NUR-111: Unit 1

studied byStudied by 95 people
5.0(3)
Get a hint
Hint

stridor

1 / 89

flashcard set

Earn XP

Description and Tags

Assessment, Perfusion, Oxygenation, Clinical Decision Making

Nursing

90 Terms

1

stridor

narrow, upper airway. High pitch, harsh, inspiration

New cards
2

wheezes

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

New cards
3

crackles/rales

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

New cards
4

Rhonchi

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

New cards
5

pleural friction rub

inflammation pleural lining

New cards
6

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

New cards
7

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

New cards
8

s3 heart sound

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

New cards
9

s4 heart sound

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

New cards
10

Gallop

S3 and S4 (with S1 and S2)

New cards
11

Opening snap

diseased AV valve opening

New cards
12

Systolic click

diseased semilunar valve opening

New cards
13

Murmur

whooshing; turbulent flow in the heart (across valve)

New cards
14

abnormal findings in perfusion

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

New cards
15

Tachycardia

greater than 100 bpm

New cards
16

bradycardia

less than 60 bpm

New cards
17

hypotension

below 90/60

New cards
18

hypertension

above 120/80

New cards
19

arrhythmia

irregular heartbeat

New cards
20

edema

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

New cards
21

palpitations

A subjective feeling of heart racing or fluttering

New cards
22

Respirations normal count

12-20

New cards
23

tachypnea

greater than 20 respirations

New cards
24

bradypnea

lower than 12 respirations

New cards
25

clubbing

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

New cards
26

retractions

can see rib outlines, abnormal breathing that involves the abdomen

New cards
27

dyspnea

shortness of breath, difficulty breathing

New cards
28

orthopnea

difficulty breathing lying down, resolves when patient sits or stands

New cards
29

apnea

period of not breathing

New cards
30

cyanosis

bluish hue on mouth or fingers

New cards
31

circumoral

bluish hue around mouth

New cards
32

ascites

fluid collection in abdomen

New cards
33

dysphagia

difficulty swallowing

New cards
34

polyuria

increase of urination or excessive urinating

New cards
35

nocturia

increase in urinating at night

New cards
36

oliguria

decrease in urinating, less than 30 ml per hour

New cards
37

anuric

no urine output, dialysis patients

New cards
38

dysuria

difficulty urination

New cards
39

hematuria

blood in urine

New cards
40

flutter valve

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

New cards
41

thoracentsis

healthcare provider uses needle to draw fluid off pleural space

New cards
42

ABG

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

New cards
43

bronchoscopy

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

New cards
44

hypoxemia

decreased O2 in arterial blood

New cards
45

hemoptysis

expectoration of blood from respiratory tract, or coughing up blood

New cards
46

hypoxia

decreased O2 in tissues/cells

New cards
47

incentive spirometer

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

New cards
48

atelectasis

incomplete lung expansion or collapse of alveoli

New cards
49

ischemia

inadequate oxygen to tissue

New cards
50

pulse deficit

difference between apical and radial pulse

New cards
51

Head/Neck Assessment

  1. PERRLA

  2. Smile

  3. Mucus Membranes

  4. JVD

  5. Glasses, hearing aids, dentures?

New cards
52

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

New cards
53

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?

New cards
54

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

New cards
55

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

New cards
56

Posterior assessment

  1. Skin color

  2. skin moisture

  3. Posterior lungs

  4. Any dressings, bandages, wounds?

New cards
57

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?

New cards
58

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?

New cards
59

Abdomen Assessment order

  1. Inspect

  2. Auscultate

  3. Percussion

  4. Palpate last!

New cards
60

Bruit

Artery, whooshing noise, turbulent blood flow

New cards
61

Aphasia

full loss of speaking

New cards
62

Dysphasia

difficulty speaking

New cards
63

Dysarthria

slurred speech

New cards
64

pulse quality

+3- bounding

+2- strong, palpable

+1- weak, palpable

0- absent/used doppler

New cards
65

Aortic valve

Right, 2nd intercostal space

New cards
66

Pulmonic valve

Left, 2nd intercostal space

New cards
67

Erbs point

Left, 3rd intercostal space

New cards
68

Tricuspid

Left, 4th intercostal space

New cards
69

Mitral valve

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

New cards
70

Bronchial

Loud, high-pitched lung sound

New cards
71

Vesicular

soft, low lung sound

New cards
72

Bronchiovesicular

Medium-pitched lung sound

New cards
73

BRADEN Scale

Scale for high risk of pressure ulcers

New cards
74

MORSE Fall scale

High risk for falls scale

New cards
75

Nasal Cannula low flow

1-6 liters

New cards
76

Nasal cannula high flow

Thicker tubing, can go up to 60 liters

New cards
77

Oxygen shields

Face or Trachea, go up past 10 liters

New cards
78

Non-rebreather

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

New cards
79

Troponin

Looks at heart specific values to show damage

New cards
80

BNP

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

New cards
81

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).

New cards
82

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.

New cards
83

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

5 mins

New cards
84

flaccid

drooping without elasticity, lack strength

New cards
85

paralysis

no sensation present, usually associated with no ability to move

New cards
86

contracted

permanent tightening of muscles

New cards
87

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.

New cards
88

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.

New cards
89

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.

New cards
90

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.

New cards

Explore top notes

note Note
studied byStudied by 7 people
... ago
5.0(1)
note Note
studied byStudied by 3 people
... ago
5.0(1)
note Note
studied byStudied by 11 people
... ago
5.0(1)
note Note
studied byStudied by 16 people
... ago
5.0(1)
note Note
studied byStudied by 10 people
... ago
5.0(1)
note Note
studied byStudied by 1207 people
... ago
4.9(15)
note Note
studied byStudied by 2333 people
... ago
4.9(8)
note Note
studied byStudied by 45 people
... ago
5.0(1)

Explore top flashcards

flashcards Flashcard (35)
studied byStudied by 12 people
... ago
5.0(3)
flashcards Flashcard (64)
studied byStudied by 6 people
... ago
5.0(1)
flashcards Flashcard (39)
studied byStudied by 8 people
... ago
5.0(1)
flashcards Flashcard (52)
studied byStudied by 21 people
... ago
5.0(3)
flashcards Flashcard (25)
studied byStudied by 4 people
... ago
4.0(1)
flashcards Flashcard (65)
studied byStudied by 27 people
... ago
4.0(3)
flashcards Flashcard (63)
studied byStudied by 66 people
... ago
4.6(5)
flashcards Flashcard (66)
studied byStudied by 46 people
... ago
5.0(1)
robot