nursing skills and assessment exam 3

apnea

temporary cessation of breathing (a - without)

dyspnea

difficulty breathing

hypoxia

low oxygen to tissues

hypoxemia 

low oxygen in the blood 

tripod positioning

bracing arms in front of you and leaning over a little but to decrease dyspnea and open the airways

barrel chest

anterior and posterior diameter is 1:1 without elliptical shape

dysphagia

difficulty swallowing

hypovolemia

abnormal low blood volume

hypervolemia

abnormal high blood volume

paroxysmal nocturnal dyspnea

sudden episodes of severe shortness of breath that occurs at night 1-2 hours falling asleep, related to congestive heart failure, needs multiple pillows to sleep

supine

laying on back with torso up

fowlers

sitting at a 45-60 degree angle

high fowlers

sitting at a 60-90 degree angle

nocturnal polyuria

excessive urination during the night time

pleural effusion

excessive fluid accumulating in pleural spaces, the area between the lung and the chest walls

hypercholesterolemia

high cholesterol in the blood stream

respiratory assessment expected findings 

• Equal Rise / Fall Chest

• Normal Pattern

• No Difficulty Breathing

• Normal Rate (10-20) breaths per minute)

• Elliptical Shaped Chest

• Clear / Auscultable Lung Sounds

respiratory assessment unexpected findings

• Dim / Absent Lung Sounds

• Adventitious Lung Sounds

• Dyspnea / Accessory Muscle Use

• Tachypnea / Bradypnea

• Clubbing or Pitting of Fingernials

• Nasal Flaring / Pursed Lip Breathing

• Asymmetrical Chest Expansion

• Crepitus

• Pain / Tenderness

• Lumps

• Decreased O2

• Alerteed LOC

• Increase Anxiety / Confusion

normal breathing ratio

pt should be exhaling double at time they should be inhaling, 1:2 ratio, bases of the lungs are smaller thn apex

respiratory health teaching

dont smoke, avoid exposure to toxins, chemicals, and smoke, use good handwashing technique

dim

lung sounds are hard to hear and dimmer in pitch

dim; whats happening

there is too much fluid at the bases pf the lungs or that the lungs are collapsed (D)

dim; diseases and disorders

pneumonia, pleaural effusion, atelectasis, obesity

absent

lung sounds cant be heard upon auscultation

absent; whats happening

there is too much fluid at the base of the lungs or that the lungs are collaped (A)

absent; diseases and disorders

pneumonia, pleaural effusion, pneumothorax, respiratory fatigue

pneumothorax

air enters the space between the lung and the chest wall

pneumonia

an infection of the lungs that causers inflammation of the air sacs

pleural friction rub

grating, scratching, or creaky sound that is in a specific area of the chest heard in short bursts during inspirations and expirations

pleural friction rub; whats happening

there is inflammation of the lungs covering

pleural friction rub; diseases and disorders

pleuritis, pneumonia, pulmonary edema, trauma, autoimmune disorders

adventitous lung sounds

wheezing, crackles, find crackles, course crackles, rhonchi

wheezing; sound

high pitched, whistling sounds that occors when air moves through a narrowed airway

wheezing; whats happening

means air is being forced through obstructed airways

wheezing; diseases and disorders

asthma, COPD, bronchitis, heart failure, foreign objects

crackles

occurs when air passes through fluid in the small airways of the lungs

crackles; whats happening

means theres fluid in the lungs (C)

crackles; diseases and disorders

pneumonia, pulmonary edema, heart failure

fine crackles; sound 

high pitched, short duration that occurs at the end of inspiration

fine crackles; whats happening 

means small airways or air sacs are collapsing and reopening

fine crackles; diseases and disorders

pneumonia, pulmonary edema, interstitial lung disease, atelectasis 

course crackles; sound

lower pitched, longer duration that occur at inspiration

course crackles; whats happening 

means there is fluid in the lungs (CC)

course crackles: diseases and disorders

bronchitis, COPD, pneumonia, pulmonary edema, bronchiectasis

rhonchi; sounds

low pitched, rattling, gurgling heard during expiration 

rhonchi; whats happening

upper airways obstruction and is a media emergency due to respiratory distress 

ronchi; diseases and disorders

pneumonia, chronic bronchitis COPD, cystic fibrosis

atelectasis

partial or complete collapse of the lung

atelectasis: signs and symptoms 

• Decreased Breath Sounds / Wheezing

• Hypoxemia

• Dyspnea / Tachypnea

• Fatiuge

• Chest Pain

• Rapid / Shallow Breaths

emphysema 

a chronic lung disease that causes permanent damage to the air sacs in the lungs 

emphysema: signs and symptoms

• Barrel Chest / Chest Tightness

• Finger Clubbing

• Dyspnea / Tachypnea / Tachycardia

• Pursed Lip Breathing

• Tripoding

• Shallow Breaths

• Chronic Cough

• Wheezing

• Increased Mucus Production

hypoxia and hypoxemia: signs and symptoms

• Confusion

• Restlessness

• Agitation

• Cyanosis

• Bradycardia

cardiac assessment auscultation location order

1.) Aortic

2.) Pulmonic

3.) Erb’s Point

4.) Tricuspid Valve

5.) Mitral Valve / Apical Pulse

cardiac assessment expected findings

• Normal Rate (60-100 beats per minute)

• No JVD / Bounding Pulse

• No Rib Cage Deformities

• S1 and S2 Present

• No Chest Pain

• Bilateral +2 Peripheral Pulses

• Less 2 Seconds Capillary Refill

cardiac assessment unexpected findings

• Tachycardia / Bradycardia

• Hypertension / Hypotension

• Poor Coloring of Extremities

• JVD / Bounding Pulse

• S3 / S4 / Murmurs Heard

• Swelling of Chest

• Sleep / Mental Status Changes

heart valves

1. tricuspid valve 

2. pulmonic valve

3. s1mitral valve 

4. aortic valve

s1 lub

heard when the mitral and tricuspid valve closes, loudest at apical pulse

s2 dub

heard when the aortic and pulmonic valve closes, loudest at the bases

s3 ventricular gallop

heard when blood rushes into ventricles that are stiff or dilated, heart failure and hypertension

s4 atrial gallop

heard when heart muscles loses it elasticity and is thickened, heart failure, hypertension, aortic stenosis

heart murrmurs

extra and abnormal heart sounds heard from increases or turbulent blood flow, malfunctioning valves, defect in structures around the heart 

cardiac murmur

heard between s1 and s2

diastolic murmur

heard after s2 and before s1 (s4)

risk factors of cardiac diseases

• High cholesterol

• Eating fatty foods

• Obesity

• Diabetes

• Smoker

pulse grading 0

absent

pulse grading +1

weak

pulse grading +2

normal

pulse grading +3

full/increased

pulse grading +4

bounding 

edema grading

accumulation of excess fluid in the tissues, its graded based on its severity and appearance

edema grading +1 

less 2 mm 

edema grading +2

2-4mm 

edema grading +3

5-7mm

edema grading +4

more 7mm

troponin

released by the myocardial muscle when injury has occurred and not present when the body is in normal healthy state 

troponin: modifiable risk factors

weight, diabetes control, smoking

troponin: non-modifiable risk factors

age, genetics, family history

fluid overload

too much fluid in the bodt caused by kidney dysfunction, heart failure excessive fluide intake

• Tachycardia

• Tachypnea

• Hypertension

• Diluted Labs

• BUN

• Cr

fluid underload

not enough fluid in the body often caused by dehydration or blood loss

• Bradycardia / Weak Pulse

• Bradypnea

• Hypotension

• High Labs

• BUN

• Cr

right sided heart failure

stops working, causing blood to back up in the body because it can’t move forward

signs and sx - dependent edema, liver and abdominal enlargement, nocturnal urination, JVD< weight gain, puffy face 

left sided heart failure

stops working, causing blood to back up in the lungs because it can’t move forward 

signs and sx - respiratory congestion (hacking/coughing, pink frothy sputum), wheezing, fatigue, weakness, SOB

venus insufficiency

failure of the veins to adequate circulate blood back to the heart

signs and sx - edema, brawny LE coloring, leg ulcers

tx - elastic stockings

peripheral arterial disease

plaque builds up the arteries that supply blood to the extremities

risk factors:

• Hypertension

• Smoking

• Obesity

• Hypercholesterolemia

• Hyperglycemia (glucose > 100)

• Hypercholesteremia (LDL >130)

• Hyperlipidemia (triglycerides > 150)

intermitten claudification

pain in legs when walking due to hypoxia that goes away with rest

peripheral arterial disease: signs and symptoms

• Pale / Cool Extremities

• Hair Loss on Extremities

• Atrophy of Muscle

• Thick Toenails

peripheral arterial disease: treatment 

•  Bypass Surgery

• Vasodilators

• Blood Thinners

• Warm Environment

vasodilators

• Meds ending in “pril” (ace inhibitors)

• Meds ending in “sartan” (arbs)

• Nitroglycerine (nitrates)

blood thinners

• Aspirin (antiplatelet)

• Heparin (anticoagulant)

• Warfarin (anticoagulant)

warm environment

• Wear Gloves

• Warm Clothes

• Socks

cardiac assessment procedure

Have the patient sit in supine, fowlers, high fowlers, sitting, or

standing when auscultating the heart

apical pulse

most accurate pulse, 5th intercostal space midclavical line, listen w stethoscope for a full minute 

COPD

chronic lung disese that causes progressive damage to the airways and the air sacs in the lungs

interstitial lung disease

a group of chronic lung diseases characterized by inflammation and scarring (fibrosis) of tissues between the air sacs (alveoli) in the lungs

cystic fibrosis

a genetic disorder that primary affects the lungs and digestive system

bronchiectasis

abnormal widening of the bronchi or their branches

respiratory assessment procedure

• have the pt sit upright

• use the diaphram of the stethoscope to listne to lung sounds

• move ina. zig zag pattere to compre both lungs

• place the stethoscope directly on the skin with firm pressure for clear sound.

  • cover the posterior chest when listening to the anterior, and vice versa.

• ask the pt to take a deep breath in and out as you reposition each stethoscope

dorsalis pedia pulse

top of your foot been the big and second toe near the center

posterior tibial pulse

just behind your anke bone on the inner side of your leg 

femoral pulse

groin area 

radial pulse

thumb side of your wrist