Exam 3 Flashcards
Cardiovascular assessment: Inspection
-Raise HOB 30-45 degrees
-Inspect rise and fall of chest
-Check neck veins
-Check for distention
-Arterial pulses
-PMI (5th intercostal space at the midclavicular line)
-skin, temp, evenly distributed hair
-nail beds and clubbing
-edema
Cardiovascular assessment: Palpation
-carotid arteries
-PMI
-peripheral pulses (rhythm, rate, quality) (+2)
-skin for temp, turgor, moisture, edema, cap refill
Cardiovascular assessment: Auscultation
-rate (expected, tacky, brady)
-rhythm
-S1 and S2
-possible extra heart sounds
What is the S1 sound?
-mitral and tricuspid closure
What is the S2 sound?
-aortic and pulmonary closure
What can we use if a pulse is not palpable?
portable doppler probe
use of bell vs diaphragm
bell = low-frequency abnormal sounds
diaphragm: high-frequency normal sounds
interventions for chest pain
-ask subjective questions
-pulse ox and vitals
-rapid response
-pt in semi fowlers position to decrease exertion
-ECG
-non rebreather mask
Cardiovascular expected changes with aging
-rise in systolic BP
-thickening of blood vessels
-thickening of left ventricle
-decreased CO and strength of contractions
-heart valves stiffen
-decrease in peripheral circulation
-irregular rhythms
-postural/orthostatic hypotension
cardiovascular health promotion strategies
-annual screenings and follow ups
-physical activity
-stress reduction/coping strategies
-nutrition
-smoking cessation
Respiratory assessment: Inspection
-Appearance: position, evidence of respiratory distress, thorax shape, diameter, symmetry, and movement
-A/P diameter to transverse diameter is 1:2
-vital signs
-RR, depth, rhythm, presence of cough, color of skin/nails/mucous membranes, trachea positionin
Respiratory assessment: palpation
-palpate anteriorly and posteriorly, note muscle mass, bone defects, nodules, masses, crepitus
-ask about tenderness
Respiratory assessment: Percussion
Provider
Respiratory assessment: Auscultation
-listen to breath sounds
Adventitious breath sounds
-Crackles/rales: fine, course “bubble
-Wheezes, high pitched whistling, louder on expiration, narrowing/inflammation
-Rhonchi: course, low pitched, fluid/mucous, can clear with cough
-Stridor: noisy, high pitched, blockage/narrowing of upper airway, possibly life threatening
-Pleural friction rub: dry, grating, rubbing, inflammation
minimal air movement nursing interventions
-ask subjective questions
-Temp, RR, O2
-elevate HOB –> encourage deep breathing and cough –> O2 therapy –> notify provider –> document –> reassess
Respiratory aging considerations
-reduced chest expansion and functional alveoli
-kyphosis due to osteoporosis and weakened cartilage
-reduced immune function
-decrease in cough reflex
-decrease in cilia functioning
respiratory health promotion behaviors
-exercise
-smoking cessation
-immunizations
Abdomen auscultation order
RLQ only or like a rainbow (RLQ, RUQ, LUQ, LLQ)
Abdomen assessment: palpation
-palpate all 4 quadrants, light 1 cm depth, one hand, circular motion
-do not palpate visible pulsations
-note masses/tenderness
-note any verbal/nonverbal pain cues
What is the correct order of assessment for abdomen?
-inspection, auscultation, percussion, palpation
Abdomen/GI aging considerations
-weaker abdominal muscles and more adipose tissue
-dental caries, periodontal (gum) disease
-decreased number of taste buds, sense of smell lessens
-less saliva (xeostomia)
-lower esophageal and intestinal motility –> constipation
-decreased HCL acid secretions
-social disparities = risk for decreased food intake and ability to obtain nutritious food
GI health promotion strategies
-exercise
-diet: well balanced, probiotics, fiber, water
-screenings: occult blood, colonoscopy/sigmoidoscopy (ages 45-75 every 10 years for average risk)
5 rights of medication admin
- right person (2 identifiers)
- right medication
- right route
- right dose
- right time
- documentation
