Exam 2 health assessment

Edema

swelling from excessive accumulation of watery fluid in cells, tissues, or serous cavities, interstitial space, sign of heart failure

Heart failure

inability of the heart to pump enough blood to sustain normal bodily functions

intermittent claudication

lameness due to pain in leg muscles because the blood supply is inadequate; pain subsides with rest

perfusion

oxygenated blood being carried to tissues of blood

murmur

a whooshing or swishing sound heard through a stethoscope when blood flows abnormally over your heart valves

systole

lub, mitral/tricuspid valves snap shut atrioventricular valves (AV), ventricles contract, S1

diastole

dub, aortic/pulmonic valves snap shut semilunar valves, relaxation of ventricles, S2

DVT deep vein thrombosis

a blood clot in a deep vein, usually in the legs

atelectasis

Complete or partial collapse of a lung or a section (lobe) of a lung

ischemia

Lack of blood supply to a part of the body. may cause tissue damage due to the lack of oxygen and nutrients.

barrel chest

the enlarged chest with a rounded cross section and fixed horizontal position of the ribs that occurs in chronic pulmonary emphysema
patients with COPD, emphysema, osteoarthritis, and CF have this

diaphragm

The thin muscle below the lungs and heart that separates the chest from the abdomen

pneumothorax

abnormal presence of air in the pleural cavity resulting in the collapse of the lung

hemothorax

a collection of blood in the space between the chest wall and the lung (the pleural cavity

tension pneumothorax

a severe condition that results when air is trapped in the pleural space under positive pressure, displacing mediastinal structures, and compromising cardiopulmonary function

tripod

sitting with elbows on knees position

accessory muscles

the scalene, the sternocleidomastoid, the pectoralis major, the trapezius, and the external intercostals

apical pulse

a pulse point on your chest at the bottom tip (apex) of your heart

How is angina, MI, pericarditis, and endocarditis assessed?

general inspection, inspect and palpate skin, turgor, edema, heart tones, pulses, amplitude rhythm

MI

def: “heart attack,” is caused by decreased or complete cessation of blood flow to a portion of the myocardium
clinical findings: chest pain, crushing squeezing, pain radiating to left arm, shoulders, neck or jaw

Angina p. 242

def: chest pain caused by reduced blood flow to the heart.
clinical findings: squeezing, pressure, heaviness, tightness or pain in chest or could have discomfort in neck/jaw/back/shoulder/arm/

Pericarditis

def: swelling and irritation of the thin, saclike tissue surrounding the heart (pericardium)
clinical findings: chest pain, fever, shortness of breath, cough

endocarditis

def: inflammation, infection of endocardium causes damages to valves
clinical findings: mitral valve prolapse back up of blood or regurgitation can occur

What do I document for pulses?

time, pulse rate, pulse quality

How do I grade pulses? 220

0+ absent
1+ diminished, barely palpable
2+ normal easily identified
3+ increased pulse
4+ full, bounding, cannot obliterate

When assessing the heart valves what am I listening for? Importance?

rhythm, amplitude, S1, S2, murmurs
can help us identify any abnormalities of the valves

What are the heart valves and each of their functions?

Aortic: helps keep blood flowing in the correct direction through the heart
Pulmonic: divides the right ventricular outflow tract from the pulmonary artery
Erb's point: auscultation location for heart sounds and heart murmurs
Tricuspid: allow blood flowing into the heart from the body to flow to the right ventricle where it's pumped to the lungs for oxygen
Mitral: keep blood flowing in the right direction

Hypertension

high blood pressure, incidence is higher in obese men with diabetes

How do we grade edema in the bilateral lower extremities?

applying pressure on the affected area and then measuring the depth of the pit (depression) and how long it lasts (rebound time).

How do we grade capillary refill? What does it mean if it's less than 3 seconds?

blanching nails, good if it is less than 3 seconds. if it is more than 3 seconds it means dehydration, shock, hypothermia

Why do we try so hard to prevent DVT? 240

because it causes blood clots and they can break off and cause an emboli which travels to lungs and cause respiratory distress

What is considered a respiratory emergency? How do I prioritize this?

pneumonia, chronic obstructive pulmonary disease (COPD), asthma, and lung cancer. ABC airway, breathing, circulation

What are the adventitious lung sounds? p 194

crackles: fine, high pitched crackling and popping noises, not cleared by cough, heard during inspiration, may be heard in pneumonia, heart failure, restrictive pulmonary diseases
wheeze: high-pitched musical sound similar to squeak, commonly heard during expiration, in small airways, heard in airway diseases when the thickness of airways increases such as asthma
rhonchi: low-pitched, coarse, loud, low snoring or moaning tone, heard primarily during expiration, coughing may clear
pleural friction rub: superficial, low-pitched, coarse rubbing or grating sound, two surfaces rubbing together, heard through inspiration and expiration, loudest over lower anterolateral surface, not cleared by cough, may be heard in pleurisy, or pericarditis

How is CHF assessed? Clinical presentation? 208-209

CHF can lead to pulmonary edema very quickly so be prepared to act quickly. Baseline vital signs are important here as well as for our other assessments, including an apical pulse; history is also important. Assess heart rhythm, and strength of the heartbeat. Assess pulses, skin color, turgor and blanching.
clinical presentation: shortness of breath, fatigue, problems with the heart's rhythm called arrhythmias, and edema—or fluid buildup—in the legs.
CHF crackling

How does chronic illness affect overall health? Why is this such an important factor when assessing a patient with an acute presentation of either heart problems or respiratory problems?

can affect physical, cognitive, social, and emotional development. it can develop into chronic if not treated or diagnosed properly

How does a patient with pneumonia present? General assessment? Clinical findings?

Cough, which may produce greenish, yellow or even bloody mucus, fever, sweating and shaking chills, shortness of breath
changes in temperature and pulse; amount, odor, and color of secretions; frequency and severity of cough; degree of tachypnea or shortness of breath; and changes in the chest x-ray findings.
crackling sounds

Who is at risk to develop pneumonia?

babies 2 years and younger
premies have higher risk
older adults 65 and older

When a young child presents with respiratory distress, what is a priority for the nurse? 202

clear airway and provide oxygen

Why do we care about murmurs?

an important nursing assessment of flow of blood, early identification of valvular heart disease and ultimately patient outcomes

How does vascular disease, inadequate heart pumping, and heart arrhythmia affect tissue perfusion?

lack of oxygenated blood, blood flow is restricted to the tissue

What are the presenting signs/symptoms of chronic pulmonary disease?

SOB, wheezing, chest tightness, chronic cough that produces mucus, frequent respiratory infections, lack of energy

What are the expected abnormal findings of asthma and emphysema and how are they assessed?

cyanosis, tachypnea, use of accessory respiratory muscles, paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign), elevated jugular venous pulse and peripheral edema
listen to lung sounds (wheezing), examine nose throat upper airways, examine skin, palpate, auscultate

Document pack years of smoking. 186

multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked

What muscles are used to breathe?

the diaphragm, the rib cage muscles and the abdominal muscles

How can we tell if a patient is struggling to breathe?

increased respirations, breathing with upper chest, color changes, cyanosis

What are the relationships vital signs have with one another, how does one affect the other?

low blood pressure increased heart rate

How can we care for a patient with cultural competence? 52

Provide interpreter services.
Recruit and retain minority staff.
Provide training to increase cultural awareness, knowledge, and skills.
Coordinate with traditional healers.
Use community health workers.
Incorporate culture-specific attitudes and values into health promotion tools

How do we assess, document, and evaluate chronic and acute pain?

assess using clinical judgment based on observation of the type, significance and context of the individual's pain experience
P = Provocation/Palliation. What were you doing when the pain started?
Q = Quality/Quantity. What does it feel like?
R = Region/Radiation. Where is the pain located?
S = Severity Scale
T = Timing
Document level on a scale of 0-10

What are the functions of the skin? 97

Provides a protective barrier against mechanical, thermal and physical injury and hazardous substances.
Prevents loss of moisture.
Reduces harmful effects of UV radiation.
Acts as a sensory organ (touch, detects temperature).
Helps regulate temperature.
An immune organ to detect infections etc.

How does the use of open-ended questions facilitate obtaining more information?

allow to collect qualitative answers from customers that are, for the most part, full of information. By asking this type of question, you are giving your customers the opportunity to answer whatever they like, without limiting or influencing them with predefined answers

sinoatrial node

1st pacemaker, SA node, 60-100

atrioventricular node

2nd AV node 40-60

bundle if his

3rd tired, short of breath, pale, 20-40