NURS 3140 Unit 2

Comprehensive Health Assessment: Respiratory, Cardiac, Musculoskeletal, and Vascular Systems Study Guide

I. Respiratory System

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Main Function: Gas exchange and delivering oxygen to the body.

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Other Functions: Acid-base balance and breathing. Lungs control blood pH by releasing carbon dioxide.

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Anatomy and Physiology of the Lungs:

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Upper Respiratory Tract:

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Nostrils to nasal cavity: filtration, warming, and moistening of air.

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Oropharynx: No gas exchange, role in speech and prevents aspiration.

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Lower Respiratory Tract:

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Trachea, bronchi, bronchioles, and alveoli.

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Bronchioles: Bring air to alveoli.

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Alveoli: Produce surfactant.

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Lungs: Right (3 lobes: upper, middle, lower), Left (2 lobes: upper, lower).

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Diaphragm: Dome-shaped muscle for breathing. Contracts and flattens during inhalation. Relaxes during exhalation. Principle muscle for respirations.

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Pleura: Serous membrane protecting lungs. Parietal (chest wall) and visceral (lungs) layers.

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Respiratory Assessment:

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Positioning: Sitting for optimal lung expansion.

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Order: Inspect, palpate, percuss, auscultate . Complete one area (anterior, posterior, lateral) before moving on .

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Landmarks:

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Anterior: mid-clavicular line, mid-sternal .

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Posterior: scapular line, vertebral line .

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Lateral: axillary lines (anterior, mid, posterior) .

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Inspection of the Thoracic Cage:

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Size and Shape: Note abnormalities .

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Costal Angle: Normally < 90 degrees . > 90 degrees seen in barrel chest .

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AP to Lateral Ratio: Normal 1:2 . Equal in barrel chest .

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Shape: Normally cone-shaped . Abnormal: pectus excavatum (sunken), pectus carinatum (pigeon) .

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Scapula: Same height .

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Movement: Symmetrical .

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Skin Color: Uniform . Cyanosis (blue) = hypoxia . Red = vasodilation, infection, high BP . Pale = lack of oxygen, poor circulation .

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Respiratory Rate and Rhythm: Normal (eupnea) 12-20 breaths/min . Expiratory phase longer than inspiratory .

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Bradypnea: < 12 .

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Tachypnea: > 20 .

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Never tell patient you are counting respirations .

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Muscle Retractions: Dips in intercostal spaces = restricted airflow .

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Nail Beds: Check for clubbing (> 180 degrees, spoon-like) = chronic hypoxia .

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Palpation:

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Fingertips for moisture and surface characteristics . Dorsum of hand for temperature .

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Tenderness: Note and ask questions .

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Crepitus: Popping/crackling under skin .

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Chest Expansion: Hands on posterior chest (thumbs at T9/T10), thumbs should move apart symmetrically with deep breath . Unequal expansion = obstruction or pneumonia . Decreased air movement also causes unequal expansion .

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Tactile Fremitus: Palpate vibrations while patient says "99," "coin," "toy," or "boy" in low pitch . Start anteriorly below clavicle, move down, repeat posteriorly . Should be equal bilaterally .

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Increased Fremitus: Increased lung tissue density (e.g., pneumonia) .

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Decreased Fremitus: Fluid in lungs (e.g., pleural effusion) or decreased air movement .

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Percussion: Assesses air in lungs and tissue density . Indirect technique, apex to base anteriorly and posteriorly, also laterally .

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Normal: Resonance - low-pitched, hollow (healthy air-filled lung) .

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Abnormal:

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Hyperresonance: Drum-like (too much air, e.g., emphysema, pneumothorax) .

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Dullness: Soft, muffled (mass or fluid, e.g., pneumonia, pleural effusion, tumor) .

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Auscultation: Listen to breath sounds with stethoscope in all lung fields (anterior, posterior, lateral) . Compare side to side . Avoid bone .

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Normal Breath Sounds:

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Bronchial: High-pitched, hollow, tubular (trachea and larynx) .

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Bronchovesicular: Medium-pitched (major bronchi areas: upper sternum, between scapulae) .

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Vesicular: Soft, low-pitched (peripheral lung fields) .

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Adventitious (Abnormal) Breath Sounds: Should not be heard .

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Diminished/Decreased: Softer, farther away (decreased air movement: obstruction, secretions, obesity, loss of elasticity - emphysema) .

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Absent: No air movement (atelectasis, tumor, pleural effusion, pneumothorax) .

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Crackles (Rales): Typically inspiration, no clearing with cough. Fine (rails): obstructive (heart failure, COPD, pneumonia) . Coarse: inflammatory, throughout inspiration/expiration, low-pitched, bubbly (pulmonary edema) .

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Rhonchi (Wheezes): Snoring sound, may clear with cough . High-pitched and musical . Associated with asthma, COPD, smokers, obstructions .

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Wheezes: Musical, whistling (airway narrowing - asthma, COPD) .

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Pleural Friction Rub: Harsh, grating (pleural inflammation) . Like rubbing leather .

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Stridor: High-pitched, harsh, crowing (significant airway obstruction - emergency) .

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Increased: Louder, closer (fluid or compression) .

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Documentation: Be specific: what, where (e.g., bilateral upper lobe), timing (insp/exp/both), rate, pulse oximetry (with/without O2) .

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Advanced Assessments (Auscultation of Voice Sounds): Posterior lung fields, apex to base .

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Bronchophony: "99," normally less distinct lower down . Abnormal: clear and loud throughout (fluid/inflammation) .

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Egophony: "ee," normally remains muffled . Abnormal: "ee" to "ay" (consolidation) .

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Whispered Pectoriloquy: Whispered words, normally faint and muffled at bottom . Abnormal: clear (increased tissue density) .

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Peak Expiratory Flow Rate (PEFR): Max expiration speed using portable device . Deep breath, forceful exhale . Record highest of several tries .

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Green Zone: 80-100% personal best (all clear) .

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Yellow Zone: 50-80% personal best (caution) .

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Red Zone: < 50% personal best (medical alert, airway narrowing) .

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Health Promotion Activities for Respiratory Health:

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Smoking cessation/reduction .

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Avoidance of environmental pollutants (e.g., mask) .

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Vaccination (pneumovax for compromised/65+) and good hygiene .

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Regular exercise .

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Respiratory Variations in Infants and Children:

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Higher rate (up to 60 normal) .

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Short pauses (5-10 sec) normal .

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No retractions .

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Belly breathers, less chest movement .

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No accessory muscle use .

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Clear, easy breath sounds .

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Abnormal: apnea > 20 sec , rate > 60 , see-saw chest movement , nasal flaring , grunting (especially after eating, don't feed if rate > 60) , intercostal/substernal/suprasternal retractions , decreased/adventitious breath sounds , head bobbing , lethargy/decreased crying , abnormal skin color (pale, mottled, blue), tachycardia, change in LOC .

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Respiratory Changes in Pregnancy:

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Increased progesterone = increased tidal volume and deeper breathing .

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Expanding uterus pushes diaphragm = shortness of breath .

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Increased chest expansion .

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Capillary enlargement = nasal congestion/epistaxis .

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Rate remains 12-20 .

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May use pursed-lip breathing .

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Respiratory Considerations in Older Adults:

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More prone to infections (multiple meds, conditions) .

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Assess medications for respiratory complications .

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Note respiratory signs and symptoms .

II. Cardiac System

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Heart: Pump, main activity . Base (top) wider, apex (bottom) narrower .

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Layers: Endocardium, myocardium, epicardium, pericardium .

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Precordium: Anterior chest wall over heart and great vessels .

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Chambers: Right atria (deoxygenated blood from body) , Right ventricle (deoxygenated to lungs) , Left atria (oxygenated from lungs) , Left ventricle (oxygenated to body) .

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Heart Valves:

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AV Valves: Separate atria/ventricles: mitral, tricuspid .

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Semilunar Valves: Separate ventricles/arteries: pulmonic, aortic .

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Closure creates heart sounds (S1, S2) .

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S1: Mitral and tricuspid closure ("lub") .

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S2: Aortic and pulmonic closure ("dub") .

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Cardiac Cycle: One heartbeat to the next .

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Systole: Ventricles contract, AV close, semilunar open .

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Diastole: Ventricles relax, semilunar close, AV open .

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Cardiac Output: Blood pumped per minute (normal ~ 6 L/min) .

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Electrical Conduction:

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SA Node: Pacemaker, initiates impulses .

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Travels to AV node, bundle of His, Purkinje fibers (atrial contraction/ventricular filling, then ventricular contraction) .

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Depolarization: Negative to positive charge, contraction (P wave on EKG) .

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Repolarization: Return to normal charge .

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Functions: Circulation, pumping blood, transporting blood .

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Normal Heart Sounds: AV and semilunar valve closure .

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S1: "Lub," loudest at apex .

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S2: "Dub," loudest at base .

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Extra Heart Sounds (Abnormal):

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S3 (Ventricular Gallop): After S2 ("lub-dub-dee"), normal in young/athletes, abnormal (>40) = heart failure . Sounds like "Kentucky" .

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S4 (Atrial Gallop): Before S1 ("dee-lub-dub"), "Tennessee" or fast horse . Atrial kick . Abnormal (>40) = diastolic heart failure .

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Ejection Click: After S1, increased CO, aortic/pulmonic stenosis .

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Opening Snap: After S2, loud/high, stenotic mitral valve opening .

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Pericardial Friction Rub: High-pitched, muffled, grating (pericardial inflammation/fluid) .

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Murmurs: Swishing/blowing (turbulent blood flow) . Any point in cycle . Congenital or developed .

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Types: Innocent (physiological, no symptoms) or pathological (heart disease/structural, often with SOB) .

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Characteristics: Grade 1-6 (6 usually pathological) . Duration, timing, location (best heard), radiation, quality (blowing, harsh, musical), pitch (velocity) . Intensity: crescendo (softer to louder), decrescendo (louder to softer), plateau (constant) .

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Cardiac Assessment:

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Patient Positioning: Supine or semi-Fowler's (30 degrees) .

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Environment: Quiet .

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Exposure: Only area being listened to .

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Landmarks for Auscultation: Aortic (2nd ICS, right sternal border), Pulmonic (2nd ICS, left sternal border), Erb's (3rd ICS, left sternal border), Tricuspid (5th ICS, left sternal border), Mitral (Apical) (5th ICS, midclavicular line) . "All People Enjoy Time Magazine."

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Inspection: Scars, pulsations, lifts, heaves . Apical impulse (PMI) visible at mitral area .

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Palpation: Precordium for pulsations, thrills (palpable murmurs), lifts, heaves . Right ventricular heave (sternal border), left ventricular heave (apex) . Apical impulse: location, diameter (1-2 cm), amplitude (strength), duration (brief) .

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Auscultation: Warm stethoscope . Diaphragm (high-pitched: S1, S2), bell (low-pitched: S3, S4, murmurs) . Listen at all five areas for rate, rhythm, S1, S2 . Listen for extra sounds and murmurs . Left lateral for mitral sounds . Carotids: bell, inhale and hold breath (avoid tracheal sounds) . Listen for bruits (turbulent flow) .

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Pulse Assessment: Peripheral (e.g., radial, ankle) vs. apical. Pulse deficit (> 10 bpm) concerning . Carotid: one at a time, rate, rhythm, amplitude .

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Cardiac Diagnostic Tests:

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Lipid Profile: Cholesterol levels (total < 200, LDL "bad," HDL "good" - high desirable) .

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Cardiac Enzymes (Troponin, CK): Detect heart damage. Troponin rises 4-6 hrs post-chest pain (MI) . CK also indicates muscle damage .

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ECG/EKG: Electrical activity, arrhythmias (e.g., Afib), tissue damage .

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Echocardiogram: Ultrasound, chambers, wall, valves, narrowing, failure .

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Holter Monitor: 24-48 hr portable ECG .

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Exercise Stress Test: ECG during exercise .

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Cardiac Health History:

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History of heart disease, current meds, family history (genetic factors) .

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Modifiable risks: smoking, exercise, diet, dental hygiene (endocarditis), weight .

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Cardiac meds: beta-blockers (↓ O2 demand), calcium channel blockers (↓ HR, vasodilate), nitrates (↑ coronary flow), ACE inhibitors (↓ BP, ↑ flow), statins (↓ cholesterol) .

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Cardiologist visits, previous tests (stress, Holter, echo, EKG) .

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Diet (heart-healthy: fruits, veggies, whole grains, lean protein, low sodium, unsaturated fats), smoking, alcohol, exercise (30 min x 3/week) .

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Chest pain (angina) - OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating, Relieving, Treatment, Severity) . Associated symptoms: diaphoresis, anxiety, nausea, jaw/shoulder pain .

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Palpitations (fluttering/racing) .

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Central (mouth, lips) and peripheral (nail beds, earlobes) cyanosis .

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Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, edema (ankles/lower), nocturia, fatigue, syncope .

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Health Promotion Activities for Cardiovascular Health:

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Improve health, reduce death/stroke .

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Focus on modifiable risks: exercise, stop smoking, limit alcohol, control diet, lose weight .

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Early identification via screenings (cholesterol) .

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Dietary Modifications: Eliminate unhealthy (processed, unsaturated fats, red meats), increase fiber .

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Cardiovascular Considerations in Infants, Children, and the Elderly:

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Infants: Prenatal history important. Often congenital (e.g., Tetralogy of Fallot). May miss milestones .

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Elderly: Fatigue major symptom. Consider med side effects .

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Healthy People 2030 Goal: Improve cardiovascular health, reduce deaths/strokes .

III. Peripheral Vascular System

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Components: Arteries, veins, lymphatic system (lymph fluid) .

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Arteries: Narrow, thick-walled, oxygenated blood away from heart ("A" for Away) .

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Veins: Deoxygenated blood back to heart . Larger than arteries . One-way valves in larger veins .

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Upper extremity drain to superior vena cava .

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Lower extremity drain to inferior vena cava .

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Superficial (near surface - saphenous) . Deep (within muscles - femoral, popliteal, tibial) . IVs in superficial .

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Venous return from legs relies on calf/leg muscle contraction .

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Peripheral Artery Disease (PAD): Narrowing of vessels (atherosclerosis) compromising flow .

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Causes/Risks: Vasoconstriction (smoking), hypertension, hyperlipidemia, diabetes, obesity, CKD, genetics, age .

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Signs/Symptoms: Intermittent claudication (pain with walking, relieved by rest) . Rest pain (burning/aching in feet/toes) .

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Five P's of Arterial Occlusion: Pain, Pallor, Pulselessness, Paresthesia, Paralysis .

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Deep Vein Thrombosis (DVT): Blood clot in deep vein, risk of pulmonary embolism (PE) .

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Signs/Symptoms: Swelling in one leg (classic), pain (back of leg), warmth, redness/darkened area .

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Compare extremities for swelling . Measure diameter .

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Don't encourage walking with DVT (risk of PE) . Prevention: early ambulation, circulation .

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Pulmonary Embolism (PE): Blood clot to lungs, emergency .

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Signs/Symptoms: Sudden SOB, chest pain, diaphoresis, anxiety, hypoxia . May have leg pain, paresthesia, tingling .

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Peripheral Vascular Assessment:

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Health History: Personal/family history of CVD, atherosclerosis, diabetes, HTN, hyperlipidemia, PAD, extremity trauma, recent travel (prolonged sitting), lymphedema (tissue/nodes removed) .

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Lifestyle: Smoking (vasoconstriction), exercise (sedentary risk), oral contraceptives (↑ clot risk) .

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Physical Exam of Upper Extremities:

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Compare symmetry (size, edema, length, shape), nail bed color (white), nail angle (160) .

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Capillary refill (< 3 sec) . Delayed = poor perfusion/dehydration .

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Inspect for lesions, scars, masses .

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Palpate pulses: radial, ulnar, brachial (rate, regular, 2+ quality) .

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Assess temperature (warm), texture (smooth) using dorsum of hand .

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Note edema (peripheral), grade 1+ to 4+ .

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Palpate epitrochlear nodes (flex arm 90, under bicep; normally non-palpable/small, non-tender, mobile if enlarged) .

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Assess pulse rate (60-100), rhythm (regular/irregular), quality/force (1+ to 4+) . Note differences between sides .

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Physical Exam of Lower Extremities:

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Inspect color (pink=good, blue=cyanosis, white/pale=↓ flow/anemia), hair distribution (loss=arterial insufficiency), venous pattern (varicose=pooling), size, muscle atrophy, skin lesions/ulcers, bulging .

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Check capillary refill .

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Palpate pulses: femoral, popliteal, dorsalis pedis, posterior tibial (rhythm, amplitude) . Use Doppler if not palpable .

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Assess temperature and texture .

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Note edema, measure diameter, grade .

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Palpate inguinal nodes (groin) .

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Ask about pain (intermittent claudication, rest pain), use pain scale .

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Emergency: no palpable pulse, cool/pale extremity (arterial blockage) .

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Edema: bilateral (systemic) or unilateral (DVT) .

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Lymphedema: non-pitting, hard/firm (lymphatic obstruction) .

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Assess arterial occlusion/insufficiency: color changes (pallor, rubor), temperature, Five P's .

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Acute Compartment Syndrome (ACS): Increased pressure, poor perfusion. Intensifying pain unrelieved by meds key sign .

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Lymphatic System:

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Lymph fluid (clear) carries fluid in circulation .

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Two major ducts: right lymphatic (right side), thoracic (rest) .

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Structures: spleen (filters blood, largest, T cells, RBC/WBC), thymus (T cells), tonsils, adenoids, lymph nodes, Peyer's patches .

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Lymph nodes filter bacteria, viruses, debris . ~450 nodes .

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Superficial palpable nodes: epitrochlear (upper arm), axillary (armpit), infraclavicular (below clavicle), inguinal (groin) .

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Lymphatic blockages assessed with CT, duplex US, MRA/angiography . Angiography uses dye for blood flow .

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Lymphedema: Obstruction, fluid retention, tissue enlargement (irreversible) .

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Lymphatic Assessment:

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Health History: Pain (OLDCARTS/PQRST), swelling (worsening, relieving, injury), lumps/bulging, skin changes (color, temp) .

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Inspection and Palpation: Nodes typically not felt or small (< 1 cm), mobile, non-tender . Enlarged, tender, fixed = abnormal . Inspect for JVD (Jugular Vein Distension) = ↑ central venous pressure (e.g., heart failure), 30-45 degrees, turn head, tangential light . Inspect/palpate upper/lower for symmetry, color, temp, texture, edema (measure/grade), pulses . Note skin discoloration (erythema, rubor, pallor) . Inspect arterial (punched out) and venous (irregular, shallow) wounds . Note varicose/spider veins .

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Health Promotion for Vascular Health: Eliminate tobacco, educate on ischemia signs, manage.