NUR 3065: Exam 2 Review - At-Risk Patient Objectives, NUR 3065: Exam 2 Review - Cardiac & Peripheral Circulation Objectives, NUR 3065: Exam 2 Review - Respiratory Objectives

NUR 3065: Exam 2 Review - At-Risk Patient
Objectives, NUR 3065: Exam 2 Review - Cardiac &
Peripheral Circulation Objectives, NUR 3065: Exam 2
Review - Respiratory Objectives



Assessment: Jugular Veins


at 45 degrees, JV pulse does not rise more than 1-2 cm


Assessment: Extremities Pulses


2+


regular rate & rhythm


equal bilat


Assessment: Extremities Pulses - Upper


brachial (inner elbow)


radial (wrist)

,Assessment: Extremities Pulses - Lower


Popliteal (back of knee)


Posterior Tibial (inner ankle)


Dorsalis Pedis (top of foot)


Assessment: Integument (Normal)


pink


warm


nails are pink & rounded wo/ clubbing


cap refill is <3

,Assessment: Integument (Abnormal)


pale


cool


diaphoretic


red


bruised


cyanotic


jaundice


Assessment: Edema (normal)


no edema


Assessment: Edema - +1


mild


slight indentation


no swelling

, Assessment: Edema - +2


moderate


indention subsides rapidly


Assessment: Edema - +3


deep


indentation remains for a short time


leg appears swollen


Assessment: Edema - +4


very deep


indention lasts for a long time


leg is grossly swollen and distorted