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75 Cards in this Set
- Front
- Back
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How would the nurse assess the carotid arteries of a patient with cardiovascular disease?
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Auscultate each carotid artery for the presence of bruit.
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Bruit
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a blowing, swishing sound indicating blood flow turbulence. Normally none is present
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What is used to auscultate the carotid artery?
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BELL of the stethoscope
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Carotid bruit
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is audible when the lumen is occluded by 1/2 to 2/3. Bruit loudness increases as the atherosclerosis worsens until the lumen is occluded by 2/3. After that bruit loudness decreases. When the lumen is completely occluded, the bruit disappears. Thus absence of a bruit does not ensure of a carotid lesion
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Describe the correct technique the nurse would use when auscultating the carotid artery for bruits
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Keep the neck in neutral position. Lightly apply the BELL of the stethoscope over the carotid artery at 3 levels: angle of the jaw, midcervical arae and the base of the neck
-avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. - ask the person to take a breath, exhale and hold it briefly while you listen so that the tracheal breath sounds do not mask or mimic a carotid artery bruit. |
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Identify where the nurse expects to palpate the apical impulse on a healthy adult
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The apical impulse should occupy one interspace, the FOURTH OR FIFTH, and be at the MEDIAL TO MIDCLAVICULAR LINE
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Apical impulse
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pulsation created as the left ventricle rotates against the chest wall during systole
- used to be called POINT OF MAXIMAL IMPULSE (PMI) |
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Is apical impulse palpable?
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It is PALPABLE in about HALF OF THE ADULTS. It is NOT PALPABLE in obese patients or with thick chest walls. With high cardiac outputs states (anxiety, fever, hyperthyroidism and anemia), the apical impulse increases in amplitude and duration
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Describe how the nurse would use the stethoscope to assess the patient for a S4 heart sound
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Listen with the DIAPHRAGM, then switch to the BELL, covering all auscultatory areas. Usually, these are silent periods. When you do detect an extra heart sound, listen carefully to note its timing and characteristics.
During systole, the MIDSYSTOLIC CLICK is the most common extra sound. |
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Midsystolic click
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associated with mitral valve prolapse
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The S3 and S4 sounds occur in
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diastole; which is either may be normal or abnormal
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Define what the nurse hears when he/she hears an extra heart sound at the apex immediately before S1
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S4 fourth heart sound is a ventricular filling, termed as ATRIAL GALLOP. it occurs when the atria contract LATE IN THE DIASTOLE. It is heard immediately before S1.
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S4- fourth heart sound
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a very soft sound, or very low pitch. It is heard best at the apex, with the person in the LEFT LATERAL POSITION. You need a good BELL and you must listen for it
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The nurse knows that normal splitting of the second heart sound is associated with
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Split S2 - more likely to occur during inspiration, lub T-Dup, normally heard about every 4 beat, heard only in pulmonic valve area, 2nd L insterspace
Fixed S2 - split always there, not affected by respiration; indicates ATRIAL SEPTAL DEFECT, R. VENT FAILURE Paradoxical split S2 - sounds fuse on inspiration, split on expiration; aortic stenosis, L. bundle branch block, PDA, patent ductus arteriosus |
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Define what the nurse hears during the cardiac assessment when a THRILL is present
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A thrill is a PALPABLE VIBRATION. It feels like the throat of purring cat. The thrill signifies turbulent blood flow and accompanies LOUD MURMURS.
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Identify NORMAL cardiovascular physiological changes with the aging process
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- From 20 to 60 years, systolic BP increases by about 20 mm Hg and by another 20 mm Hg between 60 to 80 years due to stiffening of large arteries which is in turn due to calcification of vessel walls (arteriosclerosis)
- overall size of the heart does not increase with age, but left ventricular wall thickness increases - No significant change in diastolic pressure. A rising systolic pressure with a relatively constant diastolic pressure increases the pulse pressure (difference between the two) - no change in resting heart rate - decreased ability of the heart to augment cardiac output with exercise - arrhythmias increases with age - prolonged PR interval (first degree heart block) and prolonged QT interval, but the QRS interval is unchanged - Incidence of cardiovascular diseases increases with age. HTN and Heart failure also increase with age. Lifestyle habits play a significant role in the acquisition of heart disease |
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Describe the patient's presentation with the following PVD's:
CLAUDICATION |
pain and/or cramping in the lower leg due to inadequate blood flow to the muscles
- Typically felt while walking and subsides with rest (Pain with walking) Claudication distance is the specific number of blocks, stairs it takes to produce pain. Night leg pain common in aging adults. It may indicate the ischemic rest pain of PVD, severe night muscle cramping |
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VENOUS INSUFFICIENCY
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venous reflux, it is the impaired return of venous blood from the legs and feet, often manifesting as varicose veins, swollen ankles, acing legs, skin changes or venous ulcers. Patient would claim aching pain in calf or lower leg, worse at the end of the day, worse with prolonged standing or sitting
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THROMBOPHLEBITIS
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S: sudden onset of intense, sharp, deep muscle pain, may increase with sharp dorsiflexion of food
O: increased warmth, swelling (to observe the usual shoe size); redness, dependent cyanosis is mild or may be absent, tender to palpation, Homan's sign is present only in few cases |
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EDEMA
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bilateral when caused by systemic problem such as heart failure
unilateral when to the result of local obstruction or inflammation |
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CHRONIC ARTERIAL CIRCULATION INSUFFICIENCY:
ARTERIOSCLEROSIS |
can be considered as arteriosclerosis/ischemic ulcer:
S: deep muscle pain in calf or foot, claudication (pain with walking), pain at rest indicates worsening of condition. O: cookness, pallor, elevational pallor, and dependent rubor; diminished pulses, systolic bruits, trophic skin, signs of malnutrition (thin, shiny skin, thick-ridged nails, absence of hair, atrophy of muscles) xanthoma formation, distal gangrene |
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LYMPHEDEMA
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UNILATERAL swelling, NONPITTING BRAWNY EDEMA, with overlying skin indurated, and is psychologically demoralizing as a threat to body image and constant reminder of the cancer.
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VENOUS STASIS (ULCER)
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S: aching pain in calf or lower leg, worse at the end of the day, worse with prolonged standing or sitting.
O: FIRM, BRAWNY EDEMA, COARSE, thickened skin, pulses normal, BROWN PIGMENT DISCOLORATION, petechiae, dermatitis. - It causes increased venous pressure which then causes RBCs to leak out of veins and into the skin. As these RBCs break down, they leave hemosiderin (iron deposits) behind, which are the brown pigment deposits |
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DEEP VEIN THROMBOSIS
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calf pain (positive Homan's sign) occurs in about 35% of cases of deep vein thrombosis
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RAYNAUD'S SYNDROME
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episodes of abrupt progressive TRICOLOR CHANGE of the fingers in response to cold, vibration or stress:
first WHITE(pallor) from arteriospasm and resulting deficit in supply then BLUE(cyanosis) from slight relaxation of the spasm that allows a slow trickle of blood thru the capillaries and increased oxygen extraction of HgB Finally RED(rubor) due to return of blood into the dilated capillary bed or reactive hyperemia. May have cold, numbness or pain along with pallor or cyanosis state: then burning, throbbing pain, swelling along with the rubor. Last minutes to hours, occasionally bilaterally |
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SUPERFICIAL VARICOSE VEINS
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Aching heaviness in calf, easy fatigability, nigh leg or foot cramps
O: dilated, tortuous veins |
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Edema grade
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1- mild pitting, slight indentation, no perceptible swelling of the leg
2 - moderate pitting, indentation subsides rapidly 3- deep pitting, indentation remains for a short time, legs look swollen 4 - very deep pitting, indentation remains for a long time, legs look very swollen |
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Murmur grade
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Grade i - Barely audible, heard only in quiet room and with difficulty
Grade ii - Clearly audible but faint Grade iii- moderately loud, easy to hear Grade iv - loud associated with a thrill palpable on the chest wall Grade v - very loud, heard with one corner of the stethoscope lifted off the chest wall Grade vi- loudest, still heard, with entire stethoscope lifted just off the chest wall |
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Right upper quadrant (RUQ)
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Liver
Gallbladder Duodenum Head of Pancreas Right kidney and adrenal part of transverse and ascending colon Hepatic flexure of colon |
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Left upper quadrant (LUQ)
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Stomach
spleen body of pancreas left lobe of liver left kidney and adrenal splenic flexure of colon part of descending colon and transverse colon |
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Right lower quadrant (RLQ)
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cecum
appendix right ureter right ovary and tube right spermatic cord |
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Left lower quadrant (LLQ)
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sigmoid colon
part of descending colon left ovary and tube left ureter left spermatic cord |
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Midline
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aorta
uterus (if enlarged) bladder (if distended) |
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Describe what the nurse expects to hear when assessing the patient for bowel sounds
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Depending on the time elapsed since eating, a wide range of normal sounds can occur.
BOWEL SOUNDS are HIGH PITCHED, GURGLING, CASCADING SOUNDS occurring irregular anywhere from 5 to 30 times per minute. One type of hyperactive bowel sounds is fairly COMMON. This is the hyperperistalsis when you feel your STOMACH GROWING termed BORBORYGMUS. A perfectly silent abdomen is uncommon; you must listen for 5 minutes by your watch before deciding bowel sounds are completely absent |
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Describe what the nurse will find in a normal abdominal assessment with percussion, auscultation and palpitation
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Inspect, auscultate , percuss and palpate
When assessing patient for bowel sounds the nurse should expect to hear high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5-30 times per min. Judge if they are normal, hyperactive or hypoactive. Hypoactive or absent sounds: follow abdominal surgery or with inflammation of the peritoneum. If absent sound, nurse must listen for 5 mins in each quadrant. Hyperactive sounds or borborygmus (stomach growling) are loud, high pitched, rushing tinkling sounds that increased motility. -Tympany should predominate because air in the intestine rises to the surface when person is supine. Dullness occurs over a distended bladder; adipose tissue, fluid or a mass Hyperresonance is present with gaseous distention While palpating the nurse should not find any large masses, tenderness, muscle guarding or rigidity |
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Costovertebral angle tenderness
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if sharp pain occurs, it means inflammation of the KIDNEY or paranephric area
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Etiology for ascites
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ASCITES are free fluid in the peritoneal cavity. You may suspect that a person has ascites because of distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward
- Ascites occur with heart failure, portal HTN, cirrhosis, hepatitis, pancreatitis and cancer |
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Define what is true regarding the assessment of AORTIC ANEURYSM
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Most aortic aneurysms are located BELOW THE RENAL ARTERIES and EXTEND TO UMBILICUS. About 80% of these are palpable during routine physical examination and FEEL LIKE A PULSATING MASS in the UPPER ABDOMEN just left to the midline. YOU WILL HEAR A BRUIT. Femoral pulses are present but decreased
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Describe how the nurse would perform the following assessment test:
OBTURATOR TEST |
It is performed when appendicitis is suspected. With the person supine, LIFT THE RIGHT LEG, FLEXING AT THE HIP AND 90 DEGREES AT THE KNEE. Hold the ANKLE AND ROTATE THE LEG INTERNALLY AND EXTERNALLY. A negative or normal response is no pain
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MURPHY'S SIGN
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Normally, palpating the liver causes no pain. In a person with inflammation of the GALLBLADDER or CHOLECYTITIS, pain occurs. HOLD YOUR FINGERS UNDER THE LIVER BORDER. Ask the person to take a deep breath. A normal response is to complete the deep breath without pain
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BLUMBERG'S SIGN (REBOUND TENDERNESS)
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assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. Choose a site away from the painful area. Hold your hand 90 degrees, or perpendicular, to the abdomen. PUSH DOWN SLOWLY AND DEEPLY, THEN LIFT UP QUICKLY. This makes structures that are indented by palpation rebound suddenly. A normal negative response is no pain on release of pressure. Perform tis test at the end of examination because it can cause severe pain and muscle rigidity
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ILIOPSOAS TEST
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perform this test when the ACUTE ABDOMINAL PAIN OF APPENDICITIS is suspected. With the person supine, LIFT THE RIGHT LEF STRAIGHT UP, FLEXING AT THE HIP; THEN PUSH DOWN OVER THE LOWER PART OF THE RIGHT THIGH AS THE PERSON TRIES TO HOLD THE LEG UP. When test is negative, the person feels no change
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Identify when the nurse would use DEEP AND LIGHT PALPATION with abdominal assessment
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LIGHT PALPATION - to form an overall impression of the skin surface and superficial musculature. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination
DEEP PALPATION - to find the organs, their location, size, consistency, mobility of any palpable organs and presence of any abnormal enlargement, tenderness and masses |
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Hepatomegaly
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enlargement of liver
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Identify how the nurse would perform the following range of motion of the joint:
ADDUCTION |
moving a limb TOWARD THE MIDLINE OF THE BODY
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ABDUCTION
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moving a limb AWAY FROM THE MIDLINE OF THE BODY
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FLEXION
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BENDING A LIMB at joint
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EXTENSION
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STRAIGHTENING a limb at joint
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PRONATION
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palm is DOWN
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SUPINATION
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palm is UP
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CIRCUMDUCTION
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CIRCLE around the shoulder
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INVERSION
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INWARD
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EVERSION
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OUTWARD
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ROTATION
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AROUND A CENTRAL AXIS
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PROTRACTION
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FORWARD
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RETRACTION
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BACKWARD
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ELEVATION
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RAISING
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DEPRESSION
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LOWERING
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Identify the functional units of
MUSCULOSKELETAL SYSTEM |
- for SUPPORT stand erect
- for MOVEMENT - to ENCASE and PROTECT the inner vital organs - to PRODUCE the red blood cells in the bone marrow - as a RESERVOIR for STORAGE of essential minerals; such as calcium and phosporus in the bones |
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TENDONS
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strong fibrous CORD in which the skeletal muscle is attached to bone
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LIGAMENTS
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strong fibrous BANDS running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions
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BURSA
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an enclosed sac which is filled with viscous synovial fluid located in the area of potential friction and help muscles and tendons glide smoothly over bone
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Identify the 33 vertebrae in the spinal column how many are lumbar, thoracic, sacral and cervical
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7 cervical
12 thoracic 5 sacral 5 lumbar 3 to 4 coccygeal vertebrae |
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INTERVERTEBRAL DISKS
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elastic fibrocartilaginous plates that constitute one fourth of the length of the column. Each disk center has a nucleus pulposus, made of soft, semifluid, mucoid material that has the consistency of toothpaste in the young adult. The disk CUSHION THE SPINE LIKE A SHOCK ABSORBER AND HELP IT MOVE
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Structure and function of SHOULDERS
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size, contour of joints should be symmetrical. Forward flexion, hyperextension, internal and external rotation, abduction and adduction. Test strength with shrug
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Describe how and why the nurse would have the patient perform the PHALEN TEST
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It reproduces NUMBNESS AND BURNING in a person with CARPAL TUNNEL SYNDROME.
Ask the person to hold both hands back to back while flexing the wrist 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand |
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TINEL'S SIGN
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In carpal tunnel syndrome, percussion of the median nerve produces BURNING AND TINGLING along its distribution, which is a positive Tinel's sign. Direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand
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Identify how the nurse would evaluate the patient for motor dysfunction of the hip
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Have the patient hip flexion with knee 90 degree straight, hip flexion with knee flexed 120 degree, external 45 degree and internal 40 degree rotation, abduction 45 degree and adduction 30 degree.
Limitation of ABDUCTION OF THE HIP while SUPINE is the most common motor dysfunction found in hip disease -ask the patient on supine position to swing leg laterally, then medially, with knee straight. Stabilize pelvis by pushing down on the opposite anterior superior iliac spine |
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Describe what a positive "BULGE SIGN" look like with the knee assessment
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For SWELLING IN THE SUPRAPATELLAR POUCH, the bulge sign confirms the PRESENCE OF SMALL AMOUNT OF FLUID AS YOU TRY TO MOVE the fluid FROM ONE SIDE OF THE JOINT TO THE OTHER.
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Describe the following diagnosis
EPICONDYLTIS |
tennis elbow
- chronic disabling pain at lateral EPICONDYLE OF HUMERUS, radiates down extensor surface of forearm. pain can be located with one finger. Resisting extension of the hand will increase with pain. Occurs with activities combining excessive pronationand supination of forearm with an extended wrist. Medial epicondylitis is rarer and is due to activity of forced palmar flexion of wrist against resistance |
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GOUTY ARTHRITIS
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joint effusion of synovial thickening, seen as first as bulge or fullness in grooves on either side of olecranon process. Redness and heat can extend beyond area of synovial membrane. Soft, boggy, or fluctuant fullness to palpation. Limited extension of elbow
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OLECRANON BURSITIS
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large, soft knob or 'GOOSE EGG", and redness from INFLAMMATION OF OLECRANON BURSA. Localized and easy to see because bursa lies just under skin
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SUBCUTANEOUS NODULES
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raised, firm, nontender nodules that occur with rheumatoid arthritis. Common sites are in the olecranon bursa and along extensor surface of arm. The skin slides freely over the nodules.
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KNOCK KNEES / GENU VALGUM
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when more than 2.5 cm between medial malleoli when the knees are together. Occurs on 2- 3 1/2 years age. Treatment not indicated, Also occurs with rickets, syphilis and myelitis
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Identify how the nurse would assess for the patient angle of joint flexion and what instrument would the nurse need to use to measure flexion of joint
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If there is any limitation or any increase in ROM occurs, use a GONIOMETER to measure the angles precisely. First extend the joint to neutral or 0 degrees. Center the point in the goniometer on the joint. Keep the fixed arm of the goniometer on the 0 line and use the movable arm to measure, then flex the joint and measure thru the goniometer to determine the angle of greatest flexion
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