1
Q
Anterior part of body that overlays heart and chest
A
precordium
2
Q
aortic valve palpation location
A
2nd-3rd right intercostal space
3
Q
pulmonic valve palpation location
A
2nd-3rd left intercostal space
4
Q
tricuspid valve palpation location
A
left sternal border @ 4th ICS
5
Q
mitral valve palpation location
A
heart apex - mid-clavicular line @ 5th ICS
6
Q
What is happening in the heart when you hear “the lub” (S1)
A
Closure of Atrio-Ventricular valves
Opening of the SL valves
Ventricles are filled
Beginning of systole (contraction)
7
Q
Where is the S1, lub, sound most easily heard?
A
at the apex of the heart (tricuspid and mitral valve)
8
Q
What is happening in the heart when you hear the “dub” (S2)?
A
Closure of the semi-lunar valves
Opening of the AV valves
Marks end of systole and beginning of diastole - ventricles relax as atria begin to fill
9
Q
Where is the “dub” S2 heart sound heard the loudest?
A
At the base (pulmonic and aortic valves)
10
Q
Where is the point of maximum impulse of the heart?
A
apex - mitral area
11
Q
Where do the great vessels attach to the heart?
A
at the base (top part of heart)
12
Q
what is a heart murmur?
A
Abnormal whooshing or blowing sound heard when blood flows through heart valves due to incomplete valve closure
13
Q
What heart sound is made when pericarditis/inflammation around the heart is present?
A
Friction rub - scratching sound
14
Q
Systolic murmurs are heard when?
A
Between S1 and S2
15
Q
Diastolic murmurs are heard when?
A
After S2
16
Q
What are the upper extremity pulses?
A
radial and brachial
17
Q
What are the lower extremity pulses?
A
Femoral, popliteal, dosalis pedis, posterior tibial (pedal)
18
Q
What are the head/neck pulses?
A
carotid, temporal
19
Q
What is the pulse rating scale?
A
0 = absent
1+ = weak
2+ = normal
3+ = increased, full, bounding
20
Q
When do you use an ultrasound doppler device in a CV assessment?
A
If you can’t palpate pulse at an extremity when assessing arterial blood flow to that area
21
Q
What re factors affecting CV function?
A
Smoking
HTN
Poor nutrition
Lack of exercise
Diabetes
Obesity
Medical and family history
Medications and drug use
Stress
Inflammation
22
Q
What are our expectations for cardiac assessment this semester?
A
Inspect for obvious abnormalities
Auscultate all 4 sites for cardiac sounds
Identify S1-S2 apical rate and rhythm (palpate radial at same time)
Listen for murmurs
23
Q
Signs and symptoms in CV assessment to report
A
Chest pain/pressure
Dyspnea (SOB)
24
Q
Fluid accumulation in the interstitial space between organs and cells where it should not be is known as
A
edema
25
Edema rating scale
2mm = 1+
4mm = 2+
6mm = 3+
8mm = 4+
26
CMS acronym stands for
Circulation-Motion-Sensation
27
Which part of the nursing assessment checks for neuro-vascular connections
CMS
28
How do you assess circulation?
Check pulses (radial, pedal, posterior tibial)
Look at color
Check cap refill
29
How do you assess motion?
Ask pt. to squeeze your fingers, wiggle toes
30
How do you assess sensation?
Ask pt. if they can feel you touching their extremities and if they have any tingling or numbness
31
Signs/Symptoms of Deep Vein Thrombosis
Pain, swelling, warmth redness, usually in calf
32
Test that measures the presence of fibrin degradation products in the blood. Fibrin is a protein that forms blood clots.
D-Dimer blood test
33
What are the two tests used to diagnose DVT?
D-Dimer blood test and ultrasound of legs (must be ordered by MD)
34
If left untreated, DVT can lead to what?
Pulmonary Embolism
35
What is the treatment for DVT?
Bed rest for a time and anticoagulants
36
Prophylaxis for DVT
Sequential compression devices, ambulation, hydration, anticoagulants (as ordered), and active ROM while on bed rest
37
Indications for Sequential Compression Devices
Venous insufficiency/edema
Prolonged bed rest
During/after an operation
Trauma
38
Contraindications for Sequential Compression Devices
Arterial insufficiency
Presence of DVT
39
As nurses, we need to make sure anti-embolism stockings are:
1. Properly fitted
2. Applied w/o wrinkles/bunching
3. Removed for 30 minutes q8 hours while in bed
4. only use if CMS in tact @ toes
40
What is involved with physical assessment of the mouth?
Inspecting teeth and gums, lips, tongue for symmetry, color, and pain/tenderness
41
What are we first looking for when we inspect the thorax?
Asymmetry of movement - possibly due to fracture/injury
Abnormalities of the sternum
Intercostal muscle use
Dyspnea (unreported)
42
What would documentation of Doc - O2 Sat 96% on 22LNC mean?
The patient's O2 sat. is 96% on 022 low flow nasal cannula
43
What O2 sats. are we looking for?
94%+
44
What do you assess for related to coughing?
Frequency
Productive or not, if yes, describe color and amount of mucus
45
How many lobes are in the right and left lobes respectively?
Right -3; Left - 2
46
What should you ask pt. to do when listening for lung sounds?
Breathe in and out slowly/deep through the mouth
47
Do we listen to anterior/posterior or lateral parts of chest the most during auscultation of lung sounds?
Posterior
48
Where should we listen for our 6-8 lung sounds?
2 on either side of sternum at upper chest, 2 laterally, 2 on posterior upper side, 2 at base (wings)
49
Lung sounds that are hard to hear on one side or throughout due to poor air movement, less lung space etc.
Diminished lung sounds
50
Lung sounds that indicate airflow obstruction. Typically in the upper airways and include secretions that can sometimes be cleared with coughing
Rhonchi
51
High pitched lung sounds that can occur on inspiration or expiration. Occurs when air is squeezed through narrowed passageways
Wheezes
52
Wheezes are often heard in people experiencing
asthma; allergic reaction
53
Lung sounds typically due to fluid in alveoli; what you hear is the air moving through that mucus or fluid on inspiration OR expiration
Crackles
54
What would a surgeon want to know from the nurse about a post-op pt. after bowel surgery before allowing them to eat?
bowel sounds present?
flatus?
BM?
Pain?
Ambulating?
NG tube drainage slowing?
55
How long does it take for bowels to start working again after bowel surgery?
Up to 7 days
56
Order of assessment for abdomen
Look, listen, feel
57
epigastric region
upper central part of abdomen, located below the rib cage and above the navel
58
central area of abdomen surrounding navel
umbilical
59
suprapubic/hypogastric region
part of lower abdomen located directly above the pubic bone
60
What question should we ask patient when inspecting bowels?
Is this normal for you?
61
What indicates an abnormal appearance of an abdomen?
distended, concave, asymmetric
62
What are normal bowel sounds?
irregular, gurgling/tinkling sounds that happen every 5-15 seconds
63
What is characteristic of hyperactive bowels?
Loud, high pitched, occur sooner than 5 seconds from last sound
64
Indicators of hypoactive bowels
Faint sounds, more than 5-15 seconds between sounds, may not occur in all quads or at all
65
What is abnormal during light palpations
guarding (pt. tenses when touching certain areas)
Rigid, tense, firm feel
Tenderness, pain
66
Do we palpate after abdominal surgery?
No
67
When are times other than after surgery when you would not want to palpate the abdomen?
Suspected/known appendicitis
Acute abdomen (unknown cause of pain)
Known or suspected AAA
68
What would indicate appendicitis?
RLQ rebound tenderness
69
What is AAA?
Abdominal Aortic Aneurysm - ballooning of aorta (is weaker there)
70
Loss of forward flow of intestinal contents due to decreased peristalsis
paralytic ileus
71
What is the most common cause of a paralytic ileus?
surgery
72
Signs and symptoms of an ileus
Nausea and vomiting, abdominal pain, cramping, bloating, dissension, constipation, inability to pass gas, dehydration, diarrhea (in some cases)
73
Interventions for paralytic ileus
notify MD, ambulation, hydration, GI rest, limit opioids (slow down peristalsis), NG tube to suction oral care
74
Normal Characteristics of Feces
75% water, 25% solids
Frequency varies
Color: brown
Consistency: Soft
Cylindrical
Odor due to bacterial decomposition of proteins
Flatulence
Ask during assessment: Normal pattern? Last BM?
75
Factors that affect bowel elimination
Fiber intake: 20-30 gm a day
Fluid intake: 2.5-3.5 L a day
Activity: promotes peristalsis
Lifestyle: schedule, laxatives
Bed rest
Pregnancy
Medications
Therapeutics like diagnostic tests, bowel preps and surgery
76
Criteria for constipation
2 or more:
-straining during >25% of BMs
-Lumpy or hard stools >25% of the time
-Sensation of incomplete evacuation >25% of the time
-Manual maneuvers to facilitate evacuation >25% of the time
<2-3 BMs/week
77
Do enemas require a physicians order?
Yes
78
Examples of small volume enemas (150mL)
fleets, oil retention
79
Examples of large volume enemas (up to 1000 mL)
Tap water, soap suds (soap acts as stimulant), saline
80
Medicated enema example
Kayexelate - used to reduce K+ levels
81
Best position to receive an enema
L side, left knee slightly tilted, right knee bent up
82
type of enema used to relieve gas in abdomen
Return flow 300-500mLs/aka Harris Flush
83
What is involved in a Harris Flush/Return Flow enema?
Put tap water into tube that goes into colon and then lower below pt. to soln. and allow air bubbles to return
84
Adverse effects of a Harris Flush/Return Flow enema
Abdominal pain, Excess vagal stimulation leading to bradycardia, hypotension
85
Why do we do digital disimpaction?
Help remove stool in rectum to help unblock colon. Needs order from doc!
86
What type of test looks for microscopic amounts of blood that cannot be seen by the naked eye?
Stool for occult blood aka - stool for guaiac
87
How to help pts. feel more comfortable when discussing bowel issues?
Being matter of fact
Show that you're not nervous
Be professional
88
What is a KUB?
Xray that looks at Kidneys, nephrons, Ureters, Bladder, urethra
89
What is the average volume of urine/void?
250-400 mLs
90
What is the average urine output for 24 hours?
~1500 mLs
91
Minimal U/O output for adults
30mL/hour or 720mL/24 hours
92
Abnormal urine finds
Less than normal U/O - 24 hours (1500 mL) or less than 30mL/hour (720 mL in 24 hours)
Color - orange, brown, bloody
Clarity - sediment, blood, pus
Odor - foul smelling
Discomfort with voiding
93
Bladder size
Holds 500mL - can distend to 2X (1000mL)
94
Where is the voiding reflex center?
In the SC
95
What affects urine output?
Intake/nutrition/IV fluids
NPO status
Fluid/blood loss
Body position
Cognition
Psychological factors
Obstruction
UTIs
Hypotension
Neurological injury
Muscle tone
Pregnancy
Disease processes
Surgery
Meds
Kidney failure
96
pain or discomfort while urinating
dysuria
97
Trouble peeing, especially starting, or a slow flow/dribbling
Hesitancy
98
strong urge to urinate accompanied by pain or discomfort in bladder
urinary urgency
99
Urinary frequency
Need to urinate more often than usual
100
Waking up 2+ times in night to urinate
Nocturia
101
Produces abnormally large volume of urine, usually more than 3L/day
polyuria
102
Oliguria
Producing less than 400-500mL/day of urine
103
Anuria
Absence of urine production - less than 100mL per day
104
pus/WBC in urine
pyuria
105
Nursing interventions to promote voiding
Provide privacy
Sufficient time
Assess usual voiding routine
Assist PRN
Encourage voiding Q4 hours
Decrease anxiety and discomfort
Analgesics: pros and cons
Comfortable position
Provide sensory stimuli (running water)
106
GU assessment components
Inspect perineal areas
Urine
Catheter in place
Urostomy, suprapubic catheter
107
stress incontinence
urine leakage during activity that places pressure on bladder - sneezing, laughing, exercising etc
108
Urge/overflow incontinence
Bladder leaks urine due to being overly full
109
Functional incontinence
Due to not being able to reach bathroom in time because of physical or cognitive impairment
110
Unconscious/Reflex Incontinence
Involuntary loss of urine without any warning/urge
111
How to prevent catheter related UTIs
Only use when needed
Take out as soon as we can
112
Causes of UTI
E coli from GI tract, poor catheter technique, catheter in too long
113
Change of consciousness in older person typically due to:
1. Respiratory issue
2. UTI
114
Signs of UTI
Dysuria
Increase WBC counts
Fever, Chills, rigors (feeling cold/shivering while sweating -BAD)
Older adults - confusion, cognitive impairment, irritability
Urine cloudy, foul smelling, pyuria
115
Geriatric changes in GU system
30% reduction in function
2/3 functional nephrons remain by 80
dec. blood flow to kidneys
dec muscle tone of ureters, bladder, urethra
Nocturia
Females more prone to UTIs
Males have more prostate issues
NRAD 201B
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