CV/PV
aortic
pulmonic
erbs
tricuspid
mitral
describe the three normal breath sounds (bronchial, bronchovesicular, vesicular)
bronchial: blowing, hollow sounds heard over the larynx and trachea (expiration is longer)
bronchialvesicular: medium pitched/intensity blowing sound heard over the first and second intercostal spaces (inspiration/expiration equal)
vesicular: soft, low-pitched whispering sounds heard over most of lung field (inspiration is longer)
order: 7.5 mg
available: 2 mg/5 mL solution
how many mL should you give? Round to tenths
18.8 mL
enteral tube placement verification
x-ray
external length
aspiration pH
indications that suctioning is needed
decreased SPO2
increased RR
increased HR
coughing
where are s1 and s2 best heard?
s1: mitral (cardiac apex)
s2: pulmonic (cardiac base)
list some geriatric lung assessment variations
increased RR, loss of lung elasticity, less effective cough, increased mucus retention, kyphosis, decreased thoracic expansion, decreased breath sounds, increased use of diaphragmatic/accessory muscles
order: 5 mg/kg/day
weight: 33 lb
how many mg per day?
75 mg/day
s/s of feeding intolerance
nausea, vomiting, no gastric residual, diarrhea, constipation, abdominal pain, distention, and absence of bowel sounds
true or false? trach care becomes a non-sterile procedure
true - one hand will remain sterile but the other will be considered "dirty"
when are s3 and s4 heard during the cardiac cycle? when are they considered "normal" or benign
s3: heard after s2, normal in children
s4: heard before s1, normal in older adults
instructions you would tell your pt during a resp assessment
"when you feel my stethoscope, take a deep breath in and out through your mouth - let me know if you need a break"
*have the pt sitting if possible
a 500 mL bag is hung at 0800, to be infused at 100 mL/hr
when will the bag be done in military time?
1300
potential complications from enteral tubes
aspiration, migration, dislogement, gastric intolerance, clogged tubing, skin breakdown, infection, dumping syndrome
what's the golden rule with changing trach ties
always keep the old ones on until the new ones have been secured
key characteristics of arterial insufficiency
- circular ulcers on toes
- decreased peripheral pulses
- legs rubor when dependent
- pain when walking (claudication)
- LE pallor when elevated
how would you try to prevent atelectasis?
C&DB, IS
ambulation/position changes
oral care
a 750 mL bag finishes in 4 hrs, what is the rate in mL/hr?
187.5 mL/hr
nursing responsibilities r/t enteral tubes
assess placement and patency, assess and clean insertion site, irrigating/flushing the tube, admin medications, monitoring complications, frequent oral care
true or false: a pt with a non-fenestrated trach has speaking impairment
true!
key characteristics of venous insufficiency
- jagged, above the ankle ulcers
- brawny skin on LE
- edema
- pain alleviated with exercise/elevation
- normal periph pulses
safety concerns r/t oxygen therapy
- skin breakdown
- fire hazard
- risk for injury
- synthetic material interaction
calculate the gravity flow rate for a 250 mL bag, tubing drop factor of 15, and to be completed over 2 hours
31 gtts/min
order of abdominal assessment
inspection, auscultation, percussion, palpation
what should you assess after suctioning
resp assessment + cough (lung sounds, breathing pattern, pulse rate, SPO2), pain assessment + pt tolerance, and LOC