Health Assesment Exam 2

function of respiratory system

- Supplies oxygen to the body for energy production
- Removes carbon dioxide as a waste product
- Maintains acid base balance in arterial blood
- Maintains heat exchange

anatomical lanadmarks

- Going to hear more of the upper lobes when listening to the front side
- Going to hear more of the lower lobes when listening to the back
- Lobes sit on top of each other in a diagonal-ish way

developmental variation in children (thorax and lungs)

- smaller airway lumens
- asthma

developmental variations in pregnant women (thorax and lungs)

- growing uterus displaces diaphragm
- increased oxygen demand

developmental variations in older adults (thorax and lungs)

- decreased ability to collapse and recoil

kyphosis

curvature of spine (hunchback)

subjective data for thorax and lungs

- Cough
- SOB
- Sputum and color
- Dyspnea
- Chest pain with breathing
- Edema
- Fatigue
- History of respiratory infections
- History of asthma
- Smoking
- Environmental exposures
- Vaccinations- pneumonia and influenza, COVID

edema

- Edema can be a sign of heart failure*
- Starts in lower extremities normally when assessing
- best place to check is behind the ankle (posterior tibial)

smoking

#1 risk factor for smoking

yellow/green sputum

- Likely related to a bacterial infection
- Can also mean allergies

pink/red/bloody sputum

- Could be related to an infection or cancer, in some cases
- Irritation in the respiratory system

white

Allergies, asthma, or viral infections

charcoal gray

- Environmental, common in people who work in coal mines and factories, or heavy smokers
- Inhaling a lot of dust

brown

Chronic lung disease, cystic fibrosis or bronchiectasis, TB, cystic fibrosis

respiratory quality

- Does it look automatic or that they are working hard to breathe > are they using accessory muscles to breathe (neck muscles)
- look for their posture to get more air in
- their skin color (blue=cyanosis)
- is the breathing regular (10-20 breaths), is their depth of breath okay

inspect posterior and anterior chest

- Thoracic cage: shape, configuration, symmetry
- AP Lateral Ratio: COPD can have increased AP diameter

adult respiratory pattern

- Rate: 10-20 breaths per min
- Air moving in and out with each respiration
- Even pattern, silent, automatic

tachypnea

- Rapid, shallow breathing
- Increased rate >24 breaths per min
- Response to pain fever, fear, exercise, infection
- Body goes into hypermetabolic state and needs more oxygen

hyperventilation

- Increase in both rate and depth (fast, deep breaths)
- Response to exertion, fear, and anxiety
- Trying to take more oxygen than than Co2 coming out

bradypnea

- Slow breathing
- Decreased but regular rate

hypoventilation

- Irregular shallow pattern
- Can be caused by narcotics or anesthetics and conscious splinting of the chest to avoid pain

Cheyne-Stokes

- Periods of difficult breathing (dyspnea) followed by periods of no respirations (apnea)
- Cyclic episodes of apnea and hyperventilation

biot's respirations

Variable in pattern, random apneas, clusters rapid short breaths

orthopnea

Difficulty breathing when supine

apnea

absence of breathing

dyspnea

Labored or difficult breathing

- Chest expansion
- Crackles (wrong)
- Fremitus
- Lumps and masses
- Crepitus

When palpating the chest what should the nurse look for? Select all that apply

fremitus

- tactile vibration
- can hear when the patient is breathing

crepitus

- escaped air
-Rice krispies under the skin
- Can feel it not hear it

resonance

- normal finding during percussion of the chest/lungs

auscultation of thorax and lungs

- Patient sitting
- Listen anterior and posterior
- Side by side comparison
- Listen for one full respiration in each location: inhalation and exhalation
- Monitor breathing: Offers times for the client to rest and breathe normally

bronchial

- present over the large airways in the anterior chest near the second and third the anterior chest near the second and third intercostal spaces;
- these sounds are more intercostal spaces;
- more tubular and hollow-sounding than vesicular tubular and hollow-sounding than vesicular sounds

bronchialvesicular

- heard in the posterior chest between the scapulae and in the center chest between the scapulae and in the center part of the anterior chest.
- are softer than bronchial sounds, but sounds are softer than bronchial sounds, but have a tubular quality.

vesicular

- Heard across the lungs surface. They are low pitched, rustling sounds with higher intensity during inspiration.

adventitious lung sounds

- crackles
- wheezing
- stridor
- pleural friction rub

crackles

- discontinuous popping sounds heard over inspiration
- Emphysema, bronchitis pulmonary edema, pneumonia

wheezes

- Continuous musical sounds
- constricted airway passage over expiration
- constricted airway, usually because of inflammation
- Acute Asthma, Chronic Emphysema, Bronchitis

stridor

- high pitched crowing or seal like sound
- heard on inspiration on the upper airway;
- louder over neck
- needs to be treated very quickly
- Ex. croup, foreign body inhalation

pleural friction rub

- superficial sound that is coarse and low pitched.
- sounds like two pieces of leather or sandpaper being rubbed together
- Ex. pleuritis

lung cancer

the second most diagnosed cancer among men and women

asthma

the most common chronic disease in childhood

heart function

- Muscular Pump
- Located under sternum from the 2nd to 5th Intercostal space from right sternal border to midclavicular line

blood vessels function

Provide pulmonary and systemic circulation

systole

heart contracts and pumps blood into the systemic and pulmonary system

diastole

ventricles relax and fill with blood

S1

- first heart sound
- Results from the closure of the *AV valve* (tricuspid and mitral)
- lub

S2

- second heart sound
- Results from the closure of the *semilunar valve* (aortic and pulmonic)
- loudest at the base of the heart

S3

- third heart sound
- abnormal
- Vibration of ventricles that resist filling

S4

- fourth hear sound
- abnormal
- Vibration of noncompliant ventricles when atria pushes blood

murmurs

- happen during the first and second heart sounds
- heard in the heart
- Gentle, blowing or swishing sound due to turbulent blood flow in the blood cycle
- Conditions that create turbulent blood flow and collision currents

jugular veins

give information regarding volume changes

developmental changes during pregnancy (heart and neck vessels)

- blood volume increases by 30-50%
- increases in stroke volume, cardiac output, and pulse rate

developmental changes in older adults (heart and neck vessels)

- lifestyle, habit, and disease affect cardiac state.
- Increase in BP, increases in risk for dysrhythmia and ability to compensate with exercise decreases

nocturia

excessive urination at night

chest pain questions

- onset and location
- characteristics
- precipitating events
- associated symptoms
- relieved by or made worse by
- medication or treatments

physical assessment (neck vessels)

- Inspect: inspect jugular veins venous pulse
- Palpate: palpate each carotid artery separately
- Auscultate: Auscultate each carotid artery for bruit
--- Ask patient to hold their breath when auscultating to not confuse with breathing sounds

physical assessment (pericardium)

- Assess apical pulse
- patient needs to be laying down
- Detect heave or thrill

heart auscultatory areas

- all patients take medications
- aortic
- pulmonic
- erbs point
- tricuspid
- mitral

risk factors for heart disease and stroke

- High BP
- Smoking
- High cholesterol
- Physical inactivity

health promotion/patient education for heart disease and stroke

- Preventative Aspirin Therapy
- BP and Cholesterol Control
- Smoking Cessation
- Lifestyle Modifications

vascular system

Vessels of the body that carry blood or lymph

arteries

carry blood away from the heart to the extremities and organs

veins

- Drains deoxygenated blood and waste product from waste tissues and return to the heart
- If jugular veins are distended it shows if there are any fluid imbalance issues

lymphatic system functions

- conserves fluid and plasma protein that leak out of capillaries and vascular system
--- removing lymph nodes can cause a lymphedema and cause swelling because there is no lymph nodes to drain the fluid and plasma
- immune system
- absorbs lipids from intestinal tract

components of the lymphatic system

- lymph nodes, spleen, tonsils, thymus
- all contribute to draining and immune response
- can live without the spleen, tonsils, and thymus

developmental variations in children (lymphatic system)

- large lymph nodes
- immature immune system (get sick a lot)
- lymph nodes are bigger because they grow faster than their whole body

developmental variations during pregnancy (lymphatic/peripheral vascular)

- pitting edema
- venous disease

developmental variations in older adults (lymphatic/peripheral vascular)

arteriosclerosis (hardening of the arteries)

venous disease

- a weakening of the walls and valves of the veins, causing venous insufficiency, or problems returning your blood to your heart.
- Risk factors: standing, sitting, bed rest, hypercoagulation, vein wall trauma, varicose veins, obesity, pregnancy, and genetic predisposition
- venous stasis

venous stasis

blood is not moving, it is just staying in one place can cause clots. It doesn't move to the heart

peripheral disease

- Caused by cigarette smoking, diabetes, and hypertension
- Caused by arteriosclerosis a lot of times

subjective data for peripheral vascular

- Leg pain
---oxygen/blood is not traveling to the extremities
- Leg cramps
- Skin changes on arms or legs
--- No circulation can cause this (cyanosis)
- Swelling or edema
- Lymph node enlargement
- Medications
---Birth control can put women at risk for developing blood clots
- Smoking history

inspection of upper extremities

Note:
- color
- edema lesions (no adequate circulation=at risk for developing lesions because the healing process is off so a small wound can turn into a nasty lesion)
- clubbing

inspection of lower extremities

- Note color, size, edema, hair distribution, varicosities

varicosities

- best assessed when the pt is standing
- can be benign or can cause patients a lot of pain
- can be surgically removed because of pain

palpation of extremeties

- Cap Refill
- Temperature
- Size- Calf Circumference
- Edema
- Pulse Sites
- inguinal lymph nodes can be palpated

capillary refill

- Pressing down on the fingernails to inspect for color return in less than 2 seconds or less
- Check on fingernails and toenails

size-calf circumference

- Asses for edema using a tape measure
- Track size over time

pulse force scale

3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent

pulse sites

temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis

doppler assesment

- device used to check for pulse in the case that the health care provider is unable to locate it.

allen test

- Used to evaluate collateral circulation before inserting a catheter into the radial artery
- 1. Press on ulnar and radial until color change begins,
- 2. Then release the radial to see if the blood returns quickly.
- That demonstrates how well the ulnar artery can deliver blood to the hand in the case the radial artery line is in to measure BP

pitting edema 1+

mild pitting, slight indentation, no perceptible swelling of the leg

pitting edema 2+

moderate pitting, indentation subsides rapidly

pitting edema 3+

deep pitting indentation remains for a short time, leg looks swollen

pitting edema 4+

very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted

foot care

- Checking feet everyday
- Keep blood flowing to the feet
- Wearing shoes that fit comfortably
- Keep skin soft and smooth

left upper quadrant

- stomach
- spleen
- the left lobe of the liver
- body of the pancreas
- left kidney and adrenal gland
splenic flexure of the colon
- part of the transverse and descending colon

right upper quadrant

- liver
- gallbladder
- duodenum
- head of the pancreas
- right kidney, and adrenal gland
- the hepatic flexure of the colon
- part of the ascending and transverse colon

left lower quadrant

- a portion of the descending colon
- the sigmoid colon
- left ureter
- left ovary, and fallopian tube (women)
- left spermatic cord (men)

right lower quadrant

- cecum
- appendix
- right ureter
- right ovary and fallopian tube
- right spermatic cord

developmental variations in children (abdominal)

- abdominal wall is less muscular
- organs easily palpated

developmental variations in pregnancy (abdominal)

- nausea acid indigestion
- constipation
- linea nigra
- striae/stretch marks

developmental variations in older adults (abdominal)

- fat deposits in abdominal areas
- salivation decreases (can impact taste and how easy it is to chew food)
- esophageal emptying delayed
- gastric acid increases
- gallstones
- liver size decreases

subjective data (abdominal)

- Appetite
- Dysphagia
- Food intolerance
- Abdominal pain
- Nausea and vomiting
- Bowel habits
- Past surgical history
- Current medications
- Nutrition

dysphagia

- difficulty swallowing
- can put pts at risk for aspiration

physical assessment of abdomen

- abdominal wall relaxed
- empty bladder
- supine
- make sure to perform auscultation before palpation to prevent anything from falsely stirring up

abdomen inspection

- Size, shape, symmetry
- Condition of skin: color, lesions, veins, hair distribution, hernias
- Movements: respirations, pulsations, and peristalsis

umbilicus inspection

Position, color, contour, and herniation

abdominal shapes

- Flat
- Rounded
- Scaphoid
- Protuberant (ascites)