final exam flashcards nur211
(254 cards)
1
Q
What is the clinical significance of a weight loss of less than 5% in 1 month?
A
Mild risk of malnutrition
This indicates that the individual may need monitoring for potential nutritional deficiencies.
2
Q
What does a weight loss of 5-10% in 1 month indicate?
A
Moderate risk of malnutrition -
3
Q
What is the clinical significance of a weight loss greater than 10% in 1 month?
A
Severe risk of malnutrition - needs to be verified
This level of weight loss is concerning and requires immediate assessment.
4
Q
What defines undernutrition in terms of weight loss?
A
Unintentional weight loss > 10% in 6 months
This definition highlights the chronic nature of the condition and its implications for health.
5
Q
A
6
Q
What are the contraindications for oral temperature measurement?
A
Kids under the age of 5, adults who can’t follow instructions, anyone who can’t close their mouth, unconscious, or intubated
These contraindications highlight situations where oral temperature measurement may not provide accurate results or could pose a risk to the individual.
7
Q
How far should a rectal thermometer be inserted for infants?
A
1/2 inch
8
Q
How far should a rectal thermometer be inserted for adults?
A
1 inch
9
Q
Is it safe to use a rectal thermometer for newborns?
A
No, due to the risk of rectal trauma
10
Q
When is using a rectal thermometer particularly beneficial?
A
When accurate core temperature is needed for critically ill patients
11
Q
What is the procedure for taking tympanic (ear) temperature in adults?
A
Pull the pinna (outer ear) up and back.
12
Q
What is the procedure for taking tympanic (ear) temperature in children under 3 years old?
A
Pull the pinna (outer ear) down and back.
13
Q
What are the contraindications for tympanic temperature measurement?
A
Patients with ear infections, excessive earwax, or otitis media.
Do not use on infants under 6 months due to small ear canals.
14
Q
Who is tympanic temperature measurement best for?
A
Older children and adults needing a quick, non-invasive measurement.
15
Q
True or False: Tympanic temperature measurement can be used for infants under 6 months.
A
False.
16
Q
What is the first step in the Temporal Artery temperature procedure?
A
Place the sensor on the center of the forehead
This is the initial position for accurate temperature measurement.
17
Q
What is the second step in the Temporal Artery temperature procedure?
A
Sweep across the forehead to the temple
This motion helps in collecting the temperature data effectively.
18
Q
What types of sensors can be used for Temporal Artery temperature measurement?
A
Some devices require touching the skin, while others are non-contact infrared sensors
The choice of sensor affects how the measurement is taken.
19
Q
What is a contraindication for using Temporal Artery temperature measurement?
A
Patients with excessive sweating or oily skin
These conditions may alter the accuracy of the readings.
20
Q
Is Temporal Artery temperature measurement accurate for infants under 3 months?
A
No
The method is not as accurate for this age group.
21
Q
What is the best use case for Temporal Artery temperature measurement?
A
Quick screenings in children, elderly, or mass health screenings
This includes settings like hospitals, airports, and public venues.
22
Q
What is the procedure for measuring axillary temperature?
A
- Place the thermometer in the center of the axilla (armpit)
- Ensure skin-to-skin contact (clothing must be moved aside)
- Hold the arm tightly against the body until the reading is complete
This method is often used for specific patient populations.
23
Q
What are the contraindications for axillary temperature measurement?
A
- Least accurate method
- Should only be used if other methods are unavailable
- Not ideal for fever detection in critically ill patients
This method may not provide reliable results in severe cases.
24
Q
For which patient groups is axillary temperature measurement best suited?
A
- Infants
- Unconscious patients
- Patients who cannot tolerate other methods
This method is generally more comfortable for these populations.
25
What hormone increases body temperature during the menstrual cycle?
Progesterone
## Footnote
Progesterone is released during the luteal phase of the menstrual cycle, leading to an increase in basal body temperature.
26
When is body temperature typically lower during the day?
In the morning
## Footnote
Body temperature usually rises throughout the day and peaks in the afternoon.
27
What factors can increase body temperature due to the sympathetic nervous system?
Stress and anxiety
## Footnote
The sympathetic nervous system activates the 'fight or flight' response, which can elevate body temperature.
28
How long should you wait after eating, drinking, or smoking before taking an oral temperature?
15 minutes
## Footnote
This waiting period allows the body temperature to stabilize for an accurate reading.
29
Fill in the blank: Body temperature is always lower in the _______.
morning
30
Fill in the blank: Stress and anxiety increase body temperature due to the _______.
sympathetic nervous system
31
What is a safety guideline for using thermometers?
Always use a disposable probe cover to prevent infection transmission.
## Footnote
This helps in maintaining hygiene and preventing cross-contamination.
32
What should never be done with a thermometer in a patient's mouth?
Never leave a thermometer unattended in a patient's mouth (risk of choking).
## Footnote
This is crucial for patient safety.
33
What is a safety consideration when using rectal thermometers?
Avoid forceful insertion of rectal thermometers to prevent rectal trauma.
## Footnote
Proper technique is essential to avoid injury.
34
What is important for accurate readings with tympanic and temporal thermometers?
Ensure proper positioning of tympanic and temporal thermometers for accurate readings.
## Footnote
Incorrect positioning can lead to erroneous temperature readings.
35
What temperature measurement methods are recommended for infants?
Use axillary or rectal measurements (rectal only when necessary).
## Footnote
These methods are preferred for accuracy in young children.
36
What type of thermometer should be avoided in infants under 6 months?
Avoid tympanic thermometers in infants under 6 months.
## Footnote
Their ear canals are still developing, making tympanic measurements less reliable.
37
Why should glass thermometers be avoided for infants?
Do not use glass thermometers due to breakage risk.
## Footnote
Glass thermometers can shatter, posing a safety hazard.
38
What is a common characteristic of baseline body temperature in elderly patients?
May have lower baseline body temperature (96.8°F or lower).
## Footnote
This can affect the assessment of fever.
39
How may fever present in elderly patients during infections?
Fever may be less pronounced in infections.
## Footnote
This can lead to underdiagnosis of infections in this population.
40
What should be assessed in frail or underweight elderly patients?
Assess for hypothermia in frail or underweight elderly patients.
## Footnote
They are at higher risk for temperature regulation issues.
41
What is the most accurate pulse measurement method?
Apical Pulse (Auscultation Method)
## Footnote
Directly over the heart
42
What patient groups benefit most from apical pulse measurement?
* Infants and young children
* Patients with cardiac conditions or irregular heart rhythms
* Before administering cardiac medications (e.g., digoxin, beta-blockers)
## Footnote
Due to irregular peripheral pulses
43
What is the first step in the procedure for measuring the apical pulse?
Position the patient in a supine or sitting position
## Footnote
This ensures comfort and accessibility for measurement
44
Where should the stethoscope be placed to measure the apical pulse?
Over the apex of the heart at the 5th intercostal space, midclavicular line (left side of chest)
## Footnote
This is the optimal location for accurate auscultation
45
What heart sounds should be listened for when measuring the apical pulse?
S1 and S2 heart sounds ('lub-dub')
## Footnote
These sounds indicate the closing of heart valves
46
For how long should you count the heartbeats when measuring the apical pulse?
For a full minute
## Footnote
This ensures an accurate heart rate measurement
47
What additional aspects should be noted during apical pulse measurement?
* Rate
* Rhythm
* Presence of extra heart sounds or murmurs
## Footnote
These factors can indicate underlying health issues
48
What is a key nursing consideration when measuring the apical pulse?
Use apical pulse in infants and cardiac patients for most accuracy
## Footnote
This method provides reliable data for these populations
49
What is the peripheral pulse palpation method?
Easiest and fastest method for pulse assessment
## Footnote
Used primarily to quickly assess a patient's pulse.
50
What are the best uses for the peripheral pulse palpation method?
* Routine vital signs assessment
* Assessing circulation and perfusion
## Footnote
Important for determining overall health and blood flow.
51
Where is the Carotid Pulse located?
Neck, between trachea and sternocleidomastoid muscle
## Footnote
Used in emergencies such as CPR, shock, and cardiac arrest
52
What is the location of the Brachial Pulse?
Upper arm, medial side
## Footnote
Important for infants (<1 year) and blood pressure measurement
53
Where can the Femoral Pulse be found?
Groin, near inguinal ligament
## Footnote
Used for assessing circulation in trauma/shock patients
54
What is the purpose of the Dorsalis Pedis Pulse?
Assessing peripheral circulation (diabetes, PAD)
## Footnote
Located on the top of the foot, between big toe and second toe
55
Where is the Posterior Tibial Pulse located?
Behind the medial ankle (inner ankle bone)
## Footnote
Used for assessing lower extremity perfusion
56
What is the definition of Tachycardia?
HR above normal range for age.
## Footnote
Tachycardia is often defined as a heart rate greater than 100 beats per minute in adults.
57
List three causes of Tachycardia.
* Fever
* Dehydration
* Anemia
## Footnote
Additional causes include pain, anxiety, stress, certain cardiac conditions, and stimulants.
58
What are two nursing actions for Tachycardia?
* Identify underlying cause and treat appropriately
* Monitor ECG for abnormal heart rhythms
## Footnote
Checking for additional symptoms like dizziness or chest pain is also crucial.
59
What is the definition of Bradycardia?
HR below normal range for age.
## Footnote
Bradycardia is typically defined as a heart rate less than 60 beats per minute in adults.
60
List two causes of Bradycardia.
* Hypothermia
* Electrolyte imbalances
## Footnote
Other causes include sleep, extreme relaxation, physiological bradycardia in athletes, and certain medications.
61
What is one nursing action for Bradycardia?
Check for symptoms of poor perfusion.
## Footnote
Symptoms may include dizziness, weakness, or fainting.
62
Fill in the blank: Tachycardia is defined as a heart rate above _______.
[normal range for age]
63
True or False: Stimulants can cause Tachycardia.
True
64
Fill in the blank: Bradycardia can be caused by _______ imbalances.
[electrolyte]
65
List two medications that can cause Bradycardia.
* Beta-blockers
* Opioids
## Footnote
Digoxin is another medication that can lead to bradycardia.
66
What is the respiratory rate (RR) for older adults (65+ years)?
12 – 25 bpm
## Footnote
Normal respiratory rates can vary by age.
67
What is the respiratory rate (RR) for school-age children (6-12 years)?
18 – 25 bpm
## Footnote
Respiratory rates differ across age groups.
68
What is the definition of Tachypnea?
RR >20 bpm in adults (varies by age)
## Footnote
Tachypnea indicates fast breathing.
69
List three causes of Tachypnea.
* Fever
* Anxiety
* Pain
* Asthma, COPD
* DKA
* any lung infection like pneumonia and bronchitis
## Footnote
Additional causes include lung infections, asthma, COPD, pulmonary embolism, and diabetic ketoacidosis.
70
What is the definition of Bradypnea?
RR <12 bpm in adults (varies by age)
## Footnote
Bradypnea indicates slow breathing.
71
List two causes of Bradypnea.
* Opioid overdose
* Head injuries
* Severe hypoxia because the body shuts down after a while
* Hypothyroidism
## Footnote
Other causes include hypothyroidism and severe hypoxia.
72
Infants breathe fast or slow
Fast
## Footnote
This is due to their higher metabolic needs.
73
What might cause an increased respiratory rate in elderly patients?
Decreased lung compliance
## Footnote
Age-related changes can affect respiratory patterns.
74
What is Kussmaul breathing?
Deep and RAPID breathing associated with diabetic ketoacidosis
75
What is Cheyne-Stokes Respiration?
Gradual increase, then decrease in RR, followed by apnea.
| fast slow stop
76
What conditions are associated with Cheyne-Stokes Respiration?
* Stroke
* Heart failure
* Brain damage
77
What is Biot’s Respiration?
Irregular, quick shallow breaths followed by apnea.
| fast stop fast stop
78
What conditions are associated with Biot’s Respiration?
* Brain trauma
* Meningitis
79
What factors can change oxygen saturation accuracy?
* Nail polish
* Dark skin
* Movement
80
What does blood pressure (BP) measure?
The force of circulating blood against arterial walls
## Footnote
Blood pressure is expressed in millimeters of mercury (mmHg)
81
What is Systolic Blood Pressure (SBP)?
The pressure exerted on artery walls when the heart contracts (top number)
82
What is Diastolic Blood Pressure (DBP)?
The pressure exerted on artery walls when the heart relaxes (bottom number)
83
What is the range for Stage 1 Hypertension?
130-139 / 80-89
84
What is the range for Stage 2 Hypertension?
≥140 / ≥90
85
What constitutes a Hypertensive Crisis?
≥180 / ≥120
86
What is considered Hypotension?
<90 / <60
87
True or False: Systolic Blood Pressure is the bottom number in a BP reading.
False
88
Fill in the blank: Diastolic Blood Pressure is the pressure exerted when the heart _______.
relaxes
89
What do the numbers in a blood pressure reading represent?
Systolic / Diastolic
90
What should be done if BP is irregular?
Measure again after 1-2 minutes
## Footnote
This ensures accuracy in the readings.
91
Why is it important to use the same arm for BP measurements?
For consistency in repeated measurements
## Footnote
Using the same arm helps to reduce variability in readings.
92
What should be done if BP is abnormally high or low?
Confirm with a second reading before reporting
## Footnote
This helps to ensure the reliability of the measurement.
93
What technology is used in automated blood pressure measurement?
An electronic BP cuff
## Footnote
It detects systolic and diastolic values.
94
What is a benefit of using an automated BP measurement?
Convenient for rapid assessments and monitoring trends
## Footnote
This allows for quick evaluations of blood pressure changes.
95
In which conditions is automated blood pressure measurement less accurate?
Irregular heart rhythms, low BP, or very high BP
## Footnote
These conditions can lead to unreliable readings.
96
How does arm position affect blood pressure readings?
Higher if below heart, lower if above heart
## Footnote
Proper arm positioning is critical for accurate BP measurements.
97
What is the importance of using the correct cuff size in BP measurements?
The bladder should cover 80% of arm circumference
## Footnote
An incorrect cuff size can lead to inaccurate blood pressure readings.
98
What is the definition of orthostatic hypotension?
BP drops ≥20 mmHg systolic or ≥10 mmHg diastolic when moving from lying → sitting → standing.
* Dizziness
* Weakness
* Fainting
.... after standing up during the assessment
## Footnote
This condition can indicate issues with blood volume or autonomic regulation.
99
What is the first step in the orthostatic hypotension assessment procedure?
Take BP while patient is lying supine.
## Footnote
This establishes a baseline measurement for comparison.
100
What should be done after taking BP while the patient is lying supine?
Take BP after 1-3 minutes of standing.
## Footnote
This helps assess changes in blood pressure due to postural changes.
101
What does a pulse strength grade of 0 indicate?
Absent. No pulse detected (use Doppler)
## Footnote
This indicates a critical situation requiring immediate attention.
102
What clinical significance is associated with a 1+ pulse strength?
Weak/Thready. Low cardiac output, shock, PAD
## Footnote
PAD refers to Peripheral Artery Disease.
103
What does a 2+ pulse strength signify?
Normal. Expected strength, normal perfusion
## Footnote
This indicates adequate blood flow and normal cardiovascular function.
104
What are the possible causes of a 3+ pulse strength?
Strong/Bounding. Anxiety, fever, hypertension
## Footnote
Strong bounding pulses can indicate increased stroke volume.
105
What conditions are associated with a 4+ pulse strength?
Full/Bounding. Fluid overload, sepsis, hyperthyroidism
## Footnote
These conditions can lead to an excessive volume of blood in circulation.
106
What condition can cause weak or absent pulses in the legs and feet?
Peripheral Arterial Disease (PAD)
## Footnote
PAD is a common circulatory problem in which narrowed arteries reduce blood flow to the limbs.
107
What is the definition of ptosis?
Drooping of the upper eyelid due to muscle or nerve dysfunction, injury, or disease
## Footnote
Ptosis can significantly affect vision and appearance.
108
List three causes of ptosis.
* Neurological Disorders: Stroke, Myasthenia Gravis, Horner’s Syndrome
* Aging: Weakening of eyelid muscles
* Trauma or Surgery: Eye injury or damage to cranial nerve III (oculomotor nerve)
## Footnote
Each cause can result in varying degrees of eyelid drooping and may require different treatment approaches.
109
What is a cataract?
A clouding of the eye’s lens leading to blurry, decreased, or loss of vision.
## Footnote
(Thompson, 2018, pg. 183)
110
What is the most common cause of cataracts?
Aging.
111
List three causes of cataracts.
* Aging
* Diabetes mellitus
* Prolonged sun exposure without UV protection
* long term corticosteroid use
112
What is a potential side effect of long-term corticosteroid use?
Cataracts.
113
What assessment findings are associated with cataracts?
* Cloudy or opaque lens visible through the pupil
* Blurred vision
* Glare sensitivity (especially at night)
* Loss of color vibrancy
114
What is the definition of Pterygium?
A gelatinous, abnormal growth of the conjunctiva, usually appearing on the nasal side of the eye
| terry complains so much he creates a lacrimal lake
## Footnote
(Thompson, 2018, pg. 190)
115
What are the causes of Pterygium?
Chronic sun exposure (UV radiation), dust, wind, or dry environments, genetic predisposition
## Footnote
None
116
What are some assessment findings for Pterygium?
Flesh-colored or pink triangular growth extending toward the cornea, may cause irritation, dryness, or vision impairment, visible blood vessels in the conjunctival growth
## Footnote
None
117
True or False: Pterygium typically appears on the temporal side of the eye.
False
## Footnote
Pterygium usually appears on the nasal side of the eye.
118
Fill in the blank: Pterygium is caused by chronic _______ exposure.
[sun]
## Footnote
UV radiation is a significant factor.
119
What color is the growth associated with Pterygium?
Flesh-colored or pink
## Footnote
This growth extends toward the cornea.
120
What symptoms may Pterygium cause?
Irritation, dryness, or vision impairment
## Footnote
Symptoms can vary in severity.
121
What is a visible characteristic of the conjunctival growth in Pterygium?
Visible blood vessels
## Footnote
These blood vessels are part of the abnormal growth.
122
What is the role of the oropharynx?
The oropharynx plays a key role in speech, breathing, and swallowing.
123
What is the importance of proper airway closure?
Proper closure of the airway prevents aspiration of food and liquids.
124
What does coughing while eating/drinking indicate?
Possible impaired airway closure.
125
What does a wet or gurgling voice suggest?
Secretions in airway post-swallow.
126
What is a risk associated with recurrent pneumonia?
Silent aspiration risk.
127
What does drooling or food pocketing indicate?
Difficulty managing oral secretions.
128
What should be done for at-risk patients?
Refer at-risk patients to speech-language pathologists for swallow studies.
129
What is Jugular Venous Distention (JVD)?
Bulging of the jugular vein due to increased central venous pressure (CVP).
## Footnote
This condition can indicate underlying cardiovascular issues.
130
What are the causes of Jugular Venous Distention (JVD)?
* Heart failure
* Fluid overload
* Pericardial tamponade
## Footnote
These causes lead to increased pressure in the jugular veins.
131
What is the first step in assessing for JVD?
Position patient at 45-degree angle.
## Footnote
This position helps in accurately observing the jugular vein.
132
How do you determine if JVD is present?
If vein is distended >3cm above sternal angle, JVD is present (abnormal).
## Footnote
This measurement indicates increased central venous pressure.
133
What does the presence of JVD suggest?
Heart failure or volume overload.
## Footnote
JVD is a significant clinical sign that may indicate serious health issues.
134
What should be assessed alongside JVD?
* Edema
* Crackles
## Footnote
These signs are indicative of fluid overload.
135
What is the indentation depth for Grade 1+ edema?
2mm depression
## Footnote
Grade 1+ edema is classified as mild edema.
136
What is the rebound time for Grade 1+ edema?
Immediate rebound
## Footnote
This indicates a quick return to normal after pressure is released.
137
What is the indentation depth for Grade 2+ edema?
4mm depression
## Footnote
Grade 2+ edema is classified as moderate edema.
138
What is the rebound time for Grade 2+ edema?
Rebounds in a few seconds
## Footnote
This indicates a moderate response to pressure release.
139
What is the indentation depth for Grade 3+ edema?
6mm depression
## Footnote
Grade 3+ edema is classified as severe edema.
140
What is the rebound time for Grade 3+ edema?
Rebounds in 10-20 seconds
## Footnote
This indicates a slower response to pressure release compared to lower grades.
141
What is the indentation depth for Grade 4+ edema?
8mm depression
## Footnote
Grade 4+ edema is classified as very severe edema.
142
What is the rebound time for Grade 4+ edema?
Lasts >30 seconds
## Footnote
This indicates a significantly delayed response to pressure release.
143
What should be assessed for in lower extremities?
Pitting edema
## Footnote
Pitting edema is an indication of fluid retention and may signal underlying health issues.
144
What should be monitored for as a sign of fluid retention?
Weight gain
## Footnote
Weight gain can indicate fluid overload, which may require further assessment and intervention.
145
What action should be taken if pitting edema is noted?
Elevate legs and consider diuretic therapy if indicated
## Footnote
Elevating the legs can help reduce swelling, while diuretics can assist in fluid removal.
146
What are bruits?
Abnormal, turbulent, blowing sounds heard over arteries due to partial or total obstruction.
147
What do bruits indicate?
Altered blood flow.
148
What is the most common cause of bruits?
Atherosclerosis (plaque buildup in arteries).
149
How are bruits best heard?
With the bell of the stethoscope due to their low-pitched nature.
150
What is the significance of carotid bruits?
They indicate a risk of stroke.
151
What do abdominal bruits suggest?
Aneurysm or stenosis.
152
What condition is associated with renal bruits?
Renal artery stenosis or hypertension.
153
What do peripheral bruits indicate?
Peripheral artery disease.
154
Fill in the blank: Bruits are commonly assessed over the _______.
carotid arteries, abdominal aorta, renal arteries, iliac and femoral arteries.
155
What is a Venous Hum?
Continuous medium-pitched sound caused by turbulent blood flow in a large vascular organ
## Footnote
Commonly associated with increased blood flow to the liver (portal hypertension) and best heard in the epigastric region (above umbilicus)
156
What causes a Venous Hum?
Increased blood flow to the liver (portal hypertension)
## Footnote
This condition leads to turbulent blood flow, creating the characteristic sound.
157
Where is a Venous Hum best heard?
Epigastric region (above umbilicus)
## Footnote
This location is critical for identifying the sound during a physical examination.
158
What is a Friction Rub?
Grating sound caused by inflamed organs rubbing against each other
## Footnote
This sound indicates inflammation of the peritoneum or organs like the liver and spleen.
159
What are common causes of a Friction Rub?
Peritonitis, liver/spleen inflammation
## Footnote
These conditions lead to the rubbing sound characteristic of a friction rub.
160
Where is a Friction Rub best heard?
Right Upper Quadrant (RUQ – liver), Left Upper Quadrant (LUQ – spleen)
## Footnote
Knowing the specific quadrants aids in localizing the source of the sound.
161
What do venous hums suggest?
Increased blood flow (e.g., liver disease, pregnancy)
## Footnote
Venous hums can indicate significant physiological changes.
162
What do friction rubs indicate?
Inflammation of serous membranes (peritoneal friction rub)
## Footnote
This is often associated with conditions like peritonitis.
163
What should be done if friction rubs are heard over the liver or spleen?
Further assessment for hepatosplenomegaly is required
## Footnote
Hepatosplenomegaly can indicate underlying systemic diseases.
164
What causes Peripheral Artery Disease (PAD)?
Arterial narrowing (atherosclerosis)
## Footnote
Atherosclerosis is the buildup of fats, cholesterol, and other substances in and on the artery walls.
165
What type of pain is associated with Peripheral Artery Disease (PAD)?
Intermittent claudication (pain with walking)
## Footnote
This pain typically resolves with rest.
166
What skin changes are observed in Peripheral Artery Disease (PAD)?
Cool, pale, shiny skin; no hair growth
## Footnote
These changes indicate poor blood flow to the extremities.
167
What type of ulcers are associated with Peripheral Artery Disease (PAD)?
Deep, punched-out ulcers on toes, feet
## Footnote
These ulcers are often painful and difficult to heal.
168
What is the status of pulses in Peripheral Artery Disease (PAD)?
Weak or absent
## Footnote
This indicates reduced blood flow.
169
What is the level of edema in Peripheral Artery Disease (PAD)?
Minimal
## Footnote
Edema is not a common feature in PAD.
170
What relief measures are recommended for Peripheral Artery Disease (PAD)?
Rest, dangling legs
## Footnote
These measures help improve blood flow to the affected areas.
171
What causes Chronic Venous Insufficiency (CVI)?
Weak or damaged veins (varicose veins)
## Footnote
Varicose veins can lead to chronic issues with blood return.
172
What type of pain is associated with Chronic Venous Insufficiency (CVI)?
Dull, aching pain (worse with standing)
## Footnote
This pain often improves with leg elevation.
173
What skin changes are observed in Chronic Venous Insufficiency (CVI)?
Warm, swollen, brownish discoloration
## Footnote
These changes are due to pooled blood and fluid.
174
What type of ulcers are associated with Chronic Venous Insufficiency (CVI)?
Shallow ulcers around ankles
## Footnote
These ulcers are often less painful than arterial ulcers.
175
What is the status of pulses in Chronic Venous Insufficiency (CVI)?
Normal
## Footnote
Pulses are typically intact due to preserved arterial flow.
176
What is the level of edema in Chronic Venous Insufficiency (CVI)?
Severe (worsens throughout the day)
## Footnote
Edema is a hallmark of CVI due to venous pooling.
177
What relief measures are recommended for Chronic Venous Insufficiency (CVI)?
Elevating legs
## Footnote
Elevation helps reduce swelling and improve venous return.
178
What is required when weak or absent pulses are detected?
Immediate further evaluation (Doppler, ABI test)
## Footnote
These tests assess blood flow and vascular health.
179
What type of therapy is required for venous ulcers?
Compression therapy
## Footnote
Compression helps improve venous return and reduce swelling.
180
What type of therapy is needed for arterial ulcers?
Improved circulation
## Footnote
This may include lifestyle changes and medical interventions.
181
What should be monitored for in venous disease?
Signs of deep vein thrombosis (DVT)
## Footnote
DVT is a serious condition that can lead to pulmonary embolism.
182
What does ABI stand for?
Ankle-Brachial Index
## Footnote
ABI is used to assess blood flow and diagnose PAD.
183
What is the purpose of the ABI test?
To compare blood pressure in the ankles versus the arms
## Footnote
It is a non-invasive test.
184
What is the formula for calculating ABI?
ABI = Ankle Systolic BP / Brachial Systolic BP
## Footnote
This formula helps in determining the presence of PAD.
185
What is considered a normal ABI range?
1.0 - 1.4
## Footnote
This indicates equal or higher blood pressure in the ankles than in the arms.
186
What does an ABI value of less than 0.9 indicate?
Peripheral Artery Disease (PAD)
## Footnote
This threshold is critical for diagnosing PAD.
187
What is DVT?
DVT is a life-threatening condition caused by a blood clot in a deep vein (usually in the leg)
## Footnote
DVT stands for Deep Vein Thrombosis.
188
What is a key symptom of DVT?
Unilateral leg swelling
## Footnote
This means one leg is significantly larger than the other.
189
Where is pain typically located in DVT?
Usually in calf or thigh
## Footnote
Pain and tenderness are common symptoms of DVT.
190
What might cause warmth and redness in a DVT patient?
Due to inflammation and clot
## Footnote
These signs are associated with the presence of a blood clot.
191
What is Positive Homan’s Sign?
Pain in the calf when dorsiflexing the foot
## Footnote
This sign is not always reliable for diagnosing DVT.
192
What is the first nursing consideration for DVT?
DVT requires immediate anticoagulation therapy (e.g., Heparin, Warfarin)
## Footnote
Anticoagulation is critical to prevent complications.
193
What should you NOT do with the affected leg in DVT?
Do NOT massage the affected leg
## Footnote
Massaging may dislodge the clot and lead to pulmonary embolism.
194
What are two interventions to encourage in high-risk DVT patients?
Early ambulation and compression stockings
## Footnote
These interventions help prevent DVT complications.
195
menumonic for remembering diastolic murmurs
ARMS
| after S2 and before S1
196
197
What does a grade of I/VI signify?
Barely audible, requires focused listening
## Footnote
This is the lowest grade in the grading scale for sound.
198
What is the description for a grade II/VI?
Soft, but easily heard
## Footnote
This grade indicates a sound that is not as faint as I/VI.
199
Define grade III/VI.
Moderately loud
## Footnote
This grade represents a sound that can be heard without difficulty.
200
What characterizes a grade IV/VI?
Loud with a palpable thrill
## Footnote
This grade indicates a sound that is not only loud but also has a vibration sensation.
201
What is the meaning of grade V/VI?
Very loud, heard with a stethoscope barely touching chest
## Footnote
This grade indicates a very pronounced sound.
202
What does a grade VI/VI indicate?
Extremely loud, heard without a stethoscope
## Footnote
This is the highest grade in the grading scale for sound.
203
What is a Holosystolic (Pansystolic) murmur?
A murmur heard throughout systole.
204
What is cyanosis?
Bluish discoloration of the skin and mucous membranes due to poor oxygenation of hemoglobin in the blood.
205
What are the two types of cyanosis?
* Central (systemic hypoxia)
* Peripheral (localized circulation issue)
206
What are the best sites for assessing central cyanosis?
* Lips
* Oral mucosa
* Conjunctiva
* Tongue
207
What are the best sites for assessing peripheral cyanosis?
* Fingertips
* Toes
* Earlobes
208
What is central cyanosis?
Bluish discoloration in the lips, tongue, oral mucosa, and conjunctiva due to low arterial oxygen saturation (<85%)
## Footnote
Central cyanosis indicates severe hypoxia and requires immediate assessment.
209
What are some causes of central cyanosis?
* Severe hypoxia (pneumonia, respiratory failure, COPD exacerbation)
* Congenital heart defects (Tetralogy of Fallot, transposition of great arteries)
* Pulmonary embolism, ARDS, or shock
## Footnote
These conditions can lead to insufficient oxygenation of the blood.
210
Where is central cyanosis best assessed?
In the oral mucosa, tongue, and conjunctiva
## Footnote
These areas provide a clear indication of oxygen saturation in the blood.
211
Does central cyanosis improve with warming?
No, it does NOT improve with warming
## Footnote
This differentiates it from peripheral cyanosis, which may improve with warming.
212
What is a key nursing consideration when assessing for central cyanosis?
Assess SpO₂ with pulse oximetry (normal = 95-100%; concern if <90%)
## Footnote
Monitoring oxygen saturation is crucial for determining the severity of hypoxia.
213
What should be administered if oxygen levels are low in a patient with central cyanosis?
Supplemental oxygen
## Footnote
Supplemental oxygen helps to increase arterial oxygen saturation and improve the patient's condition.
214
What does Jugular Vein Distention (JVD) refer to?
Visible enlargement or bulging of the external jugular veins due to increased central venous pressure (CVP)
## Footnote
JVD is assessed to evaluate cardiac function and fluid status.
215
What is considered a normal finding for JVD?
No visible JVD or pulsations when the patient is sitting upright
216
What is considered an abnormal finding for JVD?
Jugular vein distension greater than 3 cm above the sternal angle at a 45-degree angle
217
What condition does increased JVD suggest?
Increased right atrial pressure or heart failure
218
What causes blood to back up into the venous system in right-sided heart failure?
Weakened right ventricle
219
What is Superior Vena Cava (SVC) Syndrome?
Blockage of the SVC that prevents venous drainage from the upper body
220
What effect does pulmonary hypertension have on the heart?
Increases right heart workload, leading to venous congestion
221
What is pericardial tamponade?
Fluid in the pericardium compresses the heart, reducing venous return
222
What condition causes the heart to not expand fully, leading to venous backup?
Constrictive pericarditis
223
What is a hallmark sign of right-sided heart failure?
JVD
## Footnote
JVD stands for jugular venous distension.
224
What accompanying symptoms should be assessed with JVD?
* Edema
* Hepatomegaly
* Ascites
## Footnote
These symptoms indicate potential fluid overload.
225
What diagnostic tests should be considered if JVD is present?
* Chest X-ray
* Echocardiogram
## Footnote
These tests help evaluate heart structure and function.
226
What is the first step in the JVD assessment?
Position the patient at a 45-degree angle (semi-Fowler’s position).
227
How should the patient's head be positioned during JVD assessment?
Turn the patient’s head slightly to the left to expose the right jugular vein.
228
What is the purpose of using good lighting during JVD assessment?
To observe the vein along the sternocleidomastoid muscle.
229
What height of JVD above the sternal angle is considered abnormal?
Greater than 3 cm.
230
What does an increase in JVD during hepatojugular reflux assessment suggest?
Fluid overload or heart failure.
231
What should be suspected if JVD is greater than 3 cm above the sternal angle?
Heart failure or fluid overload.
232
What should be compared during the JVD assessment?
Findings bilaterally.
233
What are associated symptoms to check for during JVD assessment?
Dyspnea or peripheral edema.
234
What may visible pulsations indicate when the patient is upright?
Severe venous congestion.
235
Define peripheral edema.
Localized or generalized swelling due to fluid accumulation in the interstitial space.
236
In which conditions is peripheral edema commonly seen?
* Heart failure
* Kidney disease
* Liver disease
* Venous insufficiency
237
What is a normal finding regarding peripheral edema?
No visible swelling, firm skin, or pitting when pressing on extremities.
238
What characterizes an abnormal finding in peripheral edema?
Swelling, pitting (indentation when pressed), and stretched or shiny skin.
239
What causes peripheral edema in heart failure?
Blood backs up into the systemic circulation, leading to fluid retention in the legs and feet.
## Footnote
This is particularly related to right-sided heart failure.
240
What is the mechanism behind chronic venous insufficiency?
Damaged veins cause blood pooling in the lower extremities.
## Footnote
This condition often results in swelling and discomfort.
241
How does kidney disease contribute to peripheral edema?
The kidneys fail to remove excess fluid, leading to widespread swelling.
## Footnote
This can result in significant fluid retention throughout the body.
242
What role does liver disease (cirrhosis) play in peripheral edema?
Low albumin reduces oncotic pressure, allowing fluid to leak into tissues.
## Footnote
This can lead to significant fluid accumulation in various body areas.
243
What causes unilateral swelling in deep vein thrombosis (DVT)?
A clot in a deep vein blocks venous return, causing unilateral swelling.
## Footnote
This is a critical condition that requires immediate medical attention.
244
What is lymphedema and how does it affect peripheral edema?
Blockage of the lymphatic system prevents normal drainage, leading to firm, non-pitting edema.
## Footnote
This condition often results in swelling that does not leave an indentation when pressed.
245
What is a key nursing consideration regarding edema in heart failure?
Edema in heart failure is often bilateral and worse in the lower extremities.
## Footnote
This is important for monitoring and treatment strategies.
246
What does unilateral edema suggest in a patient?
Unilateral edema suggests DVT or lymphatic obstruction.
## Footnote
Quick assessment is vital to rule out serious conditions.
247
What is generalized edema also known as?
Anasarca.
## Footnote
It is seen in severe kidney or liver disease.
248
What is a characteristic of heart failure-related edema?
Worsens in the evening due to fluid shifts from gravity.
## Footnote
Accompanied by JVD, dyspnea, and weight gain.
249
What treatments are used for heart failure-related edema?
Diuretics (e.g., furosemide) and fluid restriction.
## Footnote
These treatments help manage fluid overload.
250
What are the signs of DVT-related edema?
Unilateral swelling, redness, and warmth.
## Footnote
Painful calf tenderness (Homan’s sign may be positive).
251
What is required for the diagnosis of DVT-related edema?
Anticoagulation therapy and ultrasound confirmation.
## Footnote
This helps in managing the condition effectively.
252
What type of edema is characterized as non-pitting and firm?
Lymphedema.
## Footnote
It is due to lymphatic obstruction.
253
Who is most commonly affected by lymphedema?
Cancer patients after lymph node removal.
## Footnote
This condition can arise due to surgical complications.
254
What treatments are typically used for lymphedema?
Compression therapy and lymphatic drainage.
## Footnote
These methods aim to reduce swelling and improve lymphatic flow.
