PCC1 Exam 2

to auscultate heart sounds

use diaphragm first bell second

shape to auscultate heart in

Z

heart sounds in order of Z

aortic valve, pulmonic valve, tricuspid valve, mitral valve (APTM)

acronym for heart sound order in Z

AP tomorrow

2nd ICS RSB

aortic valve

S1 heart sound is

closure of tricuspid and mitral valves (AV Valves)

S4

extra heart sound heard right before S1

murmur

blowing or swishing sound over mitral valve

shiny hairless legs indicate

atrial disease (bc less nutrients getting to the tissue- can’t waste energy on growing hair)

red/brown color on legs indicates

venous insufficiency (extra blood goes to surface after a while)

DVT indicated by

Redness, Warmth, Swelling, Pain in 1 Leg

percussion of lungs

assesses resonance

course crackles

low pitched bubbling sounds on inspiration

Bronchovesicular sound

medium pitched with equal duration lung sounds heard over major bronchi

Hypoventilation

low shallow breaths, ex RR of 8 with shallow depth

stridor

barking or honking on inspiration or auscultation of trachea is called

normal bronchi breath sounds

high pitched, loud, tubular sounds over the trachea is called

COPD pts often have

nail clubbing (more than 180 degrees) and A/P = transverse

venous because fluid backs up and triggers inflammatory response

Redness (erythema)

venous because waste isn’t moved up through body properly

Causes metabolic waste buildup

arterial because tissue doesn’t get enough O2

Deep muscle pain with activity

venous because blood sitting stagnant for a while comes up to surface

Brown Discoloration of the skin

arterial because low blood supply to part causing tingling

Paresthesia

arterial because this clogs artery

Caused by atherosclerosis

venous because the backed up fluid triggers immune response as blood is trapped

Unilateral redness, warmth, edema, and pain

venous because the excess fluid can seep out of wounds

Medial, uneven, bleeding (weeping) ulcers

artery because tissues don’t have enough nutrients

Rubor and sensory and motor function loss

venous because veins have valves to move fluid up

Incompetent valves

arterial because lack of blood flow causes pallor

Elevation pallor

arterial because it doesn’t allow blood / o2 to reach tissues enough

Causes tissue hypoxia

arterial because low blood supply causes weak pulse

\+1 thready pedal pulses

venous because fluid is backed up causing swelling

\+3 pitting edema

venous because walking helps move fluid back up, immobility makes fluid stay stagnant

Immobility is a risk factor

arterial because less nutrient rich blood is getting to body quickly

Capillary refill greater than 3 seconds

arterial because lack of fluid / nutrients

Proximal, dry, and round ulcers

arterial because lack of blood and nutrients to area

Skin is pale and cool

venous because when rested and elevated the fluid can return to normal and relieve pain

Achy legs relieved by rest

depth

if breath is deep or shallow

Tactile fremitus

testing lungs by palpating while patient says 99 and you feel the vibrations

abnormal neck findings

JVD, asymmetrical / not midline trachea, lumps on thyroid, palpable lymph nodes

artificial eyes cleaned

as needed with soap and water or saline, be gentle

artificial eyes inspected and polished

yearly by manufacturer, as needed if extra problem

denture care

brush with soft toothbrush and toothpaste

do not irrigate ear if

the tympanic membrane (TM/ ear drum) is perforated or broken

Webber test

tests for hearing loss

Rinne test

tests for air/bone conduction

eyes should be

PERRLA bilaterally

clean eyes

inner to outer

eye crust

moisten and wipe away

to test ears for hearing can use

whisper test and tuning fork test

inspect ears

outside of it and look in, see if theres immense earwax buildup

to irrigate ear (if intact TM)

squirt up at ear canal, do not squirt directly at eardrum

to clean pt teeth

brush 2x daily, floss once, if on ventilator brush more frequently

teeth cleaning for unconscious patient

put in semi fowlers position with head turned to you, use padded tongue blade to hold mouth open (never put your finger in pt mouth!), use suction tool to prevent aspiration

topical oral CHG

can be used to clean mouth, especially useful on person with artificial airway

aspiration can cause

pneumonia, choking, breathing probs

to assess conscious pt ability to care for self

watch them do tasks to see what they know, observe how they brush their teeth

hearing aid batteries

have a short life, turn off when not in use, make sure pt has good batteries in them so they can hear you

edema rated

on pitting scale 0 none - 4 most

diaphragm will hear what heart sounds

S1 and S2

bell will hear what heart sounds

murmurs or extra heart sounds

2nd ICS LSB

pulmonary valve

4-5th ICS LSB

tricuspid valve

5th ICS left mid clavicular

mitral valve

apex of heart

at bottom, mitral valve area, where strongest sound is, take pulse here for full minute

S3

extra heart sound after s2- at beginning of diastole

S2

closure of semi lunar valves (aortic and pulmonic)

S1-S2 heart is in

systole

S2-S1 (including S3 and S4 if there) heart is in

diastole

bruit

a blowing or swishing sound found in a carotid artery

a doppler ultrasound

can be used if can’t palpate peripheral pulse can use

vasoconstriction causes

pallor in skin

to assess if arterial blood is moving properly

assess pulses, skin color, capillary refill, warmth

walking around

number one way fluid is returned to heart

false low BP

arm over heart or too loose BP cuff can cause

false high BP

crossed legs, arm not supported, cuff too narrow can cause

if pulse is irregular

take for a full minute and compare to apical pulse

apical pulse

found at apex of heart / mitral valve

cold temp is

artery problem

warm temp is

vein problem

amplitude

strength of pulse, graded 0-4 scale, 2 is normal

thrill

palpate over valve areas, can feel vibration from super turbulent blood flow, shows a very high grade murmur

murmur over aorta

aortic murmur

apex of lungs

at top above clavicle

fine crackles

high pitched popping lung sounds

both crackles caused by

alveolar sacs trying to open against fluid, impairs gas exchange

wheezing and stridor occur in

mid lungs / upper airway, from inflammation or obstruction

airway prob means

breathing obstruction

breathing prob means

gas exchange

wheezing

musical squeaking lung sounds

bronchial / tracheal sounds heard

top of lungs

bronchovesicular sounds heard

in middle of lungs

vesicular sounds heard

in lower lungs

vesicular sounds

low pitched, soft, rustly like rustling leaves

to assess and document respirations

collect the rate/speed, depth, rhythm (regular or irregular)

amplitude measured with

peripheral pulses

you grade

peripheral pulses and lower leg edema

symmetrical tactile fremitus

is expected in lung assessment

what indicates overworking to breathe

intercostal retractions and use of accessory muscles

tripod positioning

leaning forward while sitting with arms on knees, shows shortness of breath / struggling to breathe