NR-304: Health Assessment II FINAL EXAM REVIEW FLASH CARDS

ABCV 1. First- level problems (immediately) A – Airway B—Breathing C- Cardiac/ circulation V – Vital signs – High fever Priorities problems 1. First Level: emergent stat, patient will die without seeking medical attention 2. Second level: urgency to avoid worse problem 3. Third level: important to patient but can wait 4. Collaborative: multiple disciplines First Level Priorities * ABCV problems * CPR Second Level Priorities * Mental status * Acute pain, urine incontinence, untreated medical problems, abnormal labs, ABG values * Risk of infection Third Level Priorities Lack of knowledge, activity/rest, family coping Hypoventilation < Shallow breathing with deeper breath < Irregular < Shorter rate < Paced, slowed down breathing Hyperventilation < Faster rate < Longer breaths < Deep breathes with fast breathing PREPARTATION TO AUSCULTATING HEART Subjective Data 1. Fatigue 2. Cyanosis or pallor 3. Edema 4. Nocturia 5. Past cardiac Hx 6. Chest pain 7. Dyspnea 8. Orthopnea 9. Cough RIGHT HEART FAILURE Everything backflows to body < Congestion of peripheral tissue < Dependent edema < Ascites < Liver congestion < GI tract congestion, distress < Impaired liver function (S/S) < Anorexia weight loss