
1. Confusion
classified 2. Lethargy use those in a state of drug
3. Anorexia
according to incentive overdose and stroke
4. R a pid
causitive agent
1. B a ct e r ial
ra te
respiratory spiometer) victims are at high risk
p (o sama n d F. Pain and dullness 2. Using
When feeding-- raise
ne g) the head of the bed and
V ir
2. to percussion over humidity to
a l 3.n
Fu
the affected lung loosen position the client on
g al
4. Chemical area sevretions his or her side and not
Pneumonia B r o c hi al b
G.
on the back.
r so e au hnd t s /c ra c (may be
may be k l e s oxylgenera
community H. Chest radiography Bronchial brath
ted)
3. Suctioning
acquired or indication of airway if sounds are heard over
nosomcomial
H i g h r isk inflitrates with necessary areas of density or
in c lu d e consolidation or C. Assess lung
groups consolidation. Sound
1. Debilitated by sounds before
lung secretions I. pleural effusions
E l e v at e d w waves are easily
2. Cigarette and after
smokers bh il ote o d c e ll c transmitted over
3. Immoblie coughing
o u ng consolidated tissues.
4. Im J. ABG of hypoxemia D. Assess rate,
e d
unosuppress K. On pulse oximetry a Hydration
5. Expereincing
depth, and
drop in O2 pattern of Enables liquefication
a depressed satruation (> 90 and respirations of mucous trapped in
gag reflex ideally 95)
6. Sedated regularly the bronchioles and
7. Experiencin (normal adult alveoli, facilitating
g rate 16 to 20 expectoration Is
neuromuscl breaths/min) essential for client
ar disorders M
E. on it or A
(pO
bg 's 2 > 8 experiencing fever
0m m 2; Is important because
Pc o 2
< 4 5 mm hg) 300 to 400 mL of fluid
F. Monitor O2 is lost daily by the lugns
saturation with through evaporation.
pulse oximetry
(ideally > Irritably and restlessnes
95%) are early signs of
G. A s s e ss skin cerebral hypoxia; the
co l o r
H. Assess mental cleint's brain is not
status, recieiing enough of O2.
restlessness,
,
, and irritability
A d m i n is Pneumonia
I.
t pr er o2e as
sc r ib e Preventaives
J.
d Older adults: flue
M on i to r shots; pneumonia,
tem p e ra t immunizations;
ure avoiding soucres of
regularly
K. Provide
infection and indoor
adequate rest pollutants (dust,
periods, smoke and aerosols);
including no smoking.
uniterrupted Immunosuppressed
sleep. and debilitated
L. Encourage at
persons: infection
risk groups to avoidance, sensible
annual nutition, adequate
pneumonia and intake, balanced rest
influenza (flu) and activy.
Comatose and
immuniziations
immoblie persons:
.
elevetion of head of
bed to fed and for 2
hours after/ frequently
turning
Pathophysiology Nursing assessment Analysis Plans Hints
Chronic airflow Changes in Ineffective airway Teach client to Exposrue to tobacco
limitation
Description: breathing pattern clearance related sit upright and smoke is the primary
chonic lung (eg. An increase to Ineffective bend slightly cause of COPD in the
disease includes with rate iand depth) breathing pattern forward to United States.
chonic Use of accessory related to promote
bronchitis; breathing (barrel Impaired gas breathing Compensation occurs
pulmonary chest) Gernalized exchage related to 1. In bed teach over time in clients
emphysema and cyanosis of the lips, Activity related to client to sit over time in clients
asthma. mucous with arms with chonic lung
Emphysema and memrbanes, face, resting on disease, and ABG's are
chonic nail beds ("blue overbed table altered.
boronchitis bloaters) Cough (tripod As COPD worsens the
termed as chonic (dry
H iorg productive)
h e r Co2 position0 amount of O2 in the
av e r a g e 2. In chair teach blood decreases
obstructive than Low O2 as
pulmonary de t e rm in ed client to lean (hypoxemia) and the
by
o pulse
x i m eta ry forward with amount of carbon
disease (COPD) Decreased breath
sound elbows dioxide (Co2) in the
are characterized
Coarse crackles resting on blood increases
bronchospasm
in lung fields that knees (tripod (hypercarbia), causing
and dyspnea. The
tend disappear position) chonic repisratory
damage to the
after coughing, Teach acidosis (increased
lung is not
wheezing diaphragmatic arterial carbon dioxide
reversity and
increases in the Dyspnea, and pursed lip (paCo2), which results
severity. Asthma, orthopena rbeathing. Teach in metabolic a
P o o r n tonui t i (increased arterial
Unlike COPD, is A c ti v it y i n tol
erance prolonged
A n x i et y co
an intermittent br
n ce eatr hn ei ingn g expiratory phase bicarbonate) as
disease with m a n ic e st e d to clear trappped compensation.
by:
1. Anger Not all clients with
reversible airflow 2. Fear of being
air Administer
obstruction. alone O2 at 1 - 2 L per COPD are Co2
3. Far of not being
able to catch nasal canula. retainers, even when
breath
, Pase activities hypoxemia is present,
to conserve because Co2 diffuses
energy more easliy across
Maintain lung memebranes than
adequate O2.
dietary intake In advanced
1. S e l e c t emphysema, due to the
s mall,
n tfr e q u e
mealse alveoli bereing affected
2. Inscreased
hypercarbia is is a
calories and problem rather than
protein Select borchitis where the
foods that derive airway are affected.
their calories It is imparitive that
from high fat basline data be
rather than high obtained for the client.
carbohydrate
level because Productive cough and
Co2 that is a comfort can be
natrual end facilited by semi fower
product of or high power
carbohydrate position, which lessens
metablism and pressure on the
can elevate diaphragm by
PaCo2 levels abdominal organs.
3. Favorite
4. Gastric distention
D i e ta r y become a proity in
su p p l e m these cliente because it
ents elevates the idaphragm
For people and inhibits full lung
contiinuing to expansion.
smoke tobacco,
adiditional N ORMAldu l t ABG
A
values pH 7 . 35 -
vatamin C may 7.45
Pco2
be necessary. Po2 80 to- 45
35 100mmHG
mmhg
H c o 3 - 21 to 28
Magnesium and mEq/L Ch i l d
clacium, pH 7.36 - 7.44
because of their Same
role in muscle as
contraction and adult
relaxation, may Same
be important for as
people with adult
COPD. Same
Routine as
monitoring of adult
magnesium and
phosphorus levels Pink puffer: barrel chest
is important is indicative of
because of their emphysema and is
role related to caused by the use of
bone mineral accessory muscles to
density breathe. The person
(osteoprorisis). works harder to
breathe, but the amount
Provide an
of O2 taken is adequate
adequate fluid
intake
