week 3

Self breast exam for elderly

Self breast exam for elderly

check same day and time every month

self breast exam for client still menstruating

do 3-5 days after menstruation

• when hormones are more stable

sinus that do not transilluminate

congested, filled with fluid

intraductal papilloma

most common cause of benign nipple discharge

• leakage, bloody discharge of the nipple

fibrocystic breast

benign breast

• common in 20’s to early 30's

• s/s

  • tenderness

  • nipple discharge

  • thickening of breat tissue

fibroadenoma

defined breast tumor with no tenderness or discharge

• common in adolescent girls 15-35 yrs

peau d’orange

orange peel skin texture on the breast

• sign of malignancy

assessing oral mucosa

is the most reliable indicator of central cyanosis when assessing a client with asthma

Early signs of hypoxia

• ALOC

Sounds will be loud and clear when

using whispered petrology or bronchophony and assessing a client with bilateral pneumonia and both lungs are filled with fluid

Whispered petrology

normal sounds will be soft and almost indistinguishable

bronchophony

-client says 9999

• sounds will be muffled

tracheal breath sound

over the trachea

I<E

harsh and high pitched

bronchial breath sounds

listen superiorly to each clavicle in the 1st ICS

E>I

loud, high pitched

Bronchovesicular breath sounds

over major bronchi in the 2nd and 3rd intercoastal space between scapulae

I=E

medium loudness and medium pitch

vesicular breath sounds

reminder of lungs

I>E

soft and low pitch

bradypnea

slow and regular pattern

hypoventilation

slow and irregular pattern

tachypnea

rapid and shallow

hyperventilation

rapid and deep

cheyne stokes

periods of apnea with regular pattern

• observed in dying patients

biot’s (ataxic) respirations

shallow, deep respirations with periods of apnea

• irregular pattern

• observed in clients with brain damage

eupnea

normal breathing

• even

• regular

• rhythmic

• unlabored

eupnea with occasional sighs

is considered normal breathing

crackles

• low pitched, bubbling, loud crackles

• due to lobar pneumonia

• from collapsed or fluid filled alveoli

Ronchi sibilant

wheezing

• continuous high pitched sounds

• found in clients with asthma

Ronchi sonorous

low pitched, continuous snoring and ruffling sound

• seen in patients with COPD or with fluid blocked airway

stridor

heard without a stethoscope

• loud, high pitched crowing

• observed in obstructive upper airway

friction rub

low pitched, grading rubbing sound

• heard with pleural inflammation

elliptical

normal chest configuration

• round shape with lateral diameter that is larger than the anteropsterior diameter in 2:1 ratio

  • by age 6 children should have normal chest shape

barrel chest

rounded with equal lateral anteroposterior diameter

• seen in infants and clients with COPD

Pectus carinatum

pigeon chest

• forward displacement of sternum with depression of adjacent costal cartilage

  • no treatment required

pectus excavatum

funnel chest

• depression of the sternum and adjacent costal cartilage compressing the heart and lungs

• cardia murmur may be present

  • in severe cases, surgery is indicated

scoliosis

lateral curvature of the spinous process

• common in females

kyphosis

exaggerated curvature of the thoracic spine

• associated with aging

lordosis

exaggerated curvature of the lumbar vertebrae

• common in late pregnancy and obese clients

hyperresonance sound on percussion of the lungs

indicates air trapped in lungs

Client with pleural effusion on percussion

will have absent breath sounds on the effected lung

loud moist bubbling quality breath sounds

indicate fluid filled alveoli