health assessment exam 2 review

above the clavicle that is where the apex of the lung is located

where do you first listen to the lungs sounds ANTERIORLY?

pleura/pleurae

2 serous membranes that cover the outer surface of the lung

1. visceral pleura

2. parietal pleura

visceral pleura

• lies Next to lungs

• No sensory Nerves;

parietal pleura

• lines the inner rib cage & upper surface of the diaphragm

1. Rich nerve innervation;

2. Lines inner rib cage

• inflammation produces pleuritic pain with deep inspiration, for example, in pleurisy, pneumonia, and pulmonary embolism

pleural effusion

accumulation of fluid between the pleurae

pt with pleuritis will avoid taking deep breaths due to pain. worsening sharp pain often occurs during breathing, coughing, or sneezing. These actions cause pleura to move, which aggravates the inflammation. As a result, the patient may take shallow breaths in an attempt to reduce discomfort.

Is the patient with pleuritis, taking deep breaths? WHY?

risk of shallow breathing include atelectasis (alveoli collapse due to underinflation), pneumonia (due to buildup of mucus), and hypoxemia (reduced amount of O2 body receives)

what is the risk of patient with pleuritis?

inspiration

primary muscle is diaphragm

muscles contract & thorax expands

expiration

muscle relax and thorax contracts

• shortness of breath

• wheezing

• cough

• hemoptysis

• purulent sputum

• chest pain

what are common or concerning symptoms that SHOULD BE assessed?

sputum

a mixture of saliva and mucus coughed up from the respiratory tract

accessory muscles

includes

• sternocleidomastoid (aid in inspiration)

• scalenes (neck)

• abdominal muscles (aid in expiration)

dyspnea

• air hunger, a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion commonly termed “shortness of breath”

• SERIOUS warrants full explanation & assessment

• can result from pulmonary or cardiac disease

severity must be determined based on the patient’s ability to talk and complete daily activities

how must the severity of the patient’s dyspnea be determined?

• pneumonia

• pump failure (HF)

• pulmonary embolism

• possible foreign body (in airway)

• pulmonary/bronchial constriction

• pneumothorax

what are the 6P’s of dyspnea?

spontaneous pneumothorax

leakage of air into pleural space through blebs on visceral pleura with resulting partial or complete collapse of the lung

timing: sudden onset of dyspnea

associated symptoms: pleuritic pain, cough

wheezes

• are musical respiratory high-pitched sounds that may be audible to the patient & others

• caused by partial obstruction of the lower airways. the airway may be narrowed by bronchoconstriction, edema, secretions (asthma) or a foreign body

• emphysema

they should be broad and open-ended, not specific. this allows patients to talk and provide more insight

when gathering health history how should questions be asked?

pneumocystis jiiroveci, pneumonia

Fever, dry nonproductive cough, and diminished breath sounds may indicate?

cystic fibrosis

tenacious sputum is seen in?

true

ACE inhibitors may produce a persistent dry cough as a side effect. T/F?

mucous membranes (lips, gums, around the eyes) and nails

In dark skinned individuals cyanosis may be easier to see in the?

tracheal deviation & fluid buildup

tracheal deviation happens because the fluid buildup causes enough pressure in the pleural space to push the trachea away from the side of the effusion, potentially indicating a large or clinically significant pleural effusion.

True

low oxygenation produces anxiety & restlessness. a decreased level of consciousness indicates poor oxygenation to the brain & other disease processes. T/F?

inspecting pt for signs of respiratory difficulty

• observe facial expressions (relaxed & calm not anxious)

• observe LOC

• assess pt’s color for cyanosis (face & mucous membranes & nail beds)

• listen to breathing sounds (wheezing, stridor)

• inspect neck (see is accessory muscles are used)

• observe shape of chest

pneumothorax, pleural effusion, or atelectasis

lateral displacement of the trachea may be seen in?

pneumothorax

during palpation (posterior chest examination), Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side is associated with?

fremitus

refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking

helps assess the density and consistency of lung tissue

• normal findings: should be equal & symmetrical vibrations felt on both sides

• intensity is generally stronger over upper part of chest and weaker near the lower ribs

increased tactile fremitus

abnormal finding*** suggests that sound vibrations are transmitted more easily through the lung tissue, which can occur in conditions where the lung becomes denser or more consolidated

• causes include unilateral pneumonia (consolidation of lung tissue, when air filled sacs become filled w/ fluid, cells or other substances in the alveoli causing lung tissue to become more solid)

decreased/absent tactile fremitus

suggests that sound vibrations are less effectively transmitted through the lung tissue, often because there is something preventing sound transmission (often seen with fluid or air in the pleural space)

causes include:

• unilateral pleural effusion

• pneumothorax

• neoplasm from decreased transmission of low-frequency sounds

• COPD, emphysema

percussion

produces audible sound, helps establish whether tissues are air-filled, fluid-filled or solid

Normal finding: should be RESONANT (hollow low-pitched sound) when tapped over air filled lung tissue NOT DULL

Dullness occurs when the lung tissue is less air-filled and more solid or fluid-filled such as in lobar pneumonia (dull) or pleural effusion (flat)

why is dullness an abnormal finding during percussion?

unaffected side

when there is a pneumothorax, the trachea deviates to the?

vesicular breath sounds

• soft and low pitched

• are heard throughout the periphery of the lungs. They are soft, low-pitched, rustling sounds.

bronchial breath sounds

• are heard over the larynx, trachea, and posterior nape of the neck. They are high-pitched, hollow, tubular breath sounds.

bronchovesicular breath sounds

often heard in the first & second intercostal spaces anteriorly and between scapulae

are heard anteriorly over the mid-chest anterior intercostal spaces. These are medium-pitched sounds.

fine crackles

discontinuous nonmusical sounds

Intermittent, nonmusical, and brief

soft, higher pitched, & more frequent but brief 5-10 msec

EX:

Pneumonia

CHF

Pulmonary Fibrosis

Atelectasis

COPD

coarse crackles

•  somewhat louder, lower in pitch, brief (20 to 30 msec)

• change or disappear with coughing and are transmitted through the mouth result from “boluses of gas passing through the airways as they open & close intermittently

EX:

• Pneumonia

• CHF

• Pulmonary Fibrosis

• Atelectasis

• COPD

continuous, somewhat louder, lower in pitch, brief (20 to 30 msec)

wheezes and rhonchi are what type of sounds?

rhonchi

relative low pitched (≤200 Hz) with snoring quality, are a variant of wheezing but lower in pitch; may disappear with coughing; secretions are involved

EX: bronchitis, COPD

stridor

• a continuous high-frequency, high pitched musical sound produced during airflow through a narrowing in the upper respiratory tract

• best heard in the neck

• causes of underlying airway obstruction include tracheal stenosis from intubation, airway edema after device removal, epiglottitis, foreign body, anaphylaxis & croup

pleural friction rub

• a discontinuous, low frequency, grating sound that arises from inflammation & roughening the visceral pleura as it slides against the parietal pleura

• “2 pieces of leather rubbing together”

• best heard in axilla & base of lungs

egophony

when “ee” is heard as “ay”, an E-to-A change

• is present indicates that the patient's lungs are consolidated (from pneumonia) or fluid-filled, or that the lung may have collapsed. It's most easily detected when comparing different areas of the lungs. 

• coronary artery disease

• COPD mortality

• lung cancer mortality

• stroke

what are the adverse effects of smoking?

precontemplation

“I don’t want to quit.”

contemplation

“I am concerned but not ready to quit now.

preparation

“I am ready to quit.”

Action

“I just quit.”

maintenance

“I quit 6 months ago.”

S1

is the first heart sound heard and is made by the tricuspid and mitral valves closing.(lub)

S2

is the second heart sound heard and is made by the aortic and pulmonic valves closing. (dub)

SA Node

located in Right atrium, natural pacemaker of heart

AV node

located in atrial septum

bundle of HIS

located in ventricular myocardium

cardiac output

the amount of blood the heart pumps or ejects from each ventricle per minute usually 4-6L per minute

SV x HR = CO

stroke volume

the volume of blood ejected with each heartbeat

preload

refers to the load that stretches the cardiac muscle before contraction

myocardial contractility

refers to the ability of the cardiac muscle, when given a load, to contract or shorten

afterload

refers to the degree of vascular resistance to ventricular contraction

jugular venous pressure

refers to the pressure within the jugular veins, which are the veins that carry blood from the head and neck back to the heart

important clinical index of right heart pressures & function. reflects right atrial pressure which in turn equals central venous pressure

measured while pt is in semi-reclining position (30-45 degrees), will look for pulsations in internal jugular vein then compared to sternal angle

NORMAL JVP <3-4cm

True

JVP falls with loss of blood and increases with right or left heart failure, pulmonary hypertension, tricuspid stenosis, and pericardial compression or tamponade (abnormal accumulation of fluid between the layers of the pericardium which places pressure on the heart; if severe it impairs cardiac pumping function). T/F?

it causes decreased blood flow to the brain and induce syncope.

why should both carotids never be pressed at the same time?

if carotid has obstruction, kinking, or thrills

brachial artery should be assessed if?

flat

assessing JVP reflects pressure in the right atrium. starting point for HOB should be 30 degrees. when hypovolemic, HOB should be?

may need to be higher

assessing JVP reflects pressure in the right atrium. starting point for HOB should be 30 degrees. when hypervolemic, HOB should be?

diaphragm

is better for picking up the relatively high-pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs.

bell

is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Pressing the bell firmly on the chest makes it function more like the diaphragm by stretching the underlying skin

mitral murmurs, s3, s4, especially mitral stenosis

left lateral decubitus position accentuates?

aortic murmurs, soft diastolic murmur of aortic regurgitation may be missed if not listened to this position

Sitting Leaning Forward, exhale completely and stop breathing in expiration accentuates?

may indicate heart failure

inspect feet, ankles & legs (peripheral edema). Why?

metabolic syndrome

• large waist circumference W: >35, M: >40

• high blood pressure: >130, >85, undergoing Tx

• high fasting blood sugar: >100mg/dL

• high triglycerides: >150, or under Tx

• low HDL: should be >40 Men, >50 Women

HTN modifications

• salt intake <6g, 2300mg

• 3,500 mg of potassium

• complete cessation of smoking

• limit alcohol intake 1:W, 2:M

• •Mushrooms

• •Oranges and orange juice

• •Peas

• •Potatoes

• •Prunes and prune juice

• •Raisins and dates

• •Spinach

• •Tomatoes, tomato juice and tomato sauce

• •Tuna

what are some foods rich in potassium?

malnutrition

Poverty (eating healthy is expensive), old age, social isolation, physical disability (is patient able to drive, can they cook, go shopping for food), emotional or mental impairment, lack of teeth, ill-fitting dentures, alcoholism, and drug abuse increase the likelihood of?

protein, vitamin C or Zinc deficiency

sore throat that won’t heal can be indicative of?

protein deficiency

edema (CV system) can be indicative of?

vitamin C or K deficiency

petechiae or ecchymosis can be indicative of?

kwashiorkor

• is due to diets that may be high in calories but contain little or no protein

• (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose-containing intravenous fluids).

• The serum albumin would be less than 3.5 g/dL.

right upper quadrant

• ascending colon

• duodenum

• gallbladder

• right kidney

• liver

• pancreas (head)

• transverse colon

• ureter (right)

right lower quadrant

• appendix

• ascending colon

• cecum

• rectum

• ovary, uterus, fallopian tubes

• prostate, spermatic cord

• small intestine

• ureter

left upper quadrant

• descending colon

• left kidney

• pancreas (body & tail)

• spleen

• stomach

• transverse colon

• ureter (left)

left lower quadrant

parietal pain

originates from inflammation in the parietal peritoneum, also known as peritonitis. It is a steady, aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure.

 It is typically aggravated by movement or coughing.

Patients with parietal pain usually prefer to lie still.

referred pain

is felt in more distant sites, which are innervated at approximately the same spinal levels as the inflamed structures. this type of pain often develops as the initial pain becomes more intense and thus seems to radiate or travel from the initial site. It may be palpated superficially or deeply but is usually well localized.

• Pain of duodenal or pancreatic origin may be referred to the back;

• pain from the biliary tree, to the right scapular region or the right posterior thorax.

• Pain from pleurisy or inferior wall myocardial infarction may be referred to the epigastric area.

dyspepsia

is a chronic or recurrent discomfort or pain centered in the upper abdomen which is characterized by postprandial fullness, early satiety, and epigastric pain or burning

rovsing’s sign

• Palpation of left lower abdomen causes pain in the right lower abdomen.

• positive in appendicitis

psoas sign

is elicited by having the patient lie on his or her left side while the right thigh is flexed backward. Pain may indicate an inflamed appendix overlying the psoas muscle.

obturator sign

is a clinical sign of acute appendicitis, it is defined as discomfort felt by the subject/patient on the slow flexion & internal rotation of the hip joint, while the right knee is flexed. It indicates an inflamed pelvic appendix that is in contact with the obturator internus muscle

murphy’s sign

is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive.

stress incontinence

For women, does sudden coughing, sneezing or laughing cause loss of urine? what is this referred to as?

urge incontinence

• Detrusor contractions are stronger than normal and overcome the normal urethral resistance.

• Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal impaction

• Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder volume

overflow incontinence

Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. The bladder is typically flaccid and large, even after an effort to void.

• Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor

• Weakness of the detrusor muscle associated with peripheral nerve disease at S2–4 level

• Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy

tympany

is a high pitched musical sound that indicates a hollow space filled by air or gas in the stomach or intestine.

heard during percussion

predominates because of GAS IN GI TRACT

dullness

fluid in solid or tissue organs

True

• Approximately 5% of normal adults only have a palpable spleen tip. Generally, the spleen is not palpable unless there is some pathology involved. T/F?

it may be enlarged, and palpation may cause it to rupture

why should you Never attempt to palpate the spleen after an accident?

bladder

• •Normally cannot be examined unless it is distended above symphysis pubis

• •Check for tenderness

• •Percuss for dullness

• Bladder volume must be 400 to 600 mL before dullness appears.

• ·Hardening of the arteries (atherosclerosis). Atherosclerosis occurs when fat and other substances build up on the lining of a blood vessel.

• ·High blood pressure. High blood pressure can damage and weaken the aorta's walls.

• ·Blood vessel diseases. ...Inherit connective tissue disorder

• ·Infection in the aorta. ...

• ·Trauma.

 What are the most common causes of abdominal aneurysms?

patient breathes out around the bare abdomen at the level of the iliac crest

abdominal circumference with measuring tape should be taken when?

minute hemorrhagic spots in the skin which do not blanch with pressure. caused by blood leaking from capillaries under the skin

what is petechiae?