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
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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
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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
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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
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What areas are auscultated during a respiratory assessment?
bronchial, bronchovesicular, and vesicular
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What are characteristics of bronchial lung sounds?
pitch: high amplitude: loud duration: inspiration will be slightly shorter than expiration quality: harsh, hollow, tubular
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What are characteristics of bronchovesicular lung sounds?
pitch: moderate amplitude: moderate duration: inspiration and expiration are equal quality: mixed
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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
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What are characteristics of fine crackles?
- discontinuous - fine, high pitched crackling - end of inspiration - not cleared by cough
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What causes fine crackles?
fluid and mucous in the lungs. seen in pneumonia, HF, COPD, asthma, and chronic bronchitis
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What are the characteristics of coarse crackles?
- discontinuous - low pitched, bubbling or gurgling - start early in inspiration, extend into expiration
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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
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What are characteristics of wheezes?
- continuous - high-pitched, musical sound similar to squeak - more common in expiration - occurs in small airways
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What causes wheezes?
air flowing through constricted airways. seen in asthma, COPD, and HF
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What are characteristics of rhonchi?
- continuous - low-pitched, coarse, loud, low snoring or moaning tone - more common in expiration - coughing may clear
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What causes rhonchi?
secretions or obstructions in the larger airways. seen in obstructed trachea, bronchitis, and pneumonia
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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
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What causes pleural friction rub?
when inflammation roughens the surfaces of the visceral and parietal pleura. seen in pleurisy, pericarditis, and pericardial effusion
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What are characteristics of stridor?
- high pitched whistling or gasping sound with harsh sound quality - heard during inspiration
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What causes stridor?
obstruction or narrowing in upper airway. seen in children with croup or epiglottitis
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What is the suprasternal notch?
little notch that is above the sternum and between the clavicles
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What is the manubrio-sternal angle?
"angle of Louis", where the manubrium meets the sternum, in line with 2nd rib, landmark for assessment locations
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How many lobes does each lung have?
right: 3 lobes (but shorter than left lung) left: 2 lobes
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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
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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
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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
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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
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What should be palpated during a breast, axilla and lymphatics assessment?
breasts: lumps, masses and tenderness axilla/lymphatics: enlarged nodes and tenderness
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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
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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)
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What is hypoxemia?
below normal level of oxygen in blood
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What is bronchophony?
the abnormal transmission of sounds from the lungs or bronchi
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What is tanner staging?
sexual maturity rating, objective classification system that is used to document a patient's puberty progression
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What is gynecomastia?
enlarged breasts in men
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What are the valves of the heart?
atrioventricular valves: tricuspid and mitral valve semilunar valves: aortic and pulmonary valve
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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
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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
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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
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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
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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
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What should be inspected during a cardiac assessment?
- overall chest and back - look for jugular vein distortion, indicates heart failure or fluid volume overload
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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
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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
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What are bruits?
murmurs in a vessel from turbulent blood flow
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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
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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
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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
- 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
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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
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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
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What are expected findings in a lymphatics assessment?
- no edema - no painful lymph nodes - no swollen lymph nodes
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What are unexpected findings in a lymphatics assessment?