N524 Assessment 2 Study Guide and Information

1+

trace, 2mm rapid skin response

spoon thickened

pudding consistency, holds shape without spreading, eaten with spoon

2+

mild 4mm, 10 to 15s skin response

3+

moderate 6mm, prolonged skin response

4+

severe 8mm, prolonged skin response

Carotid pulse

either side of the trachea, medial of the sternocleidomastoid

Radial pulse

side of wrist

Brachial pulse

antecubital fossa above elbow

Femoral pulse

midway between the symphysis pubis and the anterosuperior iliac spine

Popliteal pulse

behind the knee, deep in the popliteal fossa, just lateral to midline

Dorsalis pedis pulse

on top of the foot along a line w/ groove between the first toe and the extensor tendons of the great toe

Posterior tibial pulse

behind and below the medial malleolus of the ankles

Aortic

Just right of the sternum at the second ICS

Pulmonic

Just left of the sternum at the second ICS

Erb’s point

(second pulmonic area) just left of the sternum at the third ICS

Tricuspid

just left of the sternum at the fourth ICS

Apical/mitral (point of maximal impulse)

left midclavicular line at the fifth ICS

Pulse deficit proper technique to measure this.

Apical for one minute

S3

ventricular gallop indicates rapid ventricular filling (expected in children and young adults)

S4

strong atrial contraction and can be an expected finding in older and athletic adults and children

Dysrhythmias

occurs when heart fails to beat at regular successive intervals

Gallops

extra heart sounds

Ventricular gallop

occurs after S2, like ken tuck y

Atrial gallop

occurs before S1, ten’ es see

Murmurs

audible when blood volume in the heart is increased or its flow is impeded or altered.

Systolic murmurs

after S1

Diastolic murmurs

after S2

Thrills

palpable vibration that can accompany murmurs or cardiac malformation

Bruits

blowing or swishing sounds that indicate obstructed peripheral blood flow

What is included in the cardiac assessment?

Inspect, palpate, auscultate

S1

lub, closure of mitral and tricuspid valves signals the beginning of ventricular systole (contraction)

S2

closure or aortic and pulmonic valves signals the beginning of ventricular diastole (relaxation)

S3

ventricular gallop indicates rapid ventricular filling (expected in children and young adults)

S4

strong atrial contraction and can be an expected finding in older and athletic adults and children

Dysrhythmias

occurs when heart fails to beat at regular successive intervals

Gallops

extra heart sounds

Ventricular gallop

occurs after S2, like ken tuck y

Atrial gallop

occurs before S1, ten’ es see

Murmurs

audible when blood volume in the heart is increased or its flow is impeded or altered.

Systolic murmurs

after S1

Diastolic murmurs

after S2

Thrills

palpable vibration that can accompany murmurs or cardiac malformation

Bruits

blowing or swishing sounds that indicate obstructed peripheral blood flow

Adventitious lung sounds

wheezes,, stridor, rhonchi, and crackles.

Expected sounds

bronchial, bronchovesicular, vesicular

Bronchial

loud, high pitched and hollow quality sound

Bronchovesicular

moderate intensity and pitch, blowing sounds

Vesicular

soft, low pitched, breezy sounds, inspiration sounds last longer than expiration over the most the peripheral areas of the lungs

Crackles

crackling, popping or bubbling sounds

Wheezing

high pitched whistling, musical sounds as air passes through narrowed or obstructed airways

Rhonchi

continuous, loud, low pitched rumbling (snoring type), result from fluid mucus or growth in larger airways

Pleural friction rub

low pitched, coarse, grating tone (inflamed visceral and parietal pleura rub against each other during inspiration or expiration)

Stridor

high pitched crowing sound that can be heard w/out a stethoscope

Absence of breath sounds

from collapsed or surgically removed lobes

Macule

nonpalpable, skin color change, smaller than 1cm

Examples of macule

freckles, petechiae

Papule

palpable, circumscribed, solid elevation of skin, smaller than 1 cm

Example of papule

elevated nevus

Nodule

palpable, circumscribed, deep firm 1 to 2 cm

Example of nodule

wart

Vesicle

serous fluid filled smaller than 1 cm

Vesicle examples

blisters, herpes simplex varicella

Pustule

pus filled, varies in size

Pustule examples

acne

Tumor

solid mass, deep, larger than 1 to 2 cm

Examples of tumor

epithelioma

Wheal

palpable, irregular borders, edematous

Example of wheal

insert bite

Atrophy

thinning of skin w/ loss of normal skin furrow, skin is shiny and translucent

Atrophy example

arterial insufficiency

Primary lesions

healthy skin tissue

Secondary lesions

change of primary lesion

Erosion

lost epidermis, moist surface, no bleeding

Crust

dried blood, serum, or pus

Example of crust

scab

Scale

flakes of skin that exfoliate

Scale examples

dandruff, psoriasis, eczema

Fissure

linear crack

Examples fissure

tinea pedis

Ulcer

loss of epidermis and dermis w/ possible bleeding and scarring

Ulcer examples

venous stasis ulcer, pressure injury

ABCDE

check lesions to detect possible skin cancer

A

asymmetry of shape

B

border irregularity

C

color variation within one lesion

D

diameter greater than 6 mm

E

evolving or change in color, elevation, shape, size, or development of itching, crusting, or bleeding

Melanoma

can appear under fingernails and the palms and and soles of feet, more common among pt with african descent.

Vascular lesions

spider angioma, cherry angioma, spider veins, petechiae/purpura, ecchymosis, hematoma

Spider angioma

red center w/ radiating red legs up to 2 cm possibly raised

Cherry angioma

red 1 to 3 cm, round possible raised

Spider vein

bluish, spider shaped or linear, up to several in in size/

petechiae/purpura

deep reddish purple, flat, petechiae 1 to 3 mm, purpura larger than 3mm

Ecchymosis

purple fading to green or yellow over time, variable in size, flat

Hematoma

raised ecchymosis

Stage 1

nonblanchable, erythema, intact skin, warmer or cooler than adjacent tissue. Tissue swollen and diff texture than surrounding skin

Stage 2

partial thickness loss, w/ exposed dermis, involves dermis and epidermis. Wound bed is reddish pinkish (w/out slough, eschar, granulation, or adipose)

Stage 3

full thickness skin loss, visible adipose tissue w/ possible granulation tissue and epibole (wound edges appear rolled under), some slough, eschar presents (no exposed muscle, tendons, ligaments, cartilage, or bones)

Stage 4

full thickness skin and tissue loss, lost with cartilage, bone, fascia, muscle, ligaments, or tendons exposed in wound or easily palpable. Epibole, tunneling, and undermining

Unstagable

obscured, full thickness skin and tissue loss, no determination of stage b/c eschar or slough obscures the wound bed. Actually depth unknown unless eschar and slough removed revealing either stage 3 or 4