Health Assessment Test Iii

Front 1

thorax

Back 1

identifies the portion of the body extending from the base of the neck superiorly to the level of the diaphragm inferiorly

Front 2

What lives in the Thorax?

Back 2

The lungs, distal portion of the trachea, and the bronchi, are located in the thorax and constitute the lower respiratory system

Front 3

A thorough assessment of the lower respiratory system focuses on what?

Back 3

the external chest as well as the respiratory components in the thoracic cavity

Front 4

The thoracic cage is constructed of

Back 4

the sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles, and cartilage

Front 5

What is the importance of the Thoracic Cage?

Back 5

It provides support and protection for many important organs including those of the lower respiratory system.

Front 6

The sternum is divided into three parts...

Back 6

lies in the center of the chest anteriorly and is divided into three parts: the manubrium, the body, and the xiphoid process

Front 7

A U-shaped indentation located on the superior border of the manubrium is an important landmark known as the

Back 7

The Suprasternal Notch

Front 8

sternal angle

Back 8

-a bony ridge that can be palpated at the point where the manubrium articulates with the body of the sternum
-the location of the second pair of ribs and is a reference point for counting ribs and intercostal spaces

Front 9

Each pair of ribs has a corresponding pair of ...

Back 9

intercostal spaces located immediately inferior to it

Front 10

The first seven pairs articulate with the sternum by way of

Back 10

Costal Cartilages

Front 11

True or False:
Ribs seven through ten connect to the sternum.

Back 11

False, ribs 7-10 connect to the cartilage of the pair lying superior to them.

Front 12

costal angle

Back 12

The angle between the right and left costal margins meeting at the level of the xiphoid process

Front 13

This disease causes an angle greater than 90 degrees at the costal angle.

Back 13

Emphysema (due to long-standing hyperinflation of the lungs)

Front 14

The 11th and 12th pairs of ribs are called “________” ribs because they do not connect to either the sternum or another pair of ribs anteriorly

Back 14

Floating

Front 15

vertebra prominens

Back 15

-The spinous process of the seventh cervical vertebra (C7)

- can be easily felt with the client's neck flexed

Front 16

The process immediately inferior to the vertebra prominens is the...

Back 16

first thoracic vertebra

Front 17

When counting the spinous processes, it is helpful to know that ...

Back 17

They align with their corresponding ribs only to the fourth thoracic vertebra (T4). After this, the spinous processes angle downward from their own vertebral body and can be palpated over the vertebral body and rib below.

Front 18

The lower tip of each scapula is at the level of the _______ or ______ rib when the client's arms are at his or her side

Back 18

seventh or eighth

Front 19

The lateral aspect of the thorax is divided into three parallel lines

Back 19

-The midaxillary line runs from the apex of the axillae to the level of the 12th rib

-The anterior axillary line extends from the anterior axillary fold along the anterolateral aspect of the thorax

-the posterior axillary line runs from the posterior axillary fold down the posterolateral aspect of the chest wall

Front 20

The thoracic cavity consists of ...

Back 20

the mediastinum and the lungs

Front 21

The mediastinum refers to ...

Back 21

a central area in the thoracic cavity that contains the trachea, esophagus, heart, and great vessels

Front 22

The _____ lie on each side of the mediastinum

Back 22

lungs

Front 23

The _____ are two cone-shaped, elastic structures suspended within the thoracic cavity

Back 23

lungs

Front 24

The ____ of each lung extends slightly above the clavicle

Back 24

Apex

Front 25

The base of the lungs is at the level of the __________

Back 25

diaphragm

Front 26

The right lung is made up of _____ lobes, whereas the left lung contains _____ lobes.

Back 26

Three, two

Front 27

The thoracic cavity is lined by a thin, double-layered serous membrane collectively referred to as the ______

Back 27

Pleura

Front 28

The _______ ______ line the chest cavity, and the _______ ______ covers the external surfaces of the lungs

Back 28

pariental Pleura, visceral pleura

Front 29

In the healthy adult, the lubricating serous fluid between the two pleural layers allows ...

Back 29

movement of the visceral layer over the parietal layer during ventilation without friction

Front 30

severe dehydration will _______ the volume of pleural fluid, resulting in the _______ transmission of lung sounds and a possible friction rub

Back 30

decrease, increase

Front 31

The ______ is a flexible structure that lies anterior to the esophagus, begins at the level of the cricoid cartilage in the neck, and is approximately 10 to 12 cm long in an adult

Back 31

trachea

Front 32

C-shaped rings of _______ cartilage compose the trachea

Back 32

hyaline

-they help to maintain its shape and prevent its collapse during respiration

Front 33

The ______ main bronchus is shorter and more vertical than the _____ main bronchus, making aspirated objects more likely to enter the right lung than the left

Back 33

Right, Left

Front 34

The _______ and ________ represent “dead space” in the respiratory system, where air is transported but no gas exchange takes place

Back 34

Bronchi, Trachea

Front 35

What is the function of the Bronchi and the Trachea?

Back 35

They function primarily as a passageway for both inspired and expired air.

In addition, the trachea and bronchi are lined with mucous membranes containing cilia. These hairlike projections help sweep dust, foreign bodies, and bacteria that have been trapped by the mucus toward the mouth for removal.

Front 36

The purpose of respiration is to

Back 36

maintain an adequate oxygen level in the blood to support cellular life

Front 37

Do you ever experience difficulty breathing? Describe the difficulty

Back 37

Dyspnea (difficulty breathing) can indicate a number of health problems, most of which are related to the respiratory system. Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections

Front 38

Do you experience any other symptoms when you have difficulty breathing?

Back 38

edema or angina that occurs with dyspnea may indicate a cardiovascular problem.

Front 39

Do you have difficulty breathing when you are resting or do any specific activities cause the difficulty?

Back 39

Older adults may experience dyspnea with certain activities related to aging changes of the lungs (loss of elasticity, fewer functional capillaries, and loss of lung resiliency).

Front 40

Do you have difficulty breathing when you sleep? Do you use more than one pillow or elevate the head of the bed when you sleep?

Back 40

Orthopnea (difficulty breathing when lying supine) may be associated with heart failure. Paroxysmal nocturnal dyspnea (severe dyspnea that awakens the person from sleep) also may be associated with heart failure. Changes in sleep patterns may cause the client to feel fatigued during the day.

Front 41

Do you snore when you sleep? Have you been told that you stop breathing at night when you snore?

Back 41

Sleep apnea (periods of breathing cessation during sleep) may be the source of snoring and gasping sounds. In general, sleep apnea diminishes the quality of sleep, which may account for fatigue or excessive tiredness, depression, irritability, loss of memory, lack of energy, and a risk for auto and workplace accidents.

Front 42

Do you have chest pain? Is the pain associated with a cold, fever, or deep breathing?

Back 42

Pain-sensitive nerve endings are located in the parietal pleura, thoracic muscles, and tracheobronchial tree but not in the lungs. Thus chest pain associated with a pulmonary origin may be a late sign of pulmonary disease.

Chest pain related to pleuritis may be absent in older clients because of age-related alterations in pain perception.

Front 43

Do you have a cough? When and how often does it occur?

Back 43

Continuous coughs are usually associated with acute infections, whereas those occurring only early in the morning are often associated with chronic bronchial inflammation or smoking. Coughs late in the evening may be the result of exposure to irritant during the day. Coughs occurring at night are often related to postnasal drip or sinusitis.

The ability to cough effectively may be decreased in the older client because of weaker muscles and increased rigidity of the thoracic wall.

Front 44

Do you produce any sputum when you cough? If so, what color is the sputum? How much sputum do you cough up? Has this amount increased or decreased recently? Does the sputum have an odor?

Back 44

Nonproductive coughs are often associated with upper respiratory irritations and early congestive heart failure.
White or mucoid sputum is often seen with common colds, viral infections, or bronchitis. Yellow or green sputum is often associated with bacterial infections. Blood in the sputum (hemoptysis) is seen with more serious respiratory conditions. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia. Pink, frothy sputum may be indicative of pulmonary edema. An increase in the amount of sputum is often seen in an increase in exposure to irritants, chronic bronchitis, and pulmonary abscess. Clients with excessive, tenacious secretions may need instruction on controlled coughing and measures to reduce viscosity of secretions.

Front 45

Do you wheeze when you cough or when you are active?

Back 45

Wheezing indicates narrowing of the airways due to spasm or obstruction. Wheezing is associated with congestive heart failure (CHF), asthma (reactive airway disease), or excessive secretions.

Front 46

Do you have any gastrointestinal symptoms such as heartburn, frequent hiccups, or chronic cough?

Back 46

Studies have shown that patients with asthma often have GERD (gastroesophageal reflux disease) or are more susceptible to GERD.

Front 47

Have you recently traveled outside of the United States? Have you been in close contact with anyone known or suspected to have SARS?

Back 47

Travel to high-risk areas such as mainland China; Hong Kong; Hanoi, Vietnam; Singapore; or Toronto, Canada, may have exposed the client to SARS (severe acute respiratory syndrome).

Front 48

Have you been tested for or diagnosed with allergies?

Back 48

Many allergic responses are manifested with respiratory symptoms such as dyspnea, cough, or hoarseness. Clients may need education on controlling the amount of allergens in their environment.

Front 49

Have you ever had any thoracic surgery, biopsy, or trauma?

Back 49

Previous surgeries may alter the appearance of the thorax and cause changes in respiratory sounds. Trauma to the thorax can result in lung tissue changes.

Front 50

Is there a history of lung disease in your family?

Back 50

The development of lung cancer is thought to be partially based on genetics. A history of certain respiratory diseases (asthma, emphysema) in a family may increase the risk for development of the disease. Exposure to viral or bacterial respiratory infections in the home increases the risk for development of these conditions.

Front 51

Did any family members in your home smoke when you were growing up?

Back 51

Second-hand smoke puts individuals at risk for emphysema or lung cancer later in life.

Front 52

Have you ever smoked cigarettes or other tobacco products? Do you currently smoke? At what age did you start? How much do you smoke and how much have you smoked in the past? What activities do you usually associate with smoking? Have you ever tried to quit?

Back 52

Smoking is linked to a number of respiratory conditions, including lung cancer (see Risk Factors—Lung Cancer). The number of years a person has smoked and the number of cigarettes per day influence the risk for development of smoking-related respiratory problems. Information on smoking behavior and previous efforts to quit may be helpful later in identifying measures to assist with smoking cessation.

Front 53

Are you exposed to any environmental conditions that affect your breathing? Where do you work? Are you around smokers?

Back 53

Exposure to certain environmental inhalants can result in an increased incidence of certain respiratory conditions. Environmental irritants commonly associated with occupations include coal dust, insecticides, paint, pollution, asbestos fibers, and the like. For example, inhaling dust contaminated with Histoplasma capsulatum may cause histoplasmosis, a systemic fungal disease. This disease is common in the rural midwestern United States. Second-hand smoke is another irritant that can seriously affect a person's respiratory health.

Front 54

What kind of stress are you experiencing at this time? How does it affect your breathing?

Back 54

Shortness of breath can be a manifestation of stress. Client may need education about relaxation techniques.

Front 55

Are you currently taking medications for breathing problems or other medications (prescription or OTC) that affect your breathing? Do you use any other treatments at home for your respiratory problems?

Back 55

Consider all medications when determining if respiratory problems could be attributed to adverse reactions. Certain medications, for example, beta-adrenergic antag-onists (beta blockers) such as atenolol (Tenormin) or metoprolol (Lopressor) and angiotensin-converting enzyme (ACE) inhibitors such as enalapril (Vasotec) or lisinopril (Zestril), are associated with the side effect of persistent cough. These medications are contraindi-cated with some respiratory problems such as asthma. If the client is using oxygen or other respiratory therapy at home, it is important to evaluate knowledge of proper use and precautions as well as the client's abil-ity to afford the therapy.

Front 56

Have you used any herbal medicines or alternative therapies to manage colds or other respiratory problems?

Back 56

Many people use herbal therapies, such as Echinacea, or alternative therapies, such as zinc lozenges, to decrease cold symptoms. Knowing what clients are using enables you to check for side effects or adverse interactions with prescribed medications.

Front 57

________ ________ is the leading cause of death in the United States and Europe

Back 57

Lung Cancer

Front 58

The average age of diagnosis is __; a lung cancer diagnosis is unusual under age __

Back 58

60, 40

Front 59

Risk Factors for Lung Cancer

Back 59

Cigarette smoking
Genetic predisposition possibly associated with interaction of genetics and smoking
Beta carotene supplements esp. in presence of heavy smoking, moderate alcohol intake
Asbestos exposure
Radon exposure
Exposure to workplace pollutants: radioactive ores, mining chemicals (e.g., arsenic, vinyl chloride, nickel, coal, mustard gas, chloromethyl esters, and fuels such as gasoline)
Other environmental exposure: air pollution, passive tobacco smoke, marijuana smoking
History of previous lung cancer, silicosis, berylliosis
Recurring inflammation that leaves scars (e.g., tuberculosis, some types of pneumonia)
African American heritage, especially men
Gender; women's lung cells may have a predisposition to lung cancer when exposed to tobacco smoke
History of Hodgkin's disease treated with chemotherapy, radiation or both
Smokers who have been treated with chemotherapy or radiation
Eating a poor diet with few fruits and vegetables

Front 60

____________ men have higher incidence and mortality rates for lung cancer

Back 60

African American

Front 61

Inspect for nasal flaring and pursed lip breathing

Back 61

Nasal flaring is seen with labored respirations (especially in small children) and is indicative of hypoxia.
Pursed lip breathing may be seen in asthma, emphysema, or CHF as a physiologic response to help slow down expiration and keep alveoli open longer.

Front 62

Observe color of face, lips, and chest.

Back 62

Ruddy to purple complexion may be seen in clients with COPD or CHF as a result of polycythemia. Cyanosis may be seen if client is cold or hypoxic.

Cyanosis makes white skin appear blue-tinged, especially in the perioral, nailbed, and conjunctival areas. Dark skin appears blue, dull, and lifeless in the same areas.

Front 63

Inspect color and shape of nails.

Back 63

Pale or cyanotic nails may indicate hypoxia. Early clubbing (180-degree angle) and late clubbing (greater than a 180-degree angle) can occur from hypoxia.

Front 64

Inspect configuration. While the client sits with her arms at her sides, stand behind her and observe the position of scapulae and the shape and configuration of the chest wall

Back 64

Spinous processes that deviate later-ally in the thoracic area may indicate scoliosis.
Spinal configurations may have respiratory implications. Ribs appearing horizontal at an angle greater than 45 degrees with the spinal column are frequently the result of an increased ratio between the anteroposterior- transverse diameter (barrel chest). This condition is commonly the result of emphysema due to hyperinflation of the lungs.

Front 65

The size of the thorax, which affects pulmonary function, differs by race. Compared with African Americans, Asians and Native Americans, adult Caucasians have a ______ thorax and _______ lung capacity

Back 65

Larger, Greater

Front 66

Observe use of accessory muscles. Watch as the client breathes and note use.

Back 66

Trapezius, or shoulder, muscles are used to facilitate inspiration in cases of acute and chronic airway obstruc-tion or atelectasis

Front 67

Inspect the client's positioning. Note the client's posture and his ability to support weight while breathing comfortably.

Back 67

Client leans forward and uses arms to support weight and lift chest to increase breathing capacity, referred to as the tripod position. This is often seen in chronic obstruc-tive pulmonary disease (COPD).

Front 68

Palpate for tenderness and sensation.

Palpation may be performed with one or both hands; however, the sequence of palpation is established. Use your fingers to palpate for tenderness, warmth, pain, or other sensations. Start toward the midline at the level of the left scapula (over the apex of the left lung) and move your hand left to right, comparing findings bilaterally. Move systematically downward and out to cover the lateral portions of the lungs at the bases.

Back 68

Tender or painful areas may indicate inflamed fibrous connective tissue. Pain over the intercostal spaces may be from inflamed pleurae. Pain over the ribs, especially at the costal chondral junctions, is a symptom of fractured ribs.
Muscle soreness from exercise or the excessive work of breathing (as in COPD) may be palpated as tenderness.
Increased warmth may be related to local infection.

Front 69

Palpate for crepitus.

Crepitus, also called subcutaneous emphysema, is a crackling sensation (like bones or hairs rubbing against each other) that occurs when air passes through fluid or exudate. Use your fingers and follow the above sequence when palpating.

Back 69

Crepitus can be palpated if air escapes from the lung or other airways into the subcutaneous tissue as occurs after an open thoracic injury, around a chest tube, or tracheostomy. It also may be palpated in areas of extreme congestion or consolidation. In such situations, mark margins and moni-tor to note any decrease or increase in the crepitant area.

Front 70

Palpate Thorax surface characteristics.

Put on gloves and use your fingers to palpate any lesions that you noticed during inspection. Also feel for any unusual masses.

Back 70

Any unusual palpable mass should be evaluated further by a physician or other appropriate professional.

Front 71

Palpate for fremitus.

Following the above sequence, use the ball or ulnar edge of one hand to assess for fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall). As you move your hand to each area, ask the client to say “ninety-nine.” Assess all areas for symmetry and intensity of vibration.

Back 71

Unequal fremitus is usually the result of consolidation (which increases fremitus) or bronchial obstruction, air trapping in emphysema, pleural effusion, or pneumothorax (which all decrease fremitus). Diminished fremitus even with a loud spoken voice may indicate an obstruction of the tracheobronchial tree

Front 72

Assess chest expansion.

Place your hands on the posterior chest wall with your thumbs at the level of T9 or T10 and pressing together a small skin fold. As the client takes a deep breath, observe the movement of your thumbs.

Back 72

Unequal chest expansion can occur with severe atelectasis (collapse or incomplete expansion), pneumonia, chest trauma, or pneumothorax (air in the pleural space). Decreased chest excursion at the base of the lungs is characteristic of chronic obstructive pulmonary disease (COPD). This is due to decreased diaphragmatic function.

Front 73

Because of calcification of the costal cartilages and loss of the accessory musculature, the older client's thoracic expansion may be ________ although it should still be symmetric.

Back 73

decreased

Front 74

Percuss for tone.

Start at the apices of the scapulae and percuss across the tops of both shoulders. Then percuss the intercostal spaces across and down, comparing sides. Percuss to the lateral aspects at the bases of the lungs, comparing sides.

Back 74

Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space such as in lobar pneumonia, pleural effusion, or tumor.

Front 75

Resonance

Back 75

the percussion tone elicited over normal lung tissue. Percussion elicits flat tones over the scapula.

Front 76

Percuss for diaphragmatic excursion.

Ask the client to exhale forcefully and hold the breath. Beginning at the scapular line (T7), percuss the intercostal spaces of the right posterior chest wall. Percuss downward until the tone changes from resonance to dullness. Mark this level and allow the client to breathe. Next ask the client to inhale deeply and hold it. Percuss the intercostal spaces from the mark downward until resonance changes to dullness. Mark the level and allow the client to breathe. Measure the distance between the two marks. Perform on both sides of the posterior thorax.

Back 76

Diaphragmatic descent may be limited by atelectasis of the lower lobes or by emphysema in which diaphragmatic movement and air trapping are minimal. The diaphragm remains in a low position on inspiration and expiration.
Other possible causes for limited descent can be pain or abdomi-nal changes such as extreme ascites, tumors, or pregnancy.
Uneven excursion may be seen with inflammation from unilateral pneumonia, damage to the phrenic nerve, or splenomegaly.

Front 77

Excursion should be equal bilaterally and measure __ to __ cm in adults.

Back 77

3-5

Front 78

In well-conditioned clients, excur-sion can measure up to __ or__ cm.

Back 78

7-8

Front 79

Auscultate for breath sounds. To best assess lung sounds, you will need to hear the sounds as directly as possible. Do not attempt to listen through clothing or a drape, which may produce additional sound or muffle lung sounds that exist. To begin, place the diaphragm of the stethoscope firmly and directly on the posterior chest wall at the apex of the lung at C7. Ask the client to breathe deeply through his or her mouth for each area of auscultation (each placement of the stethoscope) in the auscultation sequence so you can best hear inspiratory and expiratory sounds. Be alert to the client's comfort and offer times for rest and normal breathing if fatigue is becoming a problem.

Back 79

Diminished or absent breath sounds often indicate that little or no air is moving in or out of the lung area being auscultated. This may indicate obstruction within the lungs as a result of secretions, mucus plug, or a foreign object. It may also indicate abnormalities of the pleural space such as pleural thickening, pleural effusion, or pneumothorax. In cases of emphysema, the hyperinflated nature of the lungs, together with a loss of elasticity of lung tissue, may result in diminished inspiratory breath sounds. Increased (louder) breath sounds often occur when consolidation or compression results in a denser lung area that enhances the transmission of sound.

Front 80

True or False?

Breath sounds are considered normal only in the area specified. Heard elsewhere, they are considered abnormal sounds.

Back 80

True

Front 81

Auscultate for adventitious sounds. Adventitious sounds are sounds added or superimposed over normal breath sounds and heard during auscultation. Be careful to note the location on the chest wall where adventitious sounds are heard as well as the location of such sounds within the respiratory cycle.

Back 81

Adventitious lung sounds, such as crackles (formerly called rales) and wheezes (formerly called rhonchi) are evident.

Front 82

If you hear an abnormal sound during auscultation, always have the client _____, then listen again and note any change.

Back 82

cough

Front 83

Auscultate voice sounds. Bronchophony: Ask the client to repeat the phrase “ninety-nine” while you auscultate the chest wall.

Back 83

The words are easily understood and louder over areas of increased density. This may indicate consolidation from pneumonia, atelectasis, or tumor.

Front 84

Egophony: Ask the client to repeat the letter “E” while you listen over the chest wall.

Back 84

Normal: Voice transmission will be soft and muffled but the letter “E” should be distinguishable.

Abnormal: Over areas of consolidation or com-pression, the sound is louder and sounds like “A”.

Front 85

Whispered Pectoriloquy: Ask the client to whisper the phrase “one–two–three” while you auscultate the chest wall.

Back 85

Normal: Transmission of sound is very faint and muffled. It may be inaudible.

Abnormal: Over areas of consolidation or compression, the sound is transmitted clearly and distinctly. In such areas, it sounds as if the client is whispering directly into the stethoscope.

Front 86

Inspect for shape and configuration of the anterior thorax.

Have the client sit with her arms at her sides. Stand in front of the client and assess shape and configuration.

Back 86

Anteroposterior equals transverse diameter, resulting in a barrel chest. This is often seen in emphysema because of hyperinflation of the lungs

Front 87

Inspect position of the sternum. Observe the sternum from an anterior and lateral viewpoint.

Back 87

Pectus excavatum is a markedly sunken sternum and adjacent carti-lages (often referred to as funnel chest). It is a congenital malforma-tion that seldom causes symptoms other than self-consciousness.

Pectus carinatum is a forward protrusion of the sternum causing the adjacent ribs to slope backward (often referred to as pigeon chest). Conditions may restrict expansion of the lungs and decrease the lung capacity.

Front 88

Watch for sternal retractions.

Back 88

Sternal retractions are noted with severely labored breathing.

Front 89

Inspect slope of the ribs. Assess the ribs from an anterior and lateral viewpoint.

Back 89

Normal: Ribs slope downward with symmetric intercostal spaces. Costal angle is within 90 degrees.

Abnormal: Barrel-chest configuration results in a more horizontal position of the ribs and costal angle of more than 90 degrees. This often results from long-standing emphysema.

Front 90

Observe quality and pattern of respiration. Note breathing characteristics as well as rate, rhythm, and depth.

Back 90

Normal: Respirations are relaxed, effortless, and quiet. They are of a regular rhythm and normal depth at a rate of 10 to 20 per minute in adults. Tachypnea and bradypnea may be normal in some clients.

Abnormal: Labored and noisy breathing is often seen with severe asthma or chronic bronchitis. Abnormal breathing patterns include tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes respiration, and Biot's respiration.

Front 91

Inspect intercostal spaces. Ask the client to breathe normally and observe the intercostal spaces.

Back 91

Retraction of the intercostal spaces indicates an increased inspiratory effort. This may be the result of an obstruction of the respiratory tract or atelectasis. Bulging of the intercostal spaces indicates trapped air such as in emphysema or asthma.

Front 92

Observe for use of accessory muscles. Ask the client to breathe normally and observe for use of accessory muscles.

Back 92

Neck muscles (sternomastoid, scalene, and trapezius) are used to facilitate inspiration in cases of acute or chronic airway obstruction or atelectasis. The abdominal muscles and the internal intercostal muscles are used to facilitate expiration in COPD.

Front 93

Palpate for tenderness, sensation, and surface masses.

Use your fingers to palpate for tenderness and sensation. Start with your hand positioned over the left clavicle (over the apex of the left lung) and move your hand left to right, comparing findings bilaterally. Move your hand systematically downward toward the midline at the level of the breasts and outward at the base to include the lateral aspect of the lung. The established sequence for palpating the anterior thorax serves as a guide for positioning your hands

Back 93

Tenderness over thoracic muscles can result from exercising (e.g., push ups and the like) especially in a previously sedentary client.

Front 94

Palpate for tenderness at costochondral junctions of ribs.

Back 94

Tenderness or pain at the costochondral junction of the ribs is seen with fractures, especially in older clients with osteo-porosis.

Front 95

Assess for crepitus as you would on the posterior thorax

Back 95

In areas of extreme congestion or consolidation, crepitus may be pal-pated particularly in clients with lung disease.

Front 96

Also palpate any surface masses or lesions on the anterior thorax

Back 96

may indicate cysts or tumors

Front 97

Palpate for fremitus on the anterior thorax. Using the sequence for the anterior chest, palpate for fremitus using the same technique as for the posterior thorax.

Back 97

Diminished vibrations, even with a loud spoken voice, may indicate an obstruction of the tracheobronchial tree.
Clients with emphysema may have considerably decreased fremitus as a result of air trapping.

Front 98

Palpate anterior chest expansion. Place your hands on the client's anterolateral wall with your thumbs along the costal margins and pointing toward the xiphoid process. As the client takes a deep breath, observe the movement of your thumbs.

Back 98

Unequal chest expansion can occur with severe atelectasis, pneumonia, chest trauma, pleural effusion, or pneumothorax. Decreased chest excursion at the bases of the lungs is seen with COPD.

Front 99

Percuss for tone. Percuss the apices above the clavicles. Then percuss the intercostal spaces across and down, comparing sides.

Back 99

Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased density such as consolidation, pleural effusion, or tumor.

Front 100

Percussion elicits _______ over breast tissue, the heart, and the liver. ______ is detected over the stomach, and flatness is detected over the muscles and bones.

Back 100

dullness, tympany

Front 101

mediastinum

Back 101

location of the heart

Front 102

The anterior chest area that overlies the heart and great vessels is called the ________

Back 102

precordium

Front 103

The large veins and arteries leading directly to and away from the heart are referred to as ...

Back 103

the great vessels

Front 104

The right and left sides of the heart are separated by a partition called the _______

Back 104

septum

Front 105

There are two AV valves

Back 105

The tricuspid valve and the bicuspid (mitral) valve

Front 106

Collagen fibers, called _______ _________, anchor the AV valve flaps to papillary muscles within the ventricles.

Back 106

chordae tendineae

Front 107

The ________ valves are located at the exit of each ventricle at the beginning of the great vessels

Back 107

semilunar valves

Front 108

There are two semilunar valves....

Back 108

the pulmonic valve and the aortic valve

Front 109

The pulmonic and aortic valves are ____ during ventricular contraction and _____ from the pressure of blood when the ventricles relax.

Back 109

open, close

Front 110

The _________ is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and, thereby, surrounds the heart

Back 110

pericardium

Front 111

A serous membrane lining, the ______ __________, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart

Back 111

parietal pericardium

Front 112

The ________ is the thickest layer of the heart and is made up of contractile cardiac muscle cells

Back 112

myocardium

Front 113

The _________ is a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels

Back 113

endocardium

Front 114

The ______ node, with inherent rhythmicity, generates impulses (at a rate of 60 to 100 per minute) that are conducted over both atria, causing them to contract simultaneously and send blood into the ventricles

Back 114

SA (Sinoatrial)

Front 115

The ________ node slightly delays incoming electrical impulses from the atria then relays the impulse to the AV bundle (bundle of His) in the upper interventricular septum

Back 115

AV

Front 116

"pacemaker of the heart"

Back 116

SA node

Front 117

P wave

Back 117

Atrial depolarization; conduction of the impulse throughout the atria

Front 118

PR interval

Back 118

Time from the beginning of the atrial depolarization to the beginning of ventricular depolarization, that is, from the beginning of the P wave to the beginning of the QRS complex.

Front 119

QRS Complex

Back 119

Ventricular depolarization (also atrial repolarization); conduction of the impulse throughout the ventricles, which then triggers contraction of the ventricles; measured from the beginning of the Q wave to the end of the S wave.

Front 120

ST Segment

Back 120

Period between ventricular depolarization and the beginning of ventricular repolarization

Front 121

T Wave

Back 121

Ventricular repolarization; the ventricles return to a resting state.

Front 122

QT Interval

Back 122

Total time for ventricular depolarization and repolarization, that is, from the beginning of the Q wave to the end of the T wave; the QT interval varies with heart rate.

Front 123

U Wave

Back 123

May or may not be present; if it is present, it follows the T wave and represents the final phase of ventricular repolarization.

Front 124

The _______ ______ refers to the filling and emptying of the heart's chambers

Back 124

cardiac cycle

Front 125

________ endures for approximately two-thirds of the cardiac cycle and ________ is the remaining one-third

Back 125

Diastole, Systole

Front 126

Heart sounds are produced by .....

Back 126

valve closure

Front 127

S1 correlates with the beginning of .....

Back 127

systole

Front 128

The second heart sound (S2) results from closure of the semilunar valves (aortic and pulmonic) and correlates with the beginning of .......

Back 128

diastole

Front 129

S3 and S4 are referred to as _______ _______ ______or ______ ______ ______, which result from ventricular vibration secondary to rapid ventricular filling

Back 129

diastolic filling sounds or extra heart sounds

Front 130

Conditions that contribute to turbulent blood flow include ....

Back 130

1. increased blood velocity
2. structural valve defects
3. valve malfunction
4. abnormal chamber openings

Front 131

Stroke volume is influenced by several factors:

Back 131

The degree of stretch of the heart muscle up to a critical length before contraction (preload); the greater the preload, the greater the stroke volume. This holds true unless the heart muscle is stretched so much that it cannot contract effectively.

The pressure against which the heart muscle has to eject blood during contraction (afterload); increased afterload results in decreased stroke volume.

Synergy of contraction (i.e., the uniform, synchronized contraction of the myocardium); conditions that cause an asynchronous contraction decrease stroke volume.

Compliance or distensibility of the ventricles; decreased compliance decreases stroke volume.

Contractility or the force of contractions of the myocardium under given loading conditions; increased contractility increases stroke volume.

Front 132

The parasympathetic impulses, travel to the heart by the _____ _____

Back 132

Vagus nerve

Front 133

The jugular veins return blood to the heart from the head and neck by way of the ________ ______ _______

Back 133

Superior Vena Cava

Front 134

Do you experience chest pain? When did it start? Describe the type of pain, location, radiation, duration, and how often you experience the pain. Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain. Does activity make the pain worse? Did you have perspiration (diaphoresis) with the chest pain?

Back 134

Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in origin. Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Diaphoresis and pain worsened by activity are usually related to cardiac chest pain.

Front 135

Do you experience palpitations?

Back 135

Palpitations may occur with an abnormality of the heart's conduction system or during the heart's attempt to increase cardiac output by increasing the heart rate. Palpitations may cause the client to feel anxious.

Front 136

Do you tire easily? Do you experience fatigue? Describe when the fatigue started. Was it sudden or gradual? Do you notice it at any particular time of day?

Back 136

Fatigue may result from compromised cardiac output. Fatigue related to decreased cardiac output is worse in the evening or as the day progresses.

Front 137

Do you have difficulty breathing or shortness of breath (dyspnea)?

Back 137

Dyspnea may result from congestive heart failure, pulmonary disorders, coronary artery disease, myocardial ischemia, and myocardial infarction. Dyspnea may occur at rest, during sleep, or with mild, moderate, or extreme exertion.

Front 138

Do you wake up at night with an urgent need to urinate (nocturia)? How many times a night?

Back 138

Increased renal perfusion during periods of rest or recumbency may cause nocturia. Decreased frequency may be related to decreased cardiac output.

Front 139

Do you experience dizziness?

Back 139

Dizziness may indicate decreased blood flow to the brain due to myocardial damage; however, there are several other causes for dizziness such as inner ear syndromes, decreased cerebral circulation, and hypotension. Dizziness may put the client at risk for falls.

Front 140

Do you experience swelling (edema) in your feet, ankles, or legs?

Back 140

Edema of the lower extremities may occur as a result of heart failure.

Front 141

Do you have frequent heart burn? When does it occur? What relieves it? How often do you experience it?

Back 141

Cardiac pain may be overlooked or misinterpreted as gastrointestinal problems.

Gastrointestinal pain may occur after meals and is relieved with antacids, whereas cardiac pain may occur anytime, is not relieved with antacids, and worsens with activity.

Front 142

Have you been diagnosed with a heart defect or a murmur?

Back 142

Congenital or acquired defects affect the heart's ability to pump, decreasing the oxygen supply to the tissues.

Front 143

Have you ever had rheumatic fever?

Back 143

Approximately 40% of people with rheumatic fever develop rheumatic carditis. Rheumatic carditis develops after exposure to group A beta-hemolytic streptococci and results in inflammation of all layers of the heart, impairing contraction and valvular function.

Front 144

Have you ever had heart surgery or cardiac balloon interventions?

Back 144

Previous heart surgery may change the heart sounds heard during auscultation. Surgery and cardiac balloon interventions indicate prior cardiac compromise.

Front 145

Have you ever had an electrocardiogram (ECG)? When was the last one performed? Do you know the results?

Back 145

A prior ECG allows the health care team to evaluate for any changes in cardiac conduction or previous myocardial infarction.

Front 146

Have you ever had a blood test called a lipid profile? Based on your last test, do you know what your cholesterol levels were?

Back 146

Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis

Front 147

Do you take medications or use other treatments for heart disease? How often do you take them? Why do you take them?

Back 147

Clients may have medications prescribed for heart disease but may not take them regularly. Clients may skip taking their diuretics because of having to urinate frequently. Beta-blockers may be omitted because of the adverse effects on sexual energy. Education about medications may be needed.

Front 148

Do you monitor your own heart rate or blood pressure?

Back 148

Self-monitoring of heart rate or blood pressure is recommended if the client is taking cardiotonic or antihypertensive medications respectively. A demonstration is necessary to ensure appropriate technique.

Front 149

Do you smoke? How many packs of cigarettes per day and for how many years?

Back 149

Cigarette smoking greatly increases the risk of heart disease

Front 150

What type of stress do you have in your life? How do you cope with it?

Back 150

Stress has been identified as a possible risk factor for heart disease.

Front 151

Describe what you usually eat in a 24-hour period.

Back 151

An elevated cholesterol level increases the chance of fatty plaque formation in the coronary vessels.

Front 152

How much alcohol do you consume each day/week?

Back 152

Excessive intake of alcohol has been linked to hypertension

Front 153

Do you exercise? What type of exercise and how often?

Back 153

A sedentary lifestyle is a known modifiable risk factor contributing to heart disease. Aerobic exercise three times per week for 30 min is more beneficial than anaerobic exercise or sporadic exercise in preventing heart disease.

Front 154

Describe your daily activities. How are they different from your routine 5 or 10 years ago? Does fatigue, chest pain, or shortness of breath limit your ability to perform daily activities? Describe. Are you able to care for yourself?

Back 154

Heart disease may impede the ability to perform daily activities. Exertional dyspnea or fatigue may indicate heart failure. An inability to complete activities of daily living may necessitate a referral for home care.

Front 155

Has your heart disease had any effect on your sexual activity?

Back 155

Many clients with heart disease are afraid that sexual activity will precipitate chest pain. If the client can walk one block or climb two flights of stairs without experiencing symptoms, it is generally acceptable for the client to engage in sexual intercourse. Nitroglycerin can be taken before intercourse as a prophylactic for chest pain. In addition, the side-lying position for sexual intercourse may reduce the workload on the heart.

Front 156

How many pillows do you use to sleep at night? Do you get up to urinate during the night? Do you feel rested in the morning?

Back 156

If heart function is compromised, cardiac output to the kidneys is reduced during episodes of activity. At rest, cardiac output increases, as does glomerular filtration and urinary output. Orthopnea (the inability to breathe while supine) and nocturia may indicate heart failure. In addition, these two conditions may also impede the ability to get adequate rest.

Front 157

Coronary Heart Disease

Back 157

CHD is the single largest killer of Americans, both men and women

Front 158

Coronary Heart Disease Risk Factors

Back 158

Age: Male over age 45; female over age 55 (postmenopausal or ovaries removed and not on estrogen replacement therapy)

Family history: Father or brother had heart attack before age 55; mother or sister before age 65; close relative had stroke

Cigarette smoking or exposure to second-hand smoke

Cholesterol or high-density lipoprotein (HDL) levels: Total cholesterol >240 mg/dL; HDL <35 mg/dL

Blood pressure above 140/90

Limited physical activity: Fewer than 30 minutes of moderate activity most days

Body weight: 20 or more pounds overweight; upper body adiposity

Diabetes or fasting blood glucose level ≥126 mg/dL

Dietary intake low in antioxidants, especially fruit

Low-grade systemic infection/inflammation (elevated C-reactive protein

Low birth weight

Stress: Psychological/emotional or physical stress; family relationship stresses; burnout; and daily hassles, especially in women

Front 159

Observe the jugular venous pulse. Inspect the jugular venous pulse by standing on the right side of the client. The client should be in a supine position with the torso elevated 30 to 45 degrees. Make sure the head and torso are on the same plane. Ask the client to turn the head slightly to the left. Shine a tangential light source onto the neck to increase visualization of pulsations as well as shadows. Next inspect the suprasternal notch or the area around the clavicles for pulsations of the internal jugular veins.

Back 159

Fully distended jugular veins with the client's torso elevated more than 45 degrees indicate increased central venous pressure that may be the result of right ventricular failure, pulmonary hypertension, pulmonary emboli, or cardiac tamponade.

Front 160

Evaluate jugular venous pressure. Evaluate jugular venous pressure by watching for distention of the jugular vein. It is normal for the jugular veins to be visible when the client is supine; to evaluate jugular vein distention, position the client in a supine position with the head of the bed elevated 30, 45, 60, and 90 degrees. At each increase of the elevation, have the client's head turned slightly away from the side being evaluated. Using tangential lighting, observe for distention, protrusion, or bulging.

Back 160

Distention, bulging, or protrusion at 45, 60, or 90 degrees may indicate right-sided heart failure. Document at which positions (45, 60, and/or 90 degrees) you observe distention.

Clients with obstructive pulmonary disease may have elevated venous pressure only during expiration.

An inspiratory increase in venous pressure, called Kussmaul's sign, may occur in clients with severe constrictive pericarditis.

Front 161

Auscultate the carotid arteries. Auscultate the carotid arteries if the client is middle-aged or older or if you suspect cardiovascular disease. Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath for a moment so breath sounds do not conceal any vascular sounds

Back 161

A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel, is indicative of occlusive arterial disease. However, if the artery is more than two-thirds occluded, a bruit may not be heard.

Pulse inequality may indicate arterial constriction or occlusion in one carotid.
Weak pulses may indicate hypovolemia, shock, or decreased cardiac output.

A bounding, firm pulse may indicate hypervolemia or increased cardiac output.

Front 162

Always auscultate the carotid arteries ______ palpating because palpation may increase or slow the heart rate, therefore, changing the strength of the carotid impulse heard

Back 162

before

Front 163

Palpate the carotid arteries. Palpate each carotid artery alternately by placing the pads of the index and middle fingers medial to the sternocleidomastoid muscle on the neck. Note amplitude and contour of the pulse, elasticity of the artery, and any thrills.

Back 163

Variations in strength from beat to beat or with respiration are abnormal and may indicate a variety of problems.

A delayed upstroke may indicate aortic stenosis.

Loss of elasticity may indicate arteriosclerosis. Thrills may indicate a narrowing of the artery

Front 164

Pulse Amplitude Scale

Back 164

0 = Absent
1+ = Weak
2+ = Normal
3+ = Increased
4+ = Bounding

Front 165

Heart: Inspect pulsations. With the client in supine position with the head of the bed elevated between 30 and 45 degrees, stand on the client's right side and look for the apical impulse and any abnormal pulsations.

Back 165

Pulsations, which may also be called heaves or lifts, other than the apical pulsation are considered abnormal and should be evaluated. A heave or lift may occur as the result of an enlarged ventricle from an overload of work.

Front 166

Palpate the apical impulse. Remain on the client's right side and ask the client to remain supine. Use the palmar surfaces of your hand to palpate the apical impulse in the mitral area (fourth or fifth intercostal space at the midclavicular line). After locating the pulse, use one finger pad for more accurate palpation

Back 166

The apical impulse may be impossible to palpate in clients with pulmonary emphysema. If the apical impulse is larger than 1 to 2 cm, displaced, more forceful, or of longer duration, suspect cardiac enlargement.

Front 167

If this pulsation cannot be palpated, have the client assume a ______ ________ position. This displaces the heart toward the left chest wall and relocates the apical impulse farther to the left.

Back 167

Left Lateral

Front 168

In older clients the apical impulse may be difficult to palpate because of ...

Back 168

increased aneroposterior chest diameter

Front 169

Heart: Palpate for abnormal pulsations. Use your palmar surfaces to palpate the apex, left sternal border, and base.

Back 169

A thrill, which feels similar to a purring cat, or a pulsation is usually associated with a grade IV or higher murmur.

Front 170

Auscultate heart rate and rhythm. Place the diaphragm of the stethoscope at the apex and listen closely to the rate and rhythm of the apical impulse.

Back 170

Bradycardia (less than 60 beats/min) or tachycardia (more than 100 beats/min) may result in decreased cardiac output. Clients with regular irregular rhythms (i.e., premature atrial contraction or premature ventricular contractions) and irregular rhythms (i.e., atrial fibrillation and atrial flutter with varying block) should be referred for further evaluation. These types of irregular patterns may predispose the client to decreased cardiac output, heart failure, or emboli

Front 171

Heart: If you detect an irregular rhythm, auscultate for a pulse rate deficit. This is done by palpating the radial pulse while you auscultate the apical pulse. Count for a full minute.

Back 171

A pulse deficit (difference between the apical and peripheral/radial pulses) may indicate atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block.

Front 172

Listen to S1. Use the diaphragm of the stethoscope to best hear S1

Back 172

Normal: A distinct sound is heard in each area but loudest at the apex. May become softer with inspiration. A split S1 may be heard normally in young adults at the left lateral sternal border.

Accentuated, diminished, varying, or split S1 are all abnormal findings

Front 173

Listen to S2. Use the diaphragm of the stethoscope. Ask the client to breath regularly.

Back 173

Normal: Distinct sound is heard in each area but is loudest at the base. A split S2 (into two distinct sounds of its components—A2 and P2) is normal and termed physiologic splitting. It is usually heard late in inspiration at the second or third left interspaces

Distinct sound is heard in each area but is loudest at the base. A split S2 (into two distinct sounds of its components—A2 and P2) is normal and termed physiologic splitting. It is usually heard late in inspiration at the second or third left interspaces

Front 174

Auscultate for extra heart sounds. Use the diaphragm first then the bell to auscultate over the entire heart area. Note the characteristics (e.g., location, timing) of any extra sound heard. Auscultate during the systolic pause (space heard between S1 and S2).

Back 174

Ejection sounds or clicks (e.g., a mid-systolic click associated with mitral valve prolapse). A friction rub may also be heard during the systolic pause. Abnormal Findings 18-4 provides a full description of the extra heart sounds (normal and abnormal) of systole and diastole.

Front 175

Auscultate during the diastolic pause (space heard between end of S2 and the next S1).

Back 175

A pathologic S3 (ventricular gallop) may be heard with ischemic heart disease, hyperkinetic states (e.g., anemia), or restrictive myocardial disease.

A pathologic S4 (atrial gallop) toward the left side of the precordium may be heard with coronary artery disease, hypertensive heart disease, cardiomyopathy, and aortic stenosis. A pathologic S4 toward the right side of the precordium may be heard with pulmonary hypertension and pulmonic stenosis.

S3 and S4 pathologic sounds together create a quadruple rhythm, which is called a summation gallop. Opening snaps occur early in diastole and indicate mitral valve stenosis. A friction rub may also be heard during the diastolic pause

Front 176

Auscultate for murmurs. A murmur is a swishing sound caused by turbulent blood flow through the heart valves or great vessels. Auscultate for murmurs across the entire heart area. Use the diaphragm and the bell of the stethoscope in all areas of auscultation because murmurs have a variety of pitches. Also auscultate with the client in different positions because some murmurs occur or subside according to the client's position

Back 176

Normally no murmurs are heard. However, innocent and physiologic midsystolic murmurs may be present in a healthy heart.

Abnormal: Pathologic midsystolic, pansystolic, and diastolic murmurs.

Front 177

Auscultate in with the client assuming other positions. Ask the client to assume a left lateral position. Use the bell of the stethoscope and listen at the apex of the heart.

Back 177

An S3 or S4 heart sound or a murmur of mitral stenosis that was not detected with the client in the supine position may be revealed when the client assumes the left lateral position.

Front 178

Six grades describe the intensity of a murmur.

Back 178

Grade 1: Very faint, heard only after the listener has “tuned in”; may not be heard in all positions
Grade 2: Quiet but heard immediately on placing the stethoscope on the chest
Grade 3: Moderately loud
Grade 4: Loud*
Grade 5: Very loud, may be heard with a stethoscope partly off the chest*
Grade 6: May be heard with the stethoscope entirely off the chest*

Front 179

__________ are the blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries

Back 179

Arteries

Front 180

Each heartbeat forces blood through the arterial vessels under high pressure, creating a surge. This surge of blood is the

Back 180

Arterial Pulse

Front 181

The _______ artery is the major artery that supplies the arm

Back 181

Brachial

Front 182

The brachial artery divides near the elbow to become the _____ artery and the _____ artery.

Back 182

radial, ulnar

Front 183

The ______ pulse can be palpated on the lateral aspect of the wrist

Back 183

radial

Front 184

The _______ artery is the major supplier of blood to the legs

Back 184

femoral

Front 185

_____ are the blood vessels that carry deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart

Back 185

Veins

Front 186

There are three types of veins:

Back 186

deep veins, superficial veins, and perforator (or communicator) veins

Front 187

venous stasis risk factors

Back 187

Risk factors for venous stasis include long periods of standing still, sitting, or lying down.

Lack of muscular activity causes blood to pool in the legs, which, in turn, increases pressure in the veins.

Other causes of venous stasis include varicose (tortuous and dilated) veins, which increase venous pressure.

Damage to the vein wall can also contribute to venous stasis.

Front 188

The lymphatic system

Back 188

a complex vascular system composed of lymphatic capillaries, lymphatic vessels, and lymph nodes

Front 189

What is the function of the Lymphatic system?

Back 189

drain excess fluid and plasma proteins from bodily tissues and return them to the venous system

a major part of the immune system defending the body against microorganisms.

absorb fats (lipids) from the small intestine into the bloodstream.

Front 190

The epitrochlear nodes

Back 190

located approximately 3 cm above the elbow on the inner (medial) aspect of the arm

drain the lower arm and hand

Front 191

The superficial inguinal nodes consist of two groups:

Back 191

a horizontal and a vertical chain of nodes

Front 192

The superficial inguinal nodes drain...

Back 192

the legs, external genitalia, and lower abdomen and buttocks

Front 193

Capillaries are small blood vessels that form the connection between the ________ and ________

Back 193

arterioles and venules

Front 194

the capillary bed is very important in ......

Back 194

maintaining the equilibrium of interstitial fluid and preventing edema

This is because the lymphatic capillaries function to remove any excess fluid left behind in the interstitial spaces

Front 195

Have you noticed any color, temperature, or texture changes in your skin?

Back 195

Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency. Warm skin and brown pigmentation around the ankles are associated with venous insufficiency.

Front 196

Do you experience pain or cramping in your legs? Describe the pain (aching, stabbing). How often does it occur? Does it occur with activity? Does it wake you from sleep?

Back 196

Intermittent claudication characterized by cramping pain in the calves, thighs, or buttocks and weakness that occurs with activity and is relieved with rest may indicate arterial disease. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and is relieved by rest are associated with venous disease. Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. However, the lack of pain may signal neuropathy in a diabetic client. Reduced sensation or an absence of pain can result in a failure to recognize a problem or fully understand the problem's significance

Front 197

Older clients with arterial disease may not have the classic symptoms of intermittent claudication, but may experience ......

Back 197

coldness, color change, numbness, and abnormal sensations

Front 198

Do you have any leg veins that are ropelike, bulging, or contorted?

Back 198

Varicose veins are hereditary but may also develop from increased venous pressure and venous pooling (e.g., as happens during pregnancy). Standing in one place for long times also increases the risk for varicosities.

Front 199

Do you have any sores or open wounds on your legs? Where are they located? Are they painful?

Back 199

Ulcers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle. Venous ulcers are usually painless and occur on the lower leg or medial ankle.

Front 200

Do you have any swelling (edema) in your legs or feet? At what time of day is swelling worst? Any pain with swelling?

Back 200

Peripheral edema (swelling) results from an obstruction of the lymphatic flow or from venous insufficiency from such conditions as incompetent valves or decreased osmotic pressure in the capillaries. It may also occur with deep vein thrombosis. With leg or foot ulcers, edema can reduce tissue perfusion and wound oxygenation

Front 201

Do you have any swollen glands or lymph nodes? If so, do they feel tender, soft, or hard?

Back 201

Enlarged lymph nodes may indicate a local or systemic infection.

Front 202

For male clients: Have you experienced a change in your usual sexual activity? Describe.

Back 202

Impotence may occur in clients with decreased blood flow or an occlusion of the blood vessels such as aortoiliac occlusion (Leriche's syndrome). Men may be reluctant to report or discuss difficulties they have achieving or maintaining an erection.

Front 203

Do you have a family history of diabetes, hypertension, coronary heart disease, or elevated cholesterol or triglyceride levels?

Back 203

These disorders or abnormalities tend to be hereditary and cause damage to blood vessels.

Front 204

Do you (or did you in the past) smoke cigarettes or use any other form of tobacco? How much and for how long?

Back 204

Smoking cigarettes (and using other forms of tobacco) significantly increases a person's risk for chronic arterial insufficiency. The risk increases according to the length of time a person smokes and the amount of tobacco smoked

Front 205

Do you exercise regularly?

Back 205

Regular exercise improves peripheral vascular circulation and decreases stress, pulse rate, and blood pressure, thereby decreasing the risk for developing peripheral vascular disease.

Front 206

For female clients: Do you take oral or transdermal (patch) contraceptives?

Back 206

These contraceptives increase the risk for thrombophlebitis, Raynaud's disease, hypertension, and edema

Front 207

Describe the degree of stress you normally have.

Back 207

Stress increases the heart rate and blood pressure and can contribute to vascular disease.

Front 208

How have problems with your circulation (i.e., peripheral vascular system) affected your ability to function?

Back 208

Discomfort or pain associated with chronic arterial disease and the aching heaviness associated with venous disease may limit a client's ability to stand or walk for long periods. This, in turn, may affect job performance and the ability to care for a home and family or participate in social events.

Front 209

Do leg ulcers or varicose veins affect how you feel about yourself?

Back 209

If clients perceive the appearance of their legs as disfiguring, their body image or feelings of self-worth may be negatively influenced.

Front 210

Do you regularly take medications prescribed by your physician to improve your circulation?

Back 210

Drugs that inhibit platelet aggregation, such as cilostazol (Pletal) or clopidogrel (Plavix), may be prescribed to increase blood flow. Aspirin also prevents blood clotting and is used to reduce the risks associated with peripheral vascular disease. Pentoxifylline (Trental) may be prescribed to reduce blood viscosity, improve blood flow to the tissues thus reducing tissue hypoxia. Topical medications such as xenaderm (Trypsin) can also improve wound oxygenation by increasing blood flow thus promoting wound healing (Strauss, 2002). Clients who fail to take their medications regularly are at risk for developing peripheral vascular problems. These clients require teaching about their medication and the importance of taking it regularly.

Front 211

Do you wear support hose to treat varicose veins?

Back 211

Support stockings help to reduce venous pooling and increase blood return to the heart.

Front 212

Peripheral Vascular Disease

Back 212

includes five common vascular disorders (aortic aneurysms, cerebrovascular disease, deep vein thrombosis and pulmonary embolism, peripheral arterial occlusive disease [PAOD], and varicose veins)

Front 213

Coronary heart disease risk factors

Back 213

Age—older adults
Black race/ethnicity
Diabetes mellitus
Tobacco smoking
Hypertension
Elevated blood lipid levels (high level of low-density lipoproteins and low level of high-density lipoproteins)
Coronary or cerebral vascular disease
Low kidney function
Male sex (somewhat higher)
Family history
Unhealthy diet

Front 214

Possible risk factors for coronary heart disease

Back 214

Poverty
Low education status
Depression
Inflammation and blood clotting disorders

Front 215

Venous disease risk factors

Back 215

Surgery
Pregnancy; recent childbirth
Obesity
Use of hormone replacement therapy
Use of oral contraceptives
Job with prolonged standing or sitting or other periods of immobility, e.g., traveling (Note: This is also a risk factor for varicose veins known as hemorrhoids)
Limited physical activity and/or poor physical fitness
Congenital or acquired vein wall or valve weakness or anatomic structure
Female sex
Increasing age
Genetics—non-African American
Family history
Lack of dietary fiber
Use of constrictive clothing

Front 216

The highest prevalence of PAOD has been found in ________ ________

Back 216

elderly italians

Front 217

Observe arm size and venous pattern; also look for edema.

Back 217

Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Prominent venous patterning with edema may indicate venous obstruction.

Front 218

Observe coloration of the hands and arms

Back 218

Raynaud's disease, a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes, is characterized by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness. The disorder commonly occurs bilaterally; symptoms last minutes to hours

Front 219

Palpate the client's fingers, hands, and arms, and note the temperature.

Back 219

A cool extremity may be a sign of arterial insufficiency. Cold fingers and hands, for example, are common findings with Raynaud's disease

Front 220

Palpate to assess capillary refill time. Compress the nailbed until it blanches. Release the pressure and calculate the time it takes for color to return. This test indicates peripheral perfusion and reflects cardiac output.

Back 220

Capillary refill time exceeding 2 seconds may indicate vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia.

Front 221

When performing capillary refill Inaccurate findings may result if ......

Back 221

the room is cool, if the client has edema, anemia, or if the client recently smoked a cigarette

Front 222

Palpate the radial pulse. Gently press the radial artery against the radius. Note elasticity and strength

Back 222

Increased radial pulse volume indicates a hyperkinetic state. Diminished or absent pulse suggests partial or complete arterial occlusion (which is more common in the legs than the arms). The pulse could also be decreased from Buerger's disease or scleroderma.
Obliteration of the pulse may re-sult from compression by external sources, as in compartment syndrome.

Front 223

Palpate the ulnar pulses. Apply pressure with your first three fingertips to the medial aspects of the inner wrists. The ulnar pulses are not routinely assessed because they are located deeper than the radial pulses and are difficult to detect. Palpate the ulnar arteries if you suspect arterial insufficiency

Back 223

Lack of resilience or inelasticity of the artery wall may indicate arteriosclerosis.

Front 224

You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps

Back 224

Normal: Brachial pulses have equal strength bilaterally.

Abnormal: Brachial pulses are increased, diminished, or absent

Front 225

Palpate the epitrochlear lymph nodes. Take the client's left hand in your right hand as if you were shaking hands. Flex the client's elbow about 90 degrees. Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles. If nodes are detected, evaluate for size, tenderness, and consistency. Repeat palpation on the opposite arm.

Back 225

Normally epitrochlear lymph nodes are not palpable.

Enlarged epitrochlear lymph nodes may indicate an infection in the hand or forearm or they may occur with generalized lymphadenopathy. Enlarged lymph nodes may also occur because of a lesion in the area.

Front 226

Perform the Allen test. The Allen test evaluates patency of the radial or ulnar arteries. It is implemented when patency is questionable or before such procedures as a radial artery puncture. The test begins by assessing ulnar patency. Have the client rest the hand palm side up on the examination table and make a fist. Then use your thumbs to occlude the radial and ulnar arteries. Continue pressure to keep both arteries occluded and have the client release the fist. Note that the palm remains pale. Release the pressure on the ulnar artery and watch for color to return to the hand. To assess radial patency, repeat the procedure as before, but at the last step, release pressure on the radial artery

Back 226

Normal: Pink coloration returns to the palms within 3 to 5 seconds if the ulnar artery is patent.
Pink coloration returns within 3 to 5 seconds if the radial artery is patent.

Abnormal: With arterial insufficiency or occlusion of the ulnar artery, pallor persists. With arterial insufficiency or occlusion of the radial artery, pallor persists.

Front 227

Ask the client to lie supine. Then drape the groin area and place a pillow under the client's head for comfort. Observe skin color while inspecting both legs from the toes to the groin.

Back 227

Pallor, especially when elevated, and rubor, when dependent, suggests arterial insufficiency. Cyanosis when dependent suggests venous insufficiency. A rusty or brownish pigmentation around the ankles indicates venous insufficiency.

Front 228

Inspect distribution of hair on lower extremities

Back 228

Loss of hair on the legs suggests arterial insufficiency. Often thin, shiny skin is noted as well.

Front 229

Inspect for lesions or ulcers on the lower extremities

Back 229

Ulcers with smooth, even margins that occur at pressure areas, such as the toes and lateral ankle, result from arterial insufficiency. Ulcers with irregular edges, bleeding, and possible bacterial infection that occur on the medial ankle, result from venous insufficiency

Front 230

Inspect for edema. Inspect the legs for unilateral or bilateral edema. Note veins, tendons, and bony prominences. If the legs appear asymmetric, use a centimeter tape to measure in four different areas: circumference at midthigh, largest circumference at the calf, smallest circumference above the ankle, and across the forefoot. Compare both extremities at the same locations

Back 230

Bilateral edema may be detected by the absence of visible veins, tendons, or bony prominences. Bilateral edema usually indicates a systemic problem, such as congestive heart failure, or a local problem, such as lymphedema (abnormal or blocked lymph vessels) or prolonged standing or sitting (orthostatic edema). Unilateral edema is characterized by a 1-cm difference in measurement at the ankles, or a 2-cm difference at the calf, and a swollen extremity. It is usually caused by venous stasis due to insufficiency or an obstruction. It may also be caused by lymphedema (Abnormal Findings 19-2). A difference in measurement between legs may also be due to muscular atrophy. Muscular atrophy usually results from disuse due to stroke or from being in a cast for a prolonged time

Front 231

Palpate edema. If edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting. Press the edematous area with the tips of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented on release, pitting edema is present.

Back 231

Pitting edema is associated with systemic problems, such as congestive heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting (orthostatic edema). A 1+ to 4+ scale is used to grade the severity of the pitting edema

Front 232

Palpate bilaterally for temperature of the feet and legs. Use the backs of your fingers. Compare your findings in the same areas bilaterally. Note location of any changes in temperature.

Back 232

Generalized coolness in one leg or change in temperature from warm to cool as you move down the leg suggests arterial insufficiency. Increased warmth in the leg may be caused by superficial thrombophlebitis resulting from a secondary inflammation in the tissue around the vein.

Front 233

Palpate the superficial inguinal lymph nodes. irst, expose the client's inguinal area, keeping the genitals draped. Feel over the upper medial thigh for the vertical and horizontal groups of superficial inguinal lymph nodes. If detected, determine size, mobility, or tenderness. Repeat palpation on the opposite thigh.

Back 233

Nontender, movable lymph nodes up to 1 or even 2 cm are commonly palpated.

Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy) may be from a local infection or generalized lymphadenopathy. Fixed nodes may indicate malignancy.

Front 234

Palpate the femoral pulses. Ask the client to bend the knee and move it out to the side. Press deeply and slowly below and medial to the inguinal ligament. Use two hands if necessary. Release pressure until you feel the pulse. Repeat palpation on the opposite leg. Compare amplitude bilaterally

Back 234

Weak or absent femoral pulses indicate partial or complete arterial occlusion.

Front 235

Auscultate the femoral pulses. If arterial occlusion is suspected in the femoral pulse, position the stethoscope over the femoral artery and listen for bruits. Repeat for other artery

Back 235

Bruits over one or both femoral arteries suggest partial obstruction of the vessel and diminished blood flow to the lower extremities

Front 236

Palpate the popliteal pulses. Ask the client to raise (flex) the knee partially. Place your thumbs on the knee while positioning your fingers deep in the bend of the knee. Apply pressure to locate the pulse. It is usually detected lateral to the medial tendon

Back 236

Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse

Front 237

Palpate the dorsalis pedis pulses. Dorsiflex the client's foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe. The pulses of both feet may be assessed at the same time to aid in making comparisons. Assess amplitude bilaterally

Back 237

A weak or absent pulse may indicate impaired arterial circulation. Further circulatory assessments (temperature and color) are warranted to determine the significance of an absent pulse.

Front 238

Palpate the posterior tibial pulses. Palpate behind and just below the medial malleolus (in the groove between the ankle and the Achilles tendon). Palpating both posterior tibial pulses at the same time aids in making comparisons. Assess amplitude bilaterally.

Back 238

The posterior tibial pulses should be strong bilaterally. However, in about 15% of healthy clients, the posterior tibial pulses are absent.

A weak or absent pulse indicates partial or complete arterial occlusion.

Front 239

Inspect for varicosities and thrombophlebitis. Ask the client to stand because varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. As the client is standing, inspect for superficial vein thrombophlebitis. To fully assess for a suspected phlebitis, palpate for tenderness. If superficial vein thrombophlebitis is present, note redness or discoloration on the skin surface over the vein.

Back 239

Varicose veins may appear as distended, nodular, bulging, and tortuous, depending on severity. Varicosities are common in the anterior lateral thigh and lower leg, the posterior lateral calf, or anus (known as hemorrhoids). Varicose veins result from incompetent valves in the veins, weak vein walls, or an obstruction above the varicosity. Despite venous dilation, blood flow is decreased and venous pressure is increased. Superficial vein thrombophlebitis is marked by redness, thickening, and tenderness along the vein. Aching or cramping may occur with walking or dorsiflexion of the foot (positive Homans' sign). Swelling and inflammation are often noted

Front 240

Check for Homans' Sign. This test has been traditionally used but is controversial now, especially if the client has a history of deep vein thrombosis because this test may dislodge the clot. You can use two methods to elicit Homans' sign. The client should be supine for both methods. First flex the client's knee about 5 degrees, place your hands under the client's calf muscle, and quickly squeeze the muscle against the tibia. Ask the client to report any pain or tenderness. Repeat procedure on opposite leg

Back 240

Normal: No pain or tenderness elicited with these maneuvers.
Homans' sign is negative.

Calf pain and tenderness elicited with these maneuvers are a positive Homans' sign. A positive sign may indicate deep vein thrombosis (blood clot in deep vein) or superficial thrombophlebitis (inflammation of a superficial vein). However, further diagnostic testing (i.e., venogram) and referral are indicated for a definitive diagnosis.

Front 241

Perform position change test for arterial insufficiency. If pulses in the legs are weak, further assessment for arterial insufficiency is warranted. The client should be in a supine position. Place both of your hands under both of the client's ankles. Raise the legs about 12 inches above the level of the heart. As you support the client's legs, ask the client to pump the feet up and down for about a minute to drain the legs of venous blood, leaving only arterial blood to color the legs

Back 241

Marked pallor with legs elevated is an indication of arterial insufficiency. Return of pink color that takes longer than 10 seconds and superficial veins that take longer than 15 seconds to fill suggest arterial insufficiency. Persistent rubor (dusky redness) of toes and feet with legs dependent also suggests arterial insufficiency.

Front 242

Use ankle-brachial pressure index (ABPI). If the client has symptoms of arterial occlusion, the ankle-brachial pressure index should be used to compare the upper and lower limbs systolic blood pressure. The ankle-brachial pressure index (ABPI) is the ratio of the ankle systolic blood pressure to the arm (brachial) systolic blood pressure. The ABPI is considered an accurate objective assessment for determining the degree of peripheral arterial disease. It detects decreased systolic pressure distal to the area of stenosis or arterial narrowing and allows the nurse to quantify this measurement

Back 242

An ABPI of 0.5 to 0.95 indicates mild to moderate arterial insufficiency whereas an ABPI of 0.25 or lower indicates severe stenosis leading to ischemia and tissue damage. In addition to the abnormal ABPI findings, reduced or absent pedal pulses, cool leg unilaterally, lack of hair, and shiny skin on leg suggests peripheral arterial occlusive disease

Front 243

Manual compression test. If the client has varicose veins, perform manual compression to assess the competence of the vein's valves. Ask the client to stand. Firmly compress the lower portion of the varicose vein with one hand. Place your other hand 6 to 8 inches above your first hand. Feel for a pulsation to your fingers in the upper hand. Repeat this test in the other leg if varicosities are present.

Back 243

You will feel a pulsation with your upper fingers if the valves in the veins are incompetent.

Front 244

Trendelenburg test. If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins. The client should lie supine. Elevate the client's leg 90 degrees for about 15 seconds or until the veins empty. With the leg elevated, apply a tourniquet to the upper thigh.

Back 244

Normal: Saphenous vein fills from below in 30 seconds. If valves are competent, there will be no rapid filling of the varicose veins from above (retrograde filling) after removal of tourniquet.

Abnormal: Filling from above with the tourniquet in place and the client standing suggests incompetent valves in the saphenous vein. Rapid filling of the superficial varicose veins from above after the tourniquet has been removed also indicates retrograde filling past incompetent valves in the veins.