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118 Cards in this Set
- Front
- Back
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Auscultation
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Listening to sounds with a stethoscope
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Sternum has three parts
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Manubrium, the body, xiphoid process
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Thorax Reference lines:
Anterior |
Midsternal
Midclavicular (Left and Right) |
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Thorax Reference lines:
Posterior |
vertebral line
Midscapular (left and right) |
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Thorax Reference lines :
Lateral |
Midaxillary
Anterior and Posterior axillary lines |
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Inspection of Respiration
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Observe quality and pattern
-labored breathing -noisy breathing (wheezing/crackels) Breathing characteristics -rate -rhythm -depth Use of accessory muscles |
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Respiration accessory muscles
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Trapezius (shoulder muscles) - facilitate inspiration in acute and chornic airway obstruction or atelectasis
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Atelectasis
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Collapse of part or all of a lung
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COPD
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Chronic obstructive pulmonary disease
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Tripod position
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Seen in COPD
Client leans forward, uses arms to support weight, lift chest to increase breathing |
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What is a normal respiration pattern ?
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12 to 20 / min and regular
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Tachypnea
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Respiration > 24/ min and shallow
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Bradypnea
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Respiration < 10/min and regular
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Hyperventilation
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Increase rate and depth of respirations
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Hypoventilation
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decrease rate, depth, irregular rhythm
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Cheyne-stokes
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Regular pattern with periods of apnea (lack of breathing or greatly reduced)
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Aspiration of fluids is more likely to occur on which bronchi ?
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Right bronchi, because it extends lower into the right lung which has 3 lobes
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Palpation of chest
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Assess tenderness, crepitus (crackling sensation), symmetry of chest expansion (rises/falls evenly unless pt is intubated)
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Name the three types of normal breath sounds
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Bronchial, bronchovesicular, vesicular
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Adventitious sounds
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Added sounds over normal breath sounds
crackles and wheezing |
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Vesicular breath sound
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low-pitched soft sounds during expiration heard over most of lungs
Long inspiration and short expiration |
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Bronchial breath sound
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high pitched and longer, heard over trachea.
Short inspiration and long expiration |
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Bronchovesicular
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Medium pitched, heard over upper anterior chest and intercoastal area (second intercostals space)
Equal inspiration/expiration |
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Crackles air sounds
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Air moving in airways through fluid.
Can be fine, medium or coarse |
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Wheezes
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Continues usually in expiration due to constricted by swelling/secretions airways
Sibilant - HIGH-PITCHED Sonorous - LOW PITCHED |
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Sinoatrial node
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<> Pacemaker of the heart
<> Initiates heartbeat <> Generates 60-100 beats per minute |
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What is diastole ?
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1. Relaxation of the ventricles (ventricles fill).
2. AV valves open(tricuspid and mitral) blood rushes into ventricles 3.Atria contract to completely empty it out |
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What is systole ?
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1. AV valves shut producing the first LUB (S1)
2. Ventricles contract forcing aortic and pulmonic (Semilunar) valves to open 3. Pressure reduces in the ventricles , causing Semilunar valves to shut. DUB (S2) |
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Heart sound regions
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Aortic (2nd intercoastal - right sternal)
Pulmonic (2nd intercoastal - left sternal) Tricuspic (4th intercoastal - left sternal) Mitral (5th intercoastal - left clavicular line) |
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The sound LUB (s1)
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Closure of av valve
mitral and tricuspid |
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DUB (s2)
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Closure of semilunar valve
Aortic and pulmonic |
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Murmurs
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Cause by turbulent blood flow in the heart
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Cardiac output
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Amount of blood pumped by the ventricles in about one minute
CO = SV(how many Liters if blood) x HR (minute rate) Decrease CO indicative of CHF |
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Jugular vein inspection
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Important for determining right side of the heart function - reflect right atrial pressure or central venous pressure.
Decrease pressure usually to decrease in volume |
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Right-side heart failure symptoms
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Pulmonary edema
Increase in pulse and pressure on jugular vein |
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Non-modifiables Risk Factors for CHD (coronary artery disease)
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Positive family history
Increasing age Men 3 times more than women Geography - highly industralized areas |
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Modifiables Risk Factors for CHD (coronary artery disease)
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Hyperlipidemia
Elevated blood pressure Cigarette Obesity Physical Inactivity Stress |
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Inspection of neck vessel
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Jugular venous pressure
Vein should not be visible above 45º (when you raise the bed) |
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Neck vessel ascultation
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no blowing or swooshing should be heard
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Heart palpation
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5th intercostal space/midclavicular line
1. Palpate apical pulse 2. Auscultate apical heart rate |
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Arteries
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Carry oxygenated blood from heart to capillaries
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Veins
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Carry deoxygenated blood to heart and have one way valve
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Femoral and Popliteal
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Deep veins accounting 90% of venous return from lower extremities
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Saphenous veins
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Superficial veins, longest veins in the legs
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Lymphatic system
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primary function is to drain excess fluid and plasma protein and return it to venous system
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Palpitation - Capillary refill
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Compress finger tip to calculate time it takes for capillary refill (should be less than 3 seconds)
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Allen test
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used to assess potency of radial and ulnar arteries
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Leg inspection
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Check venous return
Check poptileal pulse, Posterior tibial pulse, Femoral pulse or Dorsalis pedis |
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S2 and S1 sounds
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S1 - Pulmonic and Aortic
S2 - Tricuspid and Mitral |
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Cyanosis
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dependent or rusty/brown skin pigment around ankle.Aterial insufficiency - lack of blood supply associated with thin skin, haird loss
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Doppler ultrasound device
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Used in checking for peripheral arterial puls and evaluate flow, hear any swishing.
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Edema
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Associate with venous circulation
Bileteral or unileteral Scale grade from 1+ to 4+. 2 and 3+ are BS ones 1+ disappear quickly 4+ very deep and last 2 to 5 minutes |
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Lymphedema
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Non-pitting
No skin ulceration or pigmentarion |
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Venous insufficiency edema
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Pitting edema
Skin ulceration and pigmentations may be seen |
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Right Upper Quadrant:
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•Ascending and transverse colon
•Gall bladder; liver •Pylorus; right adrenal gland •Right kidney |
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Right Lower Quadrant:
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•Appendix
•Ascending colon; cecum •Right kidney •Right ovary and tube |
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Left Upper Quadrant:
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•Left adrenal gland
•Left kidney •Pancreas, spleen, stomach |
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Left Lower Quadrant:
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•Left kidney
•Left ovary and tube •Descending and sigmoid colon |
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What organs compose the Solid viscera ?
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Liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus
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What organs compose the Hollow viscera ?
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Stomach, gallbladder, small intestine, colon, bladder
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Vascular structures
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Abdominal aorta; right and left iliac arteries
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What questions to ask regarding abdominal problems ?
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Abdominal Pain
Indigestion (pyrosis) Nausea and Vomiting Appetite Bowel Elimination Yellowing of skin or eyes, dark urine or clay-colored stool – liver problems |
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Define Visceral pain
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- occurs when hollow abdominal organs, such as the intestines, become distended or contract forcefully or when the solid organs such as the liver and spleen are stretched.
•This pain is often characterized as dull, aching, burning, cramping or colicky |
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Define Parietal pain
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Occurs when the parietal peritoneum becomes inflamed, as in appendicitis or peritonitis.
– Pain is localized and is more severe and steady pain. |
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Define Referred pain
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Occurs at distant sites that are innervated at approximately the same levels as the disrupted abdominal organ.
– In other words, the pain travels, or refers, from the primary site and becomes highly localized at the distant site. |
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Abdominal Assessment Procedure
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•1st Step - Inspection
•2nd Step - Auscultation – of bowel sounds is done before touching client! •3rd Step - Percussion •4th Step - Palpation |
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Assess abdominal symmetry
fall in 4 categories (inspection): |
Flat
Scaphoid – sunken in abdomen (really skinny person/anorexia) Rounded (most americans) Distended/Protuberant (like hungry kids in Africa) |
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Auscultation of abdominal area
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•Auscultate for
–Bowel sounds – listen for up to 5 minutes per quadrant to confirm absence of bowel sounds using diaphragm –Vascular sounds – use bell of stethoscope to listen to bruits (low-pitched, murmur-like sounds) over abdominal aorta, renal, iliac or femoral arteries. |
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How to tests for ascites ? What is ascites ?
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–Test for shifting dullness
–Perform the fluid wave test –Use ballottement technique Ascites is excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity |
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How to test for appendicitis ?
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–Rebound tenderness – assess for pertioneal irritation – palpate deeply in the abdomen where the client has pain then suddenly release pressure - which hurts more – the pressing in or releasing – where on the abdomen does the pain occur.
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Rovsing’s sign –
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An indication of acute appendicitis in which pressure on the left lower quadrant of the abdomen causes pain in the right lower quadrant – referred rebound tenderness
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Psoas Sign
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Raise right leg from hip and apply pressure. Will have RLQ pain if appendix is inflamed.
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Obturator Sign
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Flex right hip and knee and rotate the leg internally
and externally. Pain in RLQ may indicate appendicitis |
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What is the purpose and how do you perform the test for Cholecystitis – Gall Bladder
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– Murphy’s sign
• Press fingertips under the liver border at the right costal margin and ask client to inhale deeply. –Accentuated sharp pain causes the client to hold breath |
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COLDSPA
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Character Describe sign/symptom
Onset When did it begin? Location Where is it? Radiate Duration How long does it last? Recur? Severity How bad is it? Pattern What makes it better or worse? Associated factors Other symptoms occur? Affects client How does it affect you? |
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How do you assess for a history of bowel problems ?
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•Bowel Patterns
–Usual bowel pattern –Recent changes or pain when defecating •Stool –Color –Hard/soft/liquid –Blood in stool •Itching and Pain |
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The skin is a physical barrier that protects the underlying tissues and structures from:
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–microorganisms
–physical trauma –ultraviolet radiation –dehydration. |
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The skin plays a vital role in ...
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– temperature maintenance
– fluid and electrolyte balance – Absorption – Excretion – Sensation |
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Epidermis
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– outermost layer of skin
– Has four distinct layers – Helps keep skin waterproof – Contains melanin (brown pigment) and carotene (yellow pigment) which gives us our skin color |
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Dermis
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– inner layer of skin
– Connected to epidermis by papillae – Papillae forms the base for swirls or ridges – provides unique patterns in fingerprints – Origin of hair follicles, sebaceous glands and sweat glands. |
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Dermis layer contains...
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• Sebaceous glands develop from hair follicles and secretes sebum which lubricates hair and skin decreasing water loss through the skin.
• Sweat glands – Eccrine glands – over entire body – odorless (non-stinky) – vital to temperature regulation |
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•Vellus hair
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- short, pale and fine – found over most of the body.
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•Terminal hair –
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particularly the scalp and eyebrows – longer, darker and coarser.
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•Examine the skin for suspected lesions
–Use the ABCDE mnemonic to assess suspicious lesions: What is the ABCDE ? |
– Asymmetry
– Border – Color – Diameter – Elevation |
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What are the most common types of skin cancer ?
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– Melanoma
– basal cell carcinoma – lighter skin more common – squamous cell carcinoma – darker skin more common |
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Skin Assessment: Inspection - must observe...
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•Note any distinctive odor
•Generalized color variations •Skin breakdown |
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Skin primary lesions
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arise from normal skin due to irritation or disease.
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Types of primary skin lesions
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•Macule
–Flat, non-palpable lesion –Freckles, petechiae, ecchymosis •Papule –Elevated, palpable solid –Pimples, warts •Nodule / tumor –Elevated, solid, palpable mass –Squamous cell Ca., poorly absorbed injection •Vesicle, Bulla –Round elevated mass containing fluid –Herpes simplex/zoster, varicella (chickenpox), 2° burn •Vesicle (small) or Bulla (larger) –Round elevated mass containing fluid –Herpes simplex/zoster, varicella (chickenpox), 2° burn•Wheal –Elevated mass with irregular borders – uticaria - hives •Pustule –Pus filled vesicle or bulla –Acne, impetigo •Cyst –Encapsulated fluid-filled or semisolid mass in subcutaneous or dermis tissue –Sebaceous or an epidermoid cyst (big guys) |
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Skin Secondary lesions
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arise from changes in primary lesions.
Erosion –Loss of superficial epidermis only –Scratch marks •Ulcer –Skin loss past epidermis –Pressure ulcer; venous insufficiency ulcer •Scar –Skin mark left after healing of wound/lesion •Fissure –Linear crack in skin – may extend to dermis –Chapped lips or hands; athlete’s foot |
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Skin Vascular lesions
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reddish-bluish lesions are seen with bleeding, venous pressure, aging, liver disease or pregnancy.
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Vascular lesions types
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Petechiae
–Round red/purple macule •Eccymosis –Macular lesion larger than patechiae –Color changes with black, yellow and green hues –Associated with trauma or bleeding. •Hematoma –Localized collection of blood creating an elevated eccymosis – associated with trauma•Cherry Angioma –Red/purple round papule –Blanches with pressure – on trunk and extremities – normal age-related skin alteration •Spider Angioma –Red arteriole lesion – looks like a spider –Found on face, neck, arms, trunk –Blanches with pressure - liver disease, pregnancy, Vitamin B deficiency •Talangiectasis (venous star) –Spider-like or linear; bluish-red –Does not blanch, legs and chest –Caused by increased venous pressure |
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Inspect Skin for the following:
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• Lesions
• Texture • Temperature and moisture • Thickness of skin • Mobility and turgor • Edema |
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Turgor
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Elasticity test usually done on abdomen by pulling the skin then release after a few seconds. If skin holds up could mean dehydration problems
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– Inspection: Nail
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grooming and cleanliness, nail color and markings, shape of nails,
– Palpation: Texture, assess texture and consistency, capillary refill |
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Hair
• Inspection and palpation |
– General color and condition, cleanliness, dryness or oiliness, parasites, and lesions
– Amount and distribution of scalp, body, axillae, and pubic hair |
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PMI
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Point of maximum impact of the apex located at the 5th intercostal space for the mitral sound
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How do you rate pulse strength ?
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0 - absent
1 - barely 2 - easily palpable 3 - full pulse 4 - strong, bounding |
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S1 and S2
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S1 - systole (ventricular contraction) LUB
S2 - diastole (ventricular relaxation) DUB |
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Name the types of primary lesions
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Macule
Papule Nodule Vesicle(small)/Bulla(large) Wheal Pustule Cyst |
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Macule
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flat non palpable lesions
i.e. freckels |
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Papule
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elevated, palpable lesions
i.e. Wart |
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Nodule/Tumor
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elevated and palpable
i.e.: Squamous cell carcinoma |
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Vesicle/Bulla
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Papule with fluid
i.e.Herpes Simplex Varicella/Zoster |
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Wheal
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elevated (papule like) with a mass
- hives, uticaria |
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Pustule
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Pus filled vesicle or bulla
-acne -pimple full of pus. |
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Cyst
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Fluid like in subcutaneous or dermis.
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Secondary lesions
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Erosion
Ulcer Scar Fissure |
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Erosion
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Loss of epidermis
Scratch marks |
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Ulcer
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Loss past the epidermis (affects dermis and/or hypodermis)
pressure ulcer venous isufficiency ulcer |
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Scar
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left after healing lesion
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Fissure
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linear crack in skin
-chapped lips/hands |
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Name the vascular skin lesions
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Petechiae
Eccymosis Hematoma Cherry angioma Spider angioma Venous star |
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Petechiae
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round red flat
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Eccymosis
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larger Petechiae - large red flat
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Hematoma
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Elevated eccymosis (large elevated petechiae)
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Cherry angioma
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red/purple round papule
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Spider angioma
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red arteriole lesion star-like shape
Sometimes indicative of liver disease |
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Venous star
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bluish/red venous lesion star-like
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