CCBC NURN155 Exam 1
ABCDE Pain Assessment - ✅✅-Ask
Believe
Choose
Deliver
Empower
Abnormal lung sounds - ✅✅-wheezing, crackles and silent chest
acute pain - ✅✅-short-term, self-limiting, often predictable trajectory; stops after
injury heals
Alterations in the Cardiovascular System - ✅✅--Dysrhythmia or arrhythmia
-Myocardial ischemia
-Angina
-Myocardial infarction
-Heart failure
Analyze Vital Signs - ✅✅ -- Compare to normal ranges
- Compare to patient's baseline
- Compare to patient's trends
- Assess for factors that could affect the patient's VS
Angiography - ✅✅ -Contrast material is injected
Visualization of the structure and patency of blood vessels
** Contraindications-allergies to shellfish or iodinated dye, renal failure
Anthropometric Measurements - ✅✅
-Height
Weight
Waist, Arm and Head Circumference
Skin fold Thickness
Apical Pulse - ✅✅-Most accurate
Place the stethoscope in the 5th intercostal space to the left of the sternum and
slightly medial of the left mid-clavicular line
,Apnea - ✅✅-Absence of breathing
attention - ✅✅-focusing awareness on a narrowed range of stimuli or events
Auscultation Points - ✅✅-
AVPU scale - ✅✅-Alert, Verbal, Painful, Unresponsive
Axillary average temp - ✅✅-Arm Pit [avg 36.5°C (97.7°F)]
B-type Natriuretic Peptide - ✅✅-- Neurohormone secreted in response to
elevated ventricular pressure.
- Normal < 100 pg/mL
*Elevated is a marker for heart failure
bedside shift report - ✅✅ -examine IVs, patient and receive report at the
patient's bedside to fill gaps in knowledge before the off-going nurse leaves
* be aware of HIPAA when the pt. has a roommate
Blood Pressure - ✅✅-<120/80
Blood Pressure Health Promotion - ✅✅ -- Teach normal values
- Risks for hypertension
- Teach caregiver or patient how to take BP
Brachial Pulse - ✅✅-Use in infants/children
Auscultated in BP
✅✅-Slow heart rate
Bradycardia -
Bradypnea - ✅✅-Abnormally slow breathing
Brawny Edema - ✅✅-Chronic edema, with discoloration of the extremity,
occurs with long standing swelling. This rarely abates and does not pit with
pressure
, ✅✅-vesicular, bronchovesicular, bronchial
breath sounds -
CAGE questionnaire - ✅✅-Have you ever felt you should Cut down on your
drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves
(Eye-opener)?
cancer pain - ✅✅ -often due to the compression of peripheral nerves or
meninges or from the damage to these structures following surgery,
chemotherapy, radiation, or tumor growth and infiltration
Capillary Refill - ✅✅ -- Depress and blanch nail beds - release and note time for
color return
- Normal if color returns in 1-2 seconds
✅✅-Heart rate x Stroke volume
Cardiac Output -
care plan - ✅✅-a written plan for each resident created by a nurse; outlines the
steps taken by the staff to help the resident reach his or her goals
Carotid Bruit -✅✅ -Noise from carotid artery narrowing heard with stethoscope
(blowing/swishing sound)
Carotid Pulse - ✅✅ -Closest to heart, use in emergency
Never palpate both sides!
Reflects heart function best
central perfusion - ✅✅ -force of blood movement generated by cardiac output;
requires adequate cardiac function, blood pressure, and blood volume
Central Perfusion Collaborative Interventions - ✅✅-Pacemaker insertion
Electrical cardioversion
Ablation therapy
Intraaortic balloon pump
ABCDE Pain Assessment - ✅✅-Ask
Believe
Choose
Deliver
Empower
Abnormal lung sounds - ✅✅-wheezing, crackles and silent chest
acute pain - ✅✅-short-term, self-limiting, often predictable trajectory; stops after
injury heals
Alterations in the Cardiovascular System - ✅✅--Dysrhythmia or arrhythmia
-Myocardial ischemia
-Angina
-Myocardial infarction
-Heart failure
Analyze Vital Signs - ✅✅ -- Compare to normal ranges
- Compare to patient's baseline
- Compare to patient's trends
- Assess for factors that could affect the patient's VS
Angiography - ✅✅ -Contrast material is injected
Visualization of the structure and patency of blood vessels
** Contraindications-allergies to shellfish or iodinated dye, renal failure
Anthropometric Measurements - ✅✅
-Height
Weight
Waist, Arm and Head Circumference
Skin fold Thickness
Apical Pulse - ✅✅-Most accurate
Place the stethoscope in the 5th intercostal space to the left of the sternum and
slightly medial of the left mid-clavicular line
,Apnea - ✅✅-Absence of breathing
attention - ✅✅-focusing awareness on a narrowed range of stimuli or events
Auscultation Points - ✅✅-
AVPU scale - ✅✅-Alert, Verbal, Painful, Unresponsive
Axillary average temp - ✅✅-Arm Pit [avg 36.5°C (97.7°F)]
B-type Natriuretic Peptide - ✅✅-- Neurohormone secreted in response to
elevated ventricular pressure.
- Normal < 100 pg/mL
*Elevated is a marker for heart failure
bedside shift report - ✅✅ -examine IVs, patient and receive report at the
patient's bedside to fill gaps in knowledge before the off-going nurse leaves
* be aware of HIPAA when the pt. has a roommate
Blood Pressure - ✅✅-<120/80
Blood Pressure Health Promotion - ✅✅ -- Teach normal values
- Risks for hypertension
- Teach caregiver or patient how to take BP
Brachial Pulse - ✅✅-Use in infants/children
Auscultated in BP
✅✅-Slow heart rate
Bradycardia -
Bradypnea - ✅✅-Abnormally slow breathing
Brawny Edema - ✅✅-Chronic edema, with discoloration of the extremity,
occurs with long standing swelling. This rarely abates and does not pit with
pressure
, ✅✅-vesicular, bronchovesicular, bronchial
breath sounds -
CAGE questionnaire - ✅✅-Have you ever felt you should Cut down on your
drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves
(Eye-opener)?
cancer pain - ✅✅ -often due to the compression of peripheral nerves or
meninges or from the damage to these structures following surgery,
chemotherapy, radiation, or tumor growth and infiltration
Capillary Refill - ✅✅ -- Depress and blanch nail beds - release and note time for
color return
- Normal if color returns in 1-2 seconds
✅✅-Heart rate x Stroke volume
Cardiac Output -
care plan - ✅✅-a written plan for each resident created by a nurse; outlines the
steps taken by the staff to help the resident reach his or her goals
Carotid Bruit -✅✅ -Noise from carotid artery narrowing heard with stethoscope
(blowing/swishing sound)
Carotid Pulse - ✅✅ -Closest to heart, use in emergency
Never palpate both sides!
Reflects heart function best
central perfusion - ✅✅ -force of blood movement generated by cardiac output;
requires adequate cardiac function, blood pressure, and blood volume
Central Perfusion Collaborative Interventions - ✅✅-Pacemaker insertion
Electrical cardioversion
Ablation therapy
Intraaortic balloon pump
