Exam 3 Flashcards

1
Q

Cardiovascular assessment: Inspection

A

-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

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2
Q

Cardiovascular assessment: Palpation

A

-carotid arteries
-PMI
-peripheral pulses (rhythm, rate, quality) (+2)
-skin for temp, turgor, moisture, edema, cap refill

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3
Q

Cardiovascular assessment: Auscultation

A

-rate (expected, tacky, brady)
-rhythm
-S1 and S2
-possible extra heart sounds

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4
Q

What is the S1 sound?

A

-mitral and tricuspid closure

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5
Q

What is the S2 sound?

A

-aortic and pulmonary closure

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6
Q

What can we use if a pulse is not palpable?

A

portable doppler probe

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7
Q

use of bell vs diaphragm

A

bell = low-frequency abnormal sounds

diaphragm: high-frequency normal sounds

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8
Q

interventions for chest pain

A

-ask subjective questions
-pulse ox and vitals
-rapid response
-pt in semi fowlers position to decrease exertion
-ECG
-non rebreather mask

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9
Q

Cardiovascular expected changes with aging

A

-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

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10
Q

cardiovascular health promotion strategies

A

-annual screenings and follow ups
-physical activity
-stress reduction/coping strategies
-nutrition
-smoking cessation

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11
Q

Respiratory assessment: Inspection

A

-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

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12
Q

Respiratory assessment: palpation

A

-palpate anteriorly and posteriorly, note muscle mass, bone defects, nodules, masses, crepitus
-ask about tenderness

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13
Q

Respiratory assessment: Percussion

A

Provider

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14
Q

Respiratory assessment: Auscultation

A

-listen to breath sounds

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15
Q

Adventitious breath sounds

A

-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

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16
Q

minimal air movement nursing interventions

A

-ask subjective questions
-Temp, RR, O2
-elevate HOB –> encourage deep breathing and cough –> O2 therapy –> notify provider –> document –> reassess

17
Q

Respiratory aging considerations

A

-reduced chest expansion and functional alveoli
-kyphosis due to osteoporosis and weakened cartilage
-reduced immune function
-decrease in cough reflex
-decrease in cilia functioning

18
Q

respiratory health promotion behaviors

A

-exercise
-smoking cessation
-immunizations

19
Q

Abdomen auscultation order

A

RLQ only or like a rainbow (RLQ, RUQ, LUQ, LLQ)

20
Q

Abdomen assessment: palpation

A

-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

21
Q

What is the correct order of assessment for abdomen?

A

-inspection, auscultation, percussion, palpation

22
Q

Abdomen/GI aging considerations

A

-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

23
Q

GI health promotion strategies

A

-exercise
-diet: well balanced, probiotics, fiber, water
-screenings: occult blood, colonoscopy/sigmoidoscopy (ages 45-75 every 10 years for average risk)

24
Q

5 rights of medication admin

A
  1. right person (2 identifiers)
  2. right medication
  3. right route
  4. right dose
  5. right time
  6. documentation
25
Q

3 checks of med admin

A
  1. safety check (compare MAR to physicians orders)
  2. 1st check: pulling meds
  3. 2nd check: prep meds
  4. 3rd check: at pts bedside before administering meds
26
Q

types of routes for meds

A

-enteral/oral
-topical/transdermal
-parental

27
Q

oral/enteral meds safety considerations

A

-assess ability to swallow
-don’t crush/split ER or SR capsules
-label expiration date for multi dose
-shake liquids

28
Q

topical/transdermal meds safety considerations

A

-remove old patch before replacing with new one
-rotate sites
-eye drop in lower eyelid
-ear drops = pt lays on side
-inhaler

29
Q

parental meds safety considerations

A

-proper needle size and gauge
-proper angle of administration
-needle stick prevention, no recapping and use sharps container

30
Q
A