final exam flashcards nur211
What is the clinical significance of a weight loss of less than 5% in 1 month?
Mild risk of malnutrition
This indicates that the individual may need monitoring for potential nutritional deficiencies.
What does a weight loss of 5-10% in 1 month indicate?
Moderate risk of malnutrition -
What is the clinical significance of a weight loss greater than 10% in 1 month?
Severe risk of malnutrition - needs to be verified
This level of weight loss is concerning and requires immediate assessment.
What defines undernutrition in terms of weight loss?
Unintentional weight loss > 10% in 6 months
This definition highlights the chronic nature of the condition and its implications for health.
What are the contraindications for oral temperature measurement?
Kids under the age of 5, adults who can’t follow instructions, anyone who can’t close their mouth, unconscious, or intubated
These contraindications highlight situations where oral temperature measurement may not provide accurate results or could pose a risk to the individual.
How far should a rectal thermometer be inserted for infants?
1/2 inch
How far should a rectal thermometer be inserted for adults?
1 inch
Is it safe to use a rectal thermometer for newborns?
No, due to the risk of rectal trauma
When is using a rectal thermometer particularly beneficial?
When accurate core temperature is needed for critically ill patients
What is the procedure for taking tympanic (ear) temperature in adults?
Pull the pinna (outer ear) up and back.
What is the procedure for taking tympanic (ear) temperature in children under 3 years old?
Pull the pinna (outer ear) down and back.
What are the contraindications for tympanic temperature measurement?
Patients with ear infections, excessive earwax, or otitis media.
Do not use on infants under 6 months due to small ear canals.
Who is tympanic temperature measurement best for?
Older children and adults needing a quick, non-invasive measurement.
True or False: Tympanic temperature measurement can be used for infants under 6 months.
False.
What is the first step in the Temporal Artery temperature procedure?
Place the sensor on the center of the forehead
This is the initial position for accurate temperature measurement.
What is the second step in the Temporal Artery temperature procedure?
Sweep across the forehead to the temple
This motion helps in collecting the temperature data effectively.
What types of sensors can be used for Temporal Artery temperature measurement?
Some devices require touching the skin, while others are non-contact infrared sensors
The choice of sensor affects how the measurement is taken.
What is a contraindication for using Temporal Artery temperature measurement?
Patients with excessive sweating or oily skin
These conditions may alter the accuracy of the readings.
Is Temporal Artery temperature measurement accurate for infants under 3 months?
No
The method is not as accurate for this age group.
What is the best use case for Temporal Artery temperature measurement?
Quick screenings in children, elderly, or mass health screenings
This includes settings like hospitals, airports, and public venues.
What is the procedure for measuring axillary temperature?
- Place the thermometer in the center of the axilla (armpit)
- Ensure skin-to-skin contact (clothing must be moved aside)
- Hold the arm tightly against the body until the reading is complete
This method is often used for specific patient populations.
What are the contraindications for axillary temperature measurement?
- Least accurate method
- Should only be used if other methods are unavailable
- Not ideal for fever detection in critically ill patients
This method may not provide reliable results in severe cases.
For which patient groups is axillary temperature measurement best suited?
- Infants
- Unconscious patients
- Patients who cannot tolerate other methods
This method is generally more comfortable for these populations.
What hormone increases body temperature during the menstrual cycle?
Progesterone
Progesterone is released during the luteal phase of the menstrual cycle, leading to an increase in basal body temperature.
When is body temperature typically lower during the day?
In the morning
Body temperature usually rises throughout the day and peaks in the afternoon.
What factors can increase body temperature due to the sympathetic nervous system?
Stress and anxiety
The sympathetic nervous system activates the ‘fight or flight’ response, which can elevate body temperature.
How long should you wait after eating, drinking, or smoking before taking an oral temperature?
15 minutes
This waiting period allows the body temperature to stabilize for an accurate reading.
Fill in the blank: Body temperature is always lower in the _______.
morning
Fill in the blank: Stress and anxiety increase body temperature due to the _______.
sympathetic nervous system
What is a safety guideline for using thermometers?
Always use a disposable probe cover to prevent infection transmission.
This helps in maintaining hygiene and preventing cross-contamination.
What should never be done with a thermometer in a patient’s mouth?
Never leave a thermometer unattended in a patient’s mouth (risk of choking).
This is crucial for patient safety.
What is a safety consideration when using rectal thermometers?
Avoid forceful insertion of rectal thermometers to prevent rectal trauma.
Proper technique is essential to avoid injury.
What is important for accurate readings with tympanic and temporal thermometers?
Ensure proper positioning of tympanic and temporal thermometers for accurate readings.
Incorrect positioning can lead to erroneous temperature readings.
What temperature measurement methods are recommended for infants?
Use axillary or rectal measurements (rectal only when necessary).
These methods are preferred for accuracy in young children.
What type of thermometer should be avoided in infants under 6 months?
Avoid tympanic thermometers in infants under 6 months.
Their ear canals are still developing, making tympanic measurements less reliable.
Why should glass thermometers be avoided for infants?
Do not use glass thermometers due to breakage risk.
Glass thermometers can shatter, posing a safety hazard.
What is a common characteristic of baseline body temperature in elderly patients?
May have lower baseline body temperature (96.8°F or lower).
This can affect the assessment of fever.
How may fever present in elderly patients during infections?
Fever may be less pronounced in infections.
This can lead to underdiagnosis of infections in this population.
What should be assessed in frail or underweight elderly patients?
Assess for hypothermia in frail or underweight elderly patients.
They are at higher risk for temperature regulation issues.
What is the most accurate pulse measurement method?
Apical Pulse (Auscultation Method)
Directly over the heart
What patient groups benefit most from apical pulse measurement?
- Infants and young children
- Patients with cardiac conditions or irregular heart rhythms
- Before administering cardiac medications (e.g., digoxin, beta-blockers)
Due to irregular peripheral pulses
What is the first step in the procedure for measuring the apical pulse?
Position the patient in a supine or sitting position
This ensures comfort and accessibility for measurement
Where should the stethoscope be placed to measure the apical pulse?
Over the apex of the heart at the 5th intercostal space, midclavicular line (left side of chest)
This is the optimal location for accurate auscultation
What heart sounds should be listened for when measuring the apical pulse?
S1 and S2 heart sounds (‘lub-dub’)
These sounds indicate the closing of heart valves
For how long should you count the heartbeats when measuring the apical pulse?
For a full minute
This ensures an accurate heart rate measurement
What additional aspects should be noted during apical pulse measurement?
- Rate
- Rhythm
- Presence of extra heart sounds or murmurs
These factors can indicate underlying health issues
What is a key nursing consideration when measuring the apical pulse?
Use apical pulse in infants and cardiac patients for most accuracy
This method provides reliable data for these populations
What is the peripheral pulse palpation method?
Easiest and fastest method for pulse assessment
Used primarily to quickly assess a patient’s pulse.
What are the best uses for the peripheral pulse palpation method?
- Routine vital signs assessment
- Assessing circulation and perfusion
Important for determining overall health and blood flow.
Where is the Carotid Pulse located?
Neck, between trachea and sternocleidomastoid muscle
Used in emergencies such as CPR, shock, and cardiac arrest
What is the location of the Brachial Pulse?
Upper arm, medial side
Important for infants (<1 year) and blood pressure measurement
Where can the Femoral Pulse be found?
Groin, near inguinal ligament
Used for assessing circulation in trauma/shock patients
What is the purpose of the Dorsalis Pedis Pulse?
Assessing peripheral circulation (diabetes, PAD)
Located on the top of the foot, between big toe and second toe
Where is the Posterior Tibial Pulse located?
Behind the medial ankle (inner ankle bone)
Used for assessing lower extremity perfusion
What is the definition of Tachycardia?
HR above normal range for age.
Tachycardia is often defined as a heart rate greater than 100 beats per minute in adults.
List three causes of Tachycardia.
- Fever
- Dehydration
- Anemia
Additional causes include pain, anxiety, stress, certain cardiac conditions, and stimulants.
What are two nursing actions for Tachycardia?
- Identify underlying cause and treat appropriately
- Monitor ECG for abnormal heart rhythms
Checking for additional symptoms like dizziness or chest pain is also crucial.
What is the definition of Bradycardia?
HR below normal range for age.
Bradycardia is typically defined as a heart rate less than 60 beats per minute in adults.
List two causes of Bradycardia.
- Hypothermia
- Electrolyte imbalances
Other causes include sleep, extreme relaxation, physiological bradycardia in athletes, and certain medications.
What is one nursing action for Bradycardia?
Check for symptoms of poor perfusion.
Symptoms may include dizziness, weakness, or fainting.
Fill in the blank: Tachycardia is defined as a heart rate above _______.
[normal range for age]
True or False: Stimulants can cause Tachycardia.
True
Fill in the blank: Bradycardia can be caused by _______ imbalances.
[electrolyte]
List two medications that can cause Bradycardia.
- Beta-blockers
- Opioids
Digoxin is another medication that can lead to bradycardia.
What is the respiratory rate (RR) for older adults (65+ years)?
12 – 25 bpm
Normal respiratory rates can vary by age.
What is the respiratory rate (RR) for school-age children (6-12 years)?
18 – 25 bpm
Respiratory rates differ across age groups.
What is the definition of Tachypnea?
RR >20 bpm in adults (varies by age)
Tachypnea indicates fast breathing.
List three causes of Tachypnea.
- Fever
- Anxiety
- Pain
- Asthma, COPD
- DKA
- any lung infection like pneumonia and bronchitis
Additional causes include lung infections, asthma, COPD, pulmonary embolism, and diabetic ketoacidosis.
What is the definition of Bradypnea?
RR <12 bpm in adults (varies by age)
Bradypnea indicates slow breathing.
List two causes of Bradypnea.
- Opioid overdose
- Head injuries
- Severe hypoxia because the body shuts down after a while
- Hypothyroidism
Other causes include hypothyroidism and severe hypoxia.
Infants breathe fast or slow
Fast
This is due to their higher metabolic needs.
What might cause an increased respiratory rate in elderly patients?
Decreased lung compliance
Age-related changes can affect respiratory patterns.
What is Kussmaul breathing?
Deep and RAPID breathing associated with diabetic ketoacidosis
What is Cheyne-Stokes Respiration?
Gradual increase, then decrease in RR, followed by apnea.
fast slow stop
What conditions are associated with Cheyne-Stokes Respiration?
- Stroke
- Heart failure
- Brain damage
What is Biot’s Respiration?
Irregular, quick shallow breaths followed by apnea.
fast stop fast stop
What conditions are associated with Biot’s Respiration?
- Brain trauma
- Meningitis
What factors can change oxygen saturation accuracy?
- Nail polish
- Dark skin
- Movement
What does blood pressure (BP) measure?
The force of circulating blood against arterial walls
Blood pressure is expressed in millimeters of mercury (mmHg)
What is Systolic Blood Pressure (SBP)?
The pressure exerted on artery walls when the heart contracts (top number)
What is Diastolic Blood Pressure (DBP)?
The pressure exerted on artery walls when the heart relaxes (bottom number)
What is the range for Stage 1 Hypertension?
130-139 / 80-89
What is the range for Stage 2 Hypertension?
≥140 / ≥90
What constitutes a Hypertensive Crisis?
≥180 / ≥120
What is considered Hypotension?
<90 / <60
True or False: Systolic Blood Pressure is the bottom number in a BP reading.
False
Fill in the blank: Diastolic Blood Pressure is the pressure exerted when the heart _______.
relaxes
What do the numbers in a blood pressure reading represent?
Systolic / Diastolic
What should be done if BP is irregular?
Measure again after 1-2 minutes
This ensures accuracy in the readings.
Why is it important to use the same arm for BP measurements?
For consistency in repeated measurements
Using the same arm helps to reduce variability in readings.
What should be done if BP is abnormally high or low?
Confirm with a second reading before reporting
This helps to ensure the reliability of the measurement.
What technology is used in automated blood pressure measurement?
An electronic BP cuff
It detects systolic and diastolic values.
What is a benefit of using an automated BP measurement?
Convenient for rapid assessments and monitoring trends
This allows for quick evaluations of blood pressure changes.
In which conditions is automated blood pressure measurement less accurate?
Irregular heart rhythms, low BP, or very high BP
These conditions can lead to unreliable readings.
How does arm position affect blood pressure readings?
Higher if below heart, lower if above heart
Proper arm positioning is critical for accurate BP measurements.
What is the importance of using the correct cuff size in BP measurements?
The bladder should cover 80% of arm circumference
An incorrect cuff size can lead to inaccurate blood pressure readings.
What is the definition of orthostatic hypotension?
BP drops ≥20 mmHg systolic or ≥10 mmHg diastolic when moving from lying → sitting → standing.
- Dizziness
- Weakness
- Fainting
…. after standing up during the assessment
This condition can indicate issues with blood volume or autonomic regulation.
What is the first step in the orthostatic hypotension assessment procedure?
Take BP while patient is lying supine.
This establishes a baseline measurement for comparison.
What should be done after taking BP while the patient is lying supine?
Take BP after 1-3 minutes of standing.
This helps assess changes in blood pressure due to postural changes.
What does a pulse strength grade of 0 indicate?
Absent. No pulse detected (use Doppler)
This indicates a critical situation requiring immediate attention.
What clinical significance is associated with a 1+ pulse strength?
Weak/Thready. Low cardiac output, shock, PAD
PAD refers to Peripheral Artery Disease.
What does a 2+ pulse strength signify?
Normal. Expected strength, normal perfusion
This indicates adequate blood flow and normal cardiovascular function.
What are the possible causes of a 3+ pulse strength?
Strong/Bounding. Anxiety, fever, hypertension
Strong bounding pulses can indicate increased stroke volume.
What conditions are associated with a 4+ pulse strength?
Full/Bounding. Fluid overload, sepsis, hyperthyroidism
These conditions can lead to an excessive volume of blood in circulation.
What condition can cause weak or absent pulses in the legs and feet?
Peripheral Arterial Disease (PAD)
PAD is a common circulatory problem in which narrowed arteries reduce blood flow to the limbs.
What is the definition of ptosis?
Drooping of the upper eyelid due to muscle or nerve dysfunction, injury, or disease
Ptosis can significantly affect vision and appearance.
List three causes of ptosis.
- Neurological Disorders: Stroke, Myasthenia Gravis, Horner’s Syndrome
- Aging: Weakening of eyelid muscles
- Trauma or Surgery: Eye injury or damage to cranial nerve III (oculomotor nerve)
Each cause can result in varying degrees of eyelid drooping and may require different treatment approaches.
What is a cataract?
A clouding of the eye’s lens leading to blurry, decreased, or loss of vision.
(Thompson, 2018, pg. 183)
What is the most common cause of cataracts?
Aging.
List three causes of cataracts.
- Aging
- Diabetes mellitus
- Prolonged sun exposure without UV protection
- long term corticosteroid use
What is a potential side effect of long-term corticosteroid use?
Cataracts.
What assessment findings are associated with cataracts?
- Cloudy or opaque lens visible through the pupil
- Blurred vision
- Glare sensitivity (especially at night)
- Loss of color vibrancy
What is the definition of Pterygium?
A gelatinous, abnormal growth of the conjunctiva, usually appearing on the nasal side of the eye
terry complains so much he creates a lacrimal lake
(Thompson, 2018, pg. 190)
What are the causes of Pterygium?
Chronic sun exposure (UV radiation), dust, wind, or dry environments, genetic predisposition
None
What are some assessment findings for Pterygium?
Flesh-colored or pink triangular growth extending toward the cornea, may cause irritation, dryness, or vision impairment, visible blood vessels in the conjunctival growth
None
True or False: Pterygium typically appears on the temporal side of the eye.
False
Pterygium usually appears on the nasal side of the eye.
Fill in the blank: Pterygium is caused by chronic _______ exposure.
[sun]
UV radiation is a significant factor.
What color is the growth associated with Pterygium?
Flesh-colored or pink
This growth extends toward the cornea.
What symptoms may Pterygium cause?
Irritation, dryness, or vision impairment
Symptoms can vary in severity.
What is a visible characteristic of the conjunctival growth in Pterygium?
Visible blood vessels
These blood vessels are part of the abnormal growth.
What is the role of the oropharynx?
The oropharynx plays a key role in speech, breathing, and swallowing.
What is the importance of proper airway closure?
Proper closure of the airway prevents aspiration of food and liquids.
What does coughing while eating/drinking indicate?
Possible impaired airway closure.
What does a wet or gurgling voice suggest?
Secretions in airway post-swallow.
What is a risk associated with recurrent pneumonia?
Silent aspiration risk.
What does drooling or food pocketing indicate?
Difficulty managing oral secretions.
What should be done for at-risk patients?
Refer at-risk patients to speech-language pathologists for swallow studies.
What is Jugular Venous Distention (JVD)?
Bulging of the jugular vein due to increased central venous pressure (CVP).
This condition can indicate underlying cardiovascular issues.
What are the causes of Jugular Venous Distention (JVD)?
- Heart failure
- Fluid overload
- Pericardial tamponade
These causes lead to increased pressure in the jugular veins.
What is the first step in assessing for JVD?
Position patient at 45-degree angle.
This position helps in accurately observing the jugular vein.
How do you determine if JVD is present?
If vein is distended >3cm above sternal angle, JVD is present (abnormal).
This measurement indicates increased central venous pressure.
What does the presence of JVD suggest?
Heart failure or volume overload.
JVD is a significant clinical sign that may indicate serious health issues.
What should be assessed alongside JVD?
- Edema
- Crackles
These signs are indicative of fluid overload.
What is the indentation depth for Grade 1+ edema?
2mm depression
Grade 1+ edema is classified as mild edema.
What is the rebound time for Grade 1+ edema?
Immediate rebound
This indicates a quick return to normal after pressure is released.
What is the indentation depth for Grade 2+ edema?
4mm depression
Grade 2+ edema is classified as moderate edema.
What is the rebound time for Grade 2+ edema?
Rebounds in a few seconds
This indicates a moderate response to pressure release.
What is the indentation depth for Grade 3+ edema?
6mm depression
Grade 3+ edema is classified as severe edema.
What is the rebound time for Grade 3+ edema?
Rebounds in 10-20 seconds
This indicates a slower response to pressure release compared to lower grades.
What is the indentation depth for Grade 4+ edema?
8mm depression
Grade 4+ edema is classified as very severe edema.
What is the rebound time for Grade 4+ edema?
Lasts >30 seconds
This indicates a significantly delayed response to pressure release.
What should be assessed for in lower extremities?
Pitting edema
Pitting edema is an indication of fluid retention and may signal underlying health issues.
What should be monitored for as a sign of fluid retention?
Weight gain
Weight gain can indicate fluid overload, which may require further assessment and intervention.
What action should be taken if pitting edema is noted?
Elevate legs and consider diuretic therapy if indicated
Elevating the legs can help reduce swelling, while diuretics can assist in fluid removal.
What are bruits?
Abnormal, turbulent, blowing sounds heard over arteries due to partial or total obstruction.
What do bruits indicate?
Altered blood flow.
What is the most common cause of bruits?
Atherosclerosis (plaque buildup in arteries).
How are bruits best heard?
With the bell of the stethoscope due to their low-pitched nature.
What is the significance of carotid bruits?
They indicate a risk of stroke.
What do abdominal bruits suggest?
Aneurysm or stenosis.
What condition is associated with renal bruits?
Renal artery stenosis or hypertension.
What do peripheral bruits indicate?
Peripheral artery disease.
Fill in the blank: Bruits are commonly assessed over the _______.
carotid arteries, abdominal aorta, renal arteries, iliac and femoral arteries.
What is a Venous Hum?
Continuous medium-pitched sound caused by turbulent blood flow in a large vascular organ
Commonly associated with increased blood flow to the liver (portal hypertension) and best heard in the epigastric region (above umbilicus)
What causes a Venous Hum?
Increased blood flow to the liver (portal hypertension)
This condition leads to turbulent blood flow, creating the characteristic sound.
Where is a Venous Hum best heard?
Epigastric region (above umbilicus)
This location is critical for identifying the sound during a physical examination.
What is a Friction Rub?
Grating sound caused by inflamed organs rubbing against each other
This sound indicates inflammation of the peritoneum or organs like the liver and spleen.
What are common causes of a Friction Rub?
Peritonitis, liver/spleen inflammation
These conditions lead to the rubbing sound characteristic of a friction rub.
Where is a Friction Rub best heard?
Right Upper Quadrant (RUQ – liver), Left Upper Quadrant (LUQ – spleen)
Knowing the specific quadrants aids in localizing the source of the sound.
What do venous hums suggest?
Increased blood flow (e.g., liver disease, pregnancy)
Venous hums can indicate significant physiological changes.
What do friction rubs indicate?
Inflammation of serous membranes (peritoneal friction rub)
This is often associated with conditions like peritonitis.
What should be done if friction rubs are heard over the liver or spleen?
Further assessment for hepatosplenomegaly is required
Hepatosplenomegaly can indicate underlying systemic diseases.
What causes Peripheral Artery Disease (PAD)?
Arterial narrowing (atherosclerosis)
Atherosclerosis is the buildup of fats, cholesterol, and other substances in and on the artery walls.
What type of pain is associated with Peripheral Artery Disease (PAD)?
Intermittent claudication (pain with walking)
This pain typically resolves with rest.
What skin changes are observed in Peripheral Artery Disease (PAD)?
Cool, pale, shiny skin; no hair growth
These changes indicate poor blood flow to the extremities.
What type of ulcers are associated with Peripheral Artery Disease (PAD)?
Deep, punched-out ulcers on toes, feet
These ulcers are often painful and difficult to heal.
What is the status of pulses in Peripheral Artery Disease (PAD)?
Weak or absent
This indicates reduced blood flow.
What is the level of edema in Peripheral Artery Disease (PAD)?
Minimal
Edema is not a common feature in PAD.
What relief measures are recommended for Peripheral Artery Disease (PAD)?
Rest, dangling legs
These measures help improve blood flow to the affected areas.
What causes Chronic Venous Insufficiency (CVI)?
Weak or damaged veins (varicose veins)
Varicose veins can lead to chronic issues with blood return.
What type of pain is associated with Chronic Venous Insufficiency (CVI)?
Dull, aching pain (worse with standing)
This pain often improves with leg elevation.
What skin changes are observed in Chronic Venous Insufficiency (CVI)?
Warm, swollen, brownish discoloration
These changes are due to pooled blood and fluid.
What type of ulcers are associated with Chronic Venous Insufficiency (CVI)?
Shallow ulcers around ankles
These ulcers are often less painful than arterial ulcers.
What is the status of pulses in Chronic Venous Insufficiency (CVI)?
Normal
Pulses are typically intact due to preserved arterial flow.
What is the level of edema in Chronic Venous Insufficiency (CVI)?
Severe (worsens throughout the day)
Edema is a hallmark of CVI due to venous pooling.
What relief measures are recommended for Chronic Venous Insufficiency (CVI)?
Elevating legs
Elevation helps reduce swelling and improve venous return.
What is required when weak or absent pulses are detected?
Immediate further evaluation (Doppler, ABI test)
These tests assess blood flow and vascular health.
What type of therapy is required for venous ulcers?
Compression therapy
Compression helps improve venous return and reduce swelling.
What type of therapy is needed for arterial ulcers?
Improved circulation
This may include lifestyle changes and medical interventions.
What should be monitored for in venous disease?
Signs of deep vein thrombosis (DVT)
DVT is a serious condition that can lead to pulmonary embolism.
What does ABI stand for?
Ankle-Brachial Index
ABI is used to assess blood flow and diagnose PAD.
What is the purpose of the ABI test?
To compare blood pressure in the ankles versus the arms
It is a non-invasive test.
What is the formula for calculating ABI?
ABI = Ankle Systolic BP / Brachial Systolic BP
This formula helps in determining the presence of PAD.
What is considered a normal ABI range?
1.0 - 1.4
This indicates equal or higher blood pressure in the ankles than in the arms.
What does an ABI value of less than 0.9 indicate?
Peripheral Artery Disease (PAD)
This threshold is critical for diagnosing PAD.
What is DVT?
DVT is a life-threatening condition caused by a blood clot in a deep vein (usually in the leg)
DVT stands for Deep Vein Thrombosis.
What is a key symptom of DVT?
Unilateral leg swelling
This means one leg is significantly larger than the other.
Where is pain typically located in DVT?
Usually in calf or thigh
Pain and tenderness are common symptoms of DVT.
What might cause warmth and redness in a DVT patient?
Due to inflammation and clot
These signs are associated with the presence of a blood clot.
What is Positive Homan’s Sign?
Pain in the calf when dorsiflexing the foot
This sign is not always reliable for diagnosing DVT.
What is the first nursing consideration for DVT?
DVT requires immediate anticoagulation therapy (e.g., Heparin, Warfarin)
Anticoagulation is critical to prevent complications.
What should you NOT do with the affected leg in DVT?
Do NOT massage the affected leg
Massaging may dislodge the clot and lead to pulmonary embolism.
What are two interventions to encourage in high-risk DVT patients?
Early ambulation and compression stockings
These interventions help prevent DVT complications.
menumonic for remembering diastolic murmurs
ARMS
after S2 and before S1
What does a grade of I/VI signify?
Barely audible, requires focused listening
This is the lowest grade in the grading scale for sound.
What is the description for a grade II/VI?
Soft, but easily heard
This grade indicates a sound that is not as faint as I/VI.
Define grade III/VI.
Moderately loud
This grade represents a sound that can be heard without difficulty.
What characterizes a grade IV/VI?
Loud with a palpable thrill
This grade indicates a sound that is not only loud but also has a vibration sensation.
What is the meaning of grade V/VI?
Very loud, heard with a stethoscope barely touching chest
This grade indicates a very pronounced sound.
What does a grade VI/VI indicate?
Extremely loud, heard without a stethoscope
This is the highest grade in the grading scale for sound.
What is a Holosystolic (Pansystolic) murmur?
A murmur heard throughout systole.
What is cyanosis?
Bluish discoloration of the skin and mucous membranes due to poor oxygenation of hemoglobin in the blood.
What are the two types of cyanosis?
- Central (systemic hypoxia)
- Peripheral (localized circulation issue)
What are the best sites for assessing central cyanosis?
- Lips
- Oral mucosa
- Conjunctiva
- Tongue
What are the best sites for assessing peripheral cyanosis?
- Fingertips
- Toes
- Earlobes
What is central cyanosis?
Bluish discoloration in the lips, tongue, oral mucosa, and conjunctiva due to low arterial oxygen saturation (<85%)
Central cyanosis indicates severe hypoxia and requires immediate assessment.
What are some causes of central cyanosis?
- Severe hypoxia (pneumonia, respiratory failure, COPD exacerbation)
- Congenital heart defects (Tetralogy of Fallot, transposition of great arteries)
- Pulmonary embolism, ARDS, or shock
These conditions can lead to insufficient oxygenation of the blood.
Where is central cyanosis best assessed?
In the oral mucosa, tongue, and conjunctiva
These areas provide a clear indication of oxygen saturation in the blood.
Does central cyanosis improve with warming?
No, it does NOT improve with warming
This differentiates it from peripheral cyanosis, which may improve with warming.
What is a key nursing consideration when assessing for central cyanosis?
Assess SpO₂ with pulse oximetry (normal = 95-100%; concern if <90%)
Monitoring oxygen saturation is crucial for determining the severity of hypoxia.
What should be administered if oxygen levels are low in a patient with central cyanosis?
Supplemental oxygen
Supplemental oxygen helps to increase arterial oxygen saturation and improve the patient’s condition.
What does Jugular Vein Distention (JVD) refer to?
Visible enlargement or bulging of the external jugular veins due to increased central venous pressure (CVP)
JVD is assessed to evaluate cardiac function and fluid status.
What is considered a normal finding for JVD?
No visible JVD or pulsations when the patient is sitting upright
What is considered an abnormal finding for JVD?
Jugular vein distension greater than 3 cm above the sternal angle at a 45-degree angle
What condition does increased JVD suggest?
Increased right atrial pressure or heart failure
What causes blood to back up into the venous system in right-sided heart failure?
Weakened right ventricle
What is Superior Vena Cava (SVC) Syndrome?
Blockage of the SVC that prevents venous drainage from the upper body
What effect does pulmonary hypertension have on the heart?
Increases right heart workload, leading to venous congestion
What is pericardial tamponade?
Fluid in the pericardium compresses the heart, reducing venous return
What condition causes the heart to not expand fully, leading to venous backup?
Constrictive pericarditis
What is a hallmark sign of right-sided heart failure?
JVD
JVD stands for jugular venous distension.
What accompanying symptoms should be assessed with JVD?
- Edema
- Hepatomegaly
- Ascites
These symptoms indicate potential fluid overload.
What diagnostic tests should be considered if JVD is present?
- Chest X-ray
- Echocardiogram
These tests help evaluate heart structure and function.
What is the first step in the JVD assessment?
Position the patient at a 45-degree angle (semi-Fowler’s position).
How should the patient’s head be positioned during JVD assessment?
Turn the patient’s head slightly to the left to expose the right jugular vein.
What is the purpose of using good lighting during JVD assessment?
To observe the vein along the sternocleidomastoid muscle.
What height of JVD above the sternal angle is considered abnormal?
Greater than 3 cm.
What does an increase in JVD during hepatojugular reflux assessment suggest?
Fluid overload or heart failure.
What should be suspected if JVD is greater than 3 cm above the sternal angle?
Heart failure or fluid overload.
What should be compared during the JVD assessment?
Findings bilaterally.
What are associated symptoms to check for during JVD assessment?
Dyspnea or peripheral edema.
What may visible pulsations indicate when the patient is upright?
Severe venous congestion.
Define peripheral edema.
Localized or generalized swelling due to fluid accumulation in the interstitial space.
In which conditions is peripheral edema commonly seen?
- Heart failure
- Kidney disease
- Liver disease
- Venous insufficiency
What is a normal finding regarding peripheral edema?
No visible swelling, firm skin, or pitting when pressing on extremities.
What characterizes an abnormal finding in peripheral edema?
Swelling, pitting (indentation when pressed), and stretched or shiny skin.
What causes peripheral edema in heart failure?
Blood backs up into the systemic circulation, leading to fluid retention in the legs and feet.
This is particularly related to right-sided heart failure.
What is the mechanism behind chronic venous insufficiency?
Damaged veins cause blood pooling in the lower extremities.
This condition often results in swelling and discomfort.
How does kidney disease contribute to peripheral edema?
The kidneys fail to remove excess fluid, leading to widespread swelling.
This can result in significant fluid retention throughout the body.
What role does liver disease (cirrhosis) play in peripheral edema?
Low albumin reduces oncotic pressure, allowing fluid to leak into tissues.
This can lead to significant fluid accumulation in various body areas.
What causes unilateral swelling in deep vein thrombosis (DVT)?
A clot in a deep vein blocks venous return, causing unilateral swelling.
This is a critical condition that requires immediate medical attention.
What is lymphedema and how does it affect peripheral edema?
Blockage of the lymphatic system prevents normal drainage, leading to firm, non-pitting edema.
This condition often results in swelling that does not leave an indentation when pressed.
What is a key nursing consideration regarding edema in heart failure?
Edema in heart failure is often bilateral and worse in the lower extremities.
This is important for monitoring and treatment strategies.
What does unilateral edema suggest in a patient?
Unilateral edema suggests DVT or lymphatic obstruction.
Quick assessment is vital to rule out serious conditions.
What is generalized edema also known as?
Anasarca.
It is seen in severe kidney or liver disease.
What is a characteristic of heart failure-related edema?
Worsens in the evening due to fluid shifts from gravity.
Accompanied by JVD, dyspnea, and weight gain.
What treatments are used for heart failure-related edema?
Diuretics (e.g., furosemide) and fluid restriction.
These treatments help manage fluid overload.
What are the signs of DVT-related edema?
Unilateral swelling, redness, and warmth.
Painful calf tenderness (Homan’s sign may be positive).
What is required for the diagnosis of DVT-related edema?
Anticoagulation therapy and ultrasound confirmation.
This helps in managing the condition effectively.
What type of edema is characterized as non-pitting and firm?
Lymphedema.
It is due to lymphatic obstruction.
Who is most commonly affected by lymphedema?
Cancer patients after lymph node removal.
This condition can arise due to surgical complications.
What treatments are typically used for lymphedema?
Compression therapy and lymphatic drainage.
These methods aim to reduce swelling and improve lymphatic flow.
