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130 Cards in this Set

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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. Vertebral Line
-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

g. Posterior chest position of the scapula and its inferior angle

h. poistion of C7
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

Older adults may have reached chest expansion d/t calcification
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 shallow
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 properties of pulmonary tissue

a surface-active agent (e.g soap or synthetic detergent
What is surfactant?
What is transverse diameter?

the internal measurement of the thorax, Oval in Adults
What is transverse diameter?
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

Older adults may have reached chest expansion d/t calcification.
What are some developmental considerations that should be taken when assessing the lungs and thorax?
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 ICS left of the sternum

•Tricuspid area: 4th ICS left of the sternum

•Mitral or apex: 5th ICS mid-clavicular line

–Should also be the Point of Maximal Impulse
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 sounds, extra or unusual sounds

RHYTHM: as you are counting the apical rate, get a feel for the regularity/irregularity of the rhythm
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 no regularity or predictability to the beat
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 heart sound of the next beat
(ventricular relaxation)
"–S2-diastole-S1"
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” S1 & S2.
This is called “splitting” and therefore you would have a “split S1” and/or a “split S2”
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-y”)

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 gallop”
“ta-lub-dub” - “Ten-nes-see”

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-dub”
Diastolic- “lub-dub-shh”

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-dub”

Diastolic:
heard after S2
“lub-dub-shh”
(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-dub”

Diastolic:
heard after S2
“lub-dub-shh”
(softer & lower pitch)
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-dub”

Diastolic:
heard after S2
“lub-dub-shh”
(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

–This is a sternal sound, not a heart sound
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
mark with a felt-tip pen

If you think you are confusing the patient’s pulse with your own, simultaneously palpate your carotid pulse
(the rates should differ)
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 not visible

If veins are visibly distended this may indicate fluid overload or cardiopulmonary disease
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:
“slight”
“moderate”
“marked”

Can be scaled
+1 is slight edema
(2mm of depression)

+2 is more edema
(4mm of depression)

+3 is even more edema
(6 mm depression)

+4 is deep pitting edema (8mm or more depression)
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 the end of the nail

Release quickly and assess how fast the color returns to the patient’s normal

Normal finding is that the color will return in less than 3 seconds
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 less than 3 seconds

Presence of pedal pulses (not rate, just quality & ( did it require use of a Doppler?)

Note edema using scale
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 tension of pulmonary fluids thus contributing to the elastic properties of pulmonary tissue
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?

“lub”

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?

“dub”

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?