exam 3 health assessment

Atelectasis (Collapse)

ConditionCollapsed shrunken section of alveoli or an entire lung as a result of (1) airway obstruction (e.g., the bronchus is completely blocked by thick exudate, aspirated foreign body, or tumor; the alveolar air beyond the obstruction is gradually absorbed by the pulmonary capillaries, and the alveolar walls cave in); (2) compression on the lung (e.g., pleural effusion); or (3) lack of surfactant (hyaline membrane disease).

InspectionCough. Lag on expansion on affected side. Increased respiratory rate and pulse. Possible cyanosis.

PalpationChest expansion decreased on affected side. Tactile fremitus decreased or absent over area. With large collapse, tracheal shift toward affected side.

PercussionDull over area (remainder of thorax sometimes may have hyperresonant note).

AuscultationBreath sounds decreased vesicular or absent over area. Voice sounds variable, usually decreased or absent over affected area.

Adventitious SoundsNone if bronchus is obstructed. Occasional fine crackles if bronchus is patent.ructed. Occasional fine crackles if bronchus is patent.

Lobar Pneumonia

ConditionInfection in lung parenchyma leaves alveolar membrane edematous and porous; thus red blood cells (RBCs) and white blood cells (WBCs) pass from blood to alveoli. Alveoli progressively fill up (become consolidated) with bacteria, solid cellular debris, fluid, and blood cells, which replace alveolar air. This decreases surface area of the respiratory membrane, causing hypoxemia. Pneumonia may lead to sepsis and/or acute respiratory distress syndrome (see p. 452).21

SubjectiveFever, cough with pleuritic chest pain, chills, SOB, fatigue, malaise. Variable sputum production, from nonproductive cough to purulent sputum to blood-tinged sputum.10 Older adults may have confusion, functional decline, or altered level of consciousness.11

InspectionIncreased respirations >24/min. Guarding and lag on expansion on affected side. Children—Sternal retraction, nasal flaring. Cyanosis with severe illness.10 Possible hypotension.

PalpationChest expansion decreased on affected side. Tactile fremitus increased if bronchus patent, decreased if bronchus obstructed.

PercussionDull over lobar pneumonia.

AuscultationTachycardia. Loud bronchial breathing with patent bronchus. Voice sounds have increased clarity; bronchophony, egophony, whispered pectoriloquy present. Children—Diminished breath sounds may occur early.

Adventitious SoundsCrackles, fine to medium.

Heart Failure

ConditionPump failure causes increased backward pressure toward the pulmonary circulation, leading to pulmonary vascular congestion (engorgement of pulmonary capillaries). Dependent air sacs deflated. Bronchial mucosa may be swollen.

InspectionIncreased respiratory rate, SOB on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, pallor in light-skinned people. In acute heart failure, may have pulmonary edema with pink, frothy sputum.

PalpationSkin moist, clammy. Tactile fremitus normal.

PercussionResonant.

AuscultationNormal vesicular. Heart sounds include S3 gallop.

Adventitious SoundsCrackles at lung bases.

Pleural Effusion (Fluid)

ConditionCollection of excess fluid in the intrapleural space, with compression of overlying lung tissue. Effusion may contain watery capillary fluid (transudative), protein (exudative), purulent matter (empyemic), blood (hemothorax), or milky lymphatic fluid (chylothorax). Gravity settles fluid in dependent areas of thorax. Presence of fluid subdues all lung sounds.

InspectionIncreased respirations, dyspnea; may have dry cough, tachycardia, cyanosis, asymmetric expansion, abdominal distention.

PalpationTactile fremitus decreased or absent. Tracheal shift away from affected side. Chest expansion decreased on affected side.

PercussionDull on affected side.

AuscultationBreath sounds decreased or absent. Voice sounds decreased or absent. When remainder of lung is compressed near the effusion, may have bronchial breath sounds over the compression along with bronchophony, egophony, whispered pectoriloquy.

Adventitious SoundsCrackles, pleural rub.

Pneumothorax

ConditionFree air in pleural space causes partial or complete lung collapse. Air in pleural space neutralizes or reverses the usual negative pressure present; thus lung collapses. Usually unilateral. Pneumothorax can be (1) spontaneous (air enters pleural space through rupture in lung wall, (2) traumatic (air enters through opening or injury in chest wall), or (3) tension (trapped air in pleural space increases, compressing lung and shifting mediastinum to the unaffected side). Vitals show increased respiratory and heart rates, possible decreased blood pressure.

InspectionUnequal chest expansion. If large, tachypnea, cyanosis, apprehension, bulging interspaces.

PalpationTactile fremitus decreased or absent. With tension pneumothorax, may see tracheal shift to opposite (unaffected) side. Chest expansion decreased on affected side.

PercussionHyperresonant.

AuscultationBreath sounds decreased or absent. Voice sounds decreased or absent.

Adventitious SoundsNone.

Asthma (Reactive Airway Disease)

ConditionAn allergic hypersensitivity to certain inhaled allergens (pollen), irritants (tobacco, ozone), microbes, stress, or exercise that produces a complex response characterized by bronchospasm and inflammation, edema in walls of bronchioles, and secretion of highly viscous mucus into airways. These factors greatly increase airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea, and chest tightness.

InspectionDuring severe attack: increased respiratory rate, SOB with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostal spaces. Expiration labored, prolonged. When chronic, may have barrel chest.

PalpationTactile fremitus decreased, tachycardia.

PercussionResonant. May be hyperresonant if chronic.

AuscultationDiminished air movement. Breath sounds decreased, with prolonged expiration. Voice sounds decreased.

Adventitious SoundsBilateral wheezing on expiration, sometimes inspiratory and expiratory wheezing.

Acute Bronchitis

Condition An acute infection of the trachea and larger bronchi characterized by cough, lasting up to 3 weeks. Most cases are viral and do not need antibiotics. Epithelium of bronchi are inflamed and damaged, releasing proinflammatory mediators. Large airways are narrowed from capillary dilation, increased mucus production, loss of cilia function, and swelling of epithelium. More cases occur with smokers, aging adults, children, and in winter months.

Inspection Cough is productive or nonproductive. Also sore throat, low-grade fever, postnasal drip, fatigue, substernal aching.

Palpation No pain, no increased fremitus.

Percussion Resonance predominates.

Auscultation May be clear and equal bilaterally. No egophony.

Adventitious sounds No crackles (distinguishes the consolidation of pneumonia, no wheeze).

Chronic Bronchitis

ConditionA type of chronic obstructive pulmonary disease (COPD), with proliferation of mucus glands in the passageways, resulting in excessive mucus secretion. Inflammation of bronchi with partial obstruction of bronchi by secretions or constrictions. Sections of lung distal to obstruction may be deflated. Bronchitis may be acute or chronic with recurrent productive cough. Chronic bronchitis is usually caused by cigarette smoking.

InspectionHacking, rasping cough productive of thick mucoid sputum. Chronic—dyspnea, fatigue, cyanosis, possible clubbing of fingers. Acute exacerbations may have worsening dyspnea and increased cyanosis.

PalpationTactile fremitus normal.

PercussionResonant.

AuscultationNormal vesicular. Voice sounds normal. Chronic—prolonged expiration.

Adventitious SoundsCrackles over deflated areas. May have wheeze, especially with acute exacerbation.

Emphysema

ConditionAlso a type of COPD, caused by destruction of pulmonary connective tissue (elastin, collagen); characterized by permanent enlargement of air sacs distal to terminal bronchioles and rupture of interalveolar walls. This increases airway resistance, especially on expiration, producing a hyperinflated lung and an increase in lung volume. Cigarette smoking accounts for 80% to 90% of cases of emphysema.

InspectionIncreased AP diameter. Barrel chest. Accessory muscles used to aid respiration. Tripod position. SOB, especially on exertion. Respiratory distress. Tachypnea.

PalpationDecreased tactile fremitus and chest expansion.

PercussionHyperresonant.

AuscultationDecreased breath sounds. May have prolonged expiration. Muffled heart sounds resulting from overdistention of lungs.

Adventitious SoundsUsually none; occasionally, wheeze.

Pulmonary Embolism

ConditionUndissolved materials (e.g., venous thrombus, air bubbles, or fat globules) embolize in the venous circulation, return to right side of heart, and are pumped out to lodge in and may occlude the pulmonary arteries. Although deep vein thromboses (DVTs) may occur in veins of legs, pelvis, and upper extremities, over 95% arise from DVTs in lower legs as a result of stasis of blood, vessel injury, or hypercoagulability. Pulmonary occlusion results in ischemia of downstream lung tissue, increased pulmonary artery pressure, decreased cardiac output, and hypoxia. Rarely, a saddle embolus in bifurcation of pulmonary arteries leads to sudden death from hypoxia and obstructive shock. More often small-to-medium pulmonary branches occlude, leading to dyspnea. These may resolve by innate fibrinolytic activity.

SubjectiveChest pain, worse on deep inspiration, dyspnea.

InspectionApprehensive, restless, anxiety, mental status changes, cyanosis, tachypnea, cough, hemoptysis. Arterial blood gases show respiratory alkalosis and hypoxemia. Possible fever.

PalpationDiaphoresis, hypotension.

AuscultationTachycardia, accentuated pulmonic component of S2 heart sound.

Adventitious SoundsCrackles, wheezes.

Acute Respiratory Distress Syndrome (ARDS)

ConditionDiffuse damage to the alveolar capillary membrane causes increased permeability of pulmonary capillaries and alveolar epithelium and leads to pulmonary edema. Causes may involve direct pulmonary injury (e.g., severe bacterial or viral pneumonia, aspiration of gastric contents) or indirect injury (e.g., sepsis, shock, severe trauma). Gross examination (autopsy) would show dark red, firm, airless tissue, with some alveoli collapsed and hyaline membranes lining the distended alveoli.

SubjectiveAcute onset of dyspnea, apprehension.

InspectionRestlessness; disorientation; rapid, shallow breathing; productive cough; thin, frothy sputum; retractions of intercostal spaces and sternum. Decreased PaO2, blood gases show respiratory alkalosis, x-ray films show diffuse bilateral pulmonary infiltrates; later signs include refractory hypoxemia and respiratory acidosis.

PalpationHypotension.

AuscultationTachycardia.

Adventitious SoundsCrackles, rhonchi.

Patent Ductus Arteriosus (PDA)

Persistence of the channel joining left pulmonary artery to aorta. This is normal in the fetus and usually closes spontaneously within hours of birth.

Atrial Septal Defect (ASD)

Abnormal opening in the atrial septum, resulting usually in left-to-right shunt and causing large increase in pulmonary blood flow.

Ventricular Septal Defect (VSD)

Abnormal opening in septum between the ventricles, usually subaortic area. The size and exact position vary considerably. If the VSD is large, the extra L→R blood volume can overload the right heart and lungs, causing right-sided heart failure.

Tetralogy of Fallot

Four defects: (1) pulmonic (right ventricular outflow) stenosis, (2) VSD, (3) compensatory right ventricular hypertrophy, and (4) overriding aorta that receives blood from both R and L ventricles. Result: shunts a lot of venous blood directly into aorta away from pulmonary system; thus blood never gets oxygenated.

Coarctation of the Aorta

Severe narrowing of descending aorta, usually at the junction of the ductus arteriosus and the aortic arch, just distal to the origin of the left subclavian artery. Results in increased workload on left ventricle and obstruction of distal blood flow.Associated with defects of aortic valve in most cases, associated patent ductus arteriosus, and associated VSD.

atherosclerosis

a chronic disease where fats, cholesterol, and other substances build up inside the walls of your arteries

Arteriosclerosis

"hardening of the arteries." It happens when your flexible artery walls grow stiff, thick, and lose their stretch over time.

Aneurysms

is an abnormal bulge or "ballooning" in the wall of a blood vessel (usually an artery) caused by a weakened or thinned area that stretches under the force of blood pressure.