Health assessment exam 2

What is cranial nerve I?

Olfactory, transmit sense of smell to the temporal lobe

What is cranial nerve II?

Optic, visual acuity. Use Snellen chart (20 feet); normal is 20/20, legal blindness is 20/200 (numerator= distance, denominator= distance at which the average pt can read)

What is cranial nerve III?

Oculomotor; size shape and equality

What are the 3 cranial nerves that control eye movement?

CN III (oculomotor): superior, inferior and medical rectus and inferior oblique muscles

CN IV (Trochlear): superior oblique muscle

CN VI (abducens): lateral rectus muscle

What is cranial nerve V?

Trigeminal. Facial sensations

What is cranial nerve VII?

Facial. Muscle function and facial structures should be equal bilaterally

What is cranial nerve XI?

Spinal accessory. Inspect sternomastoid and trapezius muscle for equal size and bilateral movement. Assess motor function and strength

What is cranial nerve XI?

Hypoglossal; extension of the tongue, check for symmetry

Mneumonic to remember cranial nerves

Oh (olfactory) Oh (optic) Oh (oculomotor) To (trochlear) Touch (trigeminal) And (abducens) Feel (facial) Very (vestibulocochlear) Good (glossopharyngeal) Velvet (vagus), AH (spinal Accessory and Hypoglossal)

What is the convergence test?

Move finger closer toward patient’s face, pt’s pupil will move towards the nose.

What is convergence?

Motor movement of the pupil

What is accommodation?

Change in size of the pupil in response to a closer object

PERRLA mnemonic

Pupils equal round reactive light accommodation. Also note size of pupil (mm)

How do you test for pupillary light reflex?

Darken room and ask person to gaze into distance. Advance light from side and note response. You should see constriction of the same-sided pupil (direct light reflex) and simultaneous constriction of the other pupil (consensual light reflex)

How should you palpate a lymph node?

GENTLE PRESSURE in a circular motion on pads of fingers

How do lymph nodes normally feel?

Movable, discrete, soft, and non-tender

What do you note for abnormal findings in lymph node assessment?

Note location, size and shape, mobility, consistency and tenderness. Drain area

What can enlargements/masses lead to in lymph nodes?

Acute infection, chronic inflammation, HIV infection, neoplasms, lymphoma

What is a lymphadenopathy?

>1cm lymph node enlargement; from infection, allergy or neoplasm

How do you test visual acuity?

Using a Snellen alphabet/picture chart

What is a cardiac rate?

heart bpm

What is cardiac amplitude?

Feeling of pulse via palpation

What is cardiac rhythm?

normal contractions and relaxations; no bradycardia and tachycardia

How does the blood flow through the heart?

Right atrium → Tricuspid valve → Right ventricle → Pulmonic valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta

What are the normal heart sounds?

S1 and S2

What is S1?

1st heart sound; closure of AV valves, beginning of systole

What is S2?

2nd heart sound; closure of SL valves, end of systole

What are abnormal cardiac sounds?

S3, S4, and mumurs

What is S3?

3rd heart sound; Abnormal, immediately after S2, when AV valves open and atrial blood goes into ventricles. Sounds like Kentucky: KEN-TU-CKY

S3 is abnormal in adults and elderly. What can it indicate in this population?

Severe mitral or tricuspid regurgitation, cardiomyopathy, and heart failure

S3 is abnormal but could be normal in what population?

Young adults and children, pregnancy and athletes

What is S4?

4th heart sound, abnormal, just before S1, at end of diastole, ventricle resistant to filling. Sounds like Tennessee: TEN-NE-SSEE

What can S4 indicate?

Almost always pathological. Can indicate DIASTOLIC heart failure.

What causes the S4 sound?

Severe left ventricular hypertrophy, cardiac ischemia, uncontrolled HTN, hypertrophic or restrictive cardiomyopathy

What is a cardiac murmur?

A blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels. Except for innocent murmurs, murmurs are abnormal

How do you assess the jugular venous pulse?

Pt supine with HOB elevated 30-45 degrees, remove pillow, turn pt’s head slightly away, direct strong light tangentially onto the neck, visualize EJ overlying sternomastoid muscle or IJ in sternal notch. EJs flatten and disappear at 45 degree (if not=JVD)

What is the apical pulse?

Pulsation of left ventricle against chest wall

What is a heave or lift?

Sustained, forceful thrusting of the ventricle during systole. Occurs with ventricular hypertrophy.

Where can the right and left ventricular heaves be seen?

Right: sternal border

Left: apex

How do you palpate PMI?

Ask pt to exhale and hold, best measured at left lateral decubitus position. 4th or 5th ICS, MCL. Short, normally occupies only first half of systole. Feel for lifts or heaves

How do you palpate the precorcium?

Use palmar aspects of four fingers, search for pulsations/vibrations. Palpate apex, left sternal border and base. None normally occur, if present note timing

What is a thrill?

Palpable vibration, signifies turbulent blood flow; can accompany a loud murmur

What is a bruit?

Auscultated over an artery and sounds like a blowing and swishing sound

How do you auscultate the precordium?

Start w/ diaphragm, note rate and rhythm, assess S1 and S2, listen for extra sounds and murmurs. Then repeat with bell

What are the five traditional valve areas? (REMEMBER THIS)

Aortic: 2nd ICS, RSB

Pulmonic: 2nd ICS, LSB

Erb’s point: 3rd ICS, LSB

Tricuspid: 4th ICS, LSB

Mitral: 5th ICS, MCL

Mnemonic to remember valve areas

A PET Monkey

How do you palpate the carotid arteries?

Palpate each one, BUT ONLY ONE AT A TIME, avoid excessive pressure. Feel contour and amplitude of pulse. Should be same bilaterally

How do you auscultate the carotid arteries?

Auscultate for bruit, keep neck in neutral position and use bell of stethoscope. Avoid compression of artery. Ask pt to take a breath, exhale and hold it briefly

What is the function of the lymph system?

Retrieves excess fluid and plasma proteins from interstitial spaces and puts them back in the bloodstream. Protects body from infection and detects & eliminates foreign substances, filters lymph, and engulfs pathogens

What do the cervical nodes drain?

Drain the head and neck

What do the axillary nodes drain?

Drain the breast and upper arm

What do the inguinal nodes drain?

Drain the lower extremities, external genitalia, and anterior abdominal wall

What do you palpate the radial pulses for?

Palpate BOTH radial pulses for rate, rhythm, elasticity, force

How do you grade the force/amplitude of the radial pulse?

3 point scale (3+ bounding, 2+ normal, 1+ weak, 0 absent)

What is the doppler ultrasonic probe used to detect?

Weak peripheral pulses, monitoring BP in infants or children, or measuring low BP/BP in a lower extremity

How do you use the doppler ultrasonic probe?

Magnifies pulsatile sounds; apply gel to transducer, place it over the pulse site and apply very light pressure and tilt probe until you locate the swishing, whooshing sound of the pulse

Subjective peripheral vascular information

No leg pain, no skin changes, no swelling or lymph node enlargement. No hx of heart or vascular problems, diabetes or obesity. Doesn’t smoke. On no medicatiosn

Objective peripheral vascular information

Extremities have color appropriate for race/ethnicity, w/o redness, cyanosis or any skin lesions. Extremity size is symmetric w/o swelling or atrophy. Temp is warm and equal bilaterally. All pulses present, 2+ and equal bilaterally. No lymphadenopathy

What is venous disease/insufficiency? (PVD) (Think Jacob from twilight)

Warm, brown or red, swollen (bilaterally). Weeping or excoriating skin, pitting edema and varicose veins

What is arterial disease/insufficiency? (PAD) (Think Edward from twilight)

Slow healing, if any. Necrosis, cold pale extremity, peripheral pulses weak, hairless, atrophic skin (thin, shiny, tight), dry skin, pallor, cyanosis, atrophic skin, unilateral coolness

Risk factors for PAD

Diabetes, arterial insufficiency, microvascular complications, slow healing wounds, foot ulcer infection, and necrosis

OLDCART for Chronic arterial symptoms

Onset: gradual after exertion

Location: deep muscle pain, usually in calf but may be in lower leg or dorsum of feet

Duration: Chronic

Character: Intermittent claudication, feels like cramp, numbness and tingling and feeling of cold

Aggravating factors: activity, claudication distance (specific number of blocks and stairs it takes to produce pain), and elevation

Relieving factors: Rest and dangling feet

Those at risk: Older and middle-age adults, African Americans, smoking, diabetes, HTN, hypercholesterolemia, obesity and chronic kidney disease (CKD)

OLDCART for acute arterial symptoms

Onset: sudden

Location: varies, distal to occlusion, may involve entire leg

Duration:

Character: throbbing

Aggravating factors:

Relieving factors:

Those at risk: hx of vascular surgery, arterial invasive procedure, abdominal aneurysm, trauma, and chronic atrial fibrillation

What does venous mean?

Brown discoloration occuring with chronic venous stasis as a result of hemosiderin deposits

OLDCART for chronic venous symptoms

Onset: increases at end of day

Location: calf, lower leg

Duration: chronic

Character: aching, tiredness, feeling of fullness

Aggravating factors: prolonged standing, sitting

Relieving factors: elevation, lying, walking

Those at risk: job w/ prolonged standing or sitting, obesity, multiple pregnancies, prolonged bedd rest, hx of heart failure, varicosities, or thrombophlebitis, veins crushed by trauma or surgery

OLDCART for acute venous symptoms (DVT)

Onset: sudden

Location: lower extremity

Duration: acute

Character: moderate to intense, sharp, deep muscle tender to touch

Aggravating factors: pain may increase w/ palpation

Relieving factors: pain meds

Those at risk: recent surgery/trauma, prolonged bed rest or inactivity, obesity, cancer, HF

What is DVT?

Deep vein thrombosis. Unilateral edema, warm, red and tender. DO NOT MASSAGE. Can cause a PE (pulmonary embolism)

How do you prevent a DVT?

SCDs and exercise of the pt (walking)

Anterior thoracic landmarks

Jugular notch, sternum, angle of Louis. In the 2nd intercostal space (ICS), site of tracheal bifurcation into right; site of left main bronchi.

What is a costal angle?

90-degree angle or less increases with chronic overinflation

Posterior thoracic landmarks

Beginning point is vertebra prominins (flex head and feel for most prominent bony spur). Spinous processes and inferior border of the scapula

What should be observed in a thoracic assessment?

Retractions and use of accessory muscle, early signs of hypoxia, rate rhythm depth and effort of breathing, and breathing position

What are the early signs of hypoxia?

Restlessness, irritation, agitation, chances in LOC

What is important to keep in mind when counting rate of breathing?

Count rate discreetly as it may change if pt knows it is being counted

What is an abnormal breathing position?

Tripod positioning; indicates respiratory distress. Leaning forward on a stationary object or with elbows on their knee

How should a normal healthy adult’s chest be?

Elliptical shaped chest, transverse diameter is approximately 2x the AP diameter (AP:T = 1:2)

What does barrel chest look like in pts?

Transverse diameter is approximately same as AP diameter (AP:T= 1:1). Older adults can develop barrel chest or COPD

What is pectus excavatum?

Sunken sternum/funnel chest. Often present at birth, sternum grows inward, causing the chest wall to sink. Can cause pressure on lungs and heart

What is pectus carinatum?

Forward protrusion of the sternum; usually doesn’t cause symptoms. Can increase during puberty or growth spurts. Braces or surgery can be done if condition becomes painful

What is the normal costal angle?

<90

What is important to identify on the inspection of the thorax assessment?

Findings related to a Hx of lung disease and/or chronic hypoxia

What should you be looking for when examining thoracic expansion?

Symmetry. If necessary, put hands on chest (along costal margins, pointed towards xiphoid process) and observe thumbs move apart symmetrically.

Why might a lag in expansion occur?

Atelectasis, pneumonia, and postoperative guarding.

What does a palpable grating sensation with breathing indicate?

Pleural friction fremitus

When palpating the posterior chest, what should you look for?

Any areas of tenderness, crepitus, and deformities. Palpate for chest excursion.

What is crepitus?

Air in the tissues

How do you palpate chest excursion?

Place hands at base of chest with fingers spread, place thumbs toward spine to create a skin fold, have the Pt take a deep breath and feel for expansion

What is normal chest excursion?

Chest expansion is symmetrical on anterior/posterior aspect of the chest, thumbs move apart equal distances

Why does unequal chest expansion occur?

Marked atelectasis, lobar pneumonia, pleural effusion, thoracic trauma (fractured ribs), or pneumothorax. Pain accompanies deep breathing when the pleurae are inflamed

What pattern do we use when auscultating lungs?

Greek key pattern; start at apices. LISTEN ON SKIN NOT OVER CLOTHES

How do you auscultate the lungs with a stethoscope?

Use diaphragm. Patient breathes through mouth deeper than normal, listen for one full breath cycle; start at apices and have side to side comparison

How are breath sounds characterized?

They are characterized by pitch and volume with respect to area of the lung

90% of lung sounds are _________

Vesicular

Types of breath sounds

Bronchovesicular: Found near bronchi / chest wall between scapula and upper back

Bronchial: From bronchi

Tracheal: By the trachea

What are the normal breath sounds?

Vesicular, bronchovesicular (heard over main bronchus area) , and bronchial/tracheal (heard only over trachea)

What are vesicular breath sounds?

Heard over most lung fields

Why might decreased breath sounds occur?

Fluid or puss has accumulated in the pleural space, secretions or a foreign body obstructs the bronchi, lungs are hyper-inflated, and shallow breathing

Describe the quality of tracheal breath sounds

Harsh, high-pitched

Describe the quality of bronchial breath sounds

Loud, high-pitched

Describe the quality of bronchovesicular breath sounds

Medium loudness, medium pitch