ATI NUR 265 – Nursing Exam Prep 2025 |
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Left sided heart failure
- blood backs up into the lungs
- paroxysmal nocturnal dyspnea
- elevated pulmonary capillary wedge pressure
- pulmonary congestion (cough, crackles, wheezes, blood-tinged sputum, tachypnea)
- restlessness
- confusion
- orthopnea
- tachycardia
- exertional dyspnea
- fatigue
- cyanosis
lymphedema assessment
Lower extremity edema
Abdominal discomfort, bloating, gas
- lymphatic vessels
- lymph nodes
- tonsils
- thymus
- spleen
- bone marrow
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lymphedema interventions
· No BP readings, venipunctures or injections on affected arm if possible
· Arm should not be dependent for long periods
· COMPRESSION bandaging
· Intermittent pneumatic compression sleeve
· Elevating arm at heath level
· Performing isometric exercises
peripheral arterial disease (PAD)
blockage of arteries carrying blood to the legs, arms, kidneys and other organs
Peripheral Venous Disease (PVD)
damage, defects or blockage in the veins that carry blood from the hands and feet to the heart
peripheral vascular normal variations for elderly
Arteries calcify- arteriosclerosis, stenosis
Arterial walls lose elasticity and vasomotor tone
Superficial vessels become more prominent
Increased peripheral vascular resistance
Decreased venous return
peripheral vascular normal variations for pregnant women
Blood pressure decreases
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blood volume increases
Bronchial breath sounds location
over lower trachea (purple)
Bronchovesicular breath sounds location
sternum (red)
Vesicular breath sounds location
peripheral lung fields (blue)
costal angle
The angle between the ribs at the costal margins. Usually 90 degrees or less.
AP:Lateral ratio
the lateral view should be half of the anterior/posterior view
Bowel sounds
start RLQ (1 min)
RUQ (1 min)
LUQ (1 min)
LLQ (1 min)
end RLQ (1 min)
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