Respiratory/cardiovascular Flashcards
Expected findings for long term chronic inadequate or insufficient oxygenation in a client.
COPD, Cyanosis, clubbing, wheezing, SOB, tachycardic
COPD
Chronic obstructive pulmonary disease- A group of lung diseases that block airflow and make it difficult to breathe.
Cyanosis
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
Clubbing
An abnormal, distorted, rounded shape of the nail bed. Caused by right sided hearted failure.
SOB
Shortness of breath
Expected findings for spinal De formalities-
Kyphosis, lordosis, scoliosis
Kyphosis
Hunched forward
Lordosis
Lumbar/hunched back
Scoliosis
Curvature of the spine
Early signs and symptoms of hypoxia and hypoxemia.
restlessness, irritability, abnormal breathing, tachycardia, tachypnea, HTN, pallor
Late signs and symptoms of hypoxia and hypoxemia
decrease LOC, cyanosis, Increase lactic acid, dysrhythmias, bradycardia, bradypnea, hypotension
Expected findings for a person with respiratory failure.
Severe Dyspnea, shortness of breath, use of accessory muscles.
How to check oxygenation without pulse oxygenation?
Check cap refill
Assessing for cap refill in
peripheral insufficiency can be tested with Allen test because
Has more edema
Alternative locations other than the fingers where pulse oximetry may be assessed?
Ear lobe, toes, forehead
Correlate the increase the rate in L of oxygen with the percentage of oxygen (% of FiO2)
Room air 21%
1L oxygen=2-4%
What transports oxygen in the bloodstream?
Hemoglobin
Nursing goal when using oxygen?
Use lowest O2 liter flow needed to manage hypoxia
Auscultating Lung sounds
Wheeze, rhonchi, stridor, crackles; assess accessory muscle use, percussion/symmetry
Breathing patterns and what that may indicate
Cheyne-stokes: near death; bradypnea: post surgery;
Ataxic-irregular verging dizziness, orthostatic hypodepths
How to assess cyanosis or pallor in a darker skinned client
Tongue, fingernail beds, oral mucosa, conjunctiva
Know the names and locations of pulse points
Brachial, radial, carotid, popliteal, posterior tib, dorsal is pedis
Unexpected findings when assessing a pulse and possible implications
Thready- poor perfusion, diminished=clot/CVT
What action does a nurse need to take if a radial pulse is irregular?
Apical pulse for full minute
Know the landmarks for assessing (whether palpating or auscultating) the heart sounds/valves.
Aortic-R 2nd, Pulmonic-L 2nd, Erbs point-L 3rd, Tricuspid-L 4th, Mitral-5th intercostal, midclavicular
What to expect if a client has mitral valve stenosis
S3-murmur
Expected assessment findings for a client with COPD.
Barrel chest, clubbing, acute: tripod position, dyspnea
Barrel Chest
a deformity in which the chest becomes expanded in size.
Dyspnea
difficult or labored breathing.
Expected findings for a client with bradycardia
Hypotension, and dizziness
Expected findings for a patient with right sided heart failure,(wreck the body), (think blood flow or sluggish blood flow through the heart)
Edema
Expected findings for a patient with left-sided heart failure, (lungs), (think blood flow or sluggish blood flow through the heart)
Rales, crackles, congestion
Expected findings in a client with peripheral neuropathy (what might the patient report?)
Sharp pain, pins & needles, burning pain
Unexpected findings with arterial or peripheral insufficiencies in the legs
Formation of clots
