z FALL06 CARDIAC, RESPIRATORY Nursing Dee
Terms
undefined, object
copy deck
-
Superficial gaiting or creeking during exhalation/inspiration is?
pleural friction rub? - Superficial gaiting or creeking during exhalation/inspiration is?
-
What is a pleural friction rub?
Superficial gaiting or creeking during exhalation/inspiration - What is a pleural friction rub?
-
A faintly reciprocal vibration felt through chest wall when patient speaks is?
fremitus - A faintly reciprocal vibration felt through chest wall when patient speaks is?
-
What are the landmarks for assessments of the lungs and thorax?
a. Midsternal line
b. Midclavicular line
c. Anterior axillary line
d. Midaxillary line
e. Midscapular(scapular)line
f. Vert -
-Midsternal line
-Midclavicular line
-Anterior axillary line
-Midaxillary line
-Midscapular(scapular)line
-Vertebral Line -
What are some Rib landmarks?
a. Angle of Louis
b. 1st & 2nd ribs
c. costal margin
d. xiphoid process
e. costal angle
f. relationship between ribs and the intercaostal spaces
- What are some Rib landmarks?
-
What are some shape deformities of the chest?
a. funnel chest
b. Barrel Chest(Common in asthmatic and COPD pts
c. Kyphosis(Osteoporosis)
d. Lordosis(Weight/pregnancy - What are some shape deformities of the chest?
-
How is pack years figured?
The # of packs/day X # of years smoked=pack/years - How is pack years figured?
-
What are the steps used to examine the posterior chest?
1. Inspect
2. Palpate any suspicious areas
3. Auscultate breath sounds using established patterns - What are the steps used to examine the posterior chest?
-
Where can Vesicular Breath Sounds be heard?
over lower 3rd of lung fields
out to sides
above the scapula(in the periphery)
are normal breath sounds - Where can Vesicular Breath Sounds be heard?
-
What causes Vesicular Sounds?
normal breath sounds created by air moving through small airways - created by air moving through small airways
-
Bronchial Breath sounds are normal sounds heard where?
course sounds heard over the large airways(trachea) - Bronchial Breath sounds are normal sounds heard where?
-
What do bronchial breath sounds sound like & are they normal?
Yes, they are normal
course sounds heard over the large airways(trachea) - What do bronchial breath sounds sound like & are they normal?
-
What are broncho-vesicular breath sounds & what do they sound like?
air movement through moderate sized airways
heard on either side of the sternum and between the scapulae to about the middle of the back -
What are broncho-vesicular breath sounds?
What do they sound like? -
What are adventitious Lung Sounds?
Added to the normal sounds - What are adventitious Lung Sounds?
-
What do you have the patient do if you hear adventitious lung sounds?
have the patient cough - What do you have the patient do if you hear adventitious lung sounds?
-
What are fine crackles?
Caused by alveoli popping open or by air bubbling through fluid
fine crinkling, popping sounds
(may sound like hair being rubbed between the fingers) - What are fine crackles?
-
When are fine crackles usually heard?
They usually occur at the beginning or end of inspiration - When are fine crackles usually heard?
-
What was the old term for crackles?
rales - What was the old term for crackles?
-
What do coarse crackles sound like?
Louder bubbling, gurgling sounds (like frying bacon) - What do coarse crackles sound like?
-
What are wheezes?
They are prolonged, high-pitched, musical sounds resulting from a rapid airflow through a narrowed airway(usually mucus). - What are wheezes ?
-
What is another term used for wheezes?
rhonchi - What is another term used for wheezes?
-
What is stridor?
A stridor is a loud, high-pitched, "crowing" sound. - What is stridor?
-
What causes a stridor?
Produced by an airway obstruction - What causes a stridor?
-
Is a stridor an emergency?
Yes, this can be a serious emergency as it may indicate impending respiratory failure. - Is a stridor an emergency?
-
What are Rubs ?
A rub is a scratchy, scraping noise(like leather on leather). - What are Rubs ?
-
When do rubs occur?
during or at the end of inspiration - When do rubs occur?
-
What are some reasons that you may not be able to hear breath sounds?
A thick chest wall.
A barrel-shaped chest(COPD) - What are some reasons that you may not be able to hear breath sounds?
-
What are some developmental considerations that should be taken when assessing the lungs and thorax?
May use the bell to assess children's lung sounds(d/t deeper pitch)
Expect children under age 6 to be abdominal breathers
- What are some developmental considerations that should be taken when assessing the lungs and thorax?
-
What are some commonly used phrases used in documenting lung sounds?
Lungs CTA
(clear to Auscultations)
respiration regular and unlabored
Bi-basilar crackles
Wheezing on expiration
respirations - What are some commonly used phrases used in documenting lung sounds?
-
What is respiratory excursion?
the physical observation by the RN to observe full and symmetric chest expansion - What is respiratory excursion?
-
What is surfactant?
in pulmonary physiology, a mixture of phospholipids secreted by alveolar cells into the alveoli and respiratory air passages that reduces the surface tension of pulmonary fluids and thus contributes to the elastic properti - What is surfactant?
-
What is transverse diameter?
the internal measurement of the thorax, Oval in Adults - What is transverse diameter?
-
What are some landmarks that you should know before beginning the cardiovascular assessment?
⬢Angle of Louis: approx 2 inches below the sternal notch
⬢Aortic area: 2nd ICS right of the sternum
⬢Pulmonic area: 2nd I - What are some landmarks that you should know before beginning the cardiovascular assessment?
-
An easy way to remember the areas you place the stethoscope when doing the cardio assessment is?
⬢APT M
⬢A (aortic)
⬢P (pulmonic)
⬢T (tricuspid)
⬢M (mitral) - An easy way to remember the areas you place the stethoscope when doing the cardio assessment is?
-
Landmark's other than APT M when doing the cardio assessment are?
A second pulmonic area at the 3rd ICS on the left of the sternum called Erb’s point
The epigastric area is located at the tip of the sternum - Landmark's other than APT M when doing the cardio assessment are?
-
What is the 1st step in the cardio asessment?
1st step:
Assess heart rate/rhythm
HEART RATE:
listen & count over the PMI for 60 seconds to measure the apical pulse
Notate: rate, rhythm, quality of soun - What is the 1st step in the cardio asessment?
-
How do you assess the heart rhythm?
REGULAR:
beats occur in a regular fashion
REGULARY IRREGULAR:
beats are not regular, but the irregularity occurs in a predictable manner
IRREGULARLY IRREGULAR:
there is n - How do you assess the heart rhythm?
-
What are some normal heart sounds?
S1: "lub"
mitral & tricuspid valve closure
S2: "dub"
aortic & pulmonary valve closure
⬢S1-S2 counts as one heartbeat - What are some normal heart sounds?
-
When using a stethoscope, how are S1-"lub" & S2-"dub" sounds heard best?
with the diaphragm - When using a stethoscope, how are S1-"lub" & S2-"dub" sounds heard best?
-
How can you discern the difference between S1-S2 sounds?
⬢S1 is heard best at the apical area
⬢S2 is heard best at the aortic area - How can you discern the difference between S1-S2 sounds?
-
If you have difficulty telling the difference between S1 & S2 sounds you can?
Palpate the patient’s carotid pulse while you are listening at the apical area....& then when you feel the pulse, the sound you are hearing is S1. - If you have difficulty telling the difference between S1 & S2 sounds you can?
-
What do you call the spaces of time in the heartbeat?
SYTOLE:
begins with 1st heart sound & ends with the 2nd heart sound
(ventricular contraction)
DIASTOLE:
begins with 2nd heart sound & ends with the 1st hea - What do you call the spaces of time in the heartbeat?
-
When listening to heart sounds, when is ventriclular contraction occurring?
in between S1 & S2
"S1 ---> systole ---> S2" - When listening to heart sounds, when is ventriclular contraction occurring?
-
When listening to heart sounds, when is ventriclular relaxation occurring?
in between S2 & S1
"S2 ---> diastole ---> S1" - When listening to heart sounds, when is ventriclular relaxation occurring?
-
What is systole?
ventricular contraction
between S1 & S2 sounds - What is systole?
-
What is Diastole?
ventricular relaxation
between S2 & S1 sounds - What is Diastole?
-
What is the normal heart rate?
Rate of 60-100 - What is the normal heart rate?
-
Bradycardia is a heart rate of?
Less than 60 - Bradycardia is a heart rate of?
-
Tachycardia is a heart rate of?
Over 100 - Tachycardia is a heart rate of?
-
How do you document a Regular heart rhythm?
“S1, S2, regular†- How do you document a Regular heart rhythm?
-
What are some sounds, other than S1 & S2, that can be heard during a cardio assessment?
Splitting:
If enough time elapses between the closure of the right-side valve & the left-side valve, you may be able to hear a “two-phase†- What are some sounds, other than S1 & S2, that can be heard during a cardio assessment?
-
What are S3 sounds?
ventricular gallop
Heard directly after S2
Caused by early, rapid filling of the ventricle
“lub-dub-ahh†(“Ken-tuck-yâ€)
Normal in children, but pathologic in adults - What are S3 sounds?
-
What is a ventricular gallop?
S3 sound heard directly after S2
"lub-dub-ahh"/ Ken-tuck-y - What is a ventricular gallop?
-
What causes S3-ventricular gallop sounds?
early, rapid filling of the ventricle - What causes S3-ventricular gallop sounds?
-
The early, rapid filling of the ventricle causes what sounds?
S3 - ventricular gallop
"lub-dub-ahh"/ Ken-tuck-y - The early, rapid filling of the ventricle causes what sounds?
-
What heart sounds are normal in children but pathological in adults?
S3 - ventricular gallop
"lub-dub-ahh"/ Ken-tuck-y
early, rapid filling of the ventricle - What heart sounds are normal in children but pathological in adults?
-
What are S4 sounds?
Always pathologic
“atrial gallopâ€
“ta-lub-dub†- “Ten-nes-seeâ€
Heard just before S1
Caused by increased ventricular stiffness - What are S4 sounds?
-
What is an “atrial gallop†?
increased ventricular stiffness
Always pathologic
S4 heard just before S1
“ta-lub-dub†- “Ten-nes-see†- What is an “atrial gallop†?
-
What causes an “atrial gallop†?
increased ventricular stiffness
Always pathologic
S4 heard just before S1
“ta-lub-dub†- “Ten-nes-see†- What causes an “atrial gallop†?
-
What is a murmur?
Systolic - “lub-shh-dubâ€
Diastolic- “lub-dub-shhâ€
Swishing or blowing sounds caused by turbulence of blood flow across a valve or through an abnormal heart wall opening - What is a murmur?
-
What does a murmur sound like?
Swishing or blowing sounds
Systolic:
heard with S1 before S2
“lub-shh-dubâ€
Diastolic:
heard after S2
“lub-dub-shhâ€
(softer & lower pitch) - What does a murmur sound like?
-
When you listen to a pt's heart & you hear a swishing or blowing sound, what does this indicate?
a murmur - When you listen to a pt's heart & you hear a swishing or blowing sound, what does this indicate?
-
How is a heart murmur characterized ?
timing, location, radiation, quality, pitch, shape, and duration
Swishing or blowing sounds
Systolic:
heard with S1 before S2
“lub-shh-dubâ€
Diastolic:
- How is a heart murmur characterized ?
-
A condition of the heart that can be a “normal abnormality†in young children is?
a systolic murmur
heard with S1 & before S2
“lub-shh-dub†- A condition of the heart that can be a “normal abnormality†in young children is?
-
How do you time a murmur?
Systolic:
heard with S1 before S2
“lub-shh-dubâ€
Diastolic:
heard after S2
“lub-dub-shhâ€
(softer & lower pitch) - How do you time a murmur?
-
How are murmurs graded?
Done by physician or more experienced nurse
May help us understand severity of problem - How are murmurs graded?
-
What is a "thrill" in cardio assessment?
vibration felt over the area of a murmur - What is a "thrill" in cardio assessment?
-
A vibration felt over the area of a murmur is called?
thrill - A vibration felt over the area of a murmur is called?
-
What is a click?
A clicking sound that can be from a Mitral valve prolapse
–Done by physician or more experienced nurse
–May help us understand severity of problem
–Mechanical heart valve
- What is a click?
-
What is a sternal click?
can be caused by instability of the sternum after surgery - What is a sternal click?
-
What is a snap?
Opening snap is a very early diastolic sound
Caused by opening of a thickened mitral valve - What is a snap?
-
A very early diastolic sound may be a?
snap - A very early diastolic sound may be a?
-
What causes a snap?
Caused by opening of a thickened mitral valve - What causes a snap?
-
What is a rub?
Sound like pleural rubs, but coincide with heartbeat - What is a rub?
-
How do you palpate a difficult pulse?
Assume a comfortable position
Use the distal pads of your index & middle fingers
apply firm pressure but not so hard that you occlude the pulse
Once pulses are located - How do you palpate a difficult pulse?
-
How do you document pulses?
0: absent
+1: barely palpable
+2: normal
+3: full, increased
+4: bounding - How do you document pulses?
-
How do you check for Jugular venous distension?
Inspection of the jugular veins should occur with patient setting at a 30-45 degree angle
(semi-Fowler’s)
head supported on a small pillow
Normal finding=veins are n - How do you check for Jugular venous distension?
-
Jugular venous distension may be indicative of?
fluid overload
cardiopulmonary disease - Jugular venous distension may be indicative of?
-
What is clubbing of the nails?
Clubbing is a condition in which the angle between the nail & nail bed is 180 degrees or greater
May be caused by a long-term lack of oxygen - What is clubbing of the nails?
-
What causes clubbing of the nails?
May be caused by a long-term lack of oxygen - What causes clubbing of the nails?
-
How is edema documented?
Assess by pressing your thumb firmly into the area for about 5 seconds
Can be documented as:
“slightâ€
“moderateâ€
“markedâ€
Can be scaled
+1 is slight edema
(2mm - How is edema documented?
-
Why is capillary refill important?
Checks circulation to the distal extremities
Method:
Assess the color of the patient’s toenail bed or fingernail bed
Apply gentle, firm pressure to the nail bed by pressing on th - Why is capillary refill important?
-
What do you document after the cardio assessment?
S1 & S2
& regular,irregular, etc
Identify underlying rhythm
(requires patient be on a cardiac monitor)
JVD (can be measured)
Capillary refill - What do you document after the cardio assessment?
-
Vesicular breath sounds?
Soft-intensity & low- pitched
“gentle sighing sounds created by air moving through smaller airways
(bronchioles & alveoli) - Vesicular breath sounds?
-
Wheezes are?
continuous & high-pitched
musical squeak or whistling sound occurring on expiration & sometimes on inspiration when air moves through a narrowed or partially obstructed airway - Wheezes are?
-
Ventilation is?
the movement of air in & out of the lungs
the process of inhalation & exhalation - Ventilation is?
-
Respiratory Excursion is?
the physical observation by the RN to observe full & symmetric chest expansion - Respiratory Excursion is?
-
Scoliosis is?
an abnormal curvature of the spine - Scoliosis is?
-
Tidal Volume is?
the volume of air that is normally inhaled and exhaled - Tidal Volume is?
-
Transverse diameter is?
the internal measurement of the thorax, Oval in Adults - Transverse diameter is?
-
A Surfactant is?
a surface-active agent (e.g soap or synthetic detergent)
in pulmonary physiology, a mixture of phospholipids secreted by alveolar cells into the alveoli & respiratory air passages that reduces the surface tensio - A Surfactant is?
-
A Stridor is?
a harsh, crowing sound made on inhalation caused by constriction of the upper airway. - A Stridor is?
-
The amount of blood ejected from the heart with each ventricular contraction is?
Cardiac Output - Cardiac Output is?
-
Lift or Heave in the chest is?
abnormal anterior movement of the chest r/t enlargement of the right ventricle -
The abnormal anterior movement of the chest r/t enlargement of the right ventricle is?
Lift or Heave -
Diastole is?
ventricular relaxation. Occurs between S2 & S1 -
Ventricular relaxation occurs between S2 & S1 it is called?
Diastole -
Apical Impulse is?
Felt where the apex thumps the chest fall - Apical Impulse is?
-
Point of maximal impulse is?
- PMI, The point where the apex of the heart touches the anterior chest wall - Point of maximal impulse is?
-
Precordium is?
area of the chest wall overlying the heart is inspected and palpated for the presence of abnormal pulsations or lifts and heaves - When an area of the chest wall overlying the heart is inspected & palpated for the presence of abnormal pulsations or lifts & heaves it is called?
-
Pulse pressure is?
difference between the systolic and diastolic blood pressures - The difference between the systolic and diastolic blood pressures is called?
-
Ventricular gallop is?
S3, heard directly after S2,
sounds like Kentucky, normal in kids - Ventricular gallop is?
-
The Apex is located?
point of the heart, sits in the left intercostals space -
The point of the heart that sits in the left intercostals space is?
The Apex -
S1-1st heart sound, mitral & tricuspid valve closure make what sound?
“lubâ€
Heard best over the apical area - S1-1st heart sound, mitral & tricuspid valve closure make what sound?
-
S2- second heart sound, aortic & pulmonary valve closure, makess what sound?
“dubâ€
sound, heard best over the aortic area - S2- second heart sound, aortic & pulmonary valve closure, makess what sound?
-
Pulse deficit?
difference between the apical pulse & radial pulse - Difference between the apical pulse & radial pulse are termed?
-
A Bruit is a?
blowing or swishing sound created by turbulence of blood flow - A Bruit is a?
-
A Thrill is a ?
vibrating sensation over a blood vessel that indicates turbulent blood flow - A Thrill is a ?
-
Rubs are?
sounds like a pleural rubs, coincide with heartbeat - Rubs are?
-
Afterload is?
The resistance against which the heart must pump to eject blood into the circulation - The resistance against which the heart must pump to eject blood into the circulation is called?
-
Angina is?
A spasmodic, cramplike choking feeling - A spasmodic, cramplike choking feeling is called?
-
Automaticity is?
An electrical impulse and contraction independent of the nervous system and generated by the cardiac muscle - An electrical impulse and contraction independent of the nervous system and generated by the cardiac muscle is called?
-
Cardiac Output is?
The amount of blood ejected by the heart with each ventricular contraction - The amount of blood ejected by the heart with each ventricular contraction is called?
-
Code blue is?
Emergency announcing cardiac/respiratory arrest and initiating interventions - An emergency announcing cardiac/respiratory arrest and initiating interventions is called?
-
Contractilityis ?
The inherent ability of cardiac muscle fibers to shorten or contract - The inherent ability of cardiac muscle fibers to shorten or contract is called?
-
CPR is?
A basic emergency procedure for life support, consisting of artificial respiration and manual external cardiac massage. - A basic emergency procedure for life support, consisting of artificial respiration and manual external cardiac massage is called?
-
Diastole is?
The period during which the ventricles relax - The period during which the ventricles relax is called?
-
Dysrhythmia is?
A pulse with an irregular rhythm - A pulse with an irregular rhythm is called?
-
Myocardial Infarction (MI) is?
Heart attack
Cardiac tissue necrosis owing to obstruction of blood flow to the heart - When cardiac tissue is necrotic owing to obstruction of blood flow to the heart is called?
-
Intermittent Claudication is?
Cramplike pains in the calves caused by poor circulation of the blood to the leg muscles - Cramplike pains in the calves caused by poor circulation of the blood to the leg muscles are called/
-
MAP—Mean Arterial Pressure is?
The arithmetic mean of the blood pressure in the arterial part of the circulation - The arithmetic mean of the blood pressure in the arterial part of the circulation is called?
-
A Murmur is?
sounds produced by turbulent blood flow through the heart - Sounds that are produced by turbulent blood flow through the heart is called a ?
-
Pulse pressure is?
the difference between the systolic BP & the diastolic BP. - The difference between the systolic BP & the diastolic BP is called the?
-
APT-M is?
away to remember the sequence of cardiac assessment. - A away to remember the sequence of cardiac assessment is ?
-
Cardiac output is the?
Stroke volume times heart rate. - The stroke volume times heart rate is the?
-
A Pulse deficit is a?
situation in which fewer radial pulses are felt than the apical pulses heard. - A situation in which fewer radial pulses are felt than the apical pulses heard is called?
-
A PMI is a?
a pulsation arising at the apex of the heart. - A pulsation arising at the apex of the heart is called?
-
A Heave is a?
sustained life of the chest wall in the pre-cordial area that can be seen or palpated - The sustained life of the chest wall in the pre-cordial area that can be seen or palpated is called a?
-
A Thrill is a?
vibration felt over a vessel. - A vibration felt over a vessel is called a ?
-
The equivilant of a Gallop is?
S3 - S3 is the equivilant of a ?
-
A Bruit is a ?
Humming heard through a stethoscope placed over a vessel. - A humming sound heard through a stethoscope placed over a vessel is called?