NR 304 HEALTH ASSESSMENT II EXAM X CONCEPTS
Steps to Setting Priorities: ABCV: 1st, 2nd, 3rd level priorities pg. 4
1st Priority Remember “ABCs plus V”
● Airway problems
● Breathing problems
● Cardiac/circulation problems
● Vital sign concerns (e.g. high fever)
Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest,
begin chest compressions immediately
2nd Priority ● Mental status change (e.g. confusion, ↓ alertness)
● Untreated medical problems requiring immediate attention (e.g. a
person w diabetes who has not had insulin)
● Acute pain
● Acute urinary elimination problems
● Abnormal laboratory values
● Risks of infection, safety, or security (for the patient or others)
3rd Priority ● Health problems that do not fit into the previous categories (e.g.
problems with lack of knowledge, activity, rest, family coping)
Abnormal Respiratory Patterns: Hyperventilation v. Hypoventilation pg. 444
HYPERventilation HYPOventilation
↑ in both rate + depth Irregular shallow pattern caused by an
Normally occurs with extreme exertion, fear, overdose of narcotics or anesthetics
or anxiety + with diabetic ketoacidosis May also occur w prolonged bed rest or
(Kussmaul respirations), hepatic coma, conscious splinting of chest to avoid
salicylate overdose (producing a respiratory respiratory pain
alkalosis to compensate for the metabolic
acidosis), lesions of midbrain, alteration in Slow + shallow
blood gas concentration ( either ↑ in CO2 or ↓ ↑CO2
in oxygen)
Hyperventilation blows off CO2 caused ↓ level
in the blood (alkalosis)
Rapid + deep
↓ CO2
, Auscultation of the Heart: Preparation Technique, Locations
All People Eat Tasty Meals = Aortic Pulmonic Erb’s point Tricuspid Mitral
Preparation: warm room, quiet, privacy (females breast covered)
Locations: Aortic- 2nd ICS RSB; Pulmonic - 2nd ICS LSB; Erbs - 3rd ICS LSB; Tricuspid - 4
ICS LSB; Mitral - 5th ICS midclavicular
1. Note rate and rhythm
2. Identify S1 S2
3. Assess S1 S2
4. Listen for extra heart sounds
5. Listen for murmurs
Clinical Portrait of Heart Failure pg. 495
*Notes to remember*
Left-sided heart failure occurs when the left ventricle doesn't pump efficiently. This prevents
your body from getting enough oxygen-rich blood. The blood backs up into your lungs instead
→ will see pulmonary s/s
Steps to Setting Priorities: ABCV: 1st, 2nd, 3rd level priorities pg. 4
1st Priority Remember “ABCs plus V”
● Airway problems
● Breathing problems
● Cardiac/circulation problems
● Vital sign concerns (e.g. high fever)
Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest,
begin chest compressions immediately
2nd Priority ● Mental status change (e.g. confusion, ↓ alertness)
● Untreated medical problems requiring immediate attention (e.g. a
person w diabetes who has not had insulin)
● Acute pain
● Acute urinary elimination problems
● Abnormal laboratory values
● Risks of infection, safety, or security (for the patient or others)
3rd Priority ● Health problems that do not fit into the previous categories (e.g.
problems with lack of knowledge, activity, rest, family coping)
Abnormal Respiratory Patterns: Hyperventilation v. Hypoventilation pg. 444
HYPERventilation HYPOventilation
↑ in both rate + depth Irregular shallow pattern caused by an
Normally occurs with extreme exertion, fear, overdose of narcotics or anesthetics
or anxiety + with diabetic ketoacidosis May also occur w prolonged bed rest or
(Kussmaul respirations), hepatic coma, conscious splinting of chest to avoid
salicylate overdose (producing a respiratory respiratory pain
alkalosis to compensate for the metabolic
acidosis), lesions of midbrain, alteration in Slow + shallow
blood gas concentration ( either ↑ in CO2 or ↓ ↑CO2
in oxygen)
Hyperventilation blows off CO2 caused ↓ level
in the blood (alkalosis)
Rapid + deep
↓ CO2
, Auscultation of the Heart: Preparation Technique, Locations
All People Eat Tasty Meals = Aortic Pulmonic Erb’s point Tricuspid Mitral
Preparation: warm room, quiet, privacy (females breast covered)
Locations: Aortic- 2nd ICS RSB; Pulmonic - 2nd ICS LSB; Erbs - 3rd ICS LSB; Tricuspid - 4
ICS LSB; Mitral - 5th ICS midclavicular
1. Note rate and rhythm
2. Identify S1 S2
3. Assess S1 S2
4. Listen for extra heart sounds
5. Listen for murmurs
Clinical Portrait of Heart Failure pg. 495
*Notes to remember*
Left-sided heart failure occurs when the left ventricle doesn't pump efficiently. This prevents
your body from getting enough oxygen-rich blood. The blood backs up into your lungs instead
→ will see pulmonary s/s
