NUR 310 Exam 1 Terms

normal respiratory rate
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Terms in this set (89)
vesicular breath soundsNORMAL, soft, low-pitched rustling sounds located over the PERIPHERY of the lungsBronchovesicular breath soundsNORMAL, moderately pitched breath sounds located between the scapulae posteriorly and on either side of the sternum at the 1 ICS and 2 ICS anteriorly, UPPER BACK and DOWN from thereBronchial/Tracheal breath soundsNORMAL, loud, high-pitched tubular sounds located over the trachea and major bronchi, ALONG THROATcrackles (rales)ABNORMAL, air traveling through vessels containing abnormal moisture (ex. congested heart failure, pneumonia)wheezesABNORMAL, high-pitched sounds produced by air passing through a narrowed passageway in the SMALL airwaysrhonchiABNORMAL, coarse rattling sounds more like a snore, moan, or groan caused by narrowed or constricted LARGE airwayspleural friction rubsABNORMAL, crackling, grating sounds produced when 2 roughened or inflamed pleural spaces rub across each other, inflammation of lungs against chest wall causes thisstridorABNORMAL, loud, high-pitched crowing sound heard usually without a stethoscope during inspiration, upper airway obstructiontachypnearapid, shallow breathing, greater than 20-24 breaths/minbradypneaslow breathing, decreased but regular rate, less than 10-12 breaths/minapneatotal absence of breathing, may be periodichyperpneaincrease DEPTH of respirations, rate can still be normalhyperventilationincreased DEPTH and RATE of breathing that exceeds body's need to remove CO2hypoventilationirregular shallow (DEPTH) breath patternCheyne-Stokesrespirations gradually wax and wane in a REGULAR pattern, depth and rate increases, then decreases, 30-45 secondsBiots (ataxic breathing)like cheyne-stokes, but IRREGULAR pattern, series of normal respirations followed by period of apnea, 10 seconds to 1 minuteKussmaul'sa panting labored kind of respiration with increased rate and depth, severe (mortality rate high w/ this)1 kg weight1 L fluid pumped, 2.2 lbsaortic area2nd ICS to right sternal borderpulmonic area2nd ICS to the left sternal borderErb's point3rd ICS to the left sternal bordertricuspid area4th or 5th ICS to the left sternal bordermitral area (apical area)5th ICS medial to the midclavicular line, 1/2 through nipple, MAX impulseepigastric areaarea overlying the xiphoid process, correlates with aortaS1"lub", first heart sound, closure of bicuspid (mitral) and tricuspid valves, ATRIOVENTRICULARS2"dub", second heart sound, closure of aortic and pulmonary valves, SEMILUNARsplit S1bicuspid (mitral) and tricuspid valves not closing together, can be normalsplit S2aortic and pulmonary valves not closing together, can be normalejection clickmovement of a stiffly deformed valve, short, high-pitchedmidsystolic clickshort, high-pitched, abnormal ballooning of part of the MITRAL valve into the left atrium, sounds like a "click"S3immediately AFTER S2, rapid filling of ventricles in early diastole, USE BELL b/c dull, low-pitchedphysiologic S3children, young adults, especially women, disappears when sit uppathologic S3called a VENTRICULAR GALLOP, can be early sign of heart failure and volume overloadS4immediately BEFORE S1, use bell b/c dull, low-pitched, best heard at mitral areaphysiologic S4may occur in adults older than 40-50 years with no evidence of cardiovascular disease, especially after exercisepathologic S4called ATRIAL GALLOP, decreased compliance of the ventricle, systolic overloadmurmurharsh, rumbling, blowing sound, turbulent blood flow, caused by congenital and acquired valvular defectsgrade i murmurbarely audible, heard only in a quiet room and then with difficultygrade ii murmurclearly audible but faintgrade iii murmurmoderately loud, easy to heargrade iv murmurloud, associated with thrillgrade v murmurvery loud, heard with one corner of the stethoscope lifted off the chest wallgrade vi murmurLoudest, still heard with entire stethoscope lifted just off the chest wall, associated thrillfirst-level priority problemsABC (airway, breathing, circulation), emergent, life-threatening, and immediate, such as establishing an airway or supporting breathingsecond-level priority problemsnext in urgency; require prompt intervention to prevent deterioration, and may include a mental status change, acute pain, abnormal lab valuesthird-level priority problemsthose that are important to the patient's health but can be addressed after more urgent health problems are addressed /health interview questions (PLEASE)Past medical history, Last oral intake, Events leading to illness, Allergies, Symptoms, Each prescribed medication/OTC med/herbal supplementsGravida (obstetrical)the number of pregnanciesTerm (obstetrical)number of term deliveriesPreterm (obstetrical)number of preterm deliveriesAbortions (obstetrical)either elective or spontaneousLiving (obstetrical)current number of living childrenoral temperature98.6 normal, range is 96.8-100.4 (36-38 degrees C)rectal temperatureSUBTRACT 1 degree, most accurate but too invasive in most casestemporal temperatureADD 1 degree, forehead, write TA next to temperature on chartaxillary temperatureADD 1 degree, armpit, write Ax next to temperature on chartnormal heart (pulse) rate60-100 beats/minbradycardiaslow HR, heart rate less than 60 beats/min, can be normal in athletestachycardiafast HR, heart rate greater than 100 beats/minasystoleabsence of a pulse0 quality pulseabsent+1 quality pulsea weak, thready, diminished pulse+2 quality pulsenormal, brisk pulse (EXPECTED)+3 quality pulseincreased, strong pulse (variation of normal)+4 quality pulsebounding, full volume pulseFactors that contribute to blood pressurecardiac output, peripheral vascular resistance, circulating blood volume, blood viscosity, elasticity of vessel wallshypotensionsystolic less than 90, <90, less than 30 SBP BELOW patient's normal is emergencyhypertensionnot based on one BP reading, over 6 months abnormally highskin assessment of abnormal lesionsABCDE (asymmetry, border irregularity, color, diameter >6mm, elevation/enlargementpetechiaetiny red dots, capillaries burstingecchymosisbruisingpurpuraextreme bruising, age spots in elderlyprimary lesionslesions arising from previously intact skinflat primary lesionsmacule, patchraised primary lesionspapule, plaqueraised, solid primary lesionswheal, nodule, tumorraised, fluid-filled primary lesionsvesicle, bulla, pustule, cystsecondary lesionsevolve from primary lesions, changes to skin surface, debris on skin surface, alteration to skin integritypotentially malignant lesionspresence of skin cancer