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NRAD 201B > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Cardiovascular assessment: Inspection

A

Look for obvious abnormality of the chest
- asymmetry of shape in sternum or clavicle

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2
Q

Base of Heart

A

Where great vessels attach

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3
Q

Apex of heart

A

Point furthest away from base

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4
Q

AV valves

A

Atrioventricular valves: tricuspid (R) and mitral/bicuspid (L)
Try (tri) before you buy (bi)

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5
Q

SL valves

A

Semilunar valves: aortic and pulmonic

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6
Q

Point of maximum impulse

A

Where the heart is the loudest

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7
Q

APT. M- where to listen to heart sounds

A

Aortic valve- 2nd/3rd right intercostal space
Pulmonic valve- 2nd/3rd left intercostal space
Tricuspid valve- left sternal border
Mitral valve- apex

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8
Q

Auscultation: the “lub”

A

S1, first sound is the closure of AV valves and beginning of systole

Heard loudest at the apex- listen @ tricuspid and mitral

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9
Q

Auscultation: the “dub”

A

S2- the second sound, closure of the semi-lunar valves and end of systole/beginning of diastole

Heard loudest @ base- listen at pulmonic and aortic

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10
Q

Murmurs

A

Abnormal heart sounds caused by incomplete valve closure. Can be systolic (between S1 and S2) or diastolic (between S2 and S1)

Sounds like added “whooshing”

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11
Q

Friction rubs

A

Abnormal heart sounds caused by pericarditis- inflammation around the heart (lack of lubrication)

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12
Q

Upper extremity pulses

A

Radial and brachial

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13
Q

lower extremity pulses

A

Femoral, popliteal, dorsal is pedis (pedal), posterity tibial

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14
Q

Head/neck pulses

A

Carotid (emergencies only) and temporal

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15
Q

Rating pulse quality/strength

A

0 (absent) to 3+ (increased, full, bounding)

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16
Q

What are Doppler devices? What are they used for?

A

Used to locate pulses (Doppler pulses) if unable to palpate blood flow to an extremity or in assessing arterial blood flow

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17
Q

Factors affecting cardiovascular function

A
  • smoking
  • HTN
  • nutrition
  • lack of exercise/obesity
  • diabetes
  • Medical/family Hx
  • stress
  • inflammation
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18
Q

Cardiac assessment steps

A
  1. Inspect for obvious abnormalities
  2. Auscultate all 4 sites, ID S1-S2, apical rate, rhythm, listen for murmurs
    * may want to palpate radial pulse at the same time listening to apical
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19
Q

Reportable signs and symptoms

A
  • chest pain/pressure
  • dyspnea
  • differences in some populations of people
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20
Q

Edema

A

Fluid in interstitial spaces “between organs/cells” where it shouldn’t be

Rated from 1+ to 4+ with finger poke

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21
Q

CMS

A

Circulation-motion-sensation
Neuromuscular, motor check
Compare extremities

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22
Q

CMS check: Assessment

A

C- pulses, color, cap refill
M- fingers/toes
S- normal/abnormal

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23
Q

CMS check: abnormalities

A
  • Pale/cyanotic
  • sluggish/absent cap refill
  • weak/absent pulses
  • numbness/tingling
  • inability to move
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24
Q

Signs of DVT

A

Pain, swelling, warmth, redness, usually in calf area

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25
Q

How to test for DVT

A
  • D-Dimer blood test (presence of clot somewhere)
  • ultrasound of legs (conclusive test)
  • Homans sign: pain in calf after straightening leg, knee pressure and abrupt dorsiflexion of toes
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26
Q

DVT risk

A

Clot can break off and travel to any part of body
Can lead to PE

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27
Q

DVT treatment

A

Bed rest for a time (getting up and moving is good though), anticoagulants, prevention

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28
Q

DVT prevention

A

SCDs (sequential compression devices), get pts ambulating, hydration, anticoagulants as ordered, active ROM while on bed rest

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29
Q

SCDs: why they’re used and indications/contraindications

A

To promote venous return and prevent DVT

Indicated in: venous insufficiency/edema, prolonged bed rest, intra-operatively, post-operatively, trauma

Contraindicated in: arterial insufficiency, presence of DVT, fall risks

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30
Q

TED hose and specifics of their use

A

Provide continuous compression from ankles to knee/thigh

  • need to be properly fitted
  • applied without wrinkles/bunching
  • removed for 30 min q8hr while in bed
  • intact CMS
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31
Q

Cardiovascular assessment: what do you document?

A
  • subjective statements
  • heart sounds/extra sounds
  • skin color/temperature/turbot
  • presence of edema and estimate
  • signs of DVT, chest pain, circulation problems, etc.
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32
Q

Physical assessment of thorax

A

Inspect for obvious abnormalities, asymmetry of movement, sternum, intercostal muscle use, dyspnea

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33
Q

Documenting O2 saturation

A

List saturation as percentage and describe mode (room air, supplemental O2)

Ex: O2 sat 96% on O22LNC

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34
Q

Cough assessment

A

Frequency, whether it is productive or not
If yes, describe color, amount, consistency, odor

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35
Q

Anatomy of lung

A

Apex on top of each lobe and base at the bottom

R lung: 3 lobes- RUL, RML, RLL
L Lung: 2 lobes- LUL, LLL, cardiac notch

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36
Q

Auscultation of breath sounds

A
  • instruct pt to breathe deeply in/out of mount
  • listen anterior/lateral chest
  • listen posterior chest (usually uppers and lowers)
  • listen for a whole breath cycle for each location
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37
Q

Auscultation is limited by

A

How much the pt is capable of breathing, respect pt preference/privacy

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38
Q

Normal breath sounds

A

Clear & smooth throughout entire lung fields, adventitious lung sounds absent

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39
Q

Diminished lung sounds

A

Sounds less on one side or through our due to poor air movement, less lung space, etc.

40
Q

Rhonchi

A

Due to airflow obstruction
- secretions (mucous, infection)
- can be cleared by coughing sometimes
- upper airways

41
Q

Wheezes

A

Air squeezed through narrowed passageways, high pitched sound

42
Q

Crackles (rales)

A
  • air moving through mucous or fluid
  • may be heard on inspiration or expiration
43
Q

Pleural friction rub

A

Lack of lubrication between pleura and lung, can be heard on inspiration and expiration

44
Q

Stridor

A

Heard on inspiration, loud high-pitched crowing, seen in croup, vascular problems, tracheal problems

45
Q

Velcro rales

A

Seen in pulmonary fibrosis

46
Q

Documentation of respiratory assessment

A
  • position of pt
  • subjective statements
  • O2 sat and mode
  • respiratory rhythm and effort
  • depth of respirations
  • breath sounds/adventitious lung sounds
  • cough and characteristics
  • use of accessory muscles
47
Q

How soon after GI surgery does the system “turn back on”?

A

Around one week, 6-7 days

48
Q

NG tubes

A

Used to decompress the stomach if there is overflow due to obstruction/inactivity. GI system turns off but bile is still produced.

49
Q

GI assessment: Subjective info

A
  • last BM and description
  • Nausea
  • passing gas (flatus)
  • distention/bloating/fullness
50
Q

GI assessment: Objective info

A
  • last BM and characteristics
  • % of meal taken
  • intake of fluids
  • Emesis
  • physical assessment
51
Q

Inspection landmarks

A

RUQ, LUQ, RLQ, LLQ

Regions: Epigastric, umbilical, suprapubic

52
Q

Order of assessment of abdomen

A

Look- inspect first
listen- auscultate all 4 quads for high pitched bowel sounds. Can be active (normal), hyperactive (loud greater than 5-15 seconds), or hypoactive (faint, not in all quads, or absent)
feel- lightly palpate for masses, pain, abnormalities

53
Q

Abnormal ABD complications

A

Don’t palpate:
- appendicitis
- acute abdomen
- known or suspected AAA

54
Q

Large abdomen

A

Uniformly rounded, umbilicus deeply sunken, + bowel sounds, soft, non-tender

55
Q

Distended abdomen

A

Single rounded curve, umbilicus may flatten or protrude, skin may glisten, varied auscultation, firm/rigid, tenderness/pain, guarding

56
Q

Ileus or paralytic ileus definition

A

Loss of forward flow of intestinal contents due to decreased peristalsis, secondary to anesthesia, handling of the intestines during surgery, electrolyte imbalance, infection of ischemic bowel

57
Q

Ileus or paralytic ileus interventions

A

Detection, notify MD, hydrate, GI rest, limit opioids, NG tube to suction, oral care.

58
Q

Ileus signs and Sxs

A

ABD distention/bloating, gas, constipation, N/V, dehydration

59
Q

Defecation reflex

A

Not under voluntary control

60
Q

Internal anal sphincter

A

Not under voluntary control , smooth muscle

61
Q

External anal sphincter

A

Is under voluntary control

62
Q

Normal feces

A

75% water, 25%solid
Frequency varies 1-2/day to 1-3/day
Brown, soft, cylindrical, bacterial decomp of protein odor
Flatus

63
Q

Factors effecting bowel elimination: Nutrition

A

Fiber intake 20-30g/day

64
Q

Factors effecting bowel elimination: fluid intake

A

2.5-3.5L/day

65
Q

Factors effecting bowel elimination: activity

A

Promotes peristalsis

66
Q

Factors effecting bowel elimination: lifestyle

A

Schedule for elimination, laxatives

67
Q

Additional Factors effecting bowel elimination

A

Position (bed rest), pregnancy, medications, therapeutics (bowel preps, surgery)

68
Q

Age related GI changes

A

Geriatric populations, Constipation and diarrhea

69
Q

Criteria for constipation

A

2 or more:
- straining during >25% BMs
- Lumpy/hard stools >25% time
- sensation of incomplete evacuation >25% time
- <2-3 BM per week

70
Q

Associated S/Sx constipation

A

Painful passage, ABD and rectal fullness, bloating, malaise, loss of appetite

71
Q

Fecal impaction secondary to constipation

A

No BM 3-5 days, passage of liquid/semi liquid stool around area of impaction, assess pt to differentiate diarrhea or constipation

72
Q

Enema rationale

A

Cleans portion of large bowel, surgical or diagnostic procedures, treat impaction, bowel training, relieve gaseous distention, administer medication (kayexalate)

73
Q

Enema: small volume

A

~150mL ex. Fleets or oil retention

74
Q

Enema: large volume

A

Up to 1000 mL water or saline ex. Tap h2o, soap suds

75
Q

Enema: medicated

A

Kayexalate to remove excess K

76
Q

Enema procedure

A
  • assess need
  • may or ay not be considered a “medication”
  • explain procedure
  • privacy
  • position pt in Sim’s (Lside)
  • use gloves
  • have supplies ready
  • insert tip 3-4 inches depending on type
  • ask pt to hold as long as possible
  • call bell, assist in elimination/cleaning
  • reassess
77
Q

Return flow enema “Harris Flush”

A

Lower enema bag and allow solution & air bubbles to return
Monitor for: ABD pain, excess vagal stimulation, bradycardia, hypotension

78
Q

Digital disempaction

A

Order needed, VS prior to procedure due to increased vagaries stimulation, gloves, lubricant, gown, bedpan/comode, use gentle hooking motion, monitor for adverse rxns (vagal, bradycardia, hypotension), avoid mucosal tissue injury

79
Q

Stool for occult blood (guaiac)

A

To test for blood in stool: Obtain small amt. stool using tongue blade, thinly smear on test portion of hemoccult slide and close flap, send to lab

80
Q

GU culture

A

Toilet/hygiene practices vary but all cultures value continency

81
Q

Normal GU findings

A

Avg void 250-400ml with ~1500ml/day
Light, clear not malordorous, and no discomfort w/ voiding

82
Q

Avg volume of adult bladder

A

About 500ml but may distend to hold 2x the amount
- volume activates stretch receptors and sends signals via spinal cord to void reflex center

83
Q

Factors affecting output

A

Intake/nutrition/IV fluids, fluid/blood loss, body position, cognition, psychological factors, obstruction, UTIs, hypotension, neurological injury, muscle tone, pregnancy, disease processes, surgery, meds, kidney failure

84
Q

GU assessment Qs

A

Is the pt experiencing any abnormalities in urination?
Open ended Qs

85
Q

Nursing interventions to promote voiding

A

Privacy, time, assess usual void routine, assist prn, encourage voiding Q4hrs, analgesics, position of comfort

86
Q

GU assessment

A
  • inspect perineal areas for excoriation or breakdown
  • urine qualities
  • catheter placement
  • urostomy and suprapubic catheter
87
Q

Incontinence terms: stress

A

Pressure put on abdomen i.e. laughing, pregnancy, coughing

88
Q

Urge/overflow incontinence

A

Sudden compelling urges to void resulting in involuntary leakage.

89
Q

Functional incontinence

A

Physically unable: both muscle tone and not being able to get to a toilet

90
Q

Unconscious incontinence

A

Either unconscious or spinal cord injury

91
Q

Urinary retention nursing role

A

Bladder inspection and palpation
May need to use bladder scanner (no order needed)

92
Q

UTI clinical manifestations

A

Dysuria, increased WBC count, fever/chills/rigors, cognitive impairment in older adults, urine cloudy, foul smelling, pyuria, symptoms vary.

93
Q

GU geriatric changes

A
  • 30% reduction in function
  • 2/3 functional nephrons remain by 80
  • decreased blood flow to kidneys
  • decreased muscle tone- bladder ureters, urethra
  • nocturia
  • male/female changes
  • most maintain homeostasis
  • Some are private about issues
94
Q

GU nursing interventions

A
  • assessments
  • protective devices- briefs/pads
  • indwelling catheter care
  • measurement of I/Os
  • adjustment of environment or schedule
  • education
  • condom cath use
95
Q

Indwelling catheter care

A

Attach tubing to the body, bag below bladder level, empty bag periodically, bag to frame of bed, clean perineal area and cath, assess urine, and no dependent loops.

96
Q

Gender alteration considerations

A

Approach with professionalism and respect, recognize your own biases, some people may have different parts, psychosocial cares and pt advocacy.

NRAD 201B (4 decks)

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