100%(1)1 out of 1 people found this document helpful
This preview shows page 1 - 2 out of 2 pages.
CONCEPT MAP #4List 6 prioritynursingassessments(History, physical assessmentincluding vital signs, labs andother diagnostic procedures)List 6 prioritynursinginterventionsList the Rationalefor eachintervention. Align each interventionto the rationale.1. Assess Respiratory function byasking the patient to take a deepbreath2. Auscultate breath sounds3. Observe Skin color for cyanosis4. Assess for abdominal distension5. Assessing vital Signs regularly6. Assess for muscle spasm.INDEPENDENT: (Nurse performswithout health care provider orders)1. Maintain Patient airway2. Educating the patient about fallrisks3. Keep the side rails up, lock bedand call light within reachCOLABORATIVE(Nurse needsorders: medications and treatments)1. NSAIDS2. Muscle Relaxants3. Anti-depressants and painkillers1C-1 to C-3 injuries result in completeloss of respiratory function2. Hypoventilation is very common,and it leads to accumulations ofsecretion and sometimes evenpneumonia.