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151 Cards in this Set

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If a pt body mass index is _____ or higher weight loss is encouraged
27
What are PVDs?
Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation
What is the basic definition of PAD?
Chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients
What is intermittent claudication?
It is the most common characteristic for which most clients with PAD seek Tx ... A person is able to walk only a certain distance before a cramping, burning muscle discomfort or pain forces them to stop
What are the accessory muscles of respiration?
* Scalene (elevate the first two ribs)
* Sternocleidomastoid (raise the sternum)
* Trapezius and Pectorlis (fix the shoulders)
What is the cardinal sign of respiratory disease?
Cough
What are things to note about sputum?
* Color
* Consistency
* Odor
* Amount
What are normal colors for sputum?
* Clear
* White
* Tan
* Gray
What color might sputum be if infection is present?
* Yellow
* Green
What are characteristics of sputum suggestive of pulmonary edema?
Voluminous, pink, and frothy
What color is pneumococcal pneumonia?
Rust-colored
Grossly bloody sputum may indicate?
* TB
* Pulmonary infarction
* Bronchial adenoma
* Lung abscess
A detailed description of chest pain is useful in differentiating what types of pain?
* Pleural
* Musculoskeletal
* Cardiac
* GI
Define Paroxysmal Nocturnal Dyspnea
Intermittent dyspnea during sleep
Define orthopnea
SOB occurring when lying down but is relieved by sitting up
Paroxysmal Nocturnal Dyspnea and Orthopnea are commonly associated with what two conditions
* Chronic pulmonary disease
* Left ventricular failure
Nasal flaring may indicate an increased _________ effort
Respiratory
When a tension pneumothorax, large pleural effusion, mediastinal mass, or neck tumor is present the trachea tends to move in which direction in relation to the affected area?
Away from the affected area
In the presence of a pneumonectomy, fibrosis, or atelactasis the trachea tends to do what in relation to the affected area?
The trachea tends to pull toward the affected area
Decreased trachea mobility may occur with carcinoma or fibrosis of the ?
Mediastinum
Underlying disease of the lung or pleura may reveal what upon inspection of the chest?
Impaired movement or unequal expansion
A prolonged expiratory phase indicate what?
An obstruction of air outflow
Normally, the ribs slope which, upward or downward?
Downward
When air is trapped in the lungs how do the ribs slope?
Little or no slope
Define fremitus –
Vibration
Define pneumothorax –
Air in the pleural cavity
What does crepitus indicate?
Air is trapped within the tissues
What is tactile fremitus?
Vibration of the chest wall produced when the client speaks
How does the nurse elicit tactile fremitus?
Place the palm or base of the fingers against the client’s chest wall and instruct patient to say “99”
Describe the pitch, intensity, quality, duration, and findings associated with RESONACNE –
* Pitch - Low
* Intensity – Moderate to loud
* Quality - Hollow
* Duration - Long
* Findings - Characteristic of normal lung tissue
Describe the pitch, intensity, quality, duration, and findings associated with HYPPERRESONANCE -
* Pitch – Higher than resonance
* Intensity – Very loud
* Quality - Booming
* Duration – Longer than resonance
* Findings - Indicates the presence of trapped air, commonly heard over an emphysematous or asthmatic lung and occasionally over a pneumothorax
Describe the pitch, intensity, quality, duration, and findings associated with FLATNESS -
* Pitch - High
* Intensity - Soft
* Quality – Extreme dullness
* Duration - Short
* Findings - Heard, for example, over the sternum. Flatness percussed over the lung fields may indicate a massive pleural effusion
Describe the pitch, intensity, quality, duration, and findings associated with DULLNESS -
* Pitch - Medium
* Intensity - Medium
* Quality - Thudlike
* Duration - Medium
* Findings - Example locations is over the liver and the kidneys. Dullness may be percussed over an atelactitic lung or a consolidated lung
Describe the pitch, intensity, quality, duration, and findings associated with TYMPANY -
* Pitch - High
* Intensity - Loud
* Quality – Musical, drumlike
* Duration - Short
* Findings - Examples are the cheek filled with air and the abdomen distended with air. Over the lung, a tympanic note usually indicates a large pneumothorax
Where are bronchial sounds normally heard?
Over the trachea and mainstem bronchi
Where are bronchovesicular sounds normally heard?
Over the branching bronchi
Where are vesicular sounds normally hear?
In the periphery over small bronchioles
Where in the respiratory cycle FINE CRACKLES, FINE RALES, or HIGH-PITCHED RALES heard, what are FINE CRACKLES, FINE RALES, or HIGH-PITCHED RALES the characteristic of, and what might FINE CRACKLES, FINE RALES, or HIGH-PITCHED RALES be associated with?
* Occurrence – Either early or late inspiration
* Character – Popping, discontinuous sounds caused by air moving into previously deflated airways; “Velcro” sounds late in inspiration usually associated with restrictive disorders
* Association – Asbestosis, Atelectasis, Interstitial fibrosis, Bronchitis, Pneumonia, Chronic pulmonary diseases
Where in the respiratory cycle COARSE CRACKLES or LOW-PITCHED CRACKLES heard, what are COARSE CRACKLES or LOW-PITCHED CRACKELS the characteristic of, and what might COARSE CRACKLES or LOW-PITCHED CRACKELS be associated with?
* Occurrence – More common on expiration but may be present early in inspiration
* Character – Lower pitched, coarse, discontinuous rattling sounds caused by fluid or secretion in large airways; likely to change with coughing or suctioning
* Association – Bronchitis, Pneumonia, Tumors, Pulmonary edema
Where in the respiratory cycle WHEEZE heard, what are WHEEZE the characteristic of, and what might WHEEZE be associated with?
* Occurrence – Audible during either inspiration, expiration, or both
* Character – Squeaky, musical, continuous sounds associated with air rushing through narrowed airways; may be heard without a stethoscope…arise from small airways…usually do not clear with coughing
* Association – Inflammation, Bronchospasm, Edema, Secretions, Pulmonary vessel engorgement
Where in the respiratory cycle RHONCUS (RHONCHI) heard, what are RHONCUS (RHONCHI) the characteristic of, and what might RHONCUS (RHONCHI) be associated with?
* Occurrence – Audible during both inspiration and expiration, but commonly more prominent on expiration
* Character – Lower-pitched, coarse, continuous snoring sounds; Arise from the large airways
* Association – Thick, tenacious secretions; Sputum production; Obstruction by foreing body; Tumors
Where in the respiratory cycle PLEURAL FRICTION RUB heard, what are PLEURAL FRICTION RUB the characteristic of, and what might PLEURAL FRICTION RUB be associated with?
* Occurrence – Heard during both inspiration and expiration, generally at the end of inspiration and the beginning of expiration
* Character – Loud, rough, grating, scraping sounds caused by the inflamed surfaces of the pleura rubbing together; often associated with pain on deep inspirations; Heard in lateral lung fields
* Association – Pleurisy, TB, Pulmonary infarction, Pneumonia, Lung cancer
Define Bronchophony –
Abnormally loud and clear transmission of voice sound through an area of increased density. “99”
Defined Whispered Pectoriloquy –
Enhanced voice heard through the chest wall. “One, two, three”
Define Egophony –
Abnormally enhanced vocal resonance; high-pitched, bleating, nasal quality. “E” heard as “A”
What is V/Q (Ventilation and Perfusion Scanning) used to support or rule out?
Dx of pulmonary embolism
Rheumatic fever is the most common cause of ?
Mitral Stenosis
Describe key features of Arterial Ulcers –
* Hx – Client complains of claudication after walking appx 1-2 blocks; rest pain usually present; pain at ulcer site; two or three risk factors present
* Ulcer location and appearance – End of toes, between the toes, deep, ulcer bed pale with even edges, little granulation tissue
* Other assessment findings – cool or cold foot; decreased or absent pulses, atrophy of skin, hair loss, pallor with elevation, dependent rubor, possible gangrene,
* Tx – Treat underlying cause, prevent trauma and infection, client education, stressing foot care
Increased systemic venous pressure and congestion are associated with which ventricular failure?
Right
What is valvular stenosis?
When the heart valves are unable to open fully
Describe key features of Venous Ulcers –
* Hx – Chronic nonhealing ulcer; no claudication or rest pain; moderate ulcer discomfort; client complains about ankle or leg swelling
* Ulcer location and appearance – ankle area; brown pigmentation; ulcer bed pink; usually superficial, with uneven edges, granulation tissue present
* Other assessment findings – Ankle discoloration and edema; full veins when leg slightly dependent; no neurologic deficit; pulses present; may have scarring from previous ulcers
* Tx – longterm wound care; elevate extremity, pt. education, prevent infection
Describe key features of Diabetic Ulcers –
* Hx – Diabetes; peripheral neuropathy; no complaints of claudication
* Ulcer location and appearance – Plantar area of foot; metatarsal heads; pressure points on feet; deep; pale, with even edges; little granulation tissue
* Other assessment findings – pulses usually present; cool or warm foot; painless
* Tx – Rule out major arterial disease; control diabetes; client education regarding foot care; prevent infection
The onset of acute arterial occlusion is often _____ and _____ -
Sudden and dramatic
What are the six “p”s of ischemia
* Pain
* Pallor
* Pulselessness
* Paresthesia
* Paralysis
* Poikilothermai (coolness)
Define atherosclerosis –
Formation of plague within the arterial wall
People with severe diabetes mellitus frequently have premature and severe atherosclerosis,
often involving the microvasculature
How might stress be r/t arterial injury?
The effect of stress may be due to its effect on the sympathetic and parasympathetic release of catecholamines and an acute rise in blood pressure
What is considered optimal LDL values?
Less than 100
What are considered LDL levels near or above optimal?
100 – 129
What are LDL levels considered borderline high and advisable to follow a fat-modified diet?
130-159
What are systolic and diastolic pressures in stage 1 hypertension?
S – 140-159
D – 90-99
What are systolic and diastolic pressures in stage 2 hypertension?
S – 160-179
D – 100-109
What are systolic and diastolic pressures in stage 3 hypertension?
S - > 180
D - > 110
Where are arterial baroreceptors found?
* Carotid sinus
* Aorta
* Wall of the left ventricle
What type of elevated blood pressure is rapidly progressive?
Malignant hypertension
What is secondary hypertension?
When a specific disease state or medication increase a person’s susceptibility to hypertension
What are two of the most common causes of secondary hypertension?
* Renal vascular disease
* Renal parenchymal disease
Coarctation of the aorta is what?
A congenital narrowing of the aorta that may cause hypertension
What are some medications that may cause secondary hypertension?
* Estrogen
* Glucocorticoids
* Mineralocorticoids
* Sympathomimetics
* Cyclosporine
* Erythropoietin
What is the effect of sympathetic stimulation on venous return to the heart?
Sympathetic stimulation increases venous return to the heart, increasing preload

Sympathetic stimulation results in arterial vasoconstriction.

Constriction of the arteries has the benefit of maintaining blood pressure and improving tissue perfusion in low-output states.

However, constriction of the arteries increases afterload.

Afterload is the major determinant of myocardial oxygen requirements.

As afterload increases, the left ventricle requires more energy to eject its contents, an stroke volume may decline
When the ventricle is unable to contract forcefully enough during systole to eject adequate amount of blood into the circulation, what type of dysfunction occurs?
Systolic
What are some conditions that outside the respiratory system that increase oxygen demand, decrease oxygen-carrying capability of the blood, or decrease cardiac output?
* Sepsis
* Fever
* Decreased hgb levels
* Poor hgb quality
Patients with what type of diseases have a principal respiratory drive driven by hypoxia?
Chronic lung disease with hypercarbia
When does the hypoxic drive occur?
In patients with chronic lung disease it is not unusual for PaCO2 levels to gradually rise over time. Central chemoreceptors in the brain normally are sensitive to increased PaCO2 le3vels and stimulate breathing and cause an increased respiratory rate (throwing of CO2), however with gradual increases over time to above 60-65 mmHg, this mechanism shuts off (i.e. the receptors lose their sensitivity to rising PaCO2 and no longer respond accordingly…the result is that breathing is then stimulated by decreased arterial oxygen concentrations as sensed by peripheral chemoreceptors in the carotid sinus areas and the aortic arch
When does the hypoxic drive occur?
In the presence of severely elevated PaCO2 levels (i.e. in the client who has hypoxemia and hypercarbia)
What are initial symptoms of acute respiratory distress syndrome?
* Nonproductive cough
* Substernal chest pain
* GI upset
* Dyspnea
What are more severe symptoms of ARDS?
* Elevated levels of oxygen
* Decreased vital capacity
* Decreased compliance (resulting in more dyspnea)
* Crackles
* Hypoxemia
What are structural damage prolonged exposure to high concentrations of oxygen causes?
* Atelectasis
* Pulmonary edema
* Pulmonary hemorrhages
* Hyaline membrane formation
What is absorption atelectasis?
The collapse of alveoli that occurs when high concentrations of oxygen are delivered, nitrogen is diluted, and oxygen diffuses from the alveoli into pulmonary circulation
When an oxygen flow rate higher than _____ L/min is needed, humidification is added
4
What is the organism often responsible for infection resulting from a humidified oxygen system?
Pseudomonas aeruginosa
Name four low-flow oxygen delivery systems
* Nasal cannula
* Simple face mask
* Partial rebreather mask
* Non-rebreather mask
When the left ventricle is unable to relax adequately during diastole, what type of failure occurs?
Diastolic failure…inadequate relaxation prevents the ventricle from filling with sufficient blood to ensure an adequate cardiac output
Nasal cannula is used to deliver oxygen concentrations ranging from what percent to what percent?
24% at 1L to 44% at 6L
A simple face mask delivers oxygen concentrations of what percentage range?
40% at 5L to 60% at 8L
A partial rebreather mask delivers oxygen concentrations of what percentage range?
60%-75% at 6-11L
A non-rebreather mask delivers oxygen concentrations of what percentage range?
80%-95% FIO2 at liter flow to maintain reservoir bag two-thirds full
Name high-flow oxygen delivery systems
* Venturi Mask
* Aerosol Mask, Face Tent, Tracheostomy Collar
* T-Piece
Which high flow oxygen delivery system delivers precise oxygen concentrations?
Venturi system
A Venturi mask delivers oxygen concentrations of what percentage range?
24%-55% at 4-10L and provides high humidity
An aerosol mask, face tent, or tracheostomy collar mask delivers oxygen concentrations of what percentage range?
24-100% at at least 10L and provides high humidity
A T-piece delivers oxygen concentrations of what percentage range?
24-100% at at least 10L and provides high humidity
What are three ways home oxygen therapy is provided?
* Compressed gas in a tank
* Liquid oxygen in a reservoir
* Oxygen concentrator
Define tracheostomy
The stoma that results from a tracheotomy
What are the six major complication that may arise postoperatively with an ET tube?
* Tube obstruction with secretions
* Tube dislodgment
* Pneumothorax
* Subcutaneous emphysema
* Bleeding
* Infection
What are ways to prevent secretions from obstructing an ET tube?
* Coughing and deep breathing
* Providing inner cannula care
* Humidifying the oxygen source
* Suctioning
For how long after surgery is bleeding from a tracheotomy to be expected?
The first few days
What is considered safe cuff pressure for an ET cuff in order to avoid tracheal damage?
14-20 mm Hg
What are assessment indications that a pt is in need of suctioning?
* Audible secretions
* Noisy secretions
* Crackles or rhonchi on auscultation
* Restlessness
* Increases pulse or respiratory rates
* Presence of mucus in the artificial airway
* Client requests
* Increase in the peak airway pressure on the ventilator
List causes of hypoxia in a pt with a tracheostomy –
* Ineffective oxygenation before, during, and after suctioning
* Use of a catheter that is too large for the artificial airway
* Prolonged suctioning time
* Excessive suction pressure
* Too frequent suctioning
How does the nurse prevent hypoxia in a patient with a tracheostomy?
* Hyperoxygenate the patient with 100% oxygen from an oxygen delivery device
* Use a correct size catheter
What are frequent causes of tissue trauma in the patient with a tracheostomy?
* Frequent suctioning
* Prolonged suctioning time
* Excessive suction pressure
* Nonrotation of the catheter
Tracheostomy care
* Assemble equipment
* Wash hands
* Suction the trach tube if necessary
* Remove old dressings and excess secretions
* Set up a sterile field
* Remove and clean the inner cannula with half strength hydrogen peroxide
* Rinse with sterile saline
* Clean the stoma site and then the trach plate with half strength hydrogen peroxide followed by sterile saline
* Change trach ties if they are soiled
* Document type and amount of secretions and general condition of the stoma and surrounding skin
In a client with a trach tachypnea may indicate ?
Hypoxia
What is it called when the heart valves are unable to close completely?
Valvular insufficiency or valvular regurgitation
Most head and neck cancers are of what type of cell origin?
Squamous
When is an obturator in place?
Only when inserting tubes
What are key features of left-sided heart failure (pulmonary congestion)?
* Hacking cough, worse at night
* Dyspnea/breathlessness
* Crackles or wheezes in lungs
* Frothy, pink-tinged sputum
* Tachypnea
* S3/S4 summation gallop
How do arterial vasodilators work to reduce afterload?
By relaxing the arterioles resistance to left ventricular ejection (afterload) allows for improved cardiac output
What is the effect of right ventricular failure on systemic veins and the systemic venous system?
Because the right ventricle is unable to empty completely, increased volume and pressure developing the systemic veins, and systemic venous congestion and peripheral edema occur
What is low-output syndrome?
When the heart fails to pump enough, resulting in impaired peripheral circulation and peripheral vasoconstriction
What is high-output syndrome?
When cardiac output remains normal or above normal, but the metabolic needs of the body are not met (such as during hyperthyroidism, fever, or pregnancy)
What are key features of left sided heart failure (decreased cardiac output)?
* Fatigue
* Weakness
* Oliguria during the day
* Angina
* Confusion, restlessness
* Dizziness
* Tachycardia, palpitations
* Pallor
* Weak peripheral pulses
* Cool extremities
What are key features of right sided heart failure (systemic congestion)?
* Jugular neck vein distention
* Enlarged liver and spleen
* Anorexia and nausea
* Dependent edema (legs and sacrum)
* Distended abdomen
* Swollen hands and fingers
* Polyuria at night
* Weight gain
* Increased blood pressure (from excess volume) or decreased blood pressure (from failure)
What happens to pressure in the pulmonary venous system as the amount of blood ejected from the left ventricle diminishes?
Pressure builds in the pulmonary venous system and results in fluid-filled alveoli and pulmonary congestion
As the right ventricle fails, what signs of systemic congestion occur?
* Fluid is retained
* Pressure builds in the venous system
Decreased cardiac output and elevated pulmonary venous pressure are associated with which ventricular failure?
Left
How do ACE inhibitors work?
By suppressing the R-A-A system, the body effectively loses water, and thereby there is a decrease in blood pressure due to a decrease in blood volume
Each beat of the heart pumps approximately how many mL of blood?
60mL (or 5 L/minute)
Where is the right ventricle located in relation to the sternum?
Behind the sternum
Define cardiac output?
The volume of blood in liters ejected by the heart each minute
Key features of Mitral Insufficiency
* Fatigue
* DOE
* Orthopnea
* Palpitations
* Atrial Fibrillation
* Neck vein distension
* Pitting edema
* High pitched holosystolic murmur
How is cardiac index determined?
Divide the cardiac output by the body surface area
Define heart rate –
The number of times the ventricles contract each minute
What is the effect of the parasympathetic system on the heart rate?
The parasympathetic system slows the heart rate
What is the effect of the sympathetic system on the heart rate?
The sympathetic system speeds the heart rate
What are the catecholamines of the sympathetic system that speed the heart rate?
Epinephrine and norepinephrine
Define stroke volume –
Amount of blood ejected by the left ventricle during each systole
Define preload –
The degree of myocardial fiber stretch at the end of diastole and just before contraction
Define afterload –
The pressure or resistance that the ventricles must overcome to eject blood through the semilunar valves into the peripheral blood vessels
Define impedance –
The pressure that the heart must overcome to open the aortic valve
How does the ANS regulate BP?
Baroreceptors, chemoreceptors, and stretch receptors are sensitive to pressure or volume changes which in turn result in signals being sent to the CNS which stimulates the SNS
How does the renal system regulate BP?
When renal blood flow or pressure decreases, the kidneys retain sodium and water. Blood pressure tends to rise because of fluid retention and because of activation of the R-A-A mechanism. Vascular volumes is also regulated by the release of antidiuretic hormone from the posterior pituitary gland
What are alternative terms to use instead of “chest pain”?
* Discomfort
* Heaviness
* Indigestion
What are assessment findings of right sided heart failure?
* Neck vein distension
* Hepatomegaly
* Pitting edema
* High pitched systolic murmur at the apex with radiation to the left axilla
What are the onset, quality and severity, location and radiation, duration, and relieving factors of ANGINA?
* Onset – sudden, usually in response to exertion, emotion, or extremes in temperature
* Quality and severity – Squeezing, vise-like pain
* Location and radiation – substernal; may spread across the chest and the back and/or down the arms
* Duration – Usually lasts less than 15 minutes
* Relieving factors – relieved with rest, nitrate administration, or oxygen therapy
What are the onset, quality and severity, location and radiation, duration, and relieving factors of MI?
* Onset – Sudden, without precipitating factors, often in early morning
* Quality and severity – Intense stabbing, vise-like pain or pressure, severe
* Location and radiation – Substernal; may spread through the anterior chest and to the arms, jaw, back, or neck
* Duration – usually lasts 30 minutes or longer
* Relieving factors – relieved with opioids
What are the onset, quality and severity, location and radiation, duration, and relieving factors of PERICARDITIS?
* Onset – sudden
* Quality and severity – sharp stabbing, moderate to severe
* Location and radiation – Substernal; usually spreads to the left side or the back
* Duration – Intermittent
* Relieving factors – sitting upright, analgesia, or administration of anti-inflammatory agents
What are the onset, quality and severity, location and radiation, duration, and relieving factors of PLEUROPULMONARY?
* Onset – Variable
* Quality and severity – Moderate ache, worse on inspiration
* Location and radiation – Lung fields
* Duration – Continuous until the underlying condition is treated or the client has rested
* Relieving factors – Tx of the underlying condition or client rest
What are the onset, quality and severity, location and radiation, duration, and relieving factors of ESOPHAGEAL-GASTRIC?
* Onset – Variable
* Quality and severity – Squeezing, heartburn, variable severity
* Location and radiation – Substernal; may spread to the shoulders or the abdomen
* Duration – Variable
* Relieving factors – Antacid administration or food intake
What are the onset, quality and severity, location and radiation, and duration of ANXIETY?
* Onset – Variable, may be in response to stress or fatigue
* Quality and severity – Dull ache to sharp stabbing; may be associated with numbness in fingers
* Location and radiation – Usually the left side of chest without radiation
* Duration – Usually lasts a few minutes
Pallor is a characteristic of ?
Anemia
When is hemodynamic monitoring used?
Critical care areas to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion
Key features of Mitral Stenosis
* Fatigue
* DOE
* Orthopnea
* PND
* Hemoptysis
* Hepatomegaly
* Neck vein distention
* Pitting edema
* Atrial fibrillation
* Rumbling apical diastolic murmur
Key features of Mitral Valve Prolapse
* Atypical chest pain
* Dizziness, syncope
* Palpitations
* Atrial tachycardia
* Ventricular tachycardia
* Systolic click
Key features of Aortic Stenosis
* DOE
* Angina
* Syncope on exertion
* Fatigue
* Orthopnea
* PND
* Harsh, systolic crescendo-decrescendo murmur
Key features of Aortic Insufficiency
* Palpitations
* Dyspnea
* Orthopnea
* PND
* Fatigue
* Angina
* Sinus tachycardia
* Blowing, decrescendo diastolic murmur
What are compensatory mechanisms when cardiac output is insufficient?
* Increased HR
* Improved stroke volume
* Arterial vasoconstriction
* Sodium and water retention
* Myocardial hypertrophy
What is the most immediate compensatory mechanism during heart failure?
Stimulation of the sympathetic nervous system
What is the effect of sympathetic stimulation on venous return to the heart?
Sympathetic stimulation increases venous return to the heart, increasing preload
Cough is a side effect of which?
a) ACE Inhibitors
b) Calcium Channel Blockers
c) Beta Adrenergic Blocking Agents
d) Diuretics
a) ACE Inhibitors