Assessment Flashcards
Vibration produced when patient articulates “99”
Tactile fremitus
Vesicular
soft and low-pitched breezy sounds heard over most of peripheral lung fields; inspiration >= expiration
medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration=expiration
Bronchovesicular
loud, coarse blowing sounds head over the trachea; inspiration <= expiration
Bronchi
abnormal lung sounds caused by fluid or inflammation
Adventitious
grating sound or vibration heard during inspiration and expiration
pleura friction rub
squeaky sounds heard during inspiration and expiration associated with narrowed airways
sibilant wheeze
musical sounds or vibrations commonly heard on expiration
sonorous wheeze
abnormal sounds caused by turbulence within a heart valve
murmurs
Bruit
turbulence within a blood vessel
same concentrations as body fluids
Isotonic fluids
Hypertonic solution
solute concentration greater than that of body fluids
hypotonic solution
solute concentration less than that of body fluids
fluid deficit causes
vomiting diarrhea GI suction sweating and warm weather decreased intake; increased caffeine and alcohol intake hyperthermia diuretics
signs and symptoms of fluid deficit
weight loss
decreased skin turgor
oliguria
concentrated urine
postural hypotension
weak, rapid pulse
increased hematocrit, hemoglobin, BUN, Na, serum osmolality
Hyperthermia- increased pulse, decreased BP, disorientation
orthostatic hypotension, falls, pressure ulcers, constipation, dry oral mucous
increase in the interstitial compartment, intravascular compartment or both
fluid overload - isotonic gain
causes of fluid overload
heart failure renal failure Cirrhosis of the liver excessive ingestion of Na excessive or too rapid intravenous infusion
signs and symptoms of fluid overload
edema
distended veins
increased BP
bounding pulse
crackles; increased RR, shallow respiration
decreased hematocrit and BUN (5-20 mg/dL)
weight gain
cause of hypokalemia (<3.5 mEq/L)
vomiting gastric suction prolonged diarrhea diuretics and steroids inadequate intake
signs and symptoms of hypokalemia
anorexia, N/V weak peripheral pulses muscle weakness, paresthesias; decreased deep tendon reflexes impaired urine concentration ventricular dysrhythmias potential for digitalis toxicity shallow respirations
hyperkalemia causes (> 5.0 mEq/L)
renal failure use of K supplements burns crushing injuries severe infection K-sparing diuretics ACE inhibitors
signs and symptoms of hyperkalemia
EKG changes-peaked T waves, wide QRS complexes
dysrhythmias, ventricular fibrillation, heart block
cardiac arrest
muscle twitching and weakness
numbness in hands and feet and around mouth
nausea
Diarrhea
causes of hyponatremia (<135 mEq/L)
vomiting diuretics excessive administration of dextrose and water IVs burns, wound drainage excessive water intake SIADH kidneys unable to excrete free water
sign and symptoms of hyponatreia
nausea muscle cramps confusion muscular twitching, coma seizures headache delirium
causes of hypernatremia (>145)
hyperventilation
diabetes insipidus
hypertonic tube feedings without water supplements
ingestion of OTC drugs such as Alka-Seltzer
saltwater
inadequate water ingestion
signs and symptoms of hypernatremia
Elevated temperature weakness Disorientation irritability and restlessness thirst dry, swollen tongue sticky mucous membranes postural hypotension with decrease ECF hypertension with normal or increase ECF tachycardia mental status changes, coma
causes of hypocalcemia
hypoparathyroidism pancreatitis renal failure steroids and loop diuretics inadequate intake post thyroid surgery
signs and symptoms of hypocalcemia
tetany hyperactive reflexes confusion paresthesias irritability seizures
causes of hypercalcemia
malignant neoplastic diseases hyperparathyroidism prolonged immobilization excessive intake immobility excessive intake of calcium carbonate antacids
signs and symptoms of hypercalcemia
lack of coordination
anorexia, N/V
confusion, decreased level of consciousness
personality changes
dysrthythmias, heart block, cardiac arrest
causes of hypomagnesemia
alcoholism GI suction Diarrhea intestinal fistulas poorly controlled diabetes mellitus malabsorption syndrome
signs and symptoms of hypomagnesemia
increased neuromuscular irritability tremors tetany hyperactive deep tendon reflexes seizures dysrhythmias disorientation confusion
causes of hypermagnesemia
renal failure
excessive magnesium administration (antacids, cathartics)
signs and symptoms of hypermagnesemia
depresses the CNS depresses cardiac impulse transmission cardiac arrest facial flushing muscle weakness absent deep tendon reflexes paralysis shallow respirations
infiltrated IV site
apply warm compresses
