Pulmonary assessment

  1. phlebitis
    Inflamation of a vein... usually due to a clot.
  2. arteriol disease makes the skin
    pale and shiney
  3. venous disease makes the skin
    ruddy color... rough, dry, and scaley.
  4. a thrill palpated on the chest is caused by....
    a murmur
  5. after surgery, snoring, shallow respirations, and a drop in pulse ox would indicate
    a reaction to a medication
  6. the largest solid organ in the abdomen is
    the liver
  7. What are hollow organs in the abdomen
    intestines, stomach, bladder
  8. Ascites
    • abnormal accumulation of serous fluid within the peritoneal cavity.
    • associated with Congestive Heart Failure, cirrhosis, cancer, or portal hypertension
  9. Bruit
    blowing, swooshing sound heart thru a stethoscope when an artery is partially occluded.
  10. Cholecytisis
    inflammation of the gallbladder
  11. costal margin
    lower border of the rib margin formed by the medial edges of the 8th, 9th, and 10th ribs
  12. Costovertebral angle
    angle formed by the 12 rib and the vertebral column on the posterior thorax overlying the kidney
  13. dysphagia
    difficulty swallowing
  14. hepatomegaly
    abnormal enlargement of the liver
  15. peritoneal friction rub
    rough grating sound heard through the stethoscope over the site of peritoneal inflammation
  16. pyrosis
    heart burn
  17. the stomach and intestines will have what sound sound (dull, tympanic, flat etc)
    Tympanic: high pitched, musical, drumlike percussion note
  18. the correct sequence of techniques used during an exam of the abdomen
    inspection, auscultation, percussion, palpation
  19. RUQ tenderness may indicate pathology in the
    liver, pancreas, or ascending colon
  20. hyperactive bowel sounds are
    high pitched, rushing, tinkling
  21. the range of normal liver span in the Right mid clavicular line in the adult is
    6-12 cm
  22. Auscultation is begun in the RLQ because
    vascular sounds are best heard in this area
  23. Spleenic percussion has a
    dull sound
  24. shifting dullness is a test for
  25. Murphys sign is described as
    pain felt when taking a deep breath when the examiners fingers are on the approximate location of the inflamed gallbladder
  26. what side should the nurse stand on during an abdominal assessment
    Right side of the client
  27. Why is auscultation performed before palpation and percussion?
    because palpation and percussion can alter bowel sounds
  28. striae
    old, white, silvery stretchmarks from past pregnancies or weight gain
  29. Caput Medusae
    engorged superficial capillaries of the abdomen
  30. when documenting scars, what should be noted
    size and quadrent
  31. Describe 4 abdominal contours
    • flat
    • scaphoid- sucked in
    • rounded
    • protruberant: abnormal... round distended stomach.this may indicate an abdominal obstruction or hernia
  32. borborygmi
    • hyperactive bowel sounds
    • normal= 5-30 bowel sounds per minute
  33. if a bruit is present... it could mean
    • aneurysm (bulging of an artery)
    • arterial stenosis (narrowing)
  34. a venous hum is heard in the ___ or ___ regions and suggests
    • epigastric or umbilical
    • obstructed portal circulation (usually when pt has cirrhosis)
  35. liver fibrosis
    is when scar tissue forms usually after a fatty liver state
  36. cirrhosis
    connective tissue forms over liver and kills cells
  37. What is the purpose of light palpation?
    • to identify areas of tenderness, masses, or muscular resistance
    • depress the abdominal wall 1 cm
  38. What is the purpose of deep palpation?
    assess for organ enlargment, masses, bulging, or swelling
Card Set
Pulmonary assessment
Nurs112 also peripheral review