test 3 Flashcards
respiratory abnormals -- UTIs
cheyne stokes
crescendo decrescendo breathing pattern
kussmaul
rapid and deep breathing pattern
atelectasis
partial or total lung collapse d/t incomplete expansion of alveoli
how to determine if chest pain or respiratory pain
have pt take a deep breath, if pain worsens, may be respiratory
surfactant
chemical that decreases surface tension and helps keep alveoli air sacs open
why does atelectasis occur
not breathing deeply enough
nursing interventions for atelectasis
- fowlers position
- incentive spirometer
- TC&DB
- splint abd when coughing
medication to precent hypoventilation
air trapping
obstruction of air exiting the lungs (seen in COPD)
COPD
chronic obstructive pulmonary disease
types of COPD
chronic bronchitis and
emphysema
normal stimulus to breathe
HIGH CO2
- body increases breathing to get rid of CO2
COPD pt O2 sat levels should be…
88-92%
do not give more than 2LPM
abnormal stimulus to breathe
LOW O2
- hypoxic drive
- body unable to correct chronically acidic blood levels
PA findings of COPD
- diminished BBS
- exertional dyspnea
- accessory muscle use
- clubbing of nails
- prolonged expirations
- barrel chest
- hyperresonance
what does vaping cause in the lungs
popcorn pneumonia
COPD nursing interventions
pursed lip breathing
- keep O2 less than 2L/min
PA findings for asthma
- wheezing
- SOB
- dyspnea
- coughing esp at night
- chest tightness
- ⬇ tactile fremitus
- intermittent hyperinflation
- hyperresonance
what does asthma do to air ways
swells walls
fill w. mucous
bronchoconstriction
pneumonia
inflammation of the bronchioles and alveolar space d/t viral, bacterial, or fungal infection
exudate leads to
lung consolidation
empyema
pus in the pleural cavity
PA findings for pneumonia
- FEVER
- CRACKLES
- dyspnea and tachypnea
- chest pain (friction rub- pleurisy)
- diminished BS
- ⬆ tactile fremitus
- green sputum
pleurisy
friction rub
acute bronchitis
inflammation of larger bronchial tubes, NOT alveolar air sacs
PA findings for acute bronchitis
- rhonchi
- cough
- fever
- SOB
tuberculosis
chronic infection caused by mycobacterium TB
PA findings for TB
- hemoptysis (bloody cough)
- night sweats
- weight loss
have to be on meds for how long for TB
8-18 months
pneumothorax
collapsed lung d/t air in the plerual space
blep
blister that ruptures
- commonly seen in tall, thin, caucasian boys
PA findings for pneumothorax
- chest pain
- SOB w/ tachypnea
- ↓ SpO2 → cyanosis
- diminished or absent BS
- crepitus *esp in tension
tension pneumothorax
EMERGENCY
air continuously enters but cannot leave
what gets crimped off in a tension pneumothorax
vena cava
what heart valve is under the highest pressure when closed
mitral
SA node pace
60-100 BPM
if AV node takes over what is the pase
40-60BPM
what artery pumps blood to the entire body
left anterior descending artery
S1
closure of AV valves as both ventricles begin to contract
S2
closure of both SL valves as ventricles begin to relax
systole=
ventricular contraction
diastole =
ventricular relaxation
which is longer diastole or systole
diastole
what is lost in tachycardia
diastole
P wave
atrial depolarization
QRS complex
ventricular depolarization and atrial repolarization
T wave
ventricular repolarization
ST segment
ventricular contraction
how to calculate pulse deficit
difference between apical and radial pulses at the same point in time
best way to listen to aortic murmur
sit up, lean forward, and exhale
best way to listen to a mitral murmur
lie on left side
normal pulse deficit
0
causes of a silent MI
DM neuropathy
heart transplant
risk factors of heart attack
- smoking
- DM
- obesity
- lack of exercise
- HTN
- high cholesterol
CABG
coronary artery bypass graft
TAVR
valve replacement
most common veins for use of CABG
mammary or saphenous
chest tube should drain
no more than 100ml/hr within first couple hours post surgery
fluid overload S&S
DVBS
Dyspnea (with crackles)
Venous distention
Bounding pulses
Sensorium decreased
what lab is high during HF
BNP
hormone from atria
left sided HF
backs up to lungs
- pulmonary edema
- hemoptysis
- orthopnea
- dyspnea
right sided HF
backs up into body
- JVD
- hepatomegaly
- ascites
- peripheral edema
left AND right HF
- oliguria (no pee)
- confusion and cheyne stokes
- slow cap refill
devise that can block off auricle to lower chance of blood pooling and clotting
watchman devise
often hear murmers where
erbs point using the bell of steth.
regurgitating valve
doesnt close tightly
stenosed valve
doesnt open all the way
S3 ken-tuck-y
caused by sudden tensing of ventricular wall, NOT VALVE, as blood enters atria
S4 ten-nes-see
atrial gallop
atrial walls contracting
indicates HTN, CAD, or MI
how to listen to S4
with pt on left side
when to do allen test
before sticking a radial artery
what is allen test for
ABGs and cardiac cath
checks to make sure blood flow via unlar artery is okay in case of radial artery spasm
how to do allen test
raise hand
make a fist
press arteries until looks pale
amplitude
pulse quality
pulsus alternans
strength of an arterial pulse alternates between strong and weak
- sign of HF
signs of decreased ARTERIAL blood flow
- cool to the touch
- sluggish cap refill
signs of decreased VENOUS blood flow
- redness
- warmth
- pain
- edema
brawny edema
form, hard, discolored, fibrosed, unable to displace
varicose veins
swollen twisted and painful
superficial veins
d/t faulty valves
varicose and spider veins can result in…
chronic venous insufficiency
- hemosiderin staining
- brawny edema
- stasis dermatitis
venous stasis ulcers
most common place for an ulcer to form
medial malleolus
Thrombophlebitis
clot in a superficial vein
worst potential outcome of DVT
pulmonary embolism
beurgers disease
arterial inflammation
1 cause of PAD
diabetes
signs of ischemia
weak or absent pulses
intermittent claudication
thin, shiny, hairless skin
coolness of skin and pale or molting
dependent rubor
severe = necrosis or gangrene
raynaud phenomenon
vasospasm of small arteries of fingers
seen with cold temps
increased with autoimmune collagenous disease (Lupus and RA)
pts with what are likely to have raynaud phenomenon
RA and lupus
ABI is screening for what
peripheral arterial disease
ideal position for GI inspection
supine with knees slightly flexed
jaundice caused by
increased biliruben
when to ask about flatus
GI surgery specific assessment
what do IV fluids do
prevent electrolyte imbalance and dehydration
TPN after how many days NPO
2-5
bridle secures NG tube via what bone
vomer
PEG stands for…
percutaneous endoscopic gastrostomy
how does PEG tube in jejunum affect flow rate
decreased flow rate more continuously
salum sump
used for suction
dobhoff
used for feeding via NJ or NG
colostomy vs ileostomy drainage
ileostomy is more watery because its the ileum– small intestine and water has not been reabsorbed yet
signs of small bowel mechanical obstruction
- paralytic ileus
- high pitched tinkling sounds when auscultating
- hyperactive then absent BS
- N/V to projectile vomiting
- emesis w feces
first action when pt has emesis w feces
make pt NPO for surgery
what is responsible for GERD
weak lower esophageal sphincter
most classic symptom of GERD
chronic, dry, unproductive cough
what treats GERD
PPIs and H2 blockers
hiatal hernia
part of stomach pases through hiatus in diaphragm
S&S of hiatal hernia
- epigastric pain relieved by sitting upright
- dysphagia
- may be asymptomatic
hematochezia
recent bleeding in the stool
- lower GI bleed
- currant jelly stools
hematemesis
recent bleeding in the vomit
- upper GI bleed
melena
old blood in stool
- black and tarry
occuult blood
not visible
- guaiac test (FOBT)
Kehr sign
referred shoulder pain if blood in peritoneal cavity irritates diaphragm
S&S hypovolemia
(low levels of fluid in body)
- BP plummets
- dizzy and weak
- diaphoresis
- tachycardia
appendicitis S&S
- low grade fever
- pain moves from periumbilical to RLQ
- Mcburney sign
- guarding
- anorexia
S&S of ruptured appendix
- sharp stabbing pain, then decreased pain
- rebound tenderness d/t rupture causing peritonitis
peritonitis
life threatening infection of membrane lining abdomen
what happens if the infection from peritonitis spreads to the blood
sepsis
what can cause peritonitis
rupture of organs or by an STI entering the pelvis
S&S of pancreatitis
epigastric tenderness
- knife like abdominal pain in LUQ
- N/V
- pyrexia
- fever
- shock
expected lab levels for pancreatitis
elevated serum amylase levels
damaged pancreas cells release amylase which enters the blood
grey turner sign
ecchymosis of flanks
- seen in pancreatitis
cullen sign
ecchymosis near umbilicus
- seen in pancreatitis
cholecystitis
inflammation of gallbladder often due to cholelithiasis
cholelithiasis
gallstones
S&S of cholecystitis
RUQ pain
murphy sign
anorexia
N/V
jaundice
murphy sign
cessation of inspiration from pain w/ RUQ palpation
S&S of intestinal parasites
- abd pain
- N/V/D
- gas and bloating
- fatigue
- weight loss
- loose stools (sometimes w mucus or blood)
S&S of spleen laceration or rupture
- LUQ pain
- Kehr sign
- abd pain radiates to left shoulder
- hypovolemic shock d/t blood loss
scientific name for worms
helminths
types of worms
round worms– 11 subtypes
pinworms – enterobiasis
enterobiasis
pinworms common in children
- severe rectal itching
test for pinworms
tape test to look for eggs
ave I&O for adults
1500-2000mL
oliguria
below average urine output
cause for polyuria
decreased insulin, causing increased glucose in blood, which pulls more fluid into the blood from cells and is excreted in the urine
urometer
box on a urine drainage bag used to measure exact urine output per hour
CBI
continuous bladder irrigation
CBI purpose
to prevent blood clots from blocking urethra
what to assess with CBI
- amount in
- quality
- amount out
where to directly percuss for CBI
over costovertebral area for kidney tenderness
where to percuss indirectly for CBI
over suprapubic are for bladder distention
what should never be irrigated
urostomy or ileal conduit
lower UTI
cystitis (ureters)
upper UTI
pyelonephritis (kidneys)
chronic renal failure
glomeruli fail to filter blood
S&S of cystitis
- dysuria
- urinary freq. & urgency
- cloudy urine odor
- confusion in older adults
- kidney = flank and fever pain
DVBS
signs of fluid overload in bloodstream
Dyspnea
Venous distention
Bounding pulses
Sensorium decreased
decreased kidney filtration leads to…
fluid overload
increased wastes (acidosis) (hyperventilation)
anemia
PA and lab findings for chronic renal failure
oliguria or anuria
fluid overload
- crackles with dyspnea
- edema
HTN
kyperkalemia
low calcium
high phosphate
decreased pH
decreased RBC and H&H (anemia)
levels of creatinine and BUN in chronic kidney failure
both increased
normals for creatinine and BUN
creatinine: 0.5 to 1.5
BUN: 7-18mg/dL
microalbuminuria
protein in urine
seen in kidney failure
what do pts on HDY require
anticoagulant
which type of HDY accesses the vena cava
temporary
- red and blue ports like a CVC
long term HDY
AV fistula
STEAL syndrome or vascular access steal syndrome (VASS)
decreased arterial blood flow to distal extremity that has the AV fistula
- tissue ischemia
- pallor,
- decreased pulses (MOST serious)
- decreased cap refill
what medicine to hold the morning of HDY
anti-HTN meds
common vital sign abnormal on pts on HDY
decreased BP
what to check daily for HDY pts
weight – should be down after HDY
good indicators post-HDY
lower weight
decreased fluid volume
crackles disappear
bounding pulses come back to normal
renal calculi
nephrolithiasis
AKA: kidney stones
increased risk for kidney stones
family history and dehydration
S&S of kidney stones
- severe colic (back and side pain)
- moves around side and down into lower abd. and into groin
- N/V
- Dysuria
- Hematuria
