Exam 2 Flashcards
1
Q
Cardiovascular assessment: Inspection
A
Look for obvious abnormality of the chest
- asymmetry of shape in sternum or clavicle
2
Q
Base of Heart
A
Where great vessels attach
3
Q
Apex of heart
A
Point furthest away from base
4
Q
AV valves
A
Atrioventricular valves: tricuspid (R) and mitral/bicuspid (L)
Try (tri) before you buy (bi)
5
Q
SL valves
A
Semilunar valves: aortic and pulmonic
6
Q
Point of maximum impulse
A
Where the heart is the loudest
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
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
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
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”
11
Q
Friction rubs
A
Abnormal heart sounds caused by pericarditis- inflammation around the heart (lack of lubrication)
12
Q
Upper extremity pulses
A
Radial and brachial
13
Q
lower extremity pulses
A
Femoral, popliteal, dorsal is pedis (pedal), posterity tibial
14
Q
Head/neck pulses
A
Carotid (emergencies only) and temporal
15
Q
Rating pulse quality/strength
A
0 (absent) to 3+ (increased, full, bounding)
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
17
Q
Factors affecting cardiovascular function
A
- smoking
- HTN
- nutrition
- lack of exercise/obesity
- diabetes
- Medical/family Hx
- stress
- inflammation
18
Q
Cardiac assessment steps
A
- Inspect for obvious abnormalities
- 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
19
Q
Reportable signs and symptoms
A
- chest pain/pressure
- dyspnea
- differences in some populations of people
20
Q
Edema
A
Fluid in interstitial spaces “between organs/cells” where it shouldn’t be
Rated from 1+ to 4+ with finger poke
21
Q
CMS
A
Circulation-motion-sensation
Neuromuscular, motor check
Compare extremities
22
Q
CMS check: Assessment
A
C- pulses, color, cap refill
M- fingers/toes
S- normal/abnormal
23
Q
CMS check: abnormalities
A
- Pale/cyanotic
- sluggish/absent cap refill
- weak/absent pulses
- numbness/tingling
- inability to move
24
Q
Signs of DVT
A
Pain, swelling, warmth, redness, usually in calf area
25
How to test for DVT
- 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
26
DVT risk
Clot can break off and travel to any part of body
Can lead to PE
27
DVT treatment
Bed rest for a time (getting up and moving is good though), anticoagulants, prevention
28
DVT prevention
SCDs (sequential compression devices), get pts ambulating, hydration, anticoagulants as ordered, active ROM while on bed rest
29
SCDs: why they’re used and indications/contraindications
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
30
TED hose and specifics of their use
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
31
Cardiovascular assessment: what do you document?
- subjective statements
- heart sounds/extra sounds
- skin color/temperature/turbot
- presence of edema and estimate
- signs of DVT, chest pain, circulation problems, etc.
32
Physical assessment of thorax
Inspect for obvious abnormalities, asymmetry of movement, sternum, intercostal muscle use, dyspnea
33
Documenting O2 saturation
List saturation as percentage and describe mode (room air, supplemental O2)
Ex: O2 sat 96% on O22LNC
34
Cough assessment
Frequency, whether it is productive or not
If yes, describe color, amount, consistency, odor
35
Anatomy of lung
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
36
Auscultation of breath sounds
- 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
37
Auscultation is limited by
How much the pt is capable of breathing, respect pt preference/privacy
38
Normal breath sounds
Clear & smooth throughout entire lung fields, adventitious lung sounds absent
39
Diminished lung sounds
Sounds less on one side or through our due to poor air movement, less lung space, etc.
40
Rhonchi
Due to airflow obstruction
- secretions (mucous, infection)
- can be cleared by coughing sometimes
- upper airways
41
Wheezes
Air squeezed through narrowed passageways, high pitched sound
42
Crackles (rales)
- air moving through mucous or fluid
- may be heard on inspiration or expiration
43
Pleural friction rub
Lack of lubrication between pleura and lung, can be heard on inspiration and expiration
44
Stridor
Heard on inspiration, loud high-pitched crowing, seen in croup, vascular problems, tracheal problems
45
Velcro rales
Seen in pulmonary fibrosis
46
Documentation of respiratory assessment
- 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
How soon after GI surgery does the system “turn back on”?
Around one week, 6-7 days
48
NG tubes
Used to decompress the stomach if there is overflow due to obstruction/inactivity. GI system turns off but bile is still produced.
49
GI assessment: Subjective info
- last BM and description
- Nausea
- passing gas (flatus)
- distention/bloating/fullness
50
GI assessment: Objective info
- last BM and characteristics
- % of meal taken
- intake of fluids
- Emesis
- physical assessment
51
Inspection landmarks
RUQ, LUQ, RLQ, LLQ
Regions: Epigastric, umbilical, suprapubic
52
Order of assessment of abdomen
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
Abnormal ABD complications
Don’t palpate:
- appendicitis
- acute abdomen
- known or suspected AAA
54
Large abdomen
Uniformly rounded, umbilicus deeply sunken, + bowel sounds, soft, non-tender
55
Distended abdomen
Single rounded curve, umbilicus may flatten or protrude, skin may glisten, varied auscultation, firm/rigid, tenderness/pain, guarding
56
Ileus or paralytic ileus definition
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
Ileus or paralytic ileus interventions
Detection, notify MD, hydrate, GI rest, limit opioids, NG tube to suction, oral care.
58
Ileus signs and Sxs
ABD distention/bloating, gas, constipation, N/V, dehydration
59
Defecation reflex
Not under voluntary control
60
Internal anal sphincter
Not under voluntary control , smooth muscle
61
External anal sphincter
Is under voluntary control
62
Normal feces
75% water, 25%solid
Frequency varies 1-2/day to 1-3/day
Brown, soft, cylindrical, bacterial decomp of protein odor
Flatus
63
Factors effecting bowel elimination: Nutrition
Fiber intake 20-30g/day
64
Factors effecting bowel elimination: fluid intake
2.5-3.5L/day
65
Factors effecting bowel elimination: activity
Promotes peristalsis
66
Factors effecting bowel elimination: lifestyle
Schedule for elimination, laxatives
67
Additional Factors effecting bowel elimination
Position (bed rest), pregnancy, medications, therapeutics (bowel preps, surgery)
68
Age related GI changes
Geriatric populations, Constipation and diarrhea
69
Criteria for constipation
2 or more:
- straining during >25% BMs
- Lumpy/hard stools >25% time
- sensation of incomplete evacuation >25% time
- <2-3 BM per week
70
Associated S/Sx constipation
Painful passage, ABD and rectal fullness, bloating, malaise, loss of appetite
71
Fecal impaction secondary to constipation
No BM 3-5 days, passage of liquid/semi liquid stool around area of impaction, assess pt to differentiate diarrhea or constipation
72
Enema rationale
Cleans portion of large bowel, surgical or diagnostic procedures, treat impaction, bowel training, relieve gaseous distention, administer medication (kayexalate)
73
Enema: small volume
~150mL ex. Fleets or oil retention
74
Enema: large volume
Up to 1000 mL water or saline ex. Tap h2o, soap suds
75
Enema: medicated
Kayexalate to remove excess K
76
Enema procedure
- 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
Return flow enema “Harris Flush”
Lower enema bag and allow solution & air bubbles to return
Monitor for: ABD pain, excess vagal stimulation, bradycardia, hypotension
78
Digital disempaction
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
Stool for occult blood (guaiac)
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
GU culture
Toilet/hygiene practices vary but all cultures value continency
81
Normal GU findings
Avg void 250-400ml with ~1500ml/day
Light, clear not malordorous, and no discomfort w/ voiding
82
Avg volume of adult bladder
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
Factors affecting output
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
GU assessment Qs
Is the pt experiencing any abnormalities in urination?
Open ended Qs
85
Nursing interventions to promote voiding
Privacy, time, assess usual void routine, assist prn, encourage voiding Q4hrs, analgesics, position of comfort
86
GU assessment
- inspect perineal areas for excoriation or breakdown
- urine qualities
- catheter placement
- urostomy and suprapubic catheter
87
Incontinence terms: stress
Pressure put on abdomen i.e. laughing, pregnancy, coughing
88
Urge/overflow incontinence
Sudden compelling urges to void resulting in involuntary leakage.
89
Functional incontinence
Physically unable: both muscle tone and not being able to get to a toilet
90
Unconscious incontinence
Either unconscious or spinal cord injury
91
Urinary retention nursing role
Bladder inspection and palpation
May need to use bladder scanner (no order needed)
92
UTI clinical manifestations
Dysuria, increased WBC count, fever/chills/rigors, cognitive impairment in older adults, urine cloudy, foul smelling, pyuria, symptoms vary.
93
GU geriatric changes
- 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
GU nursing interventions
- assessments
- protective devices- briefs/pads
- indwelling catheter care
- measurement of I/Os
- adjustment of environment or schedule
- education
- condom cath use
95
Indwelling catheter care
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
Gender alteration considerations
Approach with professionalism and respect, recognize your own biases, some people may have different parts, psychosocial cares and pt advocacy.
