Health Assessment HESI/FINAL EXAM

aneurysm

visible, prominent pulsation or dialation

diastole

ventricular relaxation, ventricular filling from atria.

erythema

redness of skin

murmur

harsh, blowing sounds caused by disruption of blood flow

myocardial ischemia

oxygen needs heightened so heart has to work harder

systole

ventricular contraction, blood leaves the ventricles to go to the lungs or body.

what is the pacemaker of the heart

sinoatrial node (SA node)

how many times is the sinoatrial node set to discharge per minute

60-100

if the heart rate is initiated in the atrioventricular node, how fast would the heart beat per minute

60

if the heart rate is initiated in the bundle branches, how fast would the heart beat per minute

30

what is the term used to describe a sudden droop in blood pressure that may occur when an older client changes position from lying or sitting to standing

orthostatic hypotension

what two cultural groups are at the highest risk for hypertension

african americans, spanish (mexicans/cuban/filipino)

dullness when percussing over the heart is

an abnormal finding that could indicate an enlarged heart.

the third heart sound (S3) is heard

immediately after S2.

S3= kentucky

the fourth heart sound (S4) is heard

immediately before S1

S4= there are 4 e's in tenessee

what is happening when S1 is heard?

tricuspid and mitral (AV) valves are closing. begins systole

what is happening when S2 is heard?

aortic and pulmonic (semilunar) valves are closing. end of systole and beginning of diastole.

when would the nurse hear S3

when AV (tricuspid & mitral) valves open, blood flow into ventricles may vibrate during mid-diastole, termed ventricular gallop.

when would the nurse hear S4

before S1, termed atrial gallop.

what is the significance of S3

may indicate heart failure or fluid overload.

what is the significance of S4

may indicate hypertension or ventricular hypertrophy

at erb's point you can hear

S1 and S2 equally

at the aortic and pulmonic valves you can hear

S2

at the mitral valve you can hear

S1

(PMI)

aortic stenosis

murmur at aortic area. narrowing of the aortic valve. may be congenital or caused by atherosclerosis

mitral stenosis

murmur heard at the apical area with the client in the left lateral position. possible causes is rheumatic fever or cardiac infection.

ventricular hypertrophy

occurs due to pumping against high pressures

myocardial ishcemia

oxygen needs of the myocardium are not met as the heart works harder. may be caused by plaque or blood clot. need to assess client for type of pain and associated factors including nausea, epigastric pain, jaw or left shoulder pain.

pulmonary stenosis

narrowing of the opening between the pulmonary artery and the right ventricle. may have murmur at pulmonic area and a thrill in the left second and third intercostal space.

congestive heart failure

caused by hearts inability to pump effectively

infective endocarditis

may see splinter hemorrhage of nail beds. caused by a bacterial infection to the lining of the heart chanbers.

tricuspid stenosis

narrowing of the tricuspid valve. murmur over the tricuspid area

aortic regurgitation

back flow of blood from the aorta into the left ventricle. murmur with the client leaning forward. may result in shortness of breath and fatigue.

left sided heart failure

results in pulmonary congestion, shortness of breath, and orthopnea. crackles may be heard on auscultation.

cor pulmonale

complication of untreated heart failure. results in JVD, peripheral edema, fluid retention and weight gain. may have clubbing.

mitral regurgitation

back flow of blood from left ventricle into left atrium. murmur at apex transmitted to left axillae.

pulmonary edema

fluid accumulation can cause severe shortness of breath, pink frothy sputum, coarse crackles that do not clear with cough, sense of doom.

myocardia infarction

complete disruption of blood flow and oxygen to the myocardial tissue. may lead to death of cardiac tissue. symptoms include chest pressure, tightness, squeezing and shortness of breath. may radiate or have referred pain to the left neck, jaw or shoulder.

pericardial friction rub

occurs due to inflammation of pericardial sac. ask client to hold breath to assess as compared to pleural issues.

blood flow pathway

vena cava, right atrium, tricuspid valve, right ventricle, pulmonic valve, pulmonic artery, lungs for oxygenation.

pulmonic veins, left atrium, mitral valve, left ventricle, aortic valve, aorta and to the body.

preload

(stretch) end diastolic filling pressure

afterload

(squeeze) amount of resistance the ventricles have to overcome to eject blood in systole

blood pressure is

cardiac output times peripheral vascular resistance.

during a physical assessment the patient should

start in upright position then proceed to supine with HOB at 45

when inspecting the precordium (anterior chest), abdomen, legs and skeletal structure:

note color, temperature of skin and presence of hair. observe precordium for any abnormal pulsation, pull, lifts or heaves.

the jugular vein may be visible

when lying flat, should disappear when sitting.

jugular vein distention (JVD) presents in

cor pulmonale (right heart failure)

where should you palpate for PMI

mitral valve over apex

myocardial ischemia or acute coronary syndrome

chest pain (angina), shortness of breath, diaphoresis. pain may be heavy, tight, squeezing, pressure. pain may be referred or radiate to jaw, shoulder, epigastric region. will result in myocardial infarction if not treated.

heart failure

progressive weakening of heart as a pump. usually begins on left side. results in pulmonary congestion and shortness of breath. may progress to cor pulmonale, which results in JVD, peripheral edema, fluid retention and weight gain.

effects of right sided heart failure (cor pulmonale)

JVD and peripheral edema. long term heart failure may have clubbing. need low sodium diet, daily weights.

effects of left sided failure

pulmonary congestion and shortness of breath.

stenotic valves do not:

fully open (narrowing)

regurgant valves do not:

fully close

what are septal defects

openings between the right and left atria or right and left ventricles.

pleuritis

chest pain worse with breathing, shallow respirations, pleural rub. can have patient hold breath to rule out cardiac cause.

apnea

absence of breathing

eupnea

normal, good, unlabored ventilation

dyspnea

difficulty breathing

egophony

patient says "E" during auscultation.

normal sounds like E.

consolidation sounds like A.

bronchophony

patient repeats "99" during auscultation.

normal= muffled.

consolidation= clear, loud.

whispered pectoriloquy

patient whispers "1,2,3"

normal = muffled.

consolidation= clear.

fremitus

a vibration felt by palpitation

crackles

brief, discontinuous, popping lung sounds that are high-pitched, intermittent, nonmusical due to fluid.

fine= crackling.

coarse= bubbling.

may hear crackles in atelectasis.

wheezes

musical high pitched breathing with a rasp or whistling sound. a sign of airway constriction or obstruction.

orthopnea

is the sensation of breathlessness when lying flat, relieved by sitting or standing.

to assess ask patient how many pillows they use to sleep or if they sleep in a recliner.

orthopnea can be caused by congestive heart failure or emphysema.

what is the significance of dullness on percussion?

consolidation.

could indicate fluid, tumor or infection.

the nurse percussions over a patient with pneumonia. percussion over an atelectasis in the lungs would reveal?

dullness

dead space where no gas exchange occurs

trachea and bronchi

which lung has 3 lobes

right

asthma

narrowing of the airways resulting in shortness of breath, weeping on expiration, sometimes inspiration, coughing and labored breathing.

alveoli

tiny sacs-like air spaces in the lung where carbon dioxide and oxygen are exchanged.

emphysema

chronic lung condition where there is permanent damage to alveoli. hyperinflated because air is stuck in alveoli. barrel chest with pursed lip breathing. clubbing may be seen due to chronic hypoxia.

pneumonia

consolidation in the lungs. alveoli fill with fluid, bacteria. patient will have crackle lung sounds.

pneumothorax

trapped air in pleural space. a large part of the lung or complete lung collapse can result in unequal chest expansion. may hear hyper resonance.

surfactant

fluid in alveoli that reduce surface tension of pulmonary fluids. helps prevent alveoli from collapsing.

palptation techniques for respiratory system

tactile fremitus, crepitus (subcutaneous emphysema), lung expansion.

palpitation of tactile fremitus

place hands over the lung fields, have client say "99". assess low, mid and high thorax for symmetry.

increased fremitus with thick secretions in central airways.

increased fremitus with pneumonia.

decreased fremitus as you move away from the midline.

hyperresonance

hyper inflated from emphysema, pneumothorax, or COPD (hyper inflated lung due to emphysema will cause hyper resonance)

documentation of normal findings

resonance over lung tissue and dullness over ribs.

auscultation of the lungs

auscultate the posterior thorax for sounds side to side. listen over bare skin to entire respiratory cycle of inspiration and expiration.

it is normal the feel tactile fremitus the strongest

between the scapulas

rhonici

musical low pitched snoring sounds due to thick bronchial secretions.

stridor

high pitched sound with inspiration and expiration. consider obstruction or swelling from allergic reaction.

cheyne-stokes

deep, rapid breathing followed by periods of apnea.

kussmal

rapid, labored breathing. seen in diabetic ketoacidosis

pleural effusion

fluid in pleural space

kyphosis

exaggerated posterior curvature of the thoracic spine. associated with aging. severe deformity may decrease lung expansion and increase cardiac problems.

scoliosis

lateral curvature and rotation of the thoracic and lumbar spine. may cause distortion of the lung, which results in decreased lung volume.

developmental considerations for pregnant females

difficulty on exertion due to pressure on diaphragm and increase oxygen consumption

developmental considerations for elderly

loss of elasticity of lungs, decreased lung expansion, decrease cough ability

developmental considerations for infants

hyper resonance is normal for infant

the braden scale is

used to assess risk for pressure ulcer development.

each topic rated on a 1 to 4 scale with 1 being very high risk and 4 being very low risk. add total score to determine if client is at risk.

peripheral cyanosis

cyanosis on the fingers and toes due to cold exposure, anxiety, or inadequate circulation.

central cyanosis

cyanosis on the head, neck and truck that usually develops during cardiac arrest or CPR due to inadequate oxygen.

circumoral cyanosis

blue around the mouth of a newborn.

pallor

pale color which may indicate bleeding, anemia or hypotension. consider checking hemoglobin and hematocrit (H&H)

jaundice

yellow color. inspect the sclera, hard palate, mucous membranes and skin.

inspect for petechiae in

buccal areas of the mouth or the conjunctivae as well as lighter areas of the skin such as the abdomen, buttocks.

pallor in dark skin will appear

ashen gray. assess for pallor in dark skinned people by their mucous membranes, lips, tongue or conjunctivae