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118 Cards in this Set

  • Front
  • Back
Listening to sounds with a stethoscope
Sternum has three parts
Manubrium, the body, xiphoid process
Thorax Reference lines:
Midclavicular (Left and Right)
Thorax Reference lines:
vertebral line
Midscapular (left and right)
Thorax Reference lines :
Anterior and Posterior axillary lines
Inspection of Respiration
Observe quality and pattern
-labored breathing
-noisy breathing (wheezing/crackels)
Breathing characteristics
Use of accessory muscles
Respiration accessory muscles
Trapezius (shoulder muscles) - facilitate inspiration in acute and chornic airway obstruction or atelectasis
Collapse of part or all of a lung
Chronic obstructive pulmonary disease
Tripod position
Seen in COPD
Client leans forward, uses arms to support weight, lift chest to increase breathing
What is a normal respiration pattern ?
12 to 20 / min and regular
Respiration > 24/ min and shallow
Respiration < 10/min and regular
Increase rate and depth of respirations
decrease rate, depth, irregular rhythm
Regular pattern with periods of apnea (lack of breathing or greatly reduced)
Aspiration of fluids is more likely to occur on which bronchi ?
Right bronchi, because it extends lower into the right lung which has 3 lobes
Palpation of chest
Assess tenderness, crepitus (crackling sensation), symmetry of chest expansion (rises/falls evenly unless pt is intubated)
Name the three types of normal breath sounds
Bronchial, bronchovesicular, vesicular
Adventitious sounds
Added sounds over normal breath sounds
crackles and wheezing
Vesicular breath sound
low-pitched soft sounds during expiration heard over most of lungs

Long inspiration and short expiration
Bronchial breath sound
high pitched and longer, heard over trachea.

Short inspiration and long expiration
Medium pitched, heard over upper anterior chest and intercoastal area (second intercostals space)

Equal inspiration/expiration
Crackles air sounds
Air moving in airways through fluid.

Can be fine, medium or coarse
Continues usually in expiration due to constricted by swelling/secretions airways

Sonorous - LOW PITCHED
Sinoatrial node
<> Pacemaker of the heart

<> Initiates heartbeat

<> Generates 60-100 beats per minute
What is diastole ?
1. Relaxation of the ventricles (ventricles fill).
2. AV valves open(tricuspid and mitral) blood rushes into ventricles
3.Atria contract to completely empty it out
What is systole ?
1. AV valves shut producing the first LUB (S1)
2. Ventricles contract forcing aortic and pulmonic (Semilunar) valves to open
3. Pressure reduces in the ventricles , causing Semilunar valves to shut. DUB (S2)
Heart sound regions
Aortic (2nd intercoastal - right sternal)
Pulmonic (2nd intercoastal - left sternal)
Tricuspic (4th intercoastal - left sternal)
Mitral (5th intercoastal - left clavicular line)
The sound LUB (s1)
Closure of av valve
mitral and tricuspid
DUB (s2)
Closure of semilunar valve
Aortic and pulmonic
Cause by turbulent blood flow in the heart
Cardiac output
Amount of blood pumped by the ventricles in about one minute

CO = SV(how many Liters if blood) x HR (minute rate)

Decrease CO indicative of CHF
Jugular vein inspection
Important for determining right side of the heart function - reflect right atrial pressure or central venous pressure.

Decrease pressure usually to decrease in volume
Right-side heart failure symptoms
Pulmonary edema
Increase in pulse and pressure on jugular vein
Non-modifiables Risk Factors for CHD (coronary artery disease)
Positive family history
Increasing age
Men 3 times more than women
Geography - highly industralized areas
Modifiables Risk Factors for CHD (coronary artery disease)
Elevated blood pressure
Physical Inactivity
Inspection of neck vessel
Jugular venous pressure
Vein should not be visible above 45º (when you raise the bed)
Neck vessel ascultation
no blowing or swooshing should be heard
Heart palpation
5th intercostal space/midclavicular line
1. Palpate apical pulse
2. Auscultate apical heart rate
Carry oxygenated blood from heart to capillaries
Carry deoxygenated blood to heart and have one way valve
Femoral and Popliteal
Deep veins accounting 90% of venous return from lower extremities
Saphenous veins
Superficial veins, longest veins in the legs
Lymphatic system
primary function is to drain excess fluid and plasma protein and return it to venous system
Palpitation - Capillary refill
Compress finger tip to calculate time it takes for capillary refill (should be less than 3 seconds)
Allen test
used to assess potency of radial and ulnar arteries
Leg inspection
Check venous return
Check poptileal pulse, Posterior tibial pulse, Femoral pulse or Dorsalis pedis
S2 and S1 sounds
S1 - Pulmonic and Aortic
S2 - Tricuspid and Mitral
dependent or rusty/brown skin pigment around ankle.Aterial insufficiency - lack of blood supply associated with thin skin, haird loss
Doppler ultrasound device
Used in checking for peripheral arterial puls and evaluate flow, hear any swishing.
Associate with venous circulation
Bileteral or unileteral
Scale grade from 1+ to 4+. 2 and 3+ are BS ones
1+ disappear quickly
4+ very deep and last 2 to 5 minutes
No skin ulceration or pigmentarion
Venous insufficiency edema
Pitting edema
Skin ulceration and pigmentations may be seen
Right Upper Quadrant:
•Ascending and transverse colon
•Gall bladder; liver
•Pylorus; right adrenal gland
•Right kidney
Right Lower Quadrant:
•Ascending colon; cecum
•Right kidney
•Right ovary and tube
Left Upper Quadrant:
•Left adrenal gland
•Left kidney
•Pancreas, spleen, stomach
Left Lower Quadrant:
•Left kidney
•Left ovary and tube
•Descending and sigmoid colon
What organs compose the Solid viscera ?
Liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus
What organs compose the Hollow viscera ?
Stomach, gallbladder, small intestine, colon, bladder
Vascular structures
Abdominal aorta; right and left iliac arteries
What questions to ask regarding abdominal problems ?
Abdominal Pain
Indigestion (pyrosis)
Nausea and Vomiting
Bowel Elimination
Yellowing of skin or eyes, dark urine or clay-colored stool – liver problems
Define Visceral pain
- occurs when hollow abdominal organs, such as the intestines, become distended or contract forcefully or when the solid organs such as the liver and spleen are stretched.
•This pain is often characterized as dull, aching, burning, cramping or colicky
Define Parietal pain
Occurs when the parietal peritoneum becomes inflamed, as in appendicitis or peritonitis.
– Pain is localized and is more severe and steady pain.
Define Referred pain
Occurs at distant sites that are innervated at approximately the same levels as the disrupted abdominal organ.
– In other words, the pain travels, or refers, from the primary site and becomes highly localized at the distant site.
Abdominal Assessment Procedure
•1st Step - Inspection
•2nd Step - Auscultation – of bowel sounds is done before touching client!
•3rd Step - Percussion
•4th Step - Palpation
Assess abdominal symmetry
fall in 4 categories (inspection):
Scaphoid – sunken in
abdomen (really skinny person/anorexia)
Rounded (most americans)
Distended/Protuberant (like hungry kids in Africa)
Auscultation of abdominal area
•Auscultate for
–Bowel sounds – listen for up to 5 minutes per quadrant to confirm absence of bowel sounds using diaphragm
–Vascular sounds – use bell of stethoscope to listen to bruits (low-pitched, murmur-like sounds) over abdominal aorta, renal, iliac or femoral arteries.
How to tests for ascites ? What is ascites ?
–Test for shifting dullness
–Perform the fluid wave test
–Use ballottement technique
Ascites is excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity
How to test for appendicitis ?
–Rebound tenderness – assess for pertioneal irritation – palpate deeply in the abdomen where the client has pain then suddenly release pressure - which hurts more – the pressing in or releasing – where on the abdomen does the pain occur.
Rovsing’s sign –
An indication of acute appendicitis in which pressure on the left lower quadrant of the abdomen causes pain in the right lower quadrant – referred rebound tenderness
Psoas Sign
Raise right leg from hip and apply pressure. Will have RLQ pain if appendix is inflamed.
Obturator Sign
Flex right hip and knee and rotate the leg internally
and externally. Pain in RLQ may indicate appendicitis
What is the purpose and how do you perform the test for Cholecystitis – Gall Bladder
– Murphy’s sign
• Press fingertips under the liver border at the right costal margin and ask client to inhale deeply.
–Accentuated sharp pain causes the client to hold breath
Character Describe sign/symptom
Onset When did it begin?
Location Where is it? Radiate
Duration How long does it last? Recur?
Severity How bad is it?
Pattern What makes it better or worse?
Associated factors Other symptoms occur?
Affects client How does it affect you?
How do you assess for a history of bowel problems ?
•Bowel Patterns
–Usual bowel pattern
–Recent changes or pain when defecating
–Blood in stool
•Itching and Pain
The skin is a physical barrier that protects the underlying tissues and structures from:
–physical trauma
–ultraviolet radiation
The skin plays a vital role in ...
– temperature maintenance
– fluid and electrolyte balance
– Absorption
– Excretion
– Sensation
– outermost layer of skin
– Has four distinct layers
– Helps keep skin waterproof
– Contains melanin (brown pigment) and carotene (yellow pigment) which gives us our skin color
– inner layer of skin
– Connected to epidermis by papillae
– Papillae forms the base for swirls or ridges – provides unique patterns in fingerprints
– Origin of hair follicles, sebaceous glands and sweat glands.
Dermis layer contains...
• Sebaceous glands develop from hair follicles and secretes sebum which lubricates hair and skin decreasing water loss through the skin.
• Sweat glands
– Eccrine glands – over entire body – odorless (non-stinky) – vital to temperature regulation
•Vellus hair
- short, pale and fine – found over most of the body.
•Terminal hair –
particularly the scalp and eyebrows – longer, darker and coarser.
•Examine the skin for suspected lesions
–Use the ABCDE mnemonic to assess suspicious lesions:
What is the ABCDE ?
– Asymmetry
– Border
– Color
– Diameter
– Elevation
What are the most common types of skin cancer ?
– Melanoma
– basal cell carcinoma – lighter skin more common
– squamous cell carcinoma – darker skin more common
Skin Assessment: Inspection - must observe...
•Note any distinctive odor
•Generalized color variations
•Skin breakdown
Skin primary lesions
arise from normal skin due to irritation or disease.
Types of primary skin lesions
–Flat, non-palpable lesion
–Freckles, petechiae, ecchymosis
–Elevated, palpable solid
–Pimples, warts
•Nodule / tumor
–Elevated, solid, palpable mass
–Squamous cell Ca., poorly absorbed injection
•Vesicle, Bulla
–Round elevated mass containing fluid
–Herpes simplex/zoster, varicella (chickenpox), 2° burn
•Vesicle (small) or Bulla (larger)
–Round elevated mass containing fluid
–Herpes simplex/zoster, varicella (chickenpox), 2° burn•Wheal
–Elevated mass with irregular borders
– uticaria - hives
–Pus filled vesicle or bulla
–Acne, impetigo
–Encapsulated fluid-filled or semisolid mass in subcutaneous or dermis tissue
–Sebaceous or an epidermoid cyst (big guys)
Skin Secondary lesions
arise from changes in primary lesions.

–Loss of superficial epidermis only
–Scratch marks
–Skin loss past epidermis
–Pressure ulcer; venous insufficiency ulcer
–Skin mark left after healing of wound/lesion
–Linear crack in skin – may extend to dermis
–Chapped lips or hands; athlete’s foot
Skin Vascular lesions
reddish-bluish lesions are seen with bleeding, venous pressure, aging, liver disease or pregnancy.
Vascular lesions types
–Round red/purple macule
–Macular lesion larger than patechiae
–Color changes with black, yellow and green hues
–Associated with trauma or bleeding.
–Localized collection of blood creating an elevated eccymosis – associated with trauma•Cherry Angioma
–Red/purple round papule
–Blanches with pressure – on trunk and extremities – normal age-related skin alteration
•Spider Angioma
–Red arteriole lesion – looks like a spider
–Found on face, neck, arms, trunk
–Blanches with pressure - liver disease, pregnancy, Vitamin B deficiency
•Talangiectasis (venous star)
–Spider-like or linear; bluish-red
–Does not blanch, legs and chest
–Caused by increased venous pressure
Inspect Skin for the following:
• Lesions
• Texture
• Temperature and moisture
• Thickness of skin
• Mobility and turgor
• Edema
Elasticity test usually done on abdomen by pulling the skin then release after a few seconds. If skin holds up could mean dehydration problems
– Inspection: Nail
grooming and cleanliness, nail color and markings, shape of nails,
– Palpation: Texture, assess texture and consistency, capillary refill
• Inspection and palpation
– General color and condition, cleanliness, dryness or oiliness, parasites, and lesions
– Amount and distribution of scalp, body, axillae, and pubic hair
Point of maximum impact of the apex located at the 5th intercostal space for the mitral sound
How do you rate pulse strength ?
0 - absent
1 - barely
2 - easily palpable
3 - full pulse
4 - strong, bounding
S1 and S2
S1 - systole (ventricular contraction) LUB
S2 - diastole (ventricular relaxation) DUB
Name the types of primary lesions
flat non palpable lesions
i.e. freckels
elevated, palpable lesions
i.e. Wart
elevated and palpable
i.e.: Squamous cell carcinoma
Papule with fluid
i.e.Herpes Simplex
elevated (papule like) with a mass
- hives, uticaria
Pus filled vesicle or bulla
-pimple full of pus.
Fluid like in subcutaneous or dermis.
Secondary lesions
Loss of epidermis
Scratch marks
Loss past the epidermis (affects dermis and/or hypodermis)
pressure ulcer
venous isufficiency ulcer
left after healing lesion
linear crack in skin
-chapped lips/hands
Name the vascular skin lesions
Cherry angioma
Spider angioma
Venous star
round red flat
larger Petechiae - large red flat
Elevated eccymosis (large elevated petechiae)
Cherry angioma
red/purple round papule
Spider angioma
red arteriole lesion star-like shape
Sometimes indicative of liver disease
Venous star
bluish/red venous lesion star-like