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NR202 test 1 Cardio Respiratory assessment


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Cardio Respiratory Assessment
The principal symptoms should be described in terms of
Quantity or Severity
timing (onset, duration, frequency)
The setting in which they occur
Factors that have aggravated or relieved them
Associated Manifestations
Relevant data from the pts chart e.g. lab reports
When a person has had dyspnea, what should they describe to the nurse
What activities are you involved in when Dyspnea occurs
Duration of Dyspnea
affected by position like supine
Affected by sleep, if orthopnic # of pillows
Severity scale 1-10
When a nurse is doing an assessment on a patient suspected to have decreased peripheral tissue perfusion What signs indicates this
hair loss on lower extremities, thick nails, and dry shiny skin indicates decreased peripheral tissue perfusion
What are the signs of Cyanosis
Central-around mouth,
Peripheral--decreased tissue perfusion or hypoxia to that tissue
What is Xanthelasma
yellow bumps on eyelids, under eyelids-Cholesterol deposits
What rhythm of respirations do you see with patients who have Heart failure
What rhythm with Brain damage
" " with Diabetic Ketoacidosis
HF- Cheyne stokes

Brain Damage-Biots

Diabetic Ketoacidosis-Kussmaul
Nursing interventions for Jugular Vein Distention
JVD seen in what kind of HF
NDx for JVD
HOB elevate 45 degrees
Measure at highest point of distention
If > 3-5 cm (1-2") above sternal angle, indicates central venous pressure (CVP) is > normal
Seen in right sided heart failure
NDx: decreased cardiac output
Edema-give ratings and how many inches it is pitting
1+ mild 0-1/4"
2+ Moderate 1/4-1/2"
3+ Severe 1/2-1"
4+ >1
Nonpitting is seen with venous disorders
Crackles-Describe, give nursing diagnosis, causes
Caused by fluid in alveoli or small areas of atelectasis
Sounds like rubbing hair (rice crispies)
NDx: impaired gas exchange
If caused by atelectasis, may clear with coughing or incintive spirometery
If caused by fluid won't clear with coughing
Gurgles-Cause, Describe, give nursing diagnosis
Caused by thick secretions in large upper airways
Usually heard on exhalation, may clear with cough
NDx: ineffective airway clearance
Wheezes-Cause, Describe, NDx
Caused by constricted or swollen airways
Does not clear with cough
Described as inspiratory or expiratory or sibilant or sonorous
NDx: Ineffective Airway Clearance
Pleural Friction Rub-Describe and what causes it
Grating sound heard at end of inspiration/beginning of exhalation
Caused by inflamed pleura rubbing together
Disappears if patient holds breath-So, if it does not go away when patient holds their breath then it is a cardiac problem
Describe Pulsus Alternans
Strong beat followed by a weak beat
May be felt with palpation or heard on BP auscultation
May be seen with acute MI or with decreased left ventricular function (CHF)
Describe Pulsus Paradoxus
Drop in systolic pressure that is greater than 10 mm Hg during inspiration
May indicate advanced CHF, cardiac tamponade, or severe COPD
S3-When is it heard, with whom, what does it indicate, what diagnosis does it support
What is it caused by
Heard best with the bell
May be normal in children and young adults
Caused by vibrations of ventricular wall caused by rapid ventricular filling
Indicates CHF or Fluid overload
Suppports NDx: Decreased cardiac output
S4-When is it heard, with whom, what does it indicate, what diagnosis does it support
What is it caused by
Heard best with the bell
May be normal in children and young adults
Caused by increased resistance or decreased ventricular compliance
Frequently develops in acute MI and CAD
Describe Pericardial Friction Rub
Sustained Coarse scratchy, grating sound
Caused by rubbing of inflamed pericardial surfaces
Sound will continue when patient holds breath
Describe clicks
Caused by valve stenosis or prolapse or valve prosthesis
Describe Bruits
may be heard over arterial malformations also
caused by a turbulent blood flow (narrowed carotid arteries, aneurysms, and dialysis fistulas
Swooshing sound
Describe Murmurs-Causes
Describe the timing of murmurs
Causes: increased blood flow through the normal valve (pregnancy, fever, hyperthyroidism)
Backflow through a stenotic (narrowed valve)
Backflow through a regurgitant (insufficient or leaky) valve

Systolic (between s1 and s2) usually benign
Diastolic-Serious-need immediate treatment
Loudness and intensity of a murmor-Grades of murmur
I/VI-very faint
II/VI-barely audible
III/VI-Easily heard
IV/VI-Easily Heard, May Have a thrill

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