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Nrsg 212 3.3.1
nrsing assessment
| Question | Answer |
|---|---|
| the bell on stethoscope hears what; the diaphragm hears what | light low sounds; high heavy sounds |
| Torso landmarks: where is mid sternal line; mid clavicular line; ant. axillary line; mid axillary line; post axillary line | cuts body in half hot dog style; cuts body at nipple9clavicle); inbetween the armpit and anterior prtion of bod; cuts body from armpit across; cuts body between posterior portion of body and armpit region |
| landmarks: where is vertebral line; where is scapular line | along the vertabra; from the inferior scapular region down |
| heart: where is it located; the medial space separates what; what are the 3 layers (inner to outer) of the heart; | in the thorax in the medialstinal space; the right and left pleural cavities; endocardium, myocardium and pericardium |
| heart: def endocardium; def myocardium; def pericardium | thin inner layer of heart; muscular layer of heart; fibrous outer layer of heart |
| heart: the pericardium has how many layers- name them; visceral layer is in contact with what; the pariatal layer is in contact with what; what is the space called between the layers; why is there fluid between the layers | 2, the visceral layer and the parietal layer; contact with epicardium; mediastinum; pericardial space; prevents friction as ht contracts |
| heart: what portion of the heart has a thicker myocardium; what myocardial wall is thickest; why is it thickest | the ventricles; left ventricle; necessary to generate the force needed to pump the blood into the systemic circulation |
| blood flow through the heart: R atrium receive blood from where; blood from right atrium goes where; | venous blood from inferior and superior venae cavae and coronary sinus; through tricuspid valve to R ventricle |
| blood flow through the heart cont: from R ventricle where does blood go, | R ventricle pumps blood through pulmonic valve into pulmonary artery and to lungs |
| blood flow through the heart: from lungs where does blood go to; where does blood go from L atrium | to L atrium by way of pulmonary veins; to mitral valve and into the left ventricle |
| blood flow through the heart: where does blood go from L ventricle; | blood moves through aortic valve into the aorta and enters systemic circulation |
| heart: how many valves are there; the cusps are attached to what; chordae tendineae are anchored to what; what valves are the semilunar valves; semilunar valves prevent what; | 4; thin strands of fibrous tissues called chardae tendineae; pappilary muscle of the ventricles; the pulmonic and aortic valves; regurgitation into the ventricles ar end of vent. contraction |
| heart: blood supply to myocardium- this is ___ circulation; when does blood flow into the two major coronary arteries; what are the 2 main coronary arteries; | coronary circulation; during distole; the left and right coronary arteries; |
| heart: blood supply to myocardium- why is obstruction of right corony artery a big deal | b/c the atriventricular node and bundle of His receives blood from this artery and they are part of the conduction system, causing serious defects in the conduction of the heart |
| heart: blood supply to myocardium- most of the blood in the coronary system drain into what; the coronary sinus empties into what; | the coronary sinus; the right atriuml |
| Heart: what is the order of assessment | IPPA |
| Heart: S1 is the closure of what valves; S2 is the closure of what valves; S1 is the opening of what valves; S2 is the opening of what valves; | the mitral and tricuspid valves; the pulmonic and aortic valves; the aoritic and pulmonic valves; the mitral and tricuspid valves |
| Heart: what is S3 sound; what is S4 sound; who has S3s; who has S4s; | heart failure; hypertension; children, young adults, WM in last trimester; MIs, hypertension |
| Heart: when is S4 heard; why is S4 heard right before S1; | right before S1; b/c there is a stiff wall from HTN and blood is heard hitting the wall; |
| Heart: if there is a murmer how do you know what is systole; | Place finger on carotid artery and this is the S1 sound |
| Heart:what is sytole; what is diastole; | the sound of S1; the sound of S2 |
| Heart ausc. landmarks: how many ausltatory landmarks are there in the heart; where is the aortic landmark; where is the pulmonic landmark; where is the tricuspid landmark; where is the mitral landmark; where is erbs point; | 5; 2nd ICS to R of sternum; 2nd ICS to left of sternum; 4th- 5 th ICS Left to L sternal border; 5th ICS medial to Left MCL; 3rd ICS L sternal border |
| Heart ausc.: S1 is loudest wehre; S2 is loudest where | loudest over apex; loudest over base |
| Heart: what does PMI stand; how long should apical pulse be assessed for; how many times should heart be listened to; | point of maximal impulse; 1 min; 4 times (1 for S1, S2, diaphram for murmers, bell for murmers) |
| Heart: is an S3 diastolic sound or systole sound; is S4 a diastolic sound or systole sound; when does S3 happen in diastole; when does S4 happen in Diastole; | diastolic; Diastolic; early; late; |
| Heart: in the cardiac cycle what sound is 1/3rd of cycle and what sound is 2/3rds the cycle | systole is 1/3rd and diastole is 2/3rds |
| heart sounds: S3- aka; sounds like what; where is it heard the loudest; when is it heard; | ventricular gallop; kentucky, Lub dud ee, slosh ing in; over the apex; after S2 |
| Heart sounds: S4- aka; sounds like what; where is it heard the loudest; when is it heard | atrial gallop; tennessee, T lub dud, a stiff wall; over the apex; just before S1; |
| heart sounds: murmer- why do murmers occur | valve not closing properly, endocarditis, birth defect, rheumatic fever, MI (bc chordea tendini ruptures) |
| heart sounds: murmer- why is it heard; if is flows backwards what does that mean; if it flows forward what does that mean; murmer sounds can radiate where; how do clinicians describe them; | bc there are problems with flow across the valve; insufficiency; stenosis; to axilla and back; by frequency, intensitity, duration, timing |
| heart sounds: murmer- what part of the cycle can they be heard; | in diastole and systole; |
| heart: if pt gets heart problems on L side of heart what occurs; s/s pulmonary edema; | pulmonary edema; crackles in the lungs; |
| heart: when aortic valve is stenotic and will not open during systole what happens | the L ventricle will pump and push the blood and the muscle will enlarge b/c increased force |
| JVD: why is it assessed; why do they bulge; what is the invasive procedure that could be done to assess this further; | this is s/s of heart failure is they are bulging at 45 deg.; there is no valve from vena cava and the blood backs right up to the jugular veins; central venous pressure |
| JVD: how are they assessed; | pt is positioned in flat position w/o a pillow and then HOB is raised to 45 deg angle; |
| Heart: apical pulse is aka; PMI occurs when; is the PMI visable; why might the PMI be visable in a larger region; the aortic and pulmonic are best heard where; | PMI; as the apex of the heart pumps against the chest wall with each heartbeat; usually in children thin chested ppl, or ppl with enlarged hearts; if the L ventricle is enlarged (hypertrophy), the PMI is displaced to left or upward; at base of heart; |
| Heart: the mitral and tricuspid are best heard where; lub is aka; dud is aka | at the mitral and tricuspid region; S1; S2 |
| heart: at erbs point what is unique; what is shorter systole or diastole; what should have a longer pause after it, S1 or S2; | the S1 and S2 are equal in sound volume; systole; S2 |
| heart: what happens if the valves do not close simultaneously; S3 and S4s are easier to hear with bell or diaphram; | the heart sounds may be split; bell; |
| Heart: bell hears what; diaphram hears what; | low light sounds; high heavy sounds; |
| heart murmer: def stenotic valve; how does blood flow through in a stenotic valve; what will the sound be like in a stenotic valve; | if valve does not open widely;in a turbulent fashion; a whooshing or swishing sound; |
| heart murmer: what is a regurgitant/incompetent valve; incompetent valve causes blood to what; how are murmers classified | it does not close tightely; this causes blood to leak backwards through it; from grade 1-6 6 is loudest |
| heart: depolarization- this triggers what; systole is what; contractions of the myocardium ejects blood where; def diastole; | mechanical activity; contraction of the myocardium; from the ventricles to lungs or aorta; relaxation of the myocardium; |
| heart: blood does what is diastole; what is cardiac output; how is CO calculated; | fills the vetricles; the amount of blood pumped by each ventricle in one minute; multiplying stroke volume by heart beat |
| heart: what is average CO in adult; | 4-8L; |
| lungs: adult average RR; COPD ppl have longer inspiratory ir expiratory phase; assessment order for lungss; | 12-20 breaths/ min; expiratory; IPPA; |
| lungs: the chest is as twice as wide as it is what; who develops a barrel shaped chest; | deep; ppl with COPd; |
| lungs: what sounds are heard superiorly; what sounds are heard medially; how many listening points in front; how many listening points in bakc; how far do u listen down in front; how far do you listen down in back; | vesicular; bronchi; 8; 10; 6-8th rib; 10th rib; |
| lungs: Tactile fremitus- def; the vibrations are felt strongest where; vibrations are felt weakest where; | vibrations felt on palpation when client states 99 as hands go inferiorly down back; superiorly; inferiorly; |
| lungs: Tactile fremitus- what would make vibrations less noticable; what would make vibrations more noticable; | fluid, air, mucus, or lesions block transmission; consolidation (ex pna) |
| lungs: bronchial sounds- what is more inspiration or expiration; where are these sounds heard; if it is heard elsewhere is that normal | expiration; trachea, loud high pitced; no |
| lungs: bronchovesicular sounds- what is louder expiration or inspiration; heard where; | the are equal; over bronchioles, med pitch; |
| lungs: s=vesicular sounds- what sound is louder insiration or expiration; where is it heard; what is sound; | inspiration; above clavicle over alveoli; soft and breevy |
| lung sounds: what lobes are heard in front; what lobes are heard in back | L upper, right uppler and middle; posteriorly all lobes |
| abnormal lung sounds: names; what does crackle sound like; what does rhonchi sound like; what does stridor sound like; where are rales heard | crackles, rhonchi, pleural friction rub, stridor; rubber hair between fingers in ear; aka wheezing-asthmatics get this; something is lodged in throat and this is bad news; in alveolar sacs |
| lung sounds: over trachea what kind of sound will you hear; over mainstem bronchi what will you hear; what are the majority of sounds that you will hear; | loud high pitched hollow sound called bronchial sounds; medium pitched and quiter sound called bronchovesicular sounds; vesicular- breezy, light and airy |
| lung sounds: when listening to lung sounds posteriorly, why is it helpful for pt to cross arm; diminished sounds are common in what pt; no breath sounds could signify what; | this pulls scapula apart and exposes more lung tissue; thick chest walls-muscular or obese; collapse lung, pneumothorax; |
| adnormal lung sounds: crackles are aka;crackels are most common when; stridor is caused by what; friction rub caused by what; | rales; at the end of inspiration; a larger airway that is blocked by a foreign body, severe inflammation or mass; when the pleural membranes covering the lungs are inflamed |
| adnormal lung sounds: what does friction rub sound like | a scratching or squeking sound that persistst throughout the respiratory cycle and does not clear with coughing |
| lungs: what main stem bronchi is shorter wider and straighter; the previous in the main cause for what; no exchange or co2 and o2 can happen until what; | the R one; aspiration being more likely in the right lung then left; the air enters the respiratory bronchioles |
| lungs: def atelectasis; why is postoperative pt at risk for atelectasis; | refers to collapsed, airless alveoli; b/c the effects of anesthesis and restricted breathing due to pain |
| lungs:irritation to what causes pain with every breath; | the pariatal pleura; |
| 60 second assessment: what does IOM stand from; what does TCAB stand for; what is purpose of 60 second assessment; what is nurse doing; | institute of medicine; transfer of care at beddside; develop situation awareness use the general survey to guide you through the process; going to room and observing for 60 seconds; |
| Heart: what should be palpated first prior to auscultating heart sounds; where is the angle of louios; the angle is at what rib; | the angle of loius; the raised notch where thw manubrium and the body of the sternum are joined, the second |
| JVD: what has increased pressure with this; what sided heart failure does this indicate | right atrial; right sided |
| Heart: a bounding pulse indicates what; what does a thready pulse indicate; irregular pulse is /s/s of what'; | anxiety, fear, anemia, hyperthyroidism; blood loss, decreased cardiac output, aortic valve disease, PAD; cardiac dyrhythmias; |
| heart: tachycardia indicates what; bradycardia indicates what; | exercise, anxiety, shock, need for increased cardiac output, hyperthyroidism; rest, SA or AV node damage, athletic conditioning, side effects of drugs |
| heart: if apical heart rate exceeds the peripheral pulse what does this indicate; | cardiac dysrhythmias; |
| heart: why are the first and second heart sounds heard best with the diaphram; why are S3 and S4 heard better with the bell; | b/c they are high pitched; b/c they are low pitched; |
| pericardial friction rubs: what do they sound like; cuase of them | igh pitched and scratchy; by friction that occurs when inflamed surfaces of the pericardium move against eachother; |
| lungs: def kussmaul breathing; def cheyne stokes breathing; | rapid deep breathing; abnormal pattern of respiration characterized by alternating period of apnea and deep rapid breathing |
| lungs: chest expansion- what is done;nnormal expansion is what; | nurse places hands over the lower anterior chest wall along the costal margin and moves them inward until the thumbs meet at midline then pt breaths deepl and nurse observes the movement of thumbs; 1 inch |
| lungs: chest expansion- unequal expansion indicates what; | when air entry is limited by conditions involving the lung or chest wall; |
| lungs: chest expansion- equal but diminished chest expansion occurs in what conditions; | barrel chest; |
| tactile fremitus: where is it most intense; | adjacent to the sternum and between the scapulae because these areas are closest to the main bronchi |
| lung sounds: in vesicular sounds what is 3 times longer inspirattion or expiration; bronchovesicular sounds have a longer inspiration or experation; the bronchial sounds have long expiration or inspiration; | inspiration; they are equal; ex[piration; |
| lungs: def abnormal breath sounds; def adventitious sounds; | these describe bronchial or bronchovesicular sounds heard in the peripheral lung fields; extra breath sounds that are abnormal |
| lungs: what does tachypnea signify; | fever, anxiey, hypoxemia, |
Created by:
jmkettel
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