Health Assessment Exam 2

why do we ask for the history of radiation tx

it can affect the thyroid

what demographic are cleft lips more common in

native americans

asians

what demographic are oral cancers more common in

african americans

caucasians

what are the steps of the physical exam for HEENT

inspect

palpate

ascultate

what are the lymphnodes of the head

preauricular

postauricular

occipital

parotid

retropharyngeal/tonsilar

submandibular

submental

in front of the ear

preauricular

behind the ear

postauricular

in front of the ear, under the preauricular, closer to jaw

parotid

behind the ear

postauricular

the back of the head, just above the nape of the neck.

occipital

the space inbetween the ear and the jaw

retropharyngeal/tonsil

under the jaw

submandibular

under the chin

submental

what are the lymph nodes of the neck

anterior cervical

posterior cervical

supraclavicular

sternocleidomastoid

lateral front side of neck

anterior cervical

lateral back side of neck

posterior cervical

above clavicle

supraclavicular

runs along the muscle that it gets its name from

sternocleidomastoid

normal thyroid stimulating hormone levels are

0.5-5 mIU/L

lymph nodes should be

non-palpable in healthy individuals

the temporal artery should not feel

stiff

how is hearing assessed

whisper test

what are the main things to look for when assessing the ear

intact

no redness

swelling 

drainage

in the eye exam there should be no

discharge

redness

swelling

upon palpation, sinuses should be

non-tender

non-palpable

what are the facial sinuses

maxillary

frontal ethmoid sphenoid

up under the eyebrows

frontal sinuses

upper part of nose

sphenoid

located below the sphenoid

ethmoid

lateral and inferior to the nose

maxillary sinuses

indicating clear nasal passages and normal breathing

patent airflow

mucosa should be

pink

moist

temporal mandibular joint should

not be tender

move properly

how should you palpate the thyroid

from behind the patient, using fingers to feel for size and nodules

the thyroid should be 

nonpalpable

if the thyroid is palpable, what is the next step

auscultation

carotid arteries are auscultated with

the bell

when do you investigate a new headache

patient is 50+

submandibular glands may be more palpable in what age range

older adults

what age range is more predisposed to arthritis, neck pain, loss of sensation

older adults

abnormal collection of CSF in the ventricles

hydrocephalus

what are common eye problems

conjunctivitis

corneal abrasion

cataracts

glaucoma

ptosis

what are common ear problems

otitis media

foreign body obstruction

common lymph/soft tissue issues in the HEENT+ mouth

epistaxis

allergies

sinusitis

tonsilitis

gingivitis

HSV 1

dysphasia

lymphoma

what are the primary muscles of breathing

diaphragm

intercostal muscles

diaphragm contracts for

inhalation

diaphragm relaxes for

exhalation

when the diaphragm contracts, what direction does it go

down

when the diaphragm relaxes, what direction does it go

up

what are the topographical markers of the anterior chest wall

suprasternal notch

manubrosternal junction

midsternal line

costal angle

clavicles and mid clavicular lines

xiphoid process

apex and base of lungs

what is the costal angle

The costal angle is the angle formed by the meeting of the lower ribs and the xiphoid process at the anterior thorax

what is the avg costal angle measurement for a healthy individual

less than 90 degrees.

where is the xiphoid process

inferior end of the sternum

where is the apex of the lung located

at the level of the first rib, extending above the clavicle.

where is the base of the lung located

at the level of the diaphragm (xiphoid)

what are the topographical markers of the lateral chest wall

anterior, mid, posterior axillary lines

what are the topographical markers of the posterior chest wall

Vertebra prominens

vertebral line

scapular lines

a quick focused assessment and then address emergency

urgent assessment

ABCs

what are the signs that you should stop your urgent assessment and get help

RR >30

O2 sat <92%

hypoxemia and/or cyanosis

what questions should you ask someone who’s experiencing cough as one of their symptoms

productive?

dry?

color?

consistency?

hacking?

hoarse?

what questions should you ask someone who’s experiencing SOB as one of their symptoms

when does it occur?

how many pillows do you need to sleep with?

palpating the chest wall to evaluate the transmission of sound vibrations.

have pt say 99

tactile fremitus

tactile fremitus

It helps identify any abnormalities such as fluid accumulation or lung consolidation/hyperinflation.

adventitious sounds

Abnormal lung sounds that are not normally heard, indicating potential respiratory issues.

how many anterior chest auscultation spots are there

8

how many lateral chest auscultation spots are there

7

how many posterior chest auscultation spots are there

10

what are the normal breath sounds

bronchial

bronchovesicular

vesicular

Loud, high-pitched, tubular sound; heard over the manubrium; expiration is longer than inspiration.

bronchial sound

Moderate intensity and pitch; heard between the scapulae and around the upper sternum; inspiration equals expiration.

bronchovesicular sound

Soft, low-pitched, whispering undertones; heard over most of the lung fields; inspiration is longer than expiration.

vesicular sound

High-pitched, brief crackles like rolling a piece of hair between fingers;

occur when deflated small airways and alveoli pop open during inspiration;

may indicate small amount of fluid;

late crackles in fibrosis or heart failure, early crackles in COPD or asthma.

fine crackles

Low-pitched, moist, longer crackling sounds like Velcro;

caused by small air bubbles flowing through secretions or narrowed airways;

often heard in fibrosis, pulmonary edema, or COPD.

coarse crackles

High-pitched, musical sounds (often described as squeaking) heard primarily during expiration;

caused by air passing through narrowed airways;

note whether during inspiration or expiration;

associated with asthma, bronchitis, or emphysema.

wheezing/sibilant

sibilant

high pitched

Low-pitched snoring or gurgling sound that may clear with coughing;

caused by air passing through secretions or narrowed large airways;

common in pneumonia.

rhonchi (low-pitched wheeze)

Loud, coarse, low-pitched grating sound like a squeaky door, heard during inspiration and expiration—

usually over lower anterolateral thorax;

due to inflamed pleural surfaces losing normal lubrication;

associated with pleuritis.

pleural friction rub

Loud, high-pitched crowing or honking sound louder over the upper airway;

due to laryngeal or tracheal inflammation or spasm causing obstruction;

medical emergency

seen in epiglottitis or croup

stridor

what are the common respiratory nursing dx

impaired gas exchange

ineffective airway clearance

ineffective breathing pattern

activity intolerance

Normal breathing rate 10–20 breaths/min,

1:4 inspiration-to-expiration ratio,

500–800 mL per breath,

regular rhythm.

eupnea

Rapid, shallow respirations >24/min;

>500 mL per breath;

regular rhythm.

tachypnea

Rapid, deep respirations >24/min;

>800 mL per breath;

regular rhythm;

can lead to respiratory alkalosis.

Hyperventilation

Slow breathing rate <10 breaths/min;

500–800 mL per breath;

shallow but regular rhythm.

bradypnea

Slow and shallow respirations <10/min;

<500 mL per breath;

irregular rhythm; can lead to respiratory acidosis.

hypoventilation

Irregular rhythm with varying rate and depth,

alternating periods of apnea and deep breathing.

normally seen in end-of-life care

Cheyne-Stokes respiration

Irregular rhythm with varying rate and depth, frequent apnea;

unpredictable pattern.

Biot respiration

Intermittent, gasping, irregular breaths; sign of end-of-life or severe brain injury.

Agonal respiration

Complete absence of breathing.

Apnea

S-shaped spinal curvature compressing chest, reducing lung expansion and inspiratory volume.

Kyphoscoliosis

Round, outward chest with horizontal ribs; common in COPD and asthma.

Barrel chest

Sternum displaced anteriorly (outward).

Pectus carinatum (pigeon chest)

Rib fractures cause chest wall to cave in during inspiration;

paradoxical movement of chest.

life threatening

flail chest

Sunken or funnel-shaped depression of the sternum;

may compress heart and lungs if severe; decreases thoracic volume and can cause exercise intolerance.

pectus excavatum (funnel chest)

What is the priority order for respiratory assessment?

1. Airway → 2. Breathing → 3. Respiration

Wheezes or diminished lung sounds;

sputum clear.

asthma

Diminished sounds in lower lobes;

no sputum.

atelectasis

Occasional wheezing or fine crackles;

sputum clear.

bronchitis

Wheezes with clear sputum;

chronic airflow limitation.

COPD

Absent breath sounds;

sanguinous sputum.

hemothorax

Absent breath sounds

no sputum.

pneumothorax