Exam 2: NR414 Rev 2 Flashcards
This is a term for “dry mouth”
Xerostomia
Another name for nosebleed
Epistaxis
Jarvis:
The second heart sound is the result of:
closing of the mitral and tricuspid valves
Jarvis:
When palpating an apical impulse what is the normal size?
2 cm
Jarvis:
Where do you listen in the pulmonic valve area?
the 2nd Left Interspace
Jarvis:
What is the difference between S2 & S3?
S3 is lower pitched and is heard at the apex
Jarvis:
When auscultating the heart your first step is to:
identify S1 & S2
Jarvis:
Where is a split S2 heard most clearly?
pulmonic
The most common site of nosebleeds
Kiesselbach Plexus
What is a common cause of dry mouth?
medications
Which side of the lungs is narrower and only has 2 sides
Left lung
This breath sound is moderate in pitch, inspiration= expiration
Bronchovesicular breath sounds
Where is the left lateral lung located?
- sixth rib, midclavicular line
Where is the Right Lateral Lung Border?
Fifth intercostal
Where is the posterior apex of the lung border?
C7
Bronchial Tracheal Characteristics:
- High pitched
- Inspiration < Experiation
- Harsh,Hollow, Tubular
- Trachea/Larynx
This breath sound is over the major bronchi where fewer alveoli are located: Posterior b/w capulae especially on Rt anterior. Around Upper sternum in 1st and 2nd ICS
Bronchovesicular
This breath sound is over peripheral lung fields where air flows through smaller bronchioles and alveoli
Vesicular
Characteristics of Vesicular Sounds
- Low pitch
- inspiration > Expiration
- Rustling like wind in trees
This is purposeful and expands the alveoli. May indicate emotional dysfunction and could lead to hyperventilation.
Sigh
Name this respiration pattern
Biot’s Respiration
This is a series of normal respiration followed by a period of apnea. Cycle is variable, lasting from 10- 60 sec.
- Biots Respiration (irregular)
- Seen with head trauma, brain abscess, heat stroke spinal meningitis, & encephalitis
Name this respiration pattern?
Normal Adult
Rate is usually 10-20 breaths/min. Depth 500-800ml. Pattern is even.
Normal Adult
Name this respiration pattern?
Cheyne Stokes
Breathing periods last 30-45 sec, with 20 sec periods of apnea. Respirations wax and wane.
- Cheyne Stokes
- severe heart failure, drug OD, older adult during sleep, infant
Name this respiration pattern
Tachypnea
Rapid shallow breathing. >24/min.
- Tachypnea
- exercise, fever, fear, pneumonia
Name this respiration pattern
Bradypnea
Slow breathing,
- Bradypnea
- drug induced
- diabetic coma
Name this respiration pattern
hyperventilation
Rate & depth both increase with this respiration type. Blows off CO2 causing a low level in the blood.
- Hyperventilation
- extreme exertion, fear, anxiety, hepatic coma, diabetic, lesions of the brain
Name this respiration pattern
Chronic Obstructive Breathing
This is when you have prolonged expiration to overcome airway resistance.
- Chronic Obstructive Breathing
- can cause air trapping (dyspneic episode)
Name this respiration pattern
Hypoventilation
An irregular shallow pattern of breathing caused by an OD of narcotics, anesthetics or prolonged bed rest.
- Hypoventilation
Name this adventitious sound pattern
Stridor
This sound is high pitched, monphonic. It is louder in the neck than over the chest wall. Upper airway obstruction- swollen tissues or lodged foreign body.
- Stridor
- croup, acute epiglottis child, foreign inhalation.
Name this adventitious sound pattern
Name this adventitious inhalation pattern
Wheeze high pitched (sibilant
This is a high pitched musical squeaking/polyphonic. Predominantly in expiration. Sounds are similar to a vibrating reed. Passageways narrowed almost to closure.
- Wheeze high, Sibilant
- airway obstruction, chronic emphysema
Name this adventitious sound
Crackles fine
This is a high pitched short crackling w/ popping sounds. Heard during inspiration. Cough does NOT clear it
- Crackles Fine
- pneumonia, heart failure, i.fibrosis, c.bronchitis, asthma
Name this adventitious sound pattern
Atelactic Crackles
This is a loud low pitched bubbling & gurgling. Starts in early inspiration. Sounds like a velcro fastener. Inhaled air is colliding with secretions in the trachea and large bronchi.
- Crackles Course
- pulmonary edema, pneumonia, depressed cough reflex
This sounds like fine crackles but do not LAST. They are not pathologic. It is when section of alveoli do not aerate. Deflate and accumulate secretions.
- Atelactic Crackles (rales)
- bedridden pateint
Name this adventitious sound pattern?
Pleural Friction Rub
This is a very superficial sound that is course and low. Like 2 pieces of leather are being rubbed together. Loss of lubricating fluid. Heard best in anterolateral wall.
- Pleural Friction Rub
- painful to breathe
Name this adventitious sound pattern
Wheeze Low pitch (sonorous ronchi)
You will hear a single note. Snoaring or moaning sounds. May clear a little by coughing. It is caused by airflow obstruction.
- Wheeze low pitched (sonorous)
- bronchitis, airway ob tumor
Characteristics of S1
- First heart sound
- Closure of the AV valves
- “Lub”
- heard best at the apex
- Beginning of systole
Characteristics of S2
- Second heart sound
- closure of semilunar valves
- “Dub”
- End of Systole
- heart at Base of heart
Where is S1 louder than S2
at the apex
Which artery does S1 coincide with?
carotid
Which wave does S1 coincide with on ECG?
R-wave
Characteristics of S3
- Vibrations from filling ventricles
- “lub-dubba” “kentucky”
- Early diastole, after S2
- At apex with bell
- left lateral position
Characteristics of S4
- Blood being pushed into a noncompliant ventricle
- “da-lub-dub” “Tennessee”
- End of diastole, presystole, before S1
- Heard at apex with bell
Characteristics of a Murmur
- Turbulent blood flow and collision currents
- “swooshing”
- structural defects in valves, unusual opening in chambers, anemia.
- Heard best at Chest Wall
What data are you gathering during Auscultation of Heart Sounds x5
- Rate / Rhythm
- Identify S1 & S2 (together)
- S1 & S2 (separate)
- S3 & S4
- Murmurs
What are you listening for with murmurs?
- Timing
- Loudness
- Ptich
- Pattern
- Quality
- Location
- Radiation
- Posture/Position
All Patients Take Meds..
- Aortic (2nd Rt, ICS)
- Pulmonary (2nd Left, ICS)
- Tricuspid (Lt lower sternum)
- Mitral (5th ICS midclavical)
Step 1: Blood has cicrulationg through the body, lost its oxygen and collected CO2, where does it enter?
- Right Atrium of the heart through the Vena Cava
Step 2: Right Atrium Contracts and pumps blood through which valves?
Tricuspid valve and right ventricle
Step 3 of 9: The Right Ventricle pumps blood where?
- Through the pulmonary artery into the lungs
Step 4: What do the tiny blood vessels (capillaries) in the lungs do?
absorb CO2 from blood and replace it with oxygen
Step 5: oxygenated blood flows through the pulmonary vein and into where?
- Left Atrium
Step 6: Oxygenated blood pumps throu the mitral valve and into where?
Left Ventricle
Once the blood has gone through the aortic arch, what are the option for where blood can be pumped?
- thru carotid artery into the brain
- auxiliary arteries into the arms
- aorta and into the torso/legs
Step 8: Blood moves through the arteries, then through capillaries, where does it return?
Veins
Step 9: What is the last step of the cardiac cycle?
Deoxygenated blood will return to the heart
this pumps blood to pulmonary circulation
right ventricle
pumps blood to the systemic circulation
left ventricle
this is a valve between LA & LV
Mitral Valve
Valve betwee RV & Pulmonary Aorta
pulmonic valve
This drains arms
subclavian vein
Organ in LUQ of the adomen that produces lymphocytes and monocytes
spleen
What is valsavle maneuver?
- bearing down
- lead to herniated disc
- tumor
This is a palpable vibration while patient says “blue moon”
fremitus
Where do sounds for tactile fremitus originate?
- Generated from larynx > patent bronchi > lung parenchyma > chest wall (where you feel them)
Unequal chest expansion occurs with x4
- marked atelectasis;
- pneumonia;
- thoracic trauma;
- pneumothorax
This is soft, muffled thud; signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis or tumor
Dull
When does the apical impulse increase in size and duration?
- anxiety,
- fever,
- hyperthyroidism
- anemia
this is felt over the precordium during systole in aortic stenosis, pulmonary stenosis, and ventricular septal defect.
systolic thrill
This is when ventricular filling creates vibrations
S3
Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention Enema by doing which of the following?
A) Administering a large volume solution 500 to 1000 ml
B) Mixing milk and molasses and equal parts for an enema
C) Instructing the patient to retain the enema for at least 30 seconds
D) Administering the enema while the patient is sitting on a toilet
c) Instructing the patient to retain the enema for at least 30 sec
During removal of a fecal impaction, which of the following could occur Because of vaginal stimulation?
A) Bradycardia
B)Atelectasid
C) Tachycardia
D) Cardiac tamponade
A) Bradycardia
Removing a fecal impaction manually may result in stimulation of the vaginal nerve and resulting bradycardia
What is the incidence of deep vein thrombosis?
Age-dependent
In a 50yo: 1/1,000 per year
Young adults: 1/10,000 per year
In elderly: 1/100 per year
What are the signs and symptoms of DVT?
- Distension of surface veins,
- pain/tenderness,
- redness/discolouration,
- swelling,
- warmth
What are subjective assessment questions for Cardiac x8
- chest pain
- cough
- shortness of breath
- swelling in feet or legs
- facial skin color
- fatigued
- family history of heart disease
- use more than one pillow
This is a condition in which one or more areas of your lungs collapse or don’t inflate properly.
Atelactic
Pathological Reasons for Listening for S3
Anemia,
sign of HF
Volume overload
hyperthyroidism
pregnancy
renal failure
persists when sitting up
Reasons for listenting for S4
decreased compliance of ventricle
systolic overload
aortic stenosis
systemic hypertension
What are reasons for having a murmur
During menstrual cycle (benign)
During Exercise
Thyroid level too high
Anemia (low blood)-less rbcs, less oxygen
expected for infants
structural defects in valve
unusual openings in chambers
What happens heart/neck when Aging?
BP increases
lifestyles
sodium
Left ventricle increases
Increase Arrhythmias
Orthostatic Hypotension (getting out of bed fast)
check for bruits in carotid
systolic heart murmur
Where do you assess an adult heart
5th ICS
Where do you assess infant heart?
3-4 ICS
High risk factors for heart disease
high blood pressure
smoking
high cholesterol
diabetes
obesity
Intraluminal valves help to ensure
blood moves towards the heart
What do varicose veins look like?
blue
torturous
you can fee
How would the skin present itself if you had arterial insufficiencies?
thin, shiny skin, thick nails
less hair on legs
Which lung lobe is shorter?
the right side, because of the liver
What is visceral pleura
sack for the lungs
What does negative pressure mean referring to the lungs
lungs are being pulled open, otherwise lungs would collapse
Where does gas exchange occur?
bronchial trees
What is Hypercapnea
too much CO2
Is expiration passive or active?
Passive
What are discontinuous sounds?
- crackles
- atelectic crackles
- pleural friction rub
What are continuous sounds
wheeze, stridor
What do stretch receptors initiate
contraction of sigmoid colon/rectal muscles
What can accompany a murmur?
a thrill
What does a thrill signify?
stenosis or hypertension
What is a heave or lift?
sustained forceful thrusting of ventricle during systole
Where can a right heave be seen
sternal border
Where is a left heave seen?
at the apex
What can a bruit indicate?
hyperplasia of the thyroid,
Characteristics of Split S2
- happens during inspiration but NOT while holding breath
- in the pulmonic area
Cardiac assessment for infant (subj)
- mother during prego
- cyanosis
- growth as expected?
- play w/o tiring?
- naps per day, how long?
Cardiac assessment for child (subj)
- growth as expected?
- keeping up?
- rest during play?
- joint pain
- headaches/nosebleeds
- respiratory infection
- siblings w/ defects
Where do you assess pulses?
- Temporal Artery
- Carotid Artery
- Brachial/Ulnar/Radial
- Legs
What is the difference for children vs adults with lymph nodes?
- enlarge in children
- atrophy in adults
What is the function of lymphatics
retrieve excess fluid from tissue spaces and return to bloodstream
What does Venous Insufficiency look like?
- wet
- darker skin pigmentation
What does Arterial Insufficiency look like?
- light color
- dry
- leg cramping
Difficulty swallowing
dysphasia
What are systemic changes with decreased oxygen?
- clubbing
- hair loss
- hypoxic
- hypoxemia
What is WOB
- work of breathing
What do you inspect for the lungs?
- shape, AP:T Ratio
- Nails
- Position
- WOB
- Skin Color
What causes decrease breath sounds?
COPD & mucous
What causes increased breath sounds
pneumonia
What position do you place patient for an enema
left lying lateral
How much fluid can an average adult handle for an enema?
- 350-500 ML
Characteristics of Small Intestine
- absorption of nutrients and electrolytes
- 20’ long
Name the 3 sections of the small intestine
- Duodenum
- Jejunum
- Ileum
Name the characteristics of the large intestine
- 5-6 ft long
- Elimination
- absorbs water/electrolytes
Name the 4 sections of the large intestine
- ascending
- transverse
- descending
- sigmoid
What does the midsection of the thoracic cavity contain?
- Esophagus
- Trachea
- Heart
- Great vessels
The nurse recognizes that the administration of a drug influences cell physiology. What is the term for this concept?
Pharmacodynamics
the study of what the body does to the drug
Pharmacokinetics
