EXAM 1 health assessment vocab

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health prevention

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168 Terms

1

health prevention

keeps people from getting sick, identifying sickness early, treating sickness as needed

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primary prevention

health promotion, advisory and consoling services and educational programmes to drive lifestyle changes for the prevention of chronic diseases

ex. health education, immunizations

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secondary prevention

health assessment and screening to facilitate early identification of chronic diseases

ex. mammogram, blood work, colonoscopy

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tertiary prevention

management of chronic diseases and rehabilitation support services to slow down the progression of diseases

ex. immunotherapy, chemotherapy, radiation therapy

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5

why does the nurse assess health?

to set a baseline for the patient so we can identify changes , to identify what type of care our patients need , to gather info

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what skills does a nurse use to access health?

  • communication (most important)

  • cognitive

  • critical thinking

  • critical reasoning (application of clinical thinking)

  • intuition

  • psychomotor (inspection, percussion, palpation, auscultation)

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therapeutic communication

  • introduce self

  • eye contact

  • be aware of non-verbal

  • use active listening

  • allow client time to answer questions

  • demonstrate: concern, empathy, compassion, unconditional regard, genuineness, respect, caring

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phases of an interview

  • introductory phase

  • working phase

  • summarization phase

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closed questions

can be answered with a yes or no

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open-ended questions

require clients to describe in more detail what is going on ; tend to yield more accurate, client-specific information

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avoid non therapeutic responses such as:

  • false reassurance

  • unwanted advice

  • technical language

  • changing the subject

  • biased questions

  • distractions (non-purposeful)

  • interrupting

  • disapproval

  • being defensive

  • using authority

  • poor use of non-verbal communication

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health history types

  • comprehensive

  • focused or problem-based

  • follow-up

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sources of info

primary and secondary

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primary info

from patient

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secondary info

children, species

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comprehensive health history

  • most critical first step in determining a client’s problems and needs

  • contents depend on context (ex. hospital admission, ER visit, primary care visit)

  • requires excellent communication/interviewing skills

  • requires excellent critical thinking skills/common sense

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key elements of a comprehensive health history

  • demographic info (name+ DOB)

  • chief complaint (CC): “what brought you here? " (this will be quotes in pt’s words)

  • history or present illness (HPI)

  • medications

  • allergies

  • immunizations

  • Past medical history (PMH)- childhood illness, adult illnesses, accidents/injuries, chronic illnesses, hospitalizations/surgeries, mental/emotional conditions and family history

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history of present illness (HPI)

  • gives a complete description of presenting concern: duration, severity (intensity), character (quality, location, radiation, aggravating factors, alleviating factors) and associated symptoms

  • OLDCARTS (onset, location, duration, character, aggravating/relieving factors, timing, severity)

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OLDCARTS

  • Onset

  • Location

  • Duration

  • Character

  • Aggravating Factors

  • Relieving Factors

  • Timing

  • Severity

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Onset

  • when did you first notice it?

  • how long did it last?

  • have you had the pain since that time?

  • then what happened?

  • have you noticed the pain is worse during your menstrual period?

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Location

  • can you tell me where you feel it?

  • has this changed over time?

  • does it radiate (move) to a specific area of the body?

  • using your finger point to where it hurts.

  • do you feel it anywhere else?

  • has the pain moved since it started?

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Duration

  • when did the pain begin?

  • what were you doing when the pain started?

  • how long has this condition lasted?

  • does it come and go?

  • how often do you have the pain?

  • is it similar to a past problem? if so, what was done at that time?

  • is the problem getting better, worse, or staying the same?

  • if it is changing, what has been the rate of change?

  • how many times did you vomit?

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Character

  • what does ti feel like?

  • can you describe the pain? (crushing, stabbing, indigestion like, dull, ache for example)

  • what do you mean by “sticking pain"?

  • did you have other symptoms with the pain such as nausea and vomiting, weakness, fatigue, breathlessness, syncope (passing out), cold and clamminess

  • when you get the pain, is it steady, or does it change?

  • does the pain radiate such as down the arm, up into the neck for example?

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Associated or Aggravating factors

  • what makes it worse?

  • what seems to bring it on?

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Relieving factors

  • what have you done that made the pain stop?

  • what do you do to get more comfortable?

  • does lying quietly in bed help?

  • does eating make it better?

  • do you take anything for the pain and does it help?

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Timing

  • have you noticed it occurring at a certain time of day?

  • does it occur with exercise?

  • does it occur at rest?

  • does it awake you from your sleep?

  • does it happen after you eat?

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Severity

  • on a scale of 1 to 10, 10 being the worst pain you can imagine, how would you rate this pain?

  • how bothersome is this problem?

  • does it interfere with your daily activities?

  • does it keep you up at night?

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Past Medical History

  • medical problems (acute, chronic, resolved)

  • childhood illnesses (with dates)

  • serious accidents and injuries

  • hospitalizations (with dates)

  • surgeries (may be separate)

  • immunizations

  • screening tests (mammogram, colonoscopy, Pap smear, lipid levels)

  • obstetric history (gravida-# of pregnancies , para- # of live births)

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Current Medications

  • prescription

  • over-the-counter

  • other supplements (vitamins, herbal products, homeopathy etc.)

  • “do you take your medications regularly?”

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Allergies

  • medication

  • food

  • contact

  • “what is the nature of the reaction?” (airway/anaphalytic vs integument/rash, GI symptoms, etc.)

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Family History

  • focus on inheritable conditions of the 1st degree (biologic parent, sibling, child) and 2nd degree (aunt, uncle, grandparents, nieces, nephews, half-siblings_ relatives

  • note age of onset

  • “what major conditions have inherited predispositions?”

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Cardiovascular Disease

  • premature CHD or sudden death in 1st degree female relative less than age 65 years or 1st degree male relative less than age 55 years

  • familial hyperlipidemia

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Colorectal Cancer

  • multiple relatives affected OR one or more affected less than age 60 years

  • FAP- familial adenomatous polyposis

  • HNPCC- hereditary Nonpolyposis Colon Cancer (more common), poses an increased risk for endometrial cancer in women

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Psychosocial History

  • education

  • occupation/hobbies

  • housing

  • finances (can you financially support yourself?)

  • exercise

  • sleep

  • safety

  • tobacco use (pack years= packs per day X number of years)

  • alcohol use

  • other elicit substances

  • support systems

  • stress/coping

  • sexuality

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Functional Assessment

  • “where was the patient before they got sick?”

  • ADL’s (washing, toileting, dressing, feeding, mobility, transferring)

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Cultural Considerations

  • communication is culturally influenced

  • non-verbal differences in eye contact, touching, facial expressions, space, gestures

  • federal law mandates provision of an interpreter as needed

  • we cannot assume we know a client’s cultural, religious, and spiritual preferences by what we are taught in the books (must ask0

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Review of Systems (ROS)

  • may reveal things missed in PMH or reveal occult disease

  • Comprehensive vs. focused

  • includes: general health, nutrition, skin, hair, nails, head, neck, eyes, ears, nose, mouth, throat, lungs, heart, neck vessels, peripheral vascular, breasts, abdomen, urinary, musculoskeletal

  • may be done by checklist and reviewed with the client

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why do nurses perform physical assessments?

  • helps with prioritization

  • identify declining client status

  • anticipate client needs

  • improve client outcomes

  • prioritize care

  • be a client advocate

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emergency assessment

  • unstable client, immediate concerns

  • ABC

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focused assessment

  • problem, situation-focused, report-focused, history-focused

  • also called "episodic assessment”

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Inspection

  • start with a general survey using sight, hearing, and smell

  • appearance (frail, posture, stature, weight, gait, facial expression)

  • affect, mood

  • behavior

  • signs of illness

  • odors (alcohol, acidosis, poor hygiene)

  • speech (fast, slow, hoarse)

  • signs of distress (pain, breathing, limping)

  • be aware of symmetry vs. asymmetry

  • need adequate lighting

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Palpation

  • palpate for temp., moisture, tenderness, pain, lumps, masses, rigidity, crepitation

  • the palm is most sensitive to vibrations

  • then ulnar and dorsal surface of the hand is most sensitive to temperature

  • always start with light palpation, deep palpation follows (abdominal exam)

  • wear gloves when touching mucous membranes (or any area where there may be body fluids)

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Percussion

  • percussion tones are used to assess location, shape, size, and density of tissue

  • uses the fingers to create vibrations on the body surface

  • blunt percussion can produce pain when an underlying structure is inflamed (as in a kidney infection)

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Auscultation

  • stethoscope

  • clean between clients

  • ear pieces point towards your nose

  • diaphragm: high pitched sounds (heart, lungs, abdomen)

  • bell: low pitched sounds (blood vessels)

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Important health assessment red flags

  • fever

  • respiratory: abnormal respiratory rate (either too high to too low), decreased O2 sat with increasing oxygen needs, shortness of breath

  • cardiac: reduced systolic blood pressure, abnormal pulse, client report of chest pain

  • neurologic change: altered mental status, change in LOC

  • change in pain status

  • active bleeding

  • vomiting

  • sensory motor deficit

  • pallor, pulseless, paresthesia (pins and needles), pain, coolness or extremities

  • dizziness (fall risk)

  • poor urine output (less than 30mL per hour0

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upper respiratory tract

nose and oropharynx

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lower respiratory tract

  • trachea

  • bronchi

  • anterior thorax

  • posterior thorax

  • lobes of the lungs (RML only anteriorly)

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pulse oximeter

measures oxygen saturation (spO2); % hemoglobin saturated with oxygen

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arterial blood gases (ABGs)

  • measurements of oxygen and carbon dioxide in the arterial blood (radial, femoral, brachial artery sites)

  • normal:

    pH (7.35-7.45)

    PaO2 (75-100 mmHg)

    PaCO2 (35-45 mmHg)

    HCO3 (22-26 meq/L)

    SaO2 (95-100%)

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thoracentesis

insertion of a needle into thoracic cavity to analyze and, or remove fluid from the pleural space (fluid means that lungs cannot inhale all the way)

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bronchoscopy

scope procedure to provide a direct visualization of larynx, trachea, and bronchial tree

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chest x-ray

projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures

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lung biopsy

removal of a small piece of lung tissue for analysis

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Mantoux test

  • intradermal insertion of tuberculin purified protein derivative to assess for tuberculosis exposure

  • reassess in 48-72 hours for induration

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PMH for a respiratory assessment

  • asthma

  • pneumonia

  • emphysema

  • frequent upper respiratory infections (URIs)

  • allergies

  • TB

  • last TB lest

  • flu vacine, pneumococcal vaccine (>65 yrs or immunocompromised), covid vaccine

  • meds (OTC, inhalers, steroids, ACE inhibitors (cough)

  • FH: lung cancer, COPD, cystic fibrosis

  • SH: smoking (2nd hand smoke), occupation (exposure to chemicals, asbestos), hobbies, exposure to radon, travel

  • ROS: persistent cough, dyspnea (exertion vs. rest), wheezing, sputum, fevers, night sweats,\

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possible causes of a dry, hacking cough

  • viral infections

  • interstitial lung disease

  • tumor

  • allergies

  • anxiety

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possible causes of a chronic, productive cough

  • bronchiectasis

  • chronic bronchitis

  • abscess

  • bacterial pneumonia

  • tuberculosis

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possible causes of a wheezing cough

  • bronchospasm

  • asthma

  • allergies

  • congestive heart failure

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possible causes of a barking cough

  • epiglottal disease (croup)

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60

possible causes of a stridor cough

  • tracheal obstruction

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possible causes of a morning cough

  • smoking

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possible causes of a nocturnal cough

  • postnasal drip

  • congestive heart failure

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coughing associated with eating and drinking

  • neuromuscular disease of the upper esophagus

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what will a nurse see on assessment if client is in acute respiratory distress?

  • confusion, combativeness (a sign of decreasing in oxygenation)

  • pausing for breath

  • dyspnea at rest

  • use of accessory muscles

  • hypotension, cyanosis

  • RR >30 breaths per min

  • O2 saturation <90%

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what will the nurse do if their patient is in acute respiratory distress?

  • elevate the head of the bed (helps to open airway)

  • call for assist/rapid response team

  • do immediate assessment

  • start oxygen and Broncho dilating inhalers

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Exam tips for respiratory assessment

  • optimal exam: client is in sitting position

  • do not palate, percuss, auscultate though clothing

  • clean diaphragm of stethoscope with alcohol prior to exam

  • for auscultation, have client take slow, deep breath though mouth

  • have client cough to clear secretions as needed

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Overall inspection during respiratory assessment

  • overall appearance

  • evidence of respiratory issues:

  • tripod position

  • flared nostrils

  • pursed lip breathing

  • air hunger (work of breathing)

  • skin color: pallor, cyanosis

  • weight

  • clubbing

  • audible wheezing

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Inspection of Thorax

  • use of accessory muscles

  • retractions

  • spine deformity: scoliosis

  • chest configurations: barrel chest, kyphosis

  • AP diameter of chest (normally 2:1)

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pectus excavatum

sunken or funnel chest

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pectus carinatum

pigeon chest

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bradypnea

RR les than 12 breaths per min

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tachypnea

RR more than 20 breaths per min

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Kussmaul’s respirations

abnormally rapid, deep, labored breathing

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Biot respirations

irregular breathing of variable depth (often shallow) alternating with shallow breathing apnea

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Cheyenne-stokes respirations

gradual increase in depth of respiration, followed by gradual shallow breathing with periods of apnea

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Apnea

absence of breathing or abnormal pauses in breathing

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Palpation for respiratory assessment

  • lumps, masses

  • tenderness

  • symmetry (1 inch)

  • equal expansion

  • crepitus (subcutaneous emphysema)

  • tactile fremitus

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Palpation of tactile fremitus

  • ask the client to say “ninety-nine” several times in a normal voice

  • you should feel palpable vibrations transmitted through the tissues (use palmar or ulnar surface of hands)

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increased tactile fremitus

suggests consolidation (increased tissue density such as tumor or mass, or infection) of the underlying lung tissues

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decreased tactile fremitus

suggests fluid (vibrations obstructed by fluid in the tissues of the lung, decreased air movement (emphysema

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81

Percussion of respiratory assessment

  • explain procedure to the client

  • percuss from side to side and top to bottom

  • omit the areas covered by the scapulae

  • compare one side to the other looking got asymmetry

  • note the location and quality of the percussion sounds you hear

  • dullness of percussion over the lung indicated increased lung tissue density (consolidation)

  • normal=resonance

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normal breath sounds

  • vesicular

  • bronchovesicular

  • bronchial

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vesicular

  • low pitch, soft intensity

  • heard over peripheral lung fields

  • inspiration longer and louder than expiration

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bronchovesicular

  • medium pitch , moderate intensity

  • heard over lower bronchi anteriorly (mid-chest0 and between the scapulae posteriorly

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bronchial

  • high pitch, hollow, tubular, loud intensity

  • heard over trachea and large bronchi

  • expiration sounds are louder and last longer than inspiratory sounds an there is a pause between

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adventitious breath sounds

  • crackles (rales)

  • wheezes

  • rhonchi

  • pleural friction rub

  • stridor

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crackles (rales)

sound produced when air passes over retained airway secretions/fluid in alveoli (pulmonary edema, CHF, pneumonia)

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wheezes

  • high-pitches whistling, musical sound when air is forced through a narrow airway (due to foreign body or other obstruction such as asthma)

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rhonchi

  • loud, deep, low-pitched sounds (like snoring) in upper bronchi during exhalation

  • secretions in large airways (bronchitis)

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90

pleural friction rub

  • grating, loud, harsh, deep sound causes by inflamed parietal and visceral pleural surfaces rubbing together

  • heard during inspiration or exhalation

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stridor

  • high pitched crowing on inspiration (upper airway obstruction)

  • a sign of respiratory distress and is a medical emergency!!

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92

bronchophony

  • ask the patient to say “ninety-nine”

  • over normal lung tissue, the words sound muffled

  • over consolidated areas, the words seem unusually loud

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egophony

  • ask the patient to say “E”

  • over normal lung tissue, the sound is muffled

  • over consolidated lung tissues , it will sound like the letter “A”

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94

whispered pectoriloquy

  • ask the patient to whisper “1..2..3”

  • over normal lung tissue, the numbers will be almost undistinguishable

  • over consolidated lung tissue, the numbers will be loud and clear

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95

health promotion for respiratory system

  • smoking cessation

  • vaccinate (influenza, covid-19, and pneumococcal vaccines)

  • prevent infection

  • exercise

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common client reports that may be related to a CV disorder

  • chest pain

  • palpitations

  • syncope

  • fatigue

  • dyspnea

  • weight gain

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chest pain associated with MI/ acute coronary syndrome

  • sudden onset of pain, diffuse, may be described as “crushing”, radiates to left arm or jaw, lasts more than 20 minutes

  • often associated with anxiety, sweating

  • nausea, vomiting, dyspnea, palpitations and anxiety

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Cardiovascular Nursing Assessment

  • HPI (OLDCARTS)

  • PMH

  • FH

  • SH

  • Meds

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HPI CV assessment

  • chest pain (onset, intensity, location, radiation, quality, duration, constant vs paroxysmal, aggravating factors, relieving factors, associated symptoms (fatigue, N+V, exercise intolerance, etc.)

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PMH CV assessment

  • HTN, rheumatoid fever, autoimmune dx, cholesterol levels, diabetes, heat, disease, heart murmur, last ECG

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