HEALTH ASSESSMENT KEY TERMS (CHECK OFF #4)

CARDIOVASCULAR ASSESSMENT

JVD

can indicate increased venous pressure and right sided heart failure

Bruit

Abnormal blowing or whooshing sound caused by turbulent blood flow

Apical pulse

bottom tip of the heart (the apex)

Heave/lift

a sustained lifting sensation against your hand, assessed on the 4th and 5th ICS

Thrill

a vibration felt over the chest caused by turbulent blood flow

S1 sound

“LUB”: closure of the mitral and tricuspid valves. Beginning of systole

• heard best in tricuspid and mitral

S2 sound

“DUB” closure of aortic and pulmonic valves. Beginning of diastole.

• heard best in aortic and pulmonic areas

S3 sound

extra heart sound after S2

• can be normal in younger children, pregnant women, younger adults

• best heard with BELL in tricuspid and mitral areas

S4 sound

extra heart sound before S1

• best heard with BELL in tricuspid and mitral areas

Apical pulse

• auscultate in mitral area with DIAPHRAGM

• count for full 60 seconds

• assess rate and rhythm

PERIPHERAL VASCULAR ASSESSMENT

Modified Allens test

1. patient fists

2. you palpate ulnar and radial pulses

3. take ulnar pulse away

4. ensure color returns to hand

Edema scale

0-4 (0 is normal)

Pitting vs. non pitting

Amount of indentation that occurs when pressing the skin in

RESPIRATORY ASSESSMENT

Tactile fremitus

the vibration felt on the chest wall when a patient speaks

Percussion of the lung fields

resonance: normal, hollow sound heard over healthy lung tissue

dullness: may indicate fluid or solid tissue replacing air in the lungs

hyperresonance: may indicate increased air in the lungs

Vesicular normal breath sound

most peripheral lung fields

Bronchovesicular normal breath sound

between scapulae and upper anterior chest near sternum

Bronchial normal breath sound

over the trachea

Crackles abnormal breath sound

popping or crackling sounds

Wheezes abnormal breath sound

high-pitched whistling sounds

Rhonchi

low pitched, snoring or rattling sounds

Stridor abnormal breath sounds

high-pitched sound, usually heard on inspiration

Bronchophony (voice sound testing)

ask patient to say 99, listen for unusually clear or loud voice sounds

Egophony (voice sound testing)

ask patient to say E, check to see if it sounds like A

Whispered pectoriloquy

ask patient to whisper 1,2,3 and listen for unusually clear whispered sounds

Meaning behind increased clarity of voice sounds

indicates lung consolidation