Health Assessment Exam #2

What subjective data is collected during a respiratory assessment?

cough, SOB, chest pain when breathing, history of respiratory infection, smoking history, environmental exposure, and self care behaviors

What should be inspected during a respiratory assessment?

• thoracic cage: shape and configuration

• skin integrity: color and condition

• position in which patient takes to breathe

• quality of respirations

What should be palpated during a respiratory assessment?

• confirm symmetric chest expansion with breathing, respiratory excursion

• check for fremitus: palpable vibration over the lungs with vocalization, looking for symmetry of vibration

• chest wall for tenderness, temperature, moisture, lumps or masses

What should be percussed during a respiratory assessment and what are the expected sounds over the lung fields?

over lung fields

• resonance: low-pitched, clear, hollow sound, healthy

• hyper-resonance: lower-pitched booming sounds, too much air is present, common in COPD patients

• dull: soft, muffled, abnormal density, possible indication of a mass diaphragmatic excursion: how far the diaphragm extends during inhalation

What areas are auscultated during a respiratory assessment?

bronchial, bronchovesicular, and vesicular

What are characteristics of bronchial lung sounds?

pitch: high amplitude: loud duration: inspiration will be slightly shorter than expiration quality: harsh, hollow, tubular

What are characteristics of bronchovesicular lung sounds?

pitch: moderate amplitude: moderate duration: inspiration and expiration are equal quality: mixed

What are characteristics of vesicular lung sounds?

pitch: low amplitude: soft duration: inspiration will be slightly longer than expiration quality: rustling, like the sounds of the wind in the trees

What are characteristics of fine crackles?

• discontinuous

• fine, high pitched crackling

• end of inspiration

• not cleared by cough

What causes fine crackles?

fluid and mucous in the lungs. seen in pneumonia, HF, COPD, asthma, and chronic bronchitis

What are the characteristics of coarse crackles?

• discontinuous

• low pitched, bubbling or gurgling

• start early in inspiration, extend into expiration

What causes coarse crackles?

fluid and mucous in the lungs but usually seen in more advanced disease. seen in pneumonia, HF, COPD, asthma, chronic bronchitis, pulmonary edema, and pulmonary fibrosis

What are characteristics of wheezes?

• continuous

• high-pitched, musical sound similar to squeak

• more common in expiration

• occurs in small airways

What causes wheezes?

air flowing through constricted airways. seen in asthma, COPD, and HF

What are characteristics of rhonchi?

• continuous

• low-pitched, coarse, loud, low snoring or moaning tone

• more common in expiration

• coughing may clear

What causes rhonchi?

secretions or obstructions in the larger airways. seen in obstructed trachea, bronchitis, and pneumonia

What are characteristics of pleural friction rub?

• superficial, low-pitched, coarse rubbing or grating sound

• sounds like two surfaces rubbing together

• heard throughout inspiration and expiration

• loudest over the lower anterolateral surface

• not cleared by cough

What causes pleural friction rub?

when inflammation roughens the surfaces of the visceral and parietal pleura. seen in pleurisy, pericarditis, and pericardial effusion

What are characteristics of stridor?

• high pitched whistling or gasping sound with harsh sound quality

• heard during inspiration

What causes stridor?

obstruction or narrowing in upper airway. seen in children with croup or epiglottitis

What is the suprasternal notch?

little notch that is above the sternum and between the clavicles

What is the manubrio-sternal angle?

"angle of Louis", where the manubrium meets the sternum, in line with 2nd rib, landmark for assessment locations

How many lobes does each lung have?

right: 3 lobes (but shorter than left lung) left: 2 lobes

What are expected findings in a respiratory assessment?

• spinous process in straight line, symmetric features

• AP diameter 1:2

• skin warm, dry and intact, no tenderness

• tactile fremitus symmetric

• resonance on percussion

• normal breath sounds

What are unexpected findings in a respiratory assessment?

• curved spine: scoliosis or kyphosis, asymmetrical features

• barrel chest, pectus excavatum, pectus carinatum

• skin not intact, hot or cold, diaphoretic

• tactile fremitus asymmetrical

• hyperresonance or dull sounds

• adventitious lung sounds: crackles, wheezes, stridor, pleural rub

What subjective data is collected during a breast, axilla and lymphatics assessment?

breasts: pain, lumps, discharge, rash, swelling, trauma, history of breast disease, surgery, self care behaviors axilla/lymphatics: tenderness, lump, swelling, rash

What should be inspected during a breast, axilla, and lymphatics assessment?

breast: symmetry and shape, skin integrity, and nipple symmetry, skin integrity, and drainage axilla/lymphatics: bulging, discoloration, edema

What should be palpated during a breast, axilla and lymphatics assessment?

breasts: lumps, masses and tenderness axilla/lymphatics: enlarged nodes and tenderness

What are expected findings in a breast, axilla, and lymphatics assessment?

• symmetry of breasts and nipples

• skin warm, dry and intact

• regional lymphatics without bulging or tenderness

• no tenderness or masses in breasts

• breasts should lift symmetrically with arms lifted over head

What are unexpected findings in a breast, axilla, and lymphatics assessment?

• asymmetry of breasts and/or nipples

• supernumerary nipple

• pain or discharge from nipple

• skin not warm, dry and intact, redness or lesions

• regional lymphatics with bulging or tenderness

• tenderness or masses in breasts

• retraction of breasts from fibrosis (breasts don't lift symmetrically when arms lifted above head)

What is hypoxemia?

below normal level of oxygen in blood

What is bronchophony?

the abnormal transmission of sounds from the lungs or bronchi

What is tanner staging?

sexual maturity rating, objective classification system that is used to document a patient's puberty progression

What is gynecomastia?

enlarged breasts in men

What are the valves of the heart?

atrioventricular valves: tricuspid and mitral valve semilunar valves: aortic and pulmonary valve

How does blood flow through the body?

superior and inferior vena cava (return deoxygenated blood to the heart) --> right atrium --> tricuspid valve --> right ventricle --> pulmonary valve --> pulmonary artery --> lungs --> pulmonary veins (oxygenated blood) --> left atrium --> mitral valve --> left ventricle --> aortic valve --> aorta --> body

What are the heart sounds and what causes them?

S1: closing of the tricuspid and mitral valves, beginning of systole (contraction) S2: closing of the pulmonary and aortic valves, end of systole and starts diastole (relaxation) S3: not usually heart and is the ventricles filling abnormally, immediately after S2 S4: not usually heard and occurs when the ventricles are resistant to filling due to stiffening or thickened tissue, just before S1 murmurs: turbulent blood flow, a gentle blowing or swooshing sound

How does an electrical impulse travel through the heart?

the SA node initiates the impulse --> the impulse goes across the atria to the AV node --> impulse travels to the right and left branches of the Bundle of His, stimulating the heart to contract

What occurs if the SA node is not working?

the AV node will take over and maintain a pulse of 40-60 bpm. if the SA and AV node aren't working the right and left branches of the Bundle of His will take over and maintain a pulse of 20-40 bpm

What subjective data is collected during a cardiac assessment?

chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis or pallor, edema, nocturia, past cardiac hx, family hx, diet, smoking, alcohol, exercise, and drug use

What should be inspected during a cardiac assessment?

• overall chest and back

• look for jugular vein distortion, indicates heart failure or fluid volume overload

What should be palpated during a cardiac assessment?

• overall chest and back

• carotid artery

• apical pulse (4th or 5th interspace midclavicular)

• heaves or lifts or thrills

What should be auscultated during a cardiac assessment?

• carotid artery with the bell of the stethoscope in the angle of the jaw, midcervical, and base of neck

  • have pt hold their breath

  • you are listening for bruits

• valves: aortic, pulmonary, Erb's point, tricuspid, and mitral

• listen for S1, S2, S3, S4

  • listen with diaphragm

  • note rate, rhythm and identify S1 and S2

What are bruits?

murmurs in a vessel from turbulent blood flow

When is S1 and S2 the loudest?

S1 is louder than S2 at the apex of the heart and S2 is louder than S1 at the base of the heart

What are the expected findings in a cardiac assessment?

• no JVD

• no heave or lift

• no thrill

• carotids 2+, equal bilateral and no bruit

• no cardiac enlargement with percussion

• S1 and S2 sounds

• regular rhythm

• HR 50-100

What are unexpected findings in a cardiac assessment?

• chest pain, fatigue

• cyanosis

• JVD

• heave or lift

• thrill

• carotids absent, weak or bounding, unequal bilaterally

• carotid bruit

• cardiac enlargement with percussion

• S1 or S2 split sounds, S3, S4, murmur, or clicks

• irregular rhythm

• HR less than 50 or more than 100

What are the different pulse sites?

temporal, brachial, radial, ulnar, femoral, popliteal, anterior tibial, dorsalis pedis, and posterior tibial

What is arteriosclerosis?

thickening and hardening of the artery walls

What is atherosclerosis?

buildup of fats in and on artery walls

What is interstitial space?

surrounds tissue cells, filled with interstitial fluid, allows for movement of ions, proteins, and nutrients across the cell barrier

What is the function of the spleen?

destroys old RBC, produce antibodies, store RBCs, and filter microorganisms

What is the function of the tonsils?

respond to local inflammation

What is the function of the thymus?

important in developing T lymphocytes, the B lymphocytes originate in the bone marrow and mature in the lymphoid tissue

What is the function of the appendix?

responds to gut flora

What subjective data is collected during a peripheral vascular and lymphatics assessment?

• leg pain or cramps

• skin changes on arms or legs

• swelling in arms or legs

• lymph node enlargement

What are lymph nodes?

small, oval clumps of lymphatic tissue located along the lymph vessels that filter fluid before it is returned to the bloodstream

What objective data is collected during a peripheral vascular and lymphatics assessment in the arms?

inspect: lesions, color, symmetry palpate: tenderness, temp, check capillary refill, radial pulses, brachial pulse, and epitrochlear nodes

How do you rate pulse?

• 0: absent

• 1+: weak

• 2+: normal

• 3+: increased, full, bounding

What objective data is collected during a peripheral vascular assessment in the legs?

• inspect: color, presence of lesions, swelling, varicose veins

• palpate: temp, moisture, pulses (femoral, popliteal, dorsalis pedis and posterior tibial), swelling/edema

How do you rate edema?

• 1+: mild, slight indentation

• 2+: moderate pitting, indentation subsides quickly

• 3+: deep pitting, indentation remains for a short time, legs look swollen

• 4+: very deep pitting, indentation lasts a long time

What are expected findings in a peripheral vascular assessment?

• arteries: 2+, regular pulses bilaterally, warm, intact skin over extremities, expected hair growth patterns, no bruit

• veins: no varicosities

• no edema

What are unexpected findings in a peripheral vascular assessment?

• arteries: absent, weak or bounding pulses, irregular pulses, cool skin over extremities, unexpected hair growth patterns, bruit

• veins: varicosities

• edema

• wounds that won't heal or heal slowly

What are expected findings in a lymphatics assessment?

• no edema

• no painful lymph nodes

• no swollen lymph nodes

What are unexpected findings in a lymphatics assessment?

• edema

• painful lymph nodes

• swollen lymph nodes