N202 Condensed

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Author:
cban09
ID:
41597
Filename:
N202 Condensed
Updated:
2010-10-12 03:13:54
Tags:
N202 assessment sdsu
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final revised cards
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  1. Diagnosis
    judgement regarding a pts health using subjective and objective data
  2. nursing diagnosis
    pts response to actual or potential health problems
  3. Nursing Process
    • A-assess
    • D-diagnose
    • O-outcomes id
    • P-plan
    • I-implement
    • E-evaluate
  4. cachexia
    low body mass
  5. BMI
    • KG/M
    • LBS/INCHES x 703
  6. Weight Gain causes
    • Fluid volume Excess
    • Hypothyroid - slows metabolism
    • Meds - corticosteroids
    • Diabetes
  7. Weight Loss causes
    • Increased metabolism
    • Diabetes
    • Malignancy
  8. Normal Temps
    • Oral 98.6/37
    • Rectal/Tympanic +1/0.5
    • Axillary -1/0.5
  9. Fever
    >101/38
  10. Sinus Arrythmia
    Pulse increases with Inspiration
  11. Pulse site before 2 years old
    Apical
  12. Pulse Deficit
    Difference b/w Apical and Radial
  13. Pulse Deficit causes
    Cardiac Arrythmia; sign of Heart Disease
  14. Respirations Assessment
    • Rate
    • Rhythym
    • Depth
    • Character (thoracic-women, abd-men/kids)
    • Abnormalities
  15. Pulse Pressure
    Difference b/n Systolic and Diastolic
  16. MAP
    • Mean Arterial Pressure
    • DBP + 1/3 PP
  17. Increased Viscosity causes
    • Polycythemia
    • Altitude
    • Chronic lung disease
    • Stimulates SNS (vasocontricts)???
  18. Korotkoff sounds (BP)
    1st and 5th
  19. Paradoxical Pulse
    Difference in SBP during inspiration v. expiration >10mm
  20. Paradoxical Pulse causes
    • Cardiac Tamponade
    • Constrictive Pericarditis
    • Emphysema
  21. Thigh BP
    10-40mm higher than brachial
  22. OLD CART
    • Onset
    • Location
    • Duration
    • Character
    • Associated factors
    • Relieving factors
    • Treatment
  23. PQRST
    • Provokes
    • Quality/Quantity
    • Region/Radiation
    • Severity
    • Timing
  24. HEEADSSS
    • Home environ
    • Education and employment
    • Eating
    • Activities
    • Drugs
    • Sexuality
    • Suicide
    • Safety
  25. Gravida
    # of pregnancies
  26. Para
    # of births - 20 weeks (twins count as 1)
  27. Calcium Needs
    • 4-8 yo: 800mg
    • 11-24: 1200-1500mg
    • >24: 1000mg
    • >64: 1500mg
  28. ABCT Mental Health Status
    • Appearance
    • Behavior
    • Cognition
    • Thought processes
  29. Tactile Hallucinations cause
    Alcohol withdrawal
  30. Increassed Costal Angle cause
    Hyperinflation (Emphysema)
  31. Anterior Lung Borders
    • 3-4cm above 1st rib
    • to
    • 5th ICS on R
    • 6th ICS on L
  32. Posterior Lung Borders
    C7 - T10 (12 with inspiration)

    UL: T1 - T3
  33. Horizontal Fissure
    • 4th rib sternal border
    • to
    • 5th rib MAL

    R only
  34. Oblique Anterior Fissures
    • 5th rib MAL
    • to
    • 6th rib MCL
  35. Trachea
    • starts at Cricoid
    • bifurcates at T4 / Louis
  36. Dead Space Volume
    150mL
  37. Right Bronchus Size
    Shorter and Straighter
  38. Respiratory Center
    Brain Stem - Pons and Medulla
  39. Chronic Hypoxia results in
    • desensitizes CO2 receptors
    • low O2 becomes stimulus to breathe
  40. Continuous Cough cause
    Respiratory Infection
  41. Nightime Cough cause
    • post nasal drip
    • GERD
    • Sinusitis
  42. Morning Cough cause
    • Chronic Bronchitis
    • Smoker's cough
  43. Hacking Cough cause
    Mycoplasma Pneumonia
  44. Dry Non-productive Cough cause
    • Early CHF
    • Meds
    • Asthma
  45. Barking Cough cause
    Croup
  46. Congested Cough cause
    • Bronchitis
    • Pneumonia
  47. Clear to White Sputum
    • Bronchitis
    • Pneumonia
  48. White to Grey Sputum
    • Chronic Bronchitis
    • Smoking
  49. Green to Yellow Sputum
    • Bacterial Bronchitis
    • Pneumonia
  50. Rust colored Sputum
    Pneumococcal Pneumonia
  51. Pink Sputum
    Pulmonary Edema
  52. Blood Sputum
    • TB
    • CA
  53. SOB / Dypsnea (Orthopnea/PND) cause
    HF
  54. Diaphoresis cause
    • HIV
    • TB
    • Infection
  55. f/c/s cause (fever/chills/sweats)
    Infection
  56. Dependent Edema cause
    HF
  57. Histoplasmosis / Coccidioidmycosis (valley fever) cause
    Inhaled fungus
  58. Pnuemoconiosis cause
    Coal miner's inhalation
  59. Older adults breathing chamge
    • Decreased Vital Capacity
    • Increased Residual Capacity
  60. Tactile Fremitus Test Results
    • "99"
    • Increased vibration: consolidation (Pneumonia)
    • Decreased vibration: Bronchial obstruction, COPD, Pneumothorax, Pleural
    • Effusion
  61. Crepitus
    • SQ Emphysema
    • Course crackiling due to escape of air into tissues
  62. Hyperresonant Percussion Sounds
    • Emphysema
    • Pneumothorax
  63. Dull Percussion Sounds (Lung Fields)
    • Atelactasis
    • Pneumonia
    • Pleural Effusion
  64. Absent Vesicular Sounds
    • Mucus Plug
    • Collapsed Lung
  65. Crackles / Rales
    • Fluid in lungs
    • Atelactasis
    • Pneumonia
    • Fibrosis
    • HF
    • Pulmonary Edema
  66. Rhonchi
    • Airflow obstructed by: secretions, spasms, or tumor (Bronchitis)
    • Deeper and prolonged during Expiration
    • Clears up with coughing
  67. Wheeze
    • Constricted airway
    • Asthma
    • Bronchitis
  68. Stridor
    • Inspiratory Wheeze
    • Obstruction
  69. Splinting
    Shallow breaths to control Pain
  70. Tension Pneumothorax
    Trachea shifts away from collapsed lung
  71. Hypertrophied Accessory Muscles
    chronic respiratory Disease
  72. Tachypnea cause
    • Insufficiency
    • Pneumonia
    • Alkalosis
    • Pleurisy
  73. Hyperventilation cause
    Diabetic Ketoacidosis
  74. Bradypnea cause
    • Meds
    • Increased ICP
    • Diabetic Coma
  75. Hypoventilation cause
    • Meds
    • Bedrest
    • Splinting

    causes acidosis
  76. Cheyne-stokes Syndrome
    • Regular then apnea breathing pattern
    • CHF
  77. Biots (Ataxic) breathing
    Precedes Cheyn-stokes
  78. Stertorous
    Snoring
  79. Stridor
    • Croup
    • Foreign Body
    • Growth on vocal cords
  80. Atelactasis
    • Collapsed Alveoli
    • Predisposes to Pneumonia
  81. Emphysema
    • Destroyed alveoli
    • Increased lung volume d/t distended alveoli
  82. Bronchitis
    Inflamation of Bronchi
  83. COPD result
    • No O2
    • May cause shutdown
  84. HF
    Loss of Contractility
  85. Hemodynamic System dependent on
    Pressure gradients
  86. Conduction order
    SA node - AV node - Bundle of HIS - Perkinje fibers
  87. P Wave
    • Depolarization of Atria
    • if missing: SA node problem
  88. PR Segment
    Stim of atria to Stim of ventricles
  89. QRS Segment
    Depolarization of ventricles
  90. T Wave
    Repolarization of ventricles (resting stage)
  91. R Wave
    S1, ventricular contraction
  92. CO
    Average
    • HR x SV
    • 70 x 70 = 4800mL
  93. Preload
    LVEDV - stretch
  94. Afterload
    PVR
  95. APE To Man
    • Aortic
    • Pulmonic
    • Erb's
    • Tricuspid
    • Mitral
    • ICS: 2,2,3,4,5
  96. Murmurs, best position
    Extra sounds
    • Sitting, leaning forward
    • Left Lateral Decubitus
  97. S1
    • AV valves close
    • Systole
    • R Wave
  98. S3
    • Ken-tucky
    • Early Diastole
    • Less compliant heart wall
    • HF, Pregnancy
  99. S4
    • Teness-ee
    • resistance during atrial kick
    • Late Diastole
    • HTN
  100. S2 Split
    • During deep Inspiration
    • At 2nd ICS
  101. Murmurs d/t
    • Increased velocity
    • Decreased viscosity
    • Decreased volume
    • Defective valves
    • Septal defects
  102. Stenosis
    Narrowed valve d/t hardening
  103. Regurg
    Insufficiency, backflow
  104. Diastolic Murmurs always indicate
    Heart disease
  105. ACS
    Acute Coronary Syndrome
  106. Cardiac chest pain d/t
    • MI
    • Angina
    • Mitral Valve Prolapse
  107. Pulmonary chest pain d/t
    • Pulmonary Emboli
    • Pneumonia
    • Pleurisy
  108. GI chest pain d/t
    • Ulcer
    • Hiatal Hernia
    • Esophagitis
    • Indigestion
  109. Nocturia d/t
    • Increased venous return while recumbent
    • Increases Renal perfusion
  110. JVP
    • Jugular Venous Pressure
    • JVD + 5cm
    • Should be <10cm
  111. Hepatojugular Reflex
    If neck veins stay distended signifies HF
  112. Thrills
    Loud, Harsh Murmurs
  113. Cardic Tamponade
    Fluid buildup in Pericardium
  114. Cor Pulmonale
    • Right side heart hypertrophy and failure
    • d/t pulmonary HTN

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