NUR-111: Unit 1

Assessment, Perfusion, Oxygenation, Clinical Decision Making

stridor

stridor

narrow, upper airway. High pitch, harsh, inspiration

wheezes

narrow passage way. High pitch, continuous, inspiration or expiration

crackles/rales

air moving through fluid. Fine: fluid in alveoli; Course: fluid in larger airways.

Rhonchi

increased amt. fluid or secretions. Course crackles, snoring noise

pleural friction rub

inflammation pleural lining

How do you notice a oxygenation problem?

Dyspnea, restlessness, tachycardia, and tachypnea, decreased O2 sat, use of accessory muscles, noisy breathing, flaring nostrils, change in skin color, position, change in loc

RN Interventions for Oxygenation

HOB Up, Adequate fluid intake, humidification, comfortable surroundings, teach/encourage breathing techniques, assist managing cough (suction), chest physiotherapy, provide oxygen, give respiratory med

s3 heart sound

abnormal older adult, too much blood volume (heard best with bell)

s4 heart sound

blood not being able to get into heart (heard best with bell)

Gallop

S3 and S4 (with S1 and S2)

Opening snap

diseased AV valve opening

Systolic click

diseased semilunar valve opening

Murmur

whooshing; turbulent flow in the heart (across valve)

abnormal findings in perfusion

Variations in pulse quality, pulse deficit, orthostatic hypotension, clogged arteries in body

Tachycardia

greater than 100 bpm

bradycardia

less than 60 bpm

hypotension

below 90/60

hypertension

above 120/80

arrhythmia

irregular heartbeat

edema

swelling, pitting—> indents non-pitting—> bounces back up

palpitations

A subjective feeling of heart racing or fluttering

Respirations normal count

12-20

tachypnea

greater than 20 respirations

bradypnea

lower than 12 respirations

clubbing

enlargement of fingers or toes that cause nail plate angle to be lost due to chronic low O2

retractions

can see rib outlines, abnormal breathing that involves the abdomen

dyspnea

shortness of breath, difficulty breathing

orthopnea

difficulty breathing lying down, resolves when patient sits or stands

apnea

period of not breathing

cyanosis

bluish hue on mouth or fingers

circumoral

bluish hue around mouth

ascites

fluid collection in abdomen

dysphagia

difficulty swallowing

polyuria

increase of urination or excessive urinating

nocturia

increase in urinating at night

oliguria

decrease in urinating, less than 30 ml per hour

anuric

no urine output, dialysis patients

dysuria

difficulty urination

hematuria

blood in urine

flutter valve

Teaching the client to exhale in device that prolongs expiration and assists with loosening secretions

thoracentsis

healthcare provider uses needle to draw fluid off pleural space

ABG

lab test that measures pH, PaCO2, PaO2, and bicarbonate in arterial blood

bronchoscopy

a tube is used to visualize the inside of the respiratory tract, take biopsies

hypoxemia

decreased O2 in arterial blood

hemoptysis

expectoration of blood from respiratory tract, or coughing up blood

hypoxia

decreased O2 in tissues/cells

incentive spirometer

teach the client to breathe in with lips around mouthpiece to try and get to a certain goal

atelectasis

incomplete lung expansion or collapse of alveoli

ischemia

inadequate oxygen to tissue

pulse deficit

difference between apical and radial pulse

Head/Neck Assessment

1. PERRLA

2. Smile

3. Mucus Membranes

4. JVD

5. Glasses, hearing aids, dentures?

Thorax Assessment

1. Assess skin

2. Skin turgor

3. APETM heart sounds with diaphragm

4. APETM heart sounds with bell

5. Ascultate anterior, posterior, lateral lung sounds

6. Cough? How long? Coughing anything up?

7. Assess for dyspnea/orthopnea

8. Oxygen modality

9. Assess flutter valve, incentive spirometer, pulse ox

Abdomen assessment

1. Skin

2. Inspect abdomen

3. Auscultate for x4 bowel sounds

4. Palpate x4 abdominal quadrants

5. Nausea/vomiting?

6. Last bowel movement?

7. What does stool look like? Diarrhea? Normal?

8. Are you passing gas?

9. How does client void?

10. Inspect urine for color, clarity, amount and odor

11. Burning, frequency, urgency, trouble getting started, incontinent episodes?

Upper Extremities assessment

1. Skin color

2. Skin temp.

3. Skin moisture

4. Dressings, bandages, wounds

5. IV Site: gauge, location, site, IV tubing

6. Radial pulses

7. Capillary refill

8. Strength

9. Edema

10. ROM

11. Sensory

Lower extremities assessment

1. Skin color

2. Skin temperature

3. Skin moisture

4. Any dressing, bandages, wounds?

5. Doralis pedis pulses

6. Posterior tibialis

7. Edema?

8. TED Hose or SCDs?

9. Calf tenderness?

10. Strength

11. Sensory

12. ROM

Posterior assessment

1. Skin color

2. skin moisture

3. Posterior lungs

4. Any dressings, bandages, wounds?

Safety assessment

1. Weakness?

2. Recent falls?

3. Cane, walker, assistive devices?

4. Any tubes coming from patient?

5. Bed locked

6. Bed rails up

7. Bed in lowest position

8. Fall socks on

9. Is there call bell at their side?

Alert and Oriented Questions

1. Name and DOB?

2. Where are you?

3. Why are you here?

4. When did this start?

5. Who is the President?

Abdomen Assessment order

1. Inspect

2. Auscultate

3. Percussion

4. Palpate last!

Bruit

Artery, whooshing noise, turbulent blood flow

Aphasia

full loss of speaking

Dysphasia

difficulty speaking

Dysarthria

slurred speech

pulse quality

+3- bounding

+2- strong, palpable

+1- weak, palpable

0- absent/used doppler

Aortic valve

Right, 2nd intercostal space

Pulmonic valve

Left, 2nd intercostal space

Erbs point

Left, 3rd intercostal space

Tricuspid

Left, 4th intercostal space

Mitral valve

Left, 5th intercostal space, mid-clavicular line. Apical pulse

Bronchial

Loud, high-pitched lung sound

Vesicular

soft, low lung sound

Bronchiovesicular

Medium-pitched lung sound

BRADEN Scale

Scale for high risk of pressure ulcers

MORSE Fall scale

High risk for falls scale

Nasal Cannula low flow

1-6 liters

Nasal cannula high flow

Thicker tubing, can go up to 60 liters

Oxygen shields

Face or Trachea, go up past 10 liters

Non-rebreather

Has bag, when O2 is on it inflates. Turn all the way up to 15 liters

Troponin

Looks at heart specific values to show damage

BNP

Brain natriuretic peptide, must be less than 100 to be normal, assesses for heart failure

bipap

A type of non-invasive ventilation that provides two levels of airway pressure: a higher pressure during inhalation and a lower pressure during exhalation, used to assist patients with _______ (e.g., sleep apnea, COPD).

cpap

________ stands for Continuous Positive Airway Pressure, a medical device used to treat sleep apnea by delivering a steady stream of air to keep the airways open during sleep.

How long must a nurse auscultate bowel sounds to say they are absent per quadrant?

5 mins

flaccid

drooping without elasticity, lack strength

paralysis

no sensation present, usually associated with no ability to move

contracted

permanent tightening of muscles

trans-thorax echocardiogram (TTE)

A ________ is a non-invasive imaging technique that uses ultrasound waves to create real-time images of the heart's structure and function by placing the transducer on the chest wall. It is commonly used to assess heart conditions, including valve function and heart size.

trans-esophageal echocardiogram (TEE)

A diagnostic imaging test that uses ________ to obtain detailed images of the heart and surrounding structures by inserting a probe into the esophagus, providing clearer views than a standard echocardiogram.

Deep Vein Thrombosis (DVT)

A medical condition characterized by the formation of a blood clot in a deep vein, typically in the legs, which can lead to complications such as ________ if the clot dislodges and travels to the lungs. Risk factors include prolonged immobility, certain medical conditions.

Heart Blood Flow Pathway

1. Oxygen-poor blood enters the right atrium via the superior and inferior vena cavae.

2. Blood flows through the tricuspid valve into the right ventricle.

3. Right ventricle pumps blood through the pulmonary valve into the pulmonary arteries.

4. Blood is oxygenated in the lungs.

5. Oxygen-rich blood returns to the left atrium via the pulmonary veins.

6. Blood flows through the mitral valve into the left ventricle.

7. Left ventricle pumps blood through the aortic valve into the aorta, distributing it to the body.