Exam 3 Study Guide: Studocu Flashcards
what breath sounds would you expect to hear with an asthma attack?
wheezing
occur when air passes through fluid-filled or re-expanding small airways
heard in inspiration
atelectatic crackles
what does atelectatic crackles sound like?
popping, bubbles
(not cleared with cough)
loud, high-pitched sound
hollow quality
expiration longer than inspiration over the trachea
bronchial breath sounds
medium pitch blowing sounds
intensity with equal inspiration and expiration times over the larger airways
bronchovesicular breath sounds
soft, low-pitched, breezy sounds
inspiration 3x longer than expiration over most of the peripheral areas of the lungs
vesicular breath sounds
generalized bluish discoloration of the body and visible mucous membranes
do to lack of oxygen (hypoxia)
central cyanosis
where would we assess for central cyanosis?
lips
tongue
mucous membranes
facial features
secondary to conditions that lead to increased deoxygenated hemoglobin
central cyanosis
Diseases that cause cyanosis?
heart failure
shock
prolonged exposure to extreme cold
deeper breaths that may quicken
followed by hypoventilation (irregular pattern but shallow respirations)
progress to apnea (lack of respirations)
occur if the central nervous system is grossly affected by lack of oxygen or disease progression
appears to have a respiratory “start-stop” breathing pattern
end-of-life breathing pattern
cheyne-stokes respirations
what assessment findings would you expect in a patient with COPD?
barrel-shaped chest
tripod position (orthopneic breathing)
clubbed fingers
low SpO2 and SOB
excessive muscle use
what is the most common cause of COPD?
smoking
what lung sounds would you expect to hear with pneumonia?
displace bronchial breath sounds
crackles/rales
rhonchi
what lung sounds would you expect to hear with croup?
stridor
what factors could interfere with your ability to assess lung sounds?
auscultate through clothes
weight
hairy chest
what are kussmaul’s respirations?
faster and deeper respirations without pauses
note: diabetes ketoacidosis
what would you expect to hear when auscultating a pleural friction rub?
dry, grating, or rubbing sound
note: the inflamed visceral and parietal pleural rub against each other during inspiration or expiration
what respiratory tool should be used for post-op patients to prevent atelectasis and pneumonia?
incentive spirometer
what is pursed lip breathing?
inhale through nose and exhale through mouth (candles)
what patients would pursed lip breathing benefit?
COPD patients - prolonged expiraton
when preparing to do a respiratory assessment, what should the nurse do first?
obtain health history
observe the client by performing a visual inspection while checking their respiratory rate along with rhythm, depth, and effort it takes to breath
caused by fluid, mucus, or a growth in the larger airways of the lungs
heard with inspiration and expiration
rhonchi
what does rhonchi sound like?
continuous, low-pitched, snoring-like sound
sometimes clears with coughing
what is the first thing we should do when a patient is experiencing SOB?
elevate head / set patient up
what can we encourage the patient to do to thin respiratory secretions?
hydrate
how can we prevent respiratory post-surgical complications?
incentive spirometer
elevate head
encourage ambulation
sitting up for meals
note: oral care helps to prevent pneumonia
where is the best place to assess for cyanosis in a dark-skinned person?
oral mucosa
when assessing a radial pulse, you determine that it is irregular, what should you do next?
feel for full minute and auscultate the apical pulse for a full minute
where should you access the apical pulse?
5th ICS, midclavicular, left of the sternum
where should the nurse assess for the dorsalis pedis pulse?
located on the top of the foot, between the extensor tendous of the first and second toes
follow big toes up the foot and assess inside of the tendon
what is the order of blood through the heart?
superior and inferior vena cava ->
right atrium ->
tricuspid valve ->
right ventricle ->
pulmonic valve ->
pulmonary artery (to the lungs) ->
pulmonary veins ->
left atrium ->
mitral valve ->
left ventricle ->
aortic valve ->
aorta (to the body)
what do we worry about when a patient has orthostatic hypotension?
falls / safety
organ distention (enlarged liver and spleen)
peripheral edema
gi distress
ascites
fatigue
blood backup in the body
jugular vein distention (JVD)
anorexia
weight gain
signs and symptoms of right-sided heart failure
pulmonary symptoms (blood-tinged sputum)
cough/wet
SOB
confusion
fatigue
orthopnea (tripod)
tachycardia
cyanosis
increased capillary pressure
signs and symptoms of left-sided failure
how should you assess the carotid pulse?
groove between the sternocleidomastoid muscle and throat
gently place the index and middle finger of your dominant hand in this area and palpate the artery for its pulse strength
what part of the stethoscope is used to listen for bruits?
bell-shaped side of stethoscope
what are the risk factors for cardiovascular disease?
obesity
tobacco use
hypertension
sedentary lifestyle
stress
family history
underlying disease
2nd ICS, right of the sternum
aortic valve
2nd ICS, left of the sternum
pulmonic valve
3rd ICS, left of the sternum
erb’s point
4th ICS, left of the sternum
tricuspid valve
5th ICS, midclavicular, left of the sternum
mitral valve
increased heart rate with respirations at rest
regular cardiac rhythm that is faster than normal
sinus tachycardia
what is the primary pacemaker of the heart called?
sinoatrial node (60 -100 bpm)
what are the signs and symptoms of inadequate circulation?
cool temperature
increased capillary refill (greater than 3 seconds)
edema
clubbed fingernails (long-term)
what tool can the nurse use if they are unable to palpate peripheral pulses?
doppler
open sore located at the medial or lateral ankle
blood flow - pedal pulses present
superficial wound
irregular or flat wound border
ulcer wound pink
ankle or leg edema
discoloration of ankle
no report of pain at rest
peripheral venous ulcer
open sore located at the ends of toes (eschar)
limited / no blood flow - pedal pulses absent
toes or fingers falling off
regular, even, wound border
ulcer wound pale
foot cool
hair loss
pain reported at rest
peripheral arterial ulcer
how would a nurse document a normal pulse in the medical record?
60 - 100 bpm
2+ strength
regular rhythm
how should the nurse assess for JVD?
30 - 45 degree angle (fowler position)
turn head 15 degrees
shine penlight
check for shadows
what order does the blood flow through the valves of the heart?
tricuspid valve
pulmonic valve
mitral valve
aortic valve
what does a murmur sound like?
blowing or swishing sound
bell-side of stethoscope
where is the best place to assess S1?
apex of the heart (lub)
closure of the mitral and tricuspid valves signals the beginning of the ventricular systole (contraction)
dull, low-pitched sound
S1
where is the best place to assess S2?
aortic area / base of the heart (dub)
closure of the aortic and pulmonic valves signals the beginning of ventricular diastole (relaxation)
slightly higher pitch than S1
S2
where is the apical pulse located?
5th ICS, midclavicular, left of sternum
apical pulse = mitral valve
what are the early signs of hypoxia?
confusion, disorientation
restlessness and agitation
altered mental status (lethargic, obtunded)
note: SOB (tachypnea) -> bradypneic
what are chronic signs of hypoxia?
cyanosis
decreased breathing (bradypneic)
clubbed fingers
note: intubation and/or invasive measures
How to check Adequacy in cardiac emergency for circulation, perfusion, and oxygenation?
Circulation = BP
Perfusion and Circulation = SpO2 and Skin Color
