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97 Cards in this Set
- Front
- Back
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landmarks for thorax |
anterior - anterior axillary line, midclavicular line, midsternal line posterior - posterior axillary line, scapular line, vertebral line lateral - anterior axillary line, midaxillary line, posterior axillary line |
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ribs |
true: 1-7 false: 8-10 floating: 11-12 |
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sternal angle |
trachea bifurcates into right and left primary bronchi right and left brachiocephalic dump into superior vena cava aortic arch curves posteriorly right thoracic duct crosses over to left T4 |
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trachea divisions |
trachea > 1 right and 1 left primary bronchi > 3 right lobar secondary bronchi and 2 left lobar secondary bronchi > tertiary/segmental bronchi |
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what controls breathing |
involuntary: medulla - rhythm, pons - rate and depth voluntary: cerebral cortex |
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fissures |
oblique (right side only): (abduct arm) spinous process T3/T4 to around the end of the 6th rib on midclavicular line horizontal (right and left): 4th rib of sternocostal junction to 5th rib of midaxillary line |
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borders of lungs |
anterior: apex = 2-3 cm superior to inner third of clavicle, inferior border crosses 6th rib at midclavicular line, inferior border crosses 8th rib at midaxillary line posterior: inferior border lies at T10 spinous process (end of expiration) and descends to T12 during deep inspiration |
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muscles of inspiration |
primary: diaphragm, external intercostals accessory: scm, trapezius, scalenes, pectorals, serratus anterior |
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muscles of expiration |
primary passive: none - air leaves due to recoil of lung primary forced: abdominals |
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components of respiratory evaluation |
history physical exam observation/inspection vital signs cough (effectiveness) palpation percussion auscultation (listen for 1 full inspriation and expiration) diagnostic tests |
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what are you looking for in respiratory evaluation during observation and inspection? |
anthropometrics - body size, chest shape, cachetic (muscle atrophy) position - how you receive and leave patient face - anxious, distressed, discoloration, alertness skin - dry skin, diurpheretic (sweating), color, trophic changes, surgical incisions neck - using accessory muscles to breathe, distended jugular veins, trachea centered breathing pattern periphery - clubbing of fingers or toes, edema (bilateral or unilateral) phonation - voice quality |
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chest wall shapes |
normal: medial-lateral is bigger than anterior-posterior barrel chest: equal m/l and a/p (COPD) kyphosis - hunchback, decrease chest expansion, greater risk of pulmonary complication pectus excavatus - divot in chest, congenital pectus carinatum - congenital, can acquire from sternal incisions not healing well, extends a/p but just in sternum, looks pointed |
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apenea |
lack of airflow for > 15 seconds airway obstruction, cariopulmonary arrest, alterations in respiratory center, narcotic overdoes |
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biot's respirations |
constant increased rate and depth of respiration followed by periods of apnea elevated ICP (intracranial pressure), meningitis |
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cheyne-stokes |
increasing depth of ventilation followed by a period of apnea elevated ICP, CHF, narcotic overdose end of life breathing |
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kussmaul respirations |
increased regular rate and depth of ventilation diabetic ketoacidosis, renal failur |
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orthopnea |
dyspnea that occurs in supine position chronic lung diseases (COPD, emphysema), CHF |
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red flags of breathing patterns |
biot's respirations cheyne-stokes kussmoul respirations |
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paradoxic ventilation |
opposite of what chest should do during respiration |
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bradypnea |
RR < 12/min CNS depressants, neurologic or metabolic disorders, excessive fatigue |
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tachypnea |
RR > 20/min acute respiratory distress, fever, pain, emotion, anemia |
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hyperpnea |
increased depth of ventilation activity, pulmonary infection, CHF |
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hyperventilation |
increased rate and depth of ventilation resulting in decreased PCO2 anxiety, nervousness, metabolic acidosis |
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hypoventilation |
decreased rate and depth of ventilation resulting in increased PCO2 sedation or over-medication, somnolence (excessively tired and overly sleepy), neurologic depression or respiratory centers |
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hoover's sign |
inward movement of lower ribs during inspiration |
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4 phases of cough |
full inspiration closure of glottis with increase in intrathoracic pressure contract abdominals forced expiration |
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cough is important because? |
essential for good bronchopulmonary hygiene |
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what to look for in examine for cough |
effectiveness - productive or not control - able to start and stop quality - wet or dry frequency sputum production hemoptysis - blood (dark is old) |
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during inhalation, rib cage moves... |
outward and upward |
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what are you looking for in palpation during respiration exam |
chest wall expansion - upper, middle, lower (measure) presence of pain, tenderness skin temperature - cold means poor blood flow and low oxygen vibrations (fremitus) - normal during speaking, can be accentuated with secretions (pneonmonia), bilateral, decreases as you move inferiorly percussion - checks tissue density |
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what are the sounds of percussion |
resonant - normal hyperresonant - louder (emphysema) tympanic - over pock of air (stomach) dull - increased tissue density (secretions) flat - exteme dullness (thigh) |
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differences between diaphragm and bell |
diaphragm: high frequency, good for BP bell: low frequency |
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tracheal lung sounds |
high pitch, loud, harsh directly over trachea equal in length for insp. and exp. (no pause between) |
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bronchial |
louder, higher in pitch over primary bronchi exp. longer, slight pause between phases |
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bronchovesicular |
intermediate or swishy ant: 1 and 2 intercostal spaces post: between scapula equal in length |
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vesicular |
soft, low pitch, rustling sounds everywhere else (distal) requires deep inspiration, sounds disaperas about 1/3 way through expiration |
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abnormal lung sounds |
bronchial - anywhere besides trachea or primary bronchi, fluid or secretion consolidation decreased - softer, anywhere, hypoventilation, severe congestion, emphysema absent - no sounds, anywhere, pneumothorax, atelectosis (collapsed lung) |
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lung sounds adventitious - continous |
rhonchi - low pitched, snoring sound, large airway obstruction wheezes - high/medium/low pitched, narrowed airways, pneumonia stridor - extremely high pitched, medical emergency, significant airway obstruction, can hear without stethoscope |
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lung sounds adventitious discontinuous |
crackles - bubbling, popping, wet, course, presence of fluid or secretion rales (crackles) - dry, fine, sudden opening of closed airways, atelectosis |
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other lung sounds to listen for |
extrapulmonary sounds - pleural friction rub (really loud sound, walking on fresh snow) voice sounds - whispered pectoriloqy, bronchophony, egophony |
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air trapping |
retention of gas in the lung as a result of partial or complete airway obstruction |
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bronchospasm |
smooth muscle contraction of the bronchi and bronchiole walls resulting in a narrowing of the airway lumen |
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consolidation |
overinflation of the lungs at resting volume as a result of airtrapping |
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hypoxemia |
low level of oxygen in blood (PaO2 < 60-80 mmHg) |
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respiratory distress |
acute or insidious onset of dyspnea, respiratory msucle fatigue, abnormal respiratory pattern and rate, anxiety, cyanosis related to inadequate gas exchange, usually precedes respiratory failure |
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respiratory failure |
inability of pulmonary systme to maintain an adequate exchange of oxygen and carbon dioxide |
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peripheral vascular disease |
impaired circulation caused by acute or chronic conditions affects arterial, venous, lymphatic flow |
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arterial disease |
lower extremities more susceptible may take 20-30 years to present related to DM, HTN, metabolic problems (thyroid) acute (blood clot) or chronic (hereditary) 4 causative types: obstruction, disruption (break in artery), fistula (graft that connects artery to vein), aneurysm (weakness in vessel) causes: thrombus, embolism, arteriosclerosis obliterans, thromboangitis obliterans, raynaud's disease |
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signs and symptoms of arterial disease |
intermittent claudication - influenced by speed, incline, surface rest pain - dull aching, tightness deep in muscle, boring, stabbing, burning, pulling, charley horse location: usually feet (popliteal occlusions), toes, calf, can also be quads and glutes (aortoiliac occlusions) most common - calf 2/3 of pts constant and reproducible exercise tolerance decreases as episodes increase
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arteriosclerosis obliterans |
arteriosclerosis in which proliferation of intima has caused complete obliteration of the lumen of the artery 95% of cases, most common DM others: smoking, HTN, obesity, CAD insidious onset (slowly and no specific event) intermittent claudication pain at rest ulceration and gangrene Rx: pharmacological, medical, exercise, stop smoking, endovascular management usually affects older patients |
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thromboangiitis obliterans |
buerger's disease vasculitis of small and medium vein and arteries in the extremities of young adults seen mostly in men 20-40 yr olds who smoke unknown pathogensis distal to proximal Rx: same as arteriosclerosis obliterans, stop msoking, pain control, regional ganglionectomy, amputation |
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signs and symptoms of thromboangiitis obliterans |
pain most common intermittent claudication rest pain with persistent ischemia of 1 or more digits cold sensitivity paresthesias (tingling) distal pulses weak or absent ulceration and gangrene usually one extremity at a time edema of legs common changes in nail beds and skin color and temperature changes (hands, persisten) clubbed or spooned nailbeds dry, scaly skin |
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Raynaud's disease |
intermittent episodes during which small arters in extremities constrict temporary pallor (whiteness) cyanosis (blueish) changes in skin temperature response to cold is strong, emotional fight or flight can trigger spasm as episode passes, extremely red phenomenon = secondary primary = vasospastic disorder connective tissue disease - trauma, use of vibrating equipment, neurogenic lesions, occlusive arterial ds causes - hypersensitivy of digital arters to cold, release of serotonin, congential 80% women 20-49 yrs old symptoms for at least 2 years, don't progress cyclical disorder Rx: limit caffeine, stop smoking, stress management, drug therapy, sympathectomy |
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arterial occlusion |
severe emergency treatment needed need to restore in 6-8 hours after parasthesias can lead to limb loss causes - trauma, embolism from hear, thrombosis at site of pre-existing chronic disease, emboli can be fat, air, clumps, cholesterol signs - pain, pallor, decrease or loss of pulses, parathesia, |
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evnous disorders |
separated into acute or chronic 4 major changes in veins - thrombosus, obstruction, dilation, hemorrhage |
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acute venous disoders |
due to formation of thrombi (obstruction of venous flow) superficial or deep veins iatrogenic - superficial deep - more common in women and adults > 40 who had major surgery or MI |
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deep vein thrombophlebitis |
clot formation and acute inflammation in deep vein usually seen in lower extremity associated with venous stasis (bedrest, lack of exercise) hyperactivity of blood coagulation, vascular trauma may lead to pulmonary emboli if clot is dislodged (presents suddenly, chest pain, dyspnea) sings - 50% have no signs, early signs are inflammation, tenderness, pain, swelling, warmth, skin discolaration homans sign - calf, pain with dorsiflexion of ankle, insensitive and nonspecific
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medical management of DVT |
anticoagulation therapy - prevents extension, embolization, reoccurence, risk of major bleed, heparin induced thrombocytopenia (HIT) bedrest until lab values therapeutic inferior vena cava (IVC) filter ambulation compression stockings |
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lab tests for DVT anticoagulation |
heparin coumadin lovenox arixtra |
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chronic venous insufficinecy |
postphlebitic syndrome signs - chronic swollen limbs, thick coarse brownish skin around ankles, venous stasis ulcers superficial - local, raised, red, indurated, warm, tender, cord along involved vein deep - (50% asymptomatic), pain, unilateral swelling, redness, warmth, dilated veins, fever, chills, malaise, pulmonary embolism hemosiderin deposits result of dysfunctional valves may take 5-10 years to develop causes - thrombus formation, hypercoagulability, injury to vein, venous stasis
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lymphedema |
excessive accumulation of fluid in tissue spaces secondary to obstruction of lymphatic system need to take measurements over bony prominences (significant if > 2 cm difference bilaterally) distal pulses slightly stronger than proximal Rx: elevate, ROM, diuretics, compression stockings, pump, manual drainage |
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pitting edema scale |
+1 barely perceptible depression +2 easily identified depression (EID), skin rebounds to original contour in 15 seconds +3 EID - skin rebounds in 15-30 seconds +4 EID - skin rebounds > 30 seconds |
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pallor dependency test |
pt supine, LEs elevated 6- seconds extreme pallor may indicate arterial insufficiency pt sits up with LEs in gravity dependent position skin should return to pink in 10 seconds bright rubor is positiv test - arterial occlusion venous filling time on dependency after elevations should not exceed 15 seconds >15 seconds - venous insufficiency |
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capillary refill |
squeeze nail bed until blanching occurs release the pressure and examine for return of color normal return 3 seconds or less |
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ankle-brachial index |
measurement of ankle systolic pressure compared to brachial systolic pressure normal - pressures should be about same lower ABI could indicate stenosis, may help determine level of blockage multiple blockages will cause lower ABI than single blockage can indicate - claudication, vascular compononet of resting pain, tissue necrosis, adequacy of distal perfusion for wound healing |
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ABI interpretation |
>0.96 normal <0.95 abnoral, stress testing needed <0.8 claudication <0.5 mutli-level disease, long occlusion <0.3 ischemic |
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common findings of arterial insufficiency |
patient hx: HTN< DM, previous bypass, amputation, smoker, pain with ambulation, pain with elevation objective: cold to touch, pallor, edema, diminished pulses, decreased ABI |
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common findings of venous insufficiency |
patient hx: DM, HTN, CHF, DVT, previous leg ulcers, rarely have resting pain, edema objective: varicosities, darker than normal skin, edema, strong distal pulses, normal ABI |
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borders of heart |
inferior - junction of xiphoid process and body of sternum apex - bottom, 5th intercostal right ventricle - most anterior surface of heart left ventricle - posterior great vessels - base of heart, top of heart |
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cardiac cycle |
period from beginning of one contraction to the beginning of the next contraction systole - contraction, AV valves closed diastole - relaxation, AV valves open |
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cacardiac output |
quantity of blood pumped by heart in 1 minute CO = HR * SV normal is 5L (70bmp * 71ml/min) too much stretch - heart failure |
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preload |
amount of tension on the ventricular wall before it contracts great the stretch, the stronger the contraction LVEDP - left ventricular end diastolic pressure ventricular diastole |
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afterload |
force agasint which a msucle must contract to initiate shortening pressure it has to overcome to get blood out left ventricle > aorta right ventricle > pulmonary artery left ventricle ahs highest afterload |
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atrial systole - atrial emptying |
initial 70% due to pressure graduent between atrium and vnetricle last 30% due to contraction |
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ventricular systole |
ventricular contraction LVEF - left ventricle ejection fraction 60% normal with cardiac failure |
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palpation in cardiac |
thrills - use ball of hand, over ascultation poitns of heart (not carotid), fine vibrations caused by turmoil of blood flow bruits - auscultate with stethoscope, over carotid, renal artery, femoral artery, will sound like abnormal blowing or squishing, stenosis, obstruction, anuerysm |
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auscultation oints for the heart |
aortic valve - 2-3 right interspace pulmonary valve - 2-3 left interspace tricuspid valve - left sternal border, 4-5 intercostal mitral valve - apex hear lub at apex hear dub at semilunar valve |
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S1 |
first sound lub longer than s2 closing of AV valves start of ventricular systole best hear in apex with diaphragm |
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S2 |
second sound dub high pitched and shorter duration than s1 closing of semilunar valve start of ventricular diastole best heard at base with bell |
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S3 |
may be considered normal or abnormal (normal in young, healthy people) ventricular gallop best heard at apex with bell lub dub bub |
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S4 |
atrial gallop best heard at apex with bell right before s1, late in ventricular diastole bub lub dub (like tennessee) |
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percardial friction rub |
best heard in 3 or 4 intercostal space along anterior axillary line sounds like leather creaking together indicates periocarditis heard because more blood staying in left ventricle, blood coming from atria slams into leftover blood |
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murmurs |
stenosis of valve or regurgitation of valve |
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cardiac pathology |
acute coronary syndrome rhythm and conduction disturbance - irregular heartbeat valvular heart disease - murmur myocardial and pericardial heart disease heart failure - s3 |
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right sided heart failure |
nausea weight gain ascites - fluid accumulation in peritineal cavity right upper quadrant pain jugular venous distention tricuspid murmur peripheral edema |
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left sided heart failure |
fatigue cough SOB DOE orthopnea diaphoresis tachycardia crackles decrease urine output confusion mitral murmur |
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vital signs |
temperature pulse/hr bp rr gait speed (1.2 m/sec) |
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hyperthermic |
rectal > 106f dilation of cutaneous blood vessels stimulation of sweat glands tissue damage fatal pyrexia (fever) causes - hypermetabolic state (excessive exercise, increased ambient temperature, hyperthyroidism), diminished heat loss (drug use, neuro deficiency, dehydration), change in central regulation mechanism from infection or inflammatory disease (pyrogens) |
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hypothermic |
rectal < 94f too cold inhibition of sweat glands increase in BMR (body's response to cold) constricts cutaneous blood vessels shivering/heat conservation mechanisms shut off below 90 signs - clumsiness with hands, skin turns blue, peripheral edema, sleepiness slowing of metabolic process - drowsy, confused, comatose, hr decrease, irregular hr causes - deficiency in heat production (malnutrition, hypoglycemia, adrenal insufficiency), abnormalities in heat regulations (drugs, alcohol, head injuries, increase heat loss from exposure) |
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normal temperature values |
oral 98.6-99.5 rectal 99.6 axillary 97.6 febrile 100 variations - time of day, age, exercise, menstruation, pregnancy
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normal heart rate |
adults 60-100 children 100-110 newborns 140 variations - age, exercise, anxiety, depressions, fever, heart disease, shock, hypoxia, heat
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scale of heartrate |
0 - absent or can't palpate +1 dorsalis pedis, posterior tibialis +2 radial +3 femoral +4 abdominal aorta |
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blood pressure |
indirect measure of pressure on arterial walls as the heart contracts and relaxes difference between systolic and diastolic pressure systolic - pressure on artery when ventricles contract diastolic - pressure that's left in artery after contraction reflects CO, vascular resistance, blood viscosity, ability of vascular walls to expand and contract |
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normal values for blood pressure |
systolic 100-135 diastolic 60-80 variations: time of day, body position, exercise, heat, stress, age normal <120, <80 prehypertension 121-139, 80-89 hypertension I 140-159, 90-99 (at least 3 times) hypertension 2 >160, >100 if > 60 yrs old, med if 150/90 30-59 yrs old, meds if diastolic > 90 |
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hypotension |
systolic < 90 diastolic < 60 causes: reduced blood volume, diarrhesis, hemorrhage, CHF, diuretics, dehydration, signs - light headedness, faintness |
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postural/orthostatic hypotension |
occurs from supine to standing position systolic bp decreases 10-15 mmHG HR increases 10-15 bpm loss of vasomotor tone (prolonged sedentary position) prevention - hose to keep compression on legs, pumps while in bed, tilt table, let person rise slowly |
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grading reflexs |
0 absent +1 little worse off than normal +2 normal +3 brisk +4 brisk with clonus |
