Exam #3 Flashcards
What is the equation for cardiac output?
Cardiac output= HR x SV (stroke volume)
What is known as the “pacemaker” ?
SA node
Rate: 60-100 bpm
generates impulses
What are the 5 areas for listening to the heart and where they are located?
All People Enjoy Time Magazine
- Aortic: right 2nd intercostal space
- Pulmonic: left 2nd intercostal space
- Erbs Point: left 3rd intercostal space
- Tricuspid: lower left eternal border; 4th intercostal space
- Mitral: left 5th intercostal, medial to midclavicular line
What is happening in the heart during systole and diastole?
- Systole: contraction and emptying; lub; S1 (closing of AV valves)
- Diastole: relaxation and filling; dub; S2 (closing of semilunar valves)
What are older client considerations for the heart?
- Be cautions with older clients because atherosclerosis may have caused obstruction, and compression may easily block circulation
- The apical impulse may be difficult to palpate because of increased anteroposterior chest diameter
When do you use the bell and diaphragm of the stethoscope?
Bruit: use the bell
Murmur: use diaphragm then bell
What carries deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart?
Veins
What is an ABI test?
Tests for peripheral artery disease
- compares ankle and arm blood pressure measurement
What are the characteristics of Arterial insufficiency?
Pain: intermittent claudication to sharp (very painful)
Pulse: diminished or absent
Skin: Dry, shiny skin
Ulcer: Deep
Edema: minimal
What are characteristics of Venous Insufficiency?
Pain: cramping, aching (minimal pain)
Pulse: present
Skin: reddish, blue in color
Ulcer: superficial
Edema: moderate to sever
What are older clients findings of the peripheral vascular system?
- Hair loss on lower extremities (occurs with aging)
- lymphatic tissue is lost, resulting in smaller and fewer lymph nodes
- Varicosities are common in older clients
While examining a patient the nurse observes abdominal pulsations between the xyphoid process and umbilicus. The nurse would suspect these are?
Normal abdominal aortic pulsations
How often should normal bowel sounds be heard?
5 - 30 times per minute
If a patient is suspected of having cholecystitis (inflamation of gallbladder) what test should the nurse do?
Murphy sign
What are the abdominal quadrants? And where should you start your assessment?
Start in Right Lower Quadrant
RUQ: right upper quadrant
RLQ: right lower quadrant
LUQ: left upper quadrant
LLQ: left lower quadrant
What is located in the Right lower quadrant?
- Appendix
- Colon/ large intestine
- Right kidney
- Right ovary and tube
- Right ureter
- Right spermatic cord
What is located in the right upper Quadrant?
- liver
- gallbladder
What is the structure and function of the liver?
Largest solid organ in the body
- stores glucose, iron, vitamins, has clotting factors, deconstruction of RBCs
What is GERD? signs and symptoms
When stomach acid or contents flow back into esophagus
*raise head of bed and have patient sleep on left side
- hoarseness
- laryngitis
- chronic dry cough
- asthma
- feeling of lump in throat
What are the steps of assessing the Abdomen?
- Insect
- Auscultation: so you can listen to bowel sounds before you disrupt them with percussion
- Percussion
- Palpation
What are the 5 F’s of abdomen distention?
- Fat
- Fluid
- Feces
- Flatus
- Fetus
How do you grade bowel sounds?
Absent:
- no BS for 5 minutes (have to check for 5 min if absent)
Hypoactive:
- less than 5 per minute
Active:
- 5 - 30 per minute
Hyperactive:
- > 30 per minute
Borborygmus: more than hyperactive
How to test for appendicitis
- Rebound tenderness
- Rovsing’s sign (left side)
- Referred rebound tenderness
- Psoas sign (push down on right leg)
- Obturator sign (External rotation of right heal)
How to test for cholecystitis?
Murphy sign
Older client considerations for abdomen
- Dilated superficial capillaries
- increased risk of peptic ulcer disease
- increased lactose intolerance
- increased likelihood of constipation (decreased GI movement)
What are the muscle movements?
- Abduction: away from midline
- Adduction: toward midline
- Circumduction: circular motion
- Inversion: soles of feet inward
- Eversion: soles of feet facing out
- Extension: increasing degree
- Flexion: degreasing degree
- Pronation: face down
- Supination: face up
- Protraction: pushing jaw out
- Retraction: pushing jaw back
- Rotation
What are the parts of the brain and their function?
- Brain stem and pons: posture, heart rate
- Frontal: communication, emotion, judgement (fully develops by 25)
- Parietal: tactile
- Occipital: primary visual; reading
- Temporal: hearing
What are the cranial nerves and their function?
- I (olfactory): smell
- II (optic): visual acuity (Snellen chart)
- III (oculomotor): PERRLA
- IV (trochlear): PERRLA
- V (trigeminal): clench jaw
- VI (abducens): PERRLA
- VII (facial): smile, frown
- VIII (acoustic, vestibulochlear): whisper test
- IX (glossopharyngeal): say “ah” swallow
- X (vagus): tested the same as glossopharyngeal
- XI (spinal/accessory): shoulder shrug
- XII (hypoglossal): stick out and move tongue
When does a cerebrovascular Accident happen (stroke)?
risk factors and signs and symptoms
When blood flow to portion of brain is interrupted or stopped; deprives brain of oxygen; cells die resulting in permanent brain damage
- Hemorrhagic: rupture or leakage of blood vessels
- ischemic: blood clot blocks blood vessel
Risk factors:
- hypertension
- diabetes
- heart disease
- oral contraceptives
- smoking and exposure
- personal or family history
- age, gender, race, ethnicity
What does BEFAST stand for?
Balance
Eyes
Face
Arms
Speech
Time
What are the different abnormal Gaits to check for?
- Cerebellar ataxia: wide-based staggering (cerebellar disease or intoxication)
- Parkinsons gait: shuffling, turns in stiff manner (might also see “masked face” known as hypomimia)
- Cerebral palsy: flexed arms held close to body, drags toe of left foot stiffly in circles or outward and forward
- footdrop: foot and knee lifted high with each step, slaps foot down. cannot walk on heels
How to test ROM of the cervical, thoracic, and lumbar spine
- Cervical: chin to chest look up to ceiling
- Thoracic: ear to shoulder
- Lumbar: bend and touch toes, lean backward
How to test for Carpal Tunnel
- Phalen test: pace backs of both hands together
- Tinel test: percussion lightly over the median nerve in wrist
How to grade joints and muscles
5 : active motion against full resistance (normal)
4 : active motion against some resistance (slight weakness)
3 : active motion against gravity (average weakness)
2 : passive ROM (poor ROM)
1: slight flicker of contraction (severe weakness)
0 : No muscular contraction (paralysis)
How do you grade reflexes?
4+ very brisk; hyperactive
3+ brisker than average
2+ average; normal
1+ somewhat diminished
0 no response
What is Decorticate posturing
Arms flexed and adducted
Wrists flexed
Legs are internally rotated and plantar feet
Decerebrate posturing
Arms extended and adducted
Wrists flexed
Feet are plantar flexed
Are veins or arteriole walls thicker?
Arteriole because there is more pressure
What are the major arteries of the arm and leg?
Arm: brachial, radial, ulnar
Leg: femoral, popliteal, dorsalis pedis, posterior tibial
How do you grade a pulse?
0 = absent
1+ = weak thready
2+ = normal
3+ = bounding
What are major veins of the leg
femoral, popliteal, saphenous veins
When assessing lymph nodes
Should be moveable and elastic
Where are Epitrochlear and Superficial Inguinal nodes found
- Epitrochlear: front inner side of elbow
- Inguinal: upper femoral crease
What is DVT and risk factors
Deep vein thrombosis: blood clot
- reduced mobility
- dehydration
- increased viscosity of the blood
- venous stasis
What are the signs, symptoms, and risk factor of PAD
Peripheral artery disease
- pain with exertion
- ischemic rest pain
Risk factors:
- smoking
- diabetes
- obesity
- high blood pressure
- high cholesterol
- family history of PAD
- excess levels of homocysteine
- african american
How do you do the Allen test and what does it identify?
Evaluates patency primarily of the ulnar arteries to ensure adequate collateral blood supply.
- have patient rest hand palm side up on table and make a fist. apply pressure using your hands to the radial and ulnar arteries.
continue pressure and have client open fist. release pressure on the ulnar artery and watch for color return.
— It is important to know if the ulnar artery would be capable of perfusing the entire hand if the radial artery was compromised.
When palpating the legs what do you want to look for?
- Temperature
- Superficial Inguinal nodes
- Femoral pulse (bruits)
and other leg pulses
How do you elicit the homans sign?
bending knee and having patient extend leg to see if there is pain
pain = positive homans sign
When palpating the abdomen the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. which structure is most likely involved?
Spleen
a student nurse hears that a patient has hepatomegaly and recognizes that this term refers to
Enlarged liver
What is located in the left Upper quadrant?
pancreas, spleen, stomach
What are the stomach regions commonly used and location
- Epigastric: upper central region of abdomen; below sternal area
- Umbilical: belly button
- Suprapubic: above pubic bone
What is the function of the spleen?
filters blood, digest microorganisms, return breakdown product to liver
What are the signs, symptoms, and risk factors for Peptic Ulcer Disease
- Burning stomach pain
- feeling of fullness, bloating
- Fatty food intolerance
- Heartburn
- Nausea or vomiting
- dark blood in stool stools black tarry.
- trouble breathing
- faint and dizzy if blood loss occurs look at hemaglobin and hematocrit
What are the 4 abdominal shapes?
- Flat
- Scaphoid (concave)
- Rounded
- Protuberant (due to a mass)
What are striae and when can you see this?
stretch marks
Cushing’s Disease
What side of the heart is the largest?
left ventricle due to more pumping
What valve comes first tricuspid or bicuspid?
Tricuspid: opens from right atrium into right ventricle
and then
Bicuspid: opens from left atrium to left ventricle
What are signs and symptoms of Coronary Artery disease
- arrhythmias
- heart infections
- congenital heart defects
- narrow or blocked blood vessels that lead to heart attack
What is Pulse Rate Deficit?
assess peripheral pulse rate and apical pulse rate and compare the two.
the difference between the two is the pulse deficit
this reflects the number of ineffective cardiac contractions in 1 min
What is Jugular venous distension
when your jugular vein visibly bulges
this is seen with CHF
What should you not do when palpating the Carotid arteries?
Do not apply pressure to both sides at the same time
- can cause someone to pass out
What are all the pulse points and where are they located?
- Temporal (side of head)
- Carotid (neck)
- Brachial (front side of elbow)
- Ulnar
- Radial
- Femoral (in femoral crease)
- Popliteal (back of Knee)
- Dorsalis pedis (top of foot)
- Posterior tibial (back of ankle)
What are cultural considerations for the heart and vessels?
- Black males have a lower resting heart rate than white males
- Black females and Mexican American females have a slower resting pulse rate than white females
- heart disease is the leading cause in all groups; highest in southern states
What are signs, symptoms, risk factors and preventions of Osteoporosis?
Risk factors:
- lack of exercise, low calcium, anorexia nervosa, low estrogen levels, smoking, caffeine, alcohol, medication intake
Prevention:
- nutritious diet with adequate calcium
- adequate protein
- adequate vitamin D
- regular physical activity
- avoid second hand smoke
Difference between skeletal, smooth, and cardiac muscle?
- Skeletal: only voluntary muscle you have
- Smooth: found in organs
- Cardiac: found in your heart
What is the sympathetic nervous system known for?
fight or flight response
What are older adult considerations for Neuroskeletal and muscular systems
- Bones lose density
- joint stiffening
- Osteoporosis is more common
- impaired sense of position
- decrease in hearing, seeing, taste, smell,
- tremors
- reduced muscle mass
- uncertain gait
