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NURSING School > NURS 301 1st exam > Flashcards

NURS 301 1st exam Flashcards

1
Q

what guides an assessment

A

questions which give you the subjective about the patient

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2
Q

episodic health assessment

A

usually done when a patient is following up with a healthcare provider for a previously identified problem. usually once a year

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3
Q

screening health assessment

A

example would be diabetes

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4
Q

what percent of an adult body weight is skin?

A

16% heaviest organ of our body

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5
Q

control mechanisms of the skin

A

thermoregulation and fluid electrolyte balance

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6
Q

what vitamin does the skin produce

A

vitamin D

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7
Q

integumentary system can provide vital information on

A

patients health status and whether the functioning of the total body system if adequately performing

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8
Q

pruritus

A

itchy skin

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9
Q

OLDCARTS

A

onset, location, duration, characteristics, aggravation or alleviation, related systems, treatment by the patient, severity

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10
Q

IPPA

A

inspection, palpation, percussion, auscultation

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11
Q

perspiration is normal on

A

face, hands, axillae, and skin folds

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12
Q

what do you test during skin assessment

A

skin texture, skin thickness, edema

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13
Q

skin texture

A

check smoothness/firmness and elasticity

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14
Q

edema

A

can be pitting or non-pitting. best place to assess is the tibial plate

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15
Q

questions to ask when assessing edema

A

Did your shoes fit okay today? do your legs feel swollen?

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16
Q

inspect the skin surfaces for

A

skin breakdown on bony prominences, lesions, tattoos, scars, rashes, bruising

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17
Q

ABCDEF format

A

asymmetric, borders, colors, diameter, elevation, and feeling

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18
Q

when assessing skin conditions always describe using

A

ABCDEF format

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19
Q

Braden skin scale

A

tool that is used to determine a patients risk in developing a pressure ulcer. based off 6 criteria: sensory perception, moisture, activity, mobility, nutrition, friction and shear

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20
Q

scoring with Braden scale

A

each category is worth 1-4 except friction and shear which is 1-3. 15-18=mild risk, 13-14 = moderate risk, 10-12.= high risk, and less than 9 = very high risk

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21
Q

populations at risk for pressure ulcers

A

people in casts or cervical collars, immobilizing devices, nasal cannulas, wound vacs, any drains

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22
Q

stage 1 pressure ulcer

A

purple/maroon discolored area/blood filled blister. the skin remains intact, nonblanchable redness

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23
Q

stage 2 pressure ulcer

A

partial thickness loss of dermis, looks like an open blister, no slough

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24
Q

stage 3 pressure ulcer

A

full thickness tissue loss, fat may be visible but not bone or tendon, can include undermining or tunneling

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25
Q

stage 4 pressure ulcer

A

full thickness loss with exposed bone, tendon, or muscle. slough or eschar can be present. high risk of osteomyelitis

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26
Q

unstageable pressure ulcer

A

full thickness tissue loss in which the base of the ulcer is covered in eschar, slough, or both. eschar has to be surgically removed unless on heal

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27
Q

common areas of skin breakdown supine position

A

occiput, scapula, sacrum, heels

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28
Q

common areas of skin breakdown lateral position

A

ear, acromion process, elbows, trochanter, heels

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29
Q

skin tears

A

skin separation between dermis and the epidermis that occurs due to a traumatic event

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30
Q

skin tear documentation

A

should be documented separate from pressure wounds as they are a result of acute, traumatic injury

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31
Q

populations at risk for skin tears

A

older adults, compromised nutrition, fluid volume deficit, edema, confusion, limited mobility, lack of independence, or bruised skin

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32
Q

skin turgor

A

a measure of skin elasticity and hydration status. normal results in less than 4 secs. more than 6 seconds = skin tenting

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33
Q

annular

A

ringed with clear center

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34
Q

linear

A

straight line (streak)

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35
Q

circinate

A

circular

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36
Q

confluent

A

lesions run together

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37
Q

discrete

A

individual/distinct

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38
Q

discoid

A

disk shaped without central clearing

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39
Q

zostiform

A

linear cluster along the nerve root

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40
Q

generalized

A

widespread

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41
Q

macule

A

color change, flat, less than 1 cm Ex: freckles

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42
Q

papule

A

something you can feel, less than 1 cm Ex: mole

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43
Q

plaque

A

papule which merge together. wider than 1 cm Ex: psoriasis

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44
Q

patch

A

macule that are larger than 1 cm Ex: birthmark?

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45
Q

nodule

A

solid, elevated, larger than 1 cm

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46
Q

wheal

A

superficial, raised, transient, slightly irregular, due to edema Ex: mosquito bite

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47
Q

urticale

A

hives

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48
Q

tumor

A

firm, soft, deeper into dermis, larger than a few cm

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49
Q

vesicle

A

elevated cavity containing free fluid ex: chx pox

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50
Q

postule

A

pus filled cavity, elevated Ex: acne

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51
Q

bulla

A

superficial in epidermis, thin walled, ruptured easily, ex: blister

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52
Q

cyst

A

encapsulated fluid filled cavity in dermis or subcutaneous layer.

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53
Q

fissure

A

linear cracks with abrupt edges. extends into the dermis

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54
Q

excoriation

A

from scratching, self inflicted abrasion

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55
Q

erosion

A

scooped out but shallow. superficial but no bleeding

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56
Q

lichenification

A

prolonged intense scratching eventually thickens the skin and produces tightly packed sets of papules

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57
Q

keloid

A

a hypertrophic scar with excess scar tissue. looks smooth, rubbery, and claw like

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58
Q

purpura

A

occurs when small blood vessels join together or leak blood under the skin

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59
Q

petechiae

A

when pupura spots are very small

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60
Q

ecchymosis

A

large purpura, bruising. look for multiple areas at different stages could be sign of abuse

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61
Q

risk factors of skin cancer

A

HPV, alcohol intake, genetics, age, Male gender, long term skin inflammation, smoking, moles, fair skin, chemical exposure

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62
Q

basal cell carcinoma

A

most common, starts as skin colored papule and grows slowly

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63
Q

squamous cell carcinoma

A

red scaly with sharp edges. develops central ulcer with redness. grows rapidly

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64
Q

melanoma

A

very aggressive. originates in the melanocytes. most are brown but can be other colors. kills about 1 person an hour

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65
Q

first degree burn

A

superficial

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66
Q

second degree burn

A

superficial partial thickness

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67
Q

third degree burn

A

deep partial thickness

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68
Q

fourth degree burn

A

full thickness

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69
Q

5th and 6th degree burns

A

lethal and found during autopsy

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70
Q

vellus hair

A

short, fine, relatively unpigmented, covers most of the body

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71
Q

terminal hair

A

coarser thicker and usually pigmented. scalp, eyebrows, pubic hair, axillae, legs

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72
Q

total body hair assessment

A

color, texture, distribution, amount/quantity, hygiene, lesions/parasites, dandruff, odor

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73
Q

nails

A

hard transparent plates of keratinized epidermal cells

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74
Q

nail assessment

A

shape, consistency, thickness, texture, attachment, color

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75
Q

nail shape and contour

A

looking for clubbing, spooning, jagged, longitudinal grooves, pitting, paronychia, hygiene, biting

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76
Q

clubbing

A

congenital or smoking. late sign of bad perfusion to peripheral extremities

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77
Q

spooning

A

concave curves - iron deficiency

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78
Q

jagged

A

chronic anxiety

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79
Q

longitudinal grooves

A

normal

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80
Q

pitting

A

from psoriasis

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81
Q

paronychia

A

infection of the nail folds

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82
Q

greying of hair

A

decrease in melanocytes

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83
Q

what are you looking at when looking at a persons vital signs

A

trends

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84
Q

vital signs

A

temp, pulse, respirations, BP, 2nd: O2 saturation and sometimes pain

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85
Q

when do you take vital signs

A

clients admission to facility, before and after surgery, changes in physical condition, before and after medication, when ordered, during blood transfusion, before and after nursing interventions

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86
Q

body temperature

A

heat produced - heat lost = body temp. normal temp is 96.8-99 F

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87
Q

99-100

A

low grade fever

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88
Q

fever

A

hyperthermia - greater than 100.4. response to infection

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89
Q

we have an issue if temp is greater than

A

102

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90
Q

rectal temp is

A

1 degree greater than oral

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91
Q

axillary temp

A

1 degree lower than oral

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92
Q

tympanic temp

A

equal to oral temp

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93
Q

hypothermia

A

skin temp below 95 F. caused by prolonged exposure to cold

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94
Q

pulse is an indicator of

A

circulatory and respiratory status

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95
Q

sites for obtaining a pulse

A

radial, apical, brachial, popliteal, dorsalis pedis, carotid, temporal, femoral, posterior tibial

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96
Q

Rate characteristics

A

normal - 60-100
bradycardia - less than 60
tachycardia - greater than 100

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97
Q

rhythm

A

can be regular, regularly irregular, or irregularly irregular

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98
Q

quality of pulse

A

weak, thready, bounding

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99
Q

respiration

A

bodys mechanism for exchanging gases. two components: inspiration and expiration. usually 1:2

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100
Q

ventilation

A

the movement of gases in and out of the lungs

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101
Q

diffusion

A

movement of oxygen and carbon dioxide between the alveoli and red blood cells

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102
Q

perfusion

A

the distribution of red blood cells to and from the capillaries

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103
Q

normal respiratory rates

A 
newborn - 30-60 
infant - 30-50
toddler - 25-32
child - 20-30
adolescent - 16-19
adult - 12-20
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104
Q

normal tidal volume

A

500cc

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105
Q

inspiration

A

diaphragm contracts

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106
Q

expiration

A

diaphragm relaxes and abdominal organs return to normal position

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107
Q

sigh

A

physiological mechanism for expanding small airways and alveoli not ventilated during a normal breath

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108
Q

blood pressure

A

force exerted on the walls of an artery by the pulsing blood under pressure from the heart. moves from area of high pressure to area of low pressure

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109
Q

systolic pressure

A

peak of maximum pressure occurring with ejection

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110
Q

diastolic pressure

A

minimal pressure exerted against the arteries at all times

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111
Q

pulse pressure

A

the difference between the systolic and diastolic pressure

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112
Q

normal BP

A

120/80

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113
Q

high BP

A

hypertension - greater than 140 = stage 1, greater than 160=stage 2, greater than 180=stage 3, greater than that hypertensive crisis

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114
Q

low BP

A

hypotensions 90/60

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115
Q

orthostatic hypotension

A

occurs when person develops low blood pressure with raising to an upright position

116
Q

factors influencing blood pressure

A

age, anxiety, ethnicity, gender, diurnal variation

117
Q

why are vital signs important?

A

indicators of the body’s status, response to stressors, provides parameters for monitoring status and progress, and provides parameters for nursing interventions

118
Q

exchange of gases is influenced by

A

central nervous system, cardiovascular system, musculoskeletal system

119
Q

autonomic mechanism of respiration is triggered where?

A

in the pons and medulla oblongata of the brain stem

120
Q

upper respiratory tract

A

nose, mouth, sinuses, pharynx, larynx, and upper trachea

121
Q

lower respiratory tract

A

lower trachea, bronchi, and lungs

122
Q

vertical lines along the anterior chest

A

anterior axillary line, midclavicular line, midsternal line

123
Q

vertical lines along the posterior chest

A

scapular line and vertebral line

124
Q

vertical lines along the lateral side of chest

A

anterior axillary line, midclavicular line, and posterior axillary line

125
Q

diaphragm does what during inhalation and exhalation?

A

contracts and flattens for inhalation (allows air to passively move in) and curves back to normal for exhalation

126
Q

how to calculate pack years

A

pack per say X years they have smoked

127
Q

cystic fibrosis

A

mucus producing cells always secreting

128
Q

COPD

A

chronic obstructive pulmonary disease. results in less air that continuously flows in and out of the airways

129
Q

pursed lips and nasal flaring

A

indicative with COPD

130
Q

precuts excavatum

A

congenital posterior displacement of lower aspect of sternum. this gives the chest a hollowed out look

131
Q

barrel chest

A

associated with emphysema and lung hyperinflation. increased transverse to AP diameter as well as diaphragmatic flattening

132
Q

kyphosis

A

causes the patient to be bent forward.

133
Q

scoliosis

A

condition where the spine is curved to either the left or right

134
Q

what is the most important part of the respiratory assessment

A

assessing air flow

135
Q

larger airways sound

A

louder and coarser

136
Q

smaller airways sound

A

softer and finer

137
Q

identify breath sounds by listening for

A

intensity, quality, pitch, and duration of inspiration and expiration

138
Q

vesicular breath sounds

A

soft, low pitched, found over fine airways and near sites of air exchange

139
Q

bronchovesicular breath sounds

A

found over major bronchi that have fewer alveoli

140
Q

bronchial breath sounds

A

loud high pitched and found over the trachea and larynx

141
Q

auscultate how many spots anteriorly and how many posteriorly

A

6 anteriorly and 8 posteriorly

142
Q

adventitious sounds of the lungs

A

crackles or rales, rhonchi, wheezes, pleural friction rub

143
Q

rhonchi

A

low pitched continuous sounds. similar to wheezes. imply obstruction of the larger airways

144
Q

adventitious sounds during percussion

A

hyper resonance (sign of emphysema), dull sounds (signs of fluid, pneumonia, or mass), or no sound present

145
Q

if you hear an abnormal sound what should you do?

A

have the patient cough and listen again

146
Q

palpate for crepitus if..

A

patient has rid fractures, recent surgery, chest tubes, or trauma

147
Q

expected findings of bronchophony

A

sounds should be muffled, is sounds are clear can indicate consolidation

148
Q

during percussion, healthy lungs should have __ sounds

A

resonant

149
Q

factors for COPD

A

elastic quality of airways and air sacs are gone, damage of the walls between the air sacs that cause chronic thickness and inflammation, the existence of mucus which blocks the airways

150
Q

COPD can include all or just one of which of the following

A

emphysema, bronchitis, asthma

151
Q

expected expiration ratio

A

expiration twice as long as inspiration 1:2

152
Q

physical exam findings with COPD

A

hyperresonance, decreased chest exclusion, decreased fremitus, dyspnea, pallor, pursed lip breathing

153
Q

number one contributor to COPD

A

smoking

154
Q

asthma

A

allergy triggers inflammation and restriction in airways. chronic condition but has acute attacks

155
Q

what is a good indicator of someones control of their asthma

A

the amount of rescue meds used

156
Q

physical exam findings with asthma

A

tachypnea, tachycardia, retractions, wheezing, hyper expansion of the thorax

157
Q

physical exam findings of pneumonia

A

SOB, fever, decreased breath sounds, increased pulse, cough, phlegm, pain in chest, decreased SaO2

158
Q

atelectasis

A

consolidation and closing of small airways. will have decreased breath sounds in the bases

159
Q

pleural effusion

A

fluid in pleural space

160
Q

pneumothorax

A

air in pleural space - can cause tracheal deviation to good side

161
Q

hemothorax

A

blood in the pleural space

162
Q

perfusion

A

blood distribution

163
Q

ischemia

A

lack of blood flow to tissue

164
Q

shock

A

decrease perfusion systemically

165
Q

what can effect perfusion

A

nutrition, metabolism, motion, tissue integrity, intracranial regulation, elimination, pain, oxygenation

166
Q

what happens when cells are without oxygen

A

they go into anaerobic metabolism

167
Q

base of the heart

A

widest part

168
Q

apex of the heart

A

point at the bottom

169
Q

arteries

A

take oxygenated blood away from the heart to the organs and tissues

170
Q

veins

A

take deoxygenated blood back to the heart

171
Q

sinus rhythm

A

normal heart beat 60 - 100 bpm

172
Q

SA node

A

body natural pacemaker

173
Q

AV node HR

A

40-60

174
Q

bundle of his HR

A

20-40

175
Q

purkinje fibers HR

A

20

176
Q

electrical condition of the heart

A

SA node, AV node, bundle of his, purkinje fibers

177
Q

S1

A

Systole. contraction of the ventricles. Lub sound. ejects blood to the heart and body.

178
Q

S2

A

Diastole. relaxation of the ventricles. dub sound.

179
Q

what is going on during systole

A

mitral and tricuspid valves are closing

180
Q

what is going on during diastole

A

pulmonic and aortic valves are closing

181
Q

exception to direction of arteries and veins

A

pulmonary vein and artery

182
Q

major arteries of the arm

A

brachial, radial, ulnar

183
Q

major arteries of the leg

A

femoral, popliteal, dorsalis pedis, posterior fibial

184
Q

types of veins

A

deep, superficial, and perforated

185
Q

major arteries of the heart

A

ascending aorta, descending aorta, and abdominal aorta

186
Q

major veins of the heart

A

superior vena cava and inferior vena cava

187
Q

how do veins differ from arteries

A

veins do not have pressure to propel blood forward, they are a low pressure system, one way valse only, utilize muscular contraction in order to propel blood forward, and are large in diameter

188
Q

arteries are

A

smaller than veins and have a force to bring blood to organs

189
Q

head and neck veins

A

internal and external jugular veins

190
Q

internal and external jugular veins function

A

to return blood back to the heart from the head and neck through the superior vena cava

191
Q

chronic illnesses to ask about with heart assessments

A

DMII, renal failure, COPD, CHF, HTN, arterial fibrillation, elevated cholesterol, MI, angina, CAD, PVD

192
Q

CABG

A

coronary artery bypass graft

193
Q

DMII

A

diabetes mellitus - bad for vessels and heat

194
Q

CHF

A

congestive heart failure

195
Q

HTN

A

hypertension

196
Q

angina

A

pain

197
Q

current complaints to ask about with heart assessment

A

chest pain, SOB, cough, nocturia, fatigue, fainting, swelling of the extremities, leg pains or cramps

198
Q

tachycardia

A

HR above 100 bpm

199
Q

bradycardia

A

HR below 60

200
Q

what do you do if there is a irregular HR

A

may indicate arrhythmia. check if an apical/radial pulse deficit exists

201
Q

how to check apical radial pulse

A

count apical pulse and radial pulse (hopefully at same time using two nurses) Apical - radial = deficit

202
Q

why do we do the apical radial pulse?

A

if apical pulse is higher than radial it can reflect insufficiency and that the heart is too weak to send blood to arteries

203
Q

grading of pulses

A 
0+ - absent 
1+ - diminished, barely there
2+ - normal 
3+ - full volume 
4+ - bounding (forceful)
204
Q

if pulse is absent what is your next course of action

A

assess for level of consciousness and call for help

205
Q

factors affecting heart rate

A

age, gender, body size, BP, medications, exercise, diet, sleep, anxiety

206
Q

pulse pressure

A

the pressure difference between the systolic and diastolic pressure. normal is 30-40

207
Q

what can high BP lead to

A

stroke

208
Q

what do you use the diaphragm of your stethoscope for? what about the bell?

A

high pitched sounds

bell - low pitched sounds

209
Q

bruit

A

abnormal finding. blowing sound. usually means plaque and narrowing

210
Q

peripheral neuropathy

A

Weakness, numbness, and pain from nerve damage, usually in the hands and feet.

211
Q

diabetes patients usually have what in their extremities

A

numbest and tingling from bad circulation

212
Q

if you can’t find a pulse but patient is awake and alert

A

use doppler machine

213
Q

anterior chest is also called

A

the precordium

214
Q

PMI

A

point of maximal impulse. apical pulse. 5th intercostal midclavicular line

215
Q

where should S2 be louder

A

at pulmonic and aortic areas

216
Q

where should S1 be louder

A

at mitral and tricuspid area

217
Q

S3

A

extra heart sound that occurs just after s2 can be normal in children. also called kentucky

218
Q

S4

A

extra heart sound occurs just before S1. normal in children. also called Tennessee

219
Q

cardiomegaly

A

enlarged heart, so pulse may be found at 6th intercostal space

220
Q

trendelenburgs test

A

evaluates the saphenous vein valves and retrograde filling of the superficial veins. elevate leg and apply tourniquet. help them stand and assess venous filling which should be from bottom up

221
Q

ankle brachial pressure index (ABI)

A

used to predict severity of PAD - peripheral artery disease . compares BP of ankle and brachial

222
Q

Coronary artery disease risk factors

A

(CAD) if you are at risk for MI or Cerebral vascular accident

223
Q

PAD

A

peripheral artery disease

224
Q

CVA

A

cerebral vascular accident = stroke

225
Q

what causes CAD

A

plaque build up, blood clot, or coronary spasm

226
Q

risk reduction for CAD

A

exercise, healthy eating, stop smoking, weight control, lipid management, DM management, HTN management, stress control, genetics

227
Q

someone has a Mi every

A

42 seconds

228
Q

dyspnea

A

Shortness of Breath

229
Q

what is angina pectoris caused by

A

ischemia of myocardium caused by plaque within coronary arteries but can also be caused by other reason

230
Q

PE

A

pulmonary embolism

231
Q

MSK

A

musculoskeletal

232
Q

GERD

A

gastro esophageal reflux disease

233
Q

cardiac arrest

A

heart stops

234
Q

myocardial infarction

A

occurs when myocardial ischemia is sustained resulting death of myocardial cells

235
Q

NSTEMI

A

someone who we don’t see changes in EKG but think the are having MI. vessel is semi blocked bu still has some blood flow

236
Q

STEMI

A

see changes in EKG. means vessel is completely blocked

237
Q

atrial fibrillation

A

(AFIB) most common irregular heart rhythm

238
Q

signs of atrial fibrillation

A

palpitations, weakness, fatigue, lightheadedness, dizziness, confusion, SOB, chest pain

239
Q

AFIB RVR

A

rapid ventricular rate

240
Q

risk factors for PVD

A

obesity, sedentary life style, smoking, genetics, DM11, HTN

241
Q

intermittent claudication

A

pain that is relieved with rest

242
Q

rubor

A

red

243
Q

arterial ulcer characteristics

A

tips of toes, heel, very painful, deep, circular shape, minimal edema

244
Q

venous ulcer characteristics

A

medial malleolus or anterior tibial, less painful than arterial, superficial depth, irregular border, granulated tissue, edema moderate to severe

245
Q

atherosclerosis

A

hardening of artery

246
Q

aneurysm

A

ballooning of vessel

247
Q

DVT

A

deep vein thrombosis. clot develops within a vein

248
Q

thrombophlebitis

A

inflammation of vein that may or may not be accompanied by a clot

249
Q

DVT risk factos

A

hospital admission, any condition with increased blood clotting, decrease blood flow, pregnancy, over 60, overweight, birth control, sedentary lifestyle

250
Q

varicose veins

A

incompetent valves in veins, weak vein walls

251
Q

cardiac output

A

amount of blood pumped by each ventricle in 1 minute. CO=SV X HR

252
Q

SV

A

stroke volume - amount of blood pumped by each ventricle with each heart beat

253
Q

stoke volume is affected by

A

pre-load, after-load, and contractibility

254
Q

HR affected by

A

sympathetic and parasympathetic nervous system, hormones, medications, ect.

255
Q

Normal adult cardiac output

A

5-6 L/min

256
Q

ejection fraction

A

measures the amount of blood that is ejected from the heart during systole - provides information about function of the left ventricle during systole

257
Q

lymph system

A

filters and removes waste

258
Q

CKD

A

chronic kidney disease

259
Q

beta blockers

A

blood pressure medication

260
Q

paresthesia

A

numbness of tingling

261
Q

chronic swelling can cause skin to

A

appear brown or dusky

262
Q

how do you tell the difference between carotid artery and jugular venous pulse

A

jugular venous pulse usually has 2 pulsations with a prominent decent, while carotid pulse has 1 pulsation and a prominent ascent

263
Q

assessing pitting edema and grade

A

apply pressure on shin.
0+ - no pitting edema
1+ - mild (2mm)
2+ - deeper pit (4mm) disappears in 10-15 sec
3+ - deep pit (6mm) last more than a minute
4+ - severe (8mm)- can last more than 2 minutes

264
Q

conditions contributing to murmurs

A

increased blood velocity, structural valve defects, valve malfunction, abnormal chamber openings

265
Q

diastolic heart murmur always indicates

A

heart disease

266
Q

valve stenosis

A

valve opening is narrowed. tissue is stiffer. heard during diastole when valve is opening. forward flow of blood impaired

267
Q

valve regurgitation

A

incomplete valve back flow of the blood. heard when valve is trying to close.

268
Q

crackles

A

consolidation in the lungs usually fluid

269
Q

wheezes

A

narrowing of airways

270
Q

pleural friction rub

A

pleural surfaces rubbing together

271
Q

pericarditis

A

inflammation of the pericardial sac. chest pain that is worse with inspiration and lying flat and relieved by sitting up.

272
Q

with pericarditis will sounds still be there when patients hold their breath

A

yes

273
Q

untreated strep throat can do what to the heart

A

can cause heart murmur

274
Q

infective endocarditis

A

infection of endothelial layer of heart. murmur heard during late infection

275
Q

cor pulmonale

A

right ventricle hypertrophy

276
Q

heart failure

A

occurs when either ventricle fails to pump. can be systolic or diastolic. can be left or right, but primary cause of left sided heart failure

277
Q

if you can’t pump right

A

back up into systemic

278
Q

if you can’t pump left

A

back up into lungs

279
Q

pulmonary edema

A

abnormal accumulation of fluid in alveoli and interstitial spaces or lungs, which impair gas exchange

280
Q

causes of pulmonary edema

A

left sided heart failure, too much iv fluid, low albumin, lymph malignancies

281
Q

What objective findings would you predict to find with pulmonary edema

A

SOB, 3 word dyspnea, increased work of breathing, tachypnea, cyanosis or pallor, crackles heard upon auscultation, increased tactile fremitus, Bronchophony potentially present, dull percussion

282
Q

What objective findings would you predict to find with left sided failure

A

Potentially anxious, pale, cyanotic. Dyspnea, tachypnea, left ventricular heave/palpable thrill, tachycardia, displaced apical pulse, S3 heart sound, Systolic murmur, Crackles (pulmonary edema)

283
Q

what techniques would you use to assess left sided heart failure

A

Inspect for signs of cyanosis, decreased oxygenation, work of breathing
Palpate/ausculate at point of maximal impulse
Auscultate heart and lung sounds
Could perform lung special techniques to assess for fluid build up in lungs

284
Q

what objective finings would you predict to find with right sided heart failure

A

Fatigue, JVD, dependent peripheral edema, dusky hyperpigmentation of LE skin, S3 heart sounds, systolic murmur, weight gain, enlarged liver, Right ventricle heave, tachycardia

285
Q

what techniques would you use to assess right sided heart failure

A

Inspect jugular veins
Palpate for edema
Assess Intake and Output
Auscultate heart and lung sounds

286
Q

what objective finings would you predict to find with mitral valve regurgitation

A

Many people asymptomatic. Weakness, fatigue, Dyspnea on exertion, palpitations, systolic murmur, possible s3 heart sound. Could be acute- signs of pulmonary edema, thready pulse, cool, Clammy extremities

287
Q

what techniques would you use to assess mitral valve regurgitation

A

Inspect-work of breathing, oxygen saturation, respiratory rate, skin color and temperature
Palpate pulse
Auscultate heart with bell, lung sounds for signs of pulmonary edema

NURSING School (17 decks)

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