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66 Cards in this Set

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vesicular breath sounds
inspiratory sounds last longer than exp ones; intensity of exp sound is soft; pitch of exp is low; heard over most of both lungs
bronchovesicular breath sounds
insp and exp sounds are equal; intensity of exp sound is intermediate; pitch of exp intermediated; heard in 1st and 2nd interspaces anteriorly and between scapulae
bronchial breath sounds
exp sound lasts longer than insp ones; intensity of exp is loud, pitch of exp is high. heard over manubrium if heard at all
adventitious breath sonds
crackles/wheezes/rhonchi
Crackles
Discontinuous; intermittent, nonmusical, brief; may be from abnormalities of lungs (pna, fibrosis, early chf) or of the airways (bronchitis, bronchiectasis). Present in dependent portions of lungs, may occur after prolonged recumbency. Fine: soft, high pitched; brief 5-10 sec. Course: louder, lower in pitch, brief 20-30 sec
Wheezes
high pitched with hissing shril. suggest narrowed airways, like in asthma, COPD, bronchitis
Rhonchi
suggest secretions in large airways
normal adult chest characteristics
thorax wider than deep, lateral diameter large than anteroposterior diameter
funnel chest (pectus excavatum)
depression in the lower part of the sternum; may have heart murmur from compression of heart and great vessels
barrel chest
increased anteroposterior diameter. normal in infancy, accompanies aging, COPD
pigeon chest (pectus carinatum)
sternum displaced anteriorly, increasing anteroposterior diameter. costal cartilages adjacent to protruding sternum are depressed
traumatic chest fail
multiple rib fxs; paradoxical movements of thorax, as descent of the diaphragm decreases intrathoracic pressure, on inspiration the injured area caves inward. on exp, it moves outward
thoracic kyphoscoliosis
abnormal spinal curvatures and vertebral rotation deform of the chest distortion of the underlying lungs may make interpretation of the lungs difficult
tripod position, when you would expect to find it
pt is sitting upright leaning forward over a bedside table, pts with COPD; aids in breathing b/c pts can use accessory muscles to aid in breathing; usually indicates pt is in resp distress
tactile fremitus
the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the pt is speaking. To detect, place bony parts of your hand on pt back and ask them to repeat 99 or 111. more prominent in the interscapular area than in the lower lung fields, and is often more prominent on the right side than on left. disappears below diaphragm
factors affecting intensity of tactile fremitus
decreased: soft voice, thick chest wall, obstructed bronchus, COPD, pleural effusion, fibrosis (pleural thickening), air (pneumo), infiltrating tumor



increased: Asymmetrical unilateral fremitus could be unilateral pneumonia

atelectasis
obstructed air flow causes affected lung tissue to collapse into an airless state. findings: percussin is dull over airless area, trachea may be shifted towards affected side, breath sounds usually absent (except when rul is affected in which case adjacent tracheal sounds may be transmitted), no adventitious sounds present, tactile fremitus usually absent
emphysema (COPD)
slowly progressive disease in which the distal air spaces enlarge and lungs become hyperinflated. Findings: percussion is diffusely resonant, trachea midline, breath sounds discreased or absent. no adventitious sounds, may have crackles, wheezes if assoc with bronchitis, decreased tactile frem, retraction in posterior chest possible, displaced downward liver
asthma
widespread narrowing of the tacheobronchial tree diminshes air flow to a fluctuating degree, during attacks air flow decreases further and lungs hyperinflate. findings: percussion resonant to diffusely hyperresonant. trachea midline, may have wheezes or crackles, tact frem decreased, retraction in severe cases
pleural effusion
fluid accumulates in the pleural space, separating lung from the chest wall, blocking the transmission of sound. findings: percussion dull to flat over liquid, trachea can be deviated toward opposite side of effusion, breath sounds decreased to absent, no adventitious except possible run, tact frem decreased to absent, by may be increased near top of large effusion
heart failure, right sided early
increased pressure in the pulmonary veins causes congestion and interstitial edema (around the alveoli); bronchial mucosa may become edematous. findings: percussion resonant, trachea midline, vesicular breath sounds, adv sounds include late insp crackles in the dependent portins of the lungs, possibly wheezes, tact frem normal
pneumothorax
when air leaks into the pleural space, usually unilaterally, the lung recoils from the chest wall; pleural air blocks transmission of sound. findings: percussion hyperresonant or tympanitic over the pleural air, shifted toward opposite if much air in pleural space, breath sounds decreased to absent, no adventitious sounds except possible rub, tact frem decreased to absent
Assessing CV System: health history
quantify pt baseline level of activity; concerning symptoms include: chest pain, palpitations, SOB,
orthopnea
occurs when lying down, improves when sitting up, causes include liver failure, mitral stenosis, obstructive lung disorder
jugular venous pressure
reflects right atrial pressure/central venous pressure/right ventricular end diastolic pressure. best estimated by the rij or rej vein. yields clues: volume status, r and l vent fx, patency of the tricuspid and pulmonary valves, pressures in the pericardium, junctinal and av block arrhythmias. jvp falls with blood/volume loss. jvp rises with r of l heart failure, pulm htn, tricuspid stenosis, and tamponade.
Mechanisms that produce the first s1 and second s2 heart sounds
S1- Closure of Mitral valve



S2- Closure of Aortic valve

Thrill and what it may indicate

humming vibrations from turbulent blood flow felt during palpation; if felt on carotid artery, may indicate stenosis; if felt on chest wall could indicate murmurs (aortic stenosis, patent ductus arteriosus, vsd, and less commonly mitral valve stenosis)
Describe bruit and what it may indicate
murmur like sound caused by turbulent blood flow of vascular rather than cardiac origin; an aortic valve murmur can radiate to the carotid artery and sound like a bruit; carotid bruits can be indicative of carotid stenosis
Describe lift and what it may indicate
large cardiac pulsations "lift" your fingertips on palpation; may indicate ventricular hypertrophy
Characteristics to explore when you hear a mumur
1. Timing

2. Shape


3. Location


4. Radiation


5. Intensity


6. Pitch


7. Quality



Determining timing of murmurs

systolic murmur (falling between s1 and s2) or a diastolic murmur (falling between s2 and s1)? Palpating the carotid pulse can help decipher between the two, murmurs that occur with the carotid upstroke are systolic. systolic murmurs usually occur when the valves are normal, diastolic murmurs usually indicate valvular heart disease.

Determining shape of murmurs

determined by it's intensity over time (ex crescendo-grows louder, decresenco-grows softer, plateau-same intensity)
Determining location of murmurs
note where the murmur is loudest on the precordium (at the base, along the sternal border, or at the apex)
Determining the murmur's radiation from point of origin
this reflects the intensity of the murmur and the direction of blood flow
Determining intensity of murmurs
graded on a 6 pt scale and expressed as a fraction; the numerator describes the intensity of the murmur at the point of origin (where its loudest), the denominator indicates the scale you are using; intensity is influenced by the thickness of the chest wall and the presence of intervening tissue
Determining pitch of murmurs
high, medium, low
Determining quality of murmurs

blowing, harsh, rumbling, or musical

Grading of murmurs: grade 1
very faint, difficult to hear, may not be heard in all positions
Grading of murmurs:grade 2

quiet, heard immediatley after placing the stethescope on the chest

Grading of murmurs:grade 3

moderately loud

Grading of murmurs: grade 4

loud, with palpable thrill

Grading of murmurs: grade 5

very loud, with thrill, may be heard when stethoscope is partly off the chest

Grading of murmurs:grade 6

very loud, with thrill, may be heard when stethoscope is entirely off the chest

Important areas of examination during peripheral vascular assessment: Arms
This area is inspected for size symmetry, skin color, radial/brachial pulses, epitrochlear nodes.

Important areas of examination during peripheral vascular assessment: Legs

This area is inpected for size, symmetry, skin color, femoral pulse and inguinal lymph nodes, popliteal, dorsalis pedis and posterior tibial pulses, peripheral edema

Important areas of examination during peripheral vascular assessment: Abdomen

This area is inspected for aortic width, pulsatile mass



Key components of peripheral arterial exam

1. Measure BP in both arms;

2. Palpate carotid, brachial, radial ulnar, femoral, popliteal, dorsalis pedis, and posterior arteries


3. Auscultate for aortic, renal, and femoral bruits


4. Inspect ankles and feet for color, temperature, skin integrity; note any ulcerations; check for hair loss, trophic skin changes, hypertrophic nails

Characteristics of lymph nodes associated with cancer

The lymph node will be enlarged and hard.The lymph node will not be tender to the touch. The gland will commonly have a bumpy feel to it. The lymph glands will usually be non-movable. A connected chain of these lymph glands together is common. The lymph glands will not change size quickly

Describe the function of the lymphatic system and the lymph nodes
Lymphatic system is an extensive vascular network that drains the lymph fluid from body tissues and returns it to the venouse circulation it also plays an important role in the bodies immune system. Cells within the lymph nodes engulf cellular debris and bacteria and produce antibodies
Characteristics of acute inflammation of the lymph nodes
tender and swollen lymph nodes usually indicate an infection and should be addressed by supporting the body naturally and building up the immune system to fight the problem. Another situation where swollen lymph nodes may be noticed is after injury to the body as the lymph glands are responsible for protecting the body from infection.,

Characteristics of chronic inflammation of the lymph nodes

usually caused by an infection that has spread to the lymph nodes from a skin, ear, nose, or eye infection. Infections with streptococcal or staphylococcal bacteria, Bacterial sore throat, tonsillitis
Pulse sites accessible to examination
brachial, radial, ulnar, femoral, popliteal, dorsalis pedis and posterior tibial arteries

How are pulses graded (numerical value)

Bounding- 3+


Normal- 2+


Diminished- 1+


Absent- 0

Skin characteristics expected with chronic insufficiency of arteries
thin, shiny, atrophic skin; loss of hair over the foot and toes; nails thickened and ridged; Gangrene may develop; absent to mild edema
Chronic Venous Insufficiency skin characteristics
often brown pigmentation around the ankle, stasis dermatitis , and possible thickening of the skin and narrowing of the leg as scarring develops; marked edema present; ulcers usually develop around ankles

Effect of PR interval on the intensity of S1

S1 is louder if PR interval is shorter

Physiological and paradoxical splitting of S2

Physiological- normal splitting of S2 that is accentuated by inspiration and disappears during expiration




Paradoxical- splitting that persists throughout the respiratory cycle; suggests pulmonic stenosis, right bundle branch block or early closure of aortic valve (mitral regurg)

Abnormal sounds in early diastole

S3, pericardial knock, & opening snap of mitral stenosis

What is pulsus paradoxus?

Greater than normal drop in systolic pressure during inhalation

opening snap of mitral stenosis

occurs very early in diastole; heard best next to apex, high pitched; heard best with diaphragm

Assessing for unilateral edema

measure both legs with flexible tape at the forefoot, smallest circumference above ankle, largest circumference at calf, midthigh. a difference above 1-2 cm is not normal.

Assessing respiratory system: Health Hx

CP, SOB, wheezing, cough, hemoptysis

Health Hx info pertinent to CP

Must ask all 7 attribute questions; anxiety most frequent cause of CP in children

Health Hx info pertinent to SOB

issues climbing stairs, SOB while carrying groceries or completing ADLs, any associated symptoms? +7 attributes

Health Hx info pertinent to cough

How long have they had the cough? dry or produces sputum? volume, color, odor of sputum?

Health Hx info pertinent to hemoptysis

Volume, color (frank or dark red), related setting or activity