319 Exam 2 Flashcards
Cardiac subjective data
CP SOB Cough Any Hx of HTN, MI, CAD PND Exercise intolerance Palpitations Claudication Edema Syncopy
Respiratory subjective data
Cough SOB Orthopnea Chest pain Past history of respiratory infection Trauma Surgery PMH Environmental exposures
Subjective in common to both respiratory and cardiovascular
SOB
CP
Cough
Exercise intolerance
Respiratory Inspection
Symmetry?
Cyanosis?
Lesions?
Respiratory palpation
Thoracic expansion
Tactile fremitus (symmetrical vibration)
Tenderness
Lumps
Temperature
Palpation for tenderness, lumps, temperature using…
Fingers
Respiratory percussion
Resonance
Diaphragmatic excursion
High pitched, loud
Bronchial
Moderate, moderate
Bronchovesicular
Low pitch, soft
Vesicular
Broncophony
Say 99, hear barely
Egophony
Say eeee, expect eeee
Whispered pectoriloquy
Whispers, should be barely audible
S1 is from…
AV valves closing
S1 is loudest near the
Apex
S2 is from…
Closing of semilunar valves
S2 is loudest at the…
Base
Respiratory nursing diagnosis
Restlessness r/t dyspnea
Cyanosis r/t air hunger
Impaired cognitive function r/t ineffective breathing patterns
Ineffective airway clearance r/t inability to cough effectively
Impaired gas exchange r/t tachypnea
Activity intolerance r/t accessory muscle use
Cardiac nursing diagnosis
Activity intolerance r/t CP
Altered tissue perfusion r/t decreased cardiac output
Sensory alteration-tactile r/t impaired circulation
Impaired healing-foot ulcers r/t impaired circulation
For the respiratory exam auscultate using the…
Diaphragm
Crackles are heard during…
Inspiration
Friction rubs are heard during…
Inspiration and expiration
Not cleared by coughing
Crackles
Course sounds cleared with coughing…
Rhonchi
High-pitched piercing sound
Stridor
This sound is indicative of upper airway obstruction
Stridor
Apgar scoring system
HR
Respiratory effort
Muscle tone
Color
Reflex irritability to
The first BP change seen in shock is a…
Narrowing pulse pressure (Diastolic BP starts to rise)
What is a good heart rate?
60 to 100 BPM traditional
50 to 90 BPM AHA
Early signs of shock
Tachycardia Tachypnea BP varies/pulse pressure narrows Decreased urinary output Elevated blood glucose
What three positions is orthostatic hypotension checked?
Lying
Sitting
Standing
What signifies orthostatic hypotension?
Drop in BP more than 20 mm systolic
Increase in HR more than 20 BPM
Skin turgor is not helpful in…
Middle-aged/older adults
Signs of poor perfusion
Skin color
Skin temperature
Capillary refill
Peripheral pulses
Different cardiac symptoms in women
Shortness of breath
Fatigue
Epigastric symptoms
Neurologic symptoms
Cases where cardiac disease presents without chest pain
Elderly
Diabetics
Alcoholics and drug abusers
Previous mediastinal or thoracic surgery
For cardiovascular inspection what is normal?
No pulsation or apical pulsation
For cardiovascular palpation what is normal?
Only the apical impulse should be felt
S1 is the start of
Systole
S2 is the start of
Diastole
S3
Ventricular gallop
Indicative of LV failure
S4
Associated with HTN and CAD
Murmurs are graded on a scale of…
1 to 6
Problem with the valve not opening fully
Stenosis
Problem with valve not staying closed completely
Regurgitation
MS.ARD
Mitral stenosis and aortic regurgitation cause diastolic murmurs
MR. PASS
Mitral regurgitation and Pulmonic or aortic stenosis cause systolic murmurs
Peripheral vascular inspection
Color Clubbing Capillary refill Temperature Edema Ulceration Hair distribution
Auscultate to the carotids with
Bell
5 locations of auscultation for bruits
Carotid Abdominal Renal Iliac Femoral
What angle is JVP measured at?
45 degrees
What is a normal JVP measurement?
2 cm or less
Peripheral Pulse are measured on a scale of
0-3+
A normal peripheral pulse is
2+
Weak thready pulse
Peripheral artery disease PAD
Decreased CO
Regular rhythm, alternating weak strong
Pulsus Alternans
Indicative of Heart Failure
Pulse weaker inspiration, stronger expiration
Pulsus Paradoxus
Indicative of Tamponade
Symptoms for PAD
Calf/thigh pain Worse with activity Color change Temp change Loss of hair Slow wound healing Diminished pulses
Palpation for Peripheral Vascular
Warmth
Tenderness
Edemar
Edema scale range
1+ to 4+
Causes of pitting edema
Venous stasis Heart failure Liver failure Renal failure Poor lymphatic drainage
Venous stasis causes
Pregnancy
Obesity
DVT/VTE
Long periods sitting/standing
Peripheral vascular arterial deficiency
Ischemic ulcer Hairlessness Cool to touch Diminished pulses Claudication (leg cramps) Pain relieved by rest Color changes (cyanosis, e palor, d rubor)
Ankle-brachial pressure index normal range
0.9-1.2
DVT symptoms
Acute pain
Edema
Redness
homan’s sign (lower leg)
