Health Assessment Exam 2

Respiratory, HEENT, integumentary, musculoskeletal, GI/GU

basic respiratory assessment - expected findings

RR 12-20

SpO2 >95% on RA

breathing even and unlabored

able to speak full sentences between breaths

denies dyspnea

denies cough

chest is symmetrical, AP diameter 1:2

lung sounds clear in all lobes/locations, no adventitious sounds

bronchial lung sounds

heard most clearly when you breathe out

listen high in your chest and over your windpipe for loud, rough, and high-pitched lung sounds

these sounds are normal in bronchial area, but may be abnormal in other areas of the lungs

bronchovesicular lung sounds

these sounds are heard when you breathe in and out

listen in the middle part of your chest

sounds are lower-pitched than bronchial lung sounds but higher-pitched than vesicular lung sounds

normal lung sound locations

bronchovesicular over main bronchi

vesicular over lesser bronchi, bronchioles, and lobes

bronchial over trachea

vesicular lung sounds

these sounds are heard best when you breathe in

listen in the mid-back for soft, smooth, low-pitched sounds

these tell you that something is blocking the airways, and there’s no swelling or narrowing that is inhibiting taking a full breath

fine crackles

fine crackles:

• noncontinuous, often at the end of inspiration

• high-pitched cackling and popping sounds like rubbing hair strands near ear

• not cleared or changed by coughing or changing positions

• caused by secretions in or collapse of alveoli or small airways

course crackles:

• sounds like bubbling carbonated soft drink

may be heard in pneumonia, heart failure, and restrictive pulmonary diseases

rhonchi

loud, coarse, low-pitched snoring or moaning sound

may change or clear with coughing

caused by secretions and mucous in large airways

heard in disorders causing obstruction of the trachea or bronchus such as bronchitis or COPD

adventitious lung sound locations

stridor

high-pitched crowing sound on inspiration can often be heard without a stethoscope

caused by obstruction of larynx, trachea, or upper airways

may be an airway priority emergency

wheeze

continuous, high-pitched sound with a musical quality similar to a squeak

heard more commonly during inspiration but can be heard during expiration or at the end of expiration from narrowing or bronchospasm of small airways

heard in airway diseases when the thickness of airways increases such as asthma

stridor vs. wheeze

pleural friction rub

superficial, low-pitched, coarse rubbing or grating sound

heard throughout inspiration and expiration, loudest over lower anterolateral surface

not cleared by cough

heard in individuals with pleurisy (inflammation of pleural surfaces) or with pericarditis

pack-years

number of packs smoked per day multiplied by the number of years smoked

assessing tobacco use

for cigarette smokers, record the smoking history in pack-years

use of pipes, cigars, marijuana, vape, chewing tobacco, or snuff is usually recorded in the amount used daily

routine counseling for smoking cessation, recommend against the use of smokeless tobacco - there is no safe tobacco alternative to cigarettes

respiratory considerations for older adults

decreased elasticity and ability to clear the air passages

diminished strength of the respiratory muscles results in diminished breath sounds in the bases

as the alveoli become less elastic and more fibrous, dyspnea on exertion becomes more frequent

kyphoscoliosis: formed by an anteroposterior and a lateral curvature of the spine

• may alter the chest wall configuration and make adequate lung expansion more difficult

• may also increase the anteroposterior diameter, which may result in shallow breathing

orthopnea

SOB when lying down

paroxysmal nocturnal dyspnea

sudden severe SOB during sleep

tripod position

hands on knees and leaning forward

sign of respiratory distress

increases accessory muscle use

barrel chest

chronic hyperinflation of lungs

emphysema

pectus carinatum

pigeon chest

prominent sternum

scoliosis

spinal curvature

pectus excavatum

funnel chest

sternum goes inward

increases pressure on heart and lungs

tracheal deviation

trachea shifted left or right, close to airway collapse (pneumothorax)

Kussmaul breathing

rapid, deep, labored

Cheyne-Stokes

varying periods of increasing depth interspersed with apnea

retractions

pull in and down muscles to lower diaphragm and intercostals

crepitus

SQ emphysema, bubbles on surface of skin that can be popped

leak in lungs

atelectsis

collapsed alveoli due to external pressure or lack of air from hypoventilation or obstruction by secretions

patients after thoracic or abdominal surgery are at increased risk

may auscultate decreased, diminished, or absent lung sounds where the atelectasis is occurring

other assessment findings may include cough, dyspnea, tachypnea, hypoxia, low grade fever

take action to ensure the patient’s pain is controlled, encourage the patient to take deep breaths (incentive spirometer), and perform a focused respiratory reassessment`

signs of respiratory distress

restlessness

assuming a tripod position

appearance of apprehension

use of accessory muscles

subjective statements of dyspnea

respiratory distress assessment and planning or care actions

1. assess

2. stay with the patient and stay calm

3. position patient for best respiratory advantage

4. take a full set of vitals including pulse ox

5. auscultate all lung fields

6. ask the patient about any history or restrictive airway disease

7. check current orders for medications and supplemental oxygen therapy

8. consider asking for help from charge nurse, RT, provider

neck anatomy

anterior triangle:

• boundaries - mandible and SCM

• subdivisions - submandibular, submental, carotid, muscular

• contains - larynx, trachea, esophagus, thyroid and cricoid cartilage, anterior lymph nodes, hypoid bone

posterior triangle:

• boundaries - SCM, trapezius, clavicle

• subdivisions - occipital and supraclavicular

• contains - posterior cervical lymph nodes

neck inspection abnormal findings

thyroid goiter

thyroid nodule

tracheal deviation

lymphatic system

functions - conserve fluid, immunity, absorb liquids

spleen - filter blood, aids immunity, blood storage, iron recycling

tonsils - respond to local inflammation

thymus - gland located in superior mediastinum behind sternum and in front or aorta

lymph nodes of the head and neck

preauricular, parotid, postauricular, occipital, retropharyngeal/tonsillar, submandibular, submental, anterior and posterior chain, supraclavicular

normal findings - palpable or non-palpable, soft, non-tender, symmetrical bilaterally, and moveable

lymphadenopathy

enlarged or swollen lymph nodes

cranial nerves

CN I olfactory - smell

CN II optic - vision

CN III oculomotor - eye movement, eyelid opening, pupil constriction

CN IV trochlear - eye movement downward and inward

CN V trigeminal - facial sensation, chewing

CN VI abducens - eye movement lateral and outward

CNVII facial - facial expressions, taste on front of tongue

CN VIII vestibulocochlear - hearing and balance

CN IX glossopharyngeal - taste on back of tongue, swallowing

CN X vagus - swallowing, speech, parasympathetic control of organs

CN XI spinal accessory - shoulder and neck movement

CN XII hypoglossal - tongue movement

focused eye assessment

sclera, corneal transparency, PERRLA, EOMs

snellen chart - tests far vision

rosenbaum chart - tests near vision

confrontation

ear anatomy

darwin’s tubercle

possible normal variant

hearing assessment

do not rely only on patient self-report

whispered voice test - hear and repeat at least 50% of words

presbycusis: age-related, gradual loss of hearing, typically affecting high-frequency sounds, caused by degeneration of inner ear structure or the auditory nerve

types of hearing loss

conductive

• middle and outer ear

• blockage

• sound is louder in the bad ear during weber test

• bone > air during rhine test

sensorineural

• inner ear

• sound is louder in good ear during weber test

• air > bone (normal) during rhine test

weber test

place tuning fork on top of head

patient should hear tone equally in both ears

rhine test

place tuning fork behind ears on mastoid process

when patient no longer hears it, place fork in front of ear

air conduction should be twice as long than bone conduction

expected findings for ears, nose, mouth and throat

otalgia

otorrhea

tinnitus

xerostomia

rhinorrhea

epistaxis

parotitis

presbyopia

cataract

strabismus

scleral icterus

vertigo

presyncope

torticollis

nuchal rigidity

goiter

nystagmus

lymphedema

chronic swelling cause by blockage in lymph draining