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What is Nursing?

Nursing is promoting health, protecting, and caring for patients. It is prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.

What is a Scratch Test (GI) and how do you perform it?

- Helps to locate lower edge of liver

- Place stethoscope over RUQ above liver. With one finger of other hand, lightly scratch abdomen starting in RLQ moving up toward liver.

- When scratching sound heard thru stethoscope becomes magnified, you have reached liver border.

How do you percuss liver span?

- Right midclavicular line
- Below umbilicus, percuss upward (tympany to dullness)
- Over lung, percuss downward (resonance to dullness)
- Distance between two lines = liver span (2.5 inches/6-12 cm)

How do you test for Fluid Wave?

- Have the patient lying supine.
- The pt or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the pt's mid abdomen, applying with slight pressure.
- Place the fingertips of one hand along one flank, and with the other hand firmly give a sharp tap along the opposite flank.
- Positive test: Nurse is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

How do you test for rebound tenderness (Blumberg's sign)?

- Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness.

- Suspect appendicitis, peritonitis, or diverticulitis

How do you test for Murphy's sign and what does it detect?

- Used to detect inflamed gallbladder
- Stand at pt's right side, palpate at MCL at costal angle
- Pt takes deep breath, moving gallbladder closer to examiner's hand, causing pain on inspiration

- Presence of pain is positive Murphy's sign / Gall bladder disease

Iliopsoas muscle test

- Have pt lying supine
- use hand to apply pressure to lower thigh while pt attempts to flex hip
- Pain results from irritation of iliopsoas muscle

- Associated with peritoneal irritation / appendicitis

Obturator muscle test

- pt lying supine, flexes right leg at hip and knee
- Examiner places one hand just above pt's knee and other hand at ankle, rotate leg internally and externally
- Pain results from irritation of obdurate muscle

- suspect appendix / pelvic abscess

Ballttement

Palpation technique used to determine a floating mass

McBurney's sign

- press down on abdomen 2/3 from umbilical to iliac crest

- if pt feels pain when you relieve pressure suspect appendicitis

Abdominal distention may result from the 7 F's. What are the 7 F's?

Fat (Obesity)
Fetus (Pregnancy)
Fluid (Ascites)
Flatulence (Gas)
Feces (Constipation)
Fibroid Tumor
Fatal Tumor

Age-Related Variations for Older Adults

- increased regurgitation
- decreased gastric acids & digestive enzymes
- decreased absorption of vitamin B12 & fats
- reduced storage & protein synthesis in liver

What is common to see in aging adults?

Athersclerorsis, Arteriosclerosis
Calf-Vein Enlargement- Increased risk of DVT and PE
Skin and Hair changes- loss of hair on LE, thinner/shinier skin
Atrophy of lymphatic tissue
Loss of valvular competence

What is a normal heart beat for an adult?

60-100 beats per minute

What are the great vessels?

The pulmonary arteries and aorta

Precordium

The portion of the body over the heart and lower chest.

Mediastinum

The ares in which the heart lies. The middle section of the chest cavity.

Myocardium

Thick muscular tissue that contracts to eject blood from the ventricles.

What are the 4 heart valves?

Atrioventricular
- Tricuspid (right)
- Mitral (left)

Semilunar
- Pulmonic
- Aortic

Systole

Ventricles contract, creating pressure that closes the AV valves, preventing the backflow of blood into the atria. This pressure forces the Semilunar valves to open, resulting in ejection of blood into the aorta and pulmonary arteries. As blood is ejected, the ventricular pressure decreases causing the semilunar valves to close.

Diastole

Ventricles are relaxed and fill with blood from the atria.

S1

First heart sound
Closing of the mitral and tricuspid valves
Indicates the beginning of systole.
Low pitch
Almost always synchronized with the carotid pulse

S2

2nd heart sound
Closing of the aortic and pulmonic.
Indicates the beginning of diastole
High pitch

Where is S1 heard the loudest?

The apex / lower left ventricle

Where is S2 the loudest?

The base / upper part of the heart

S3

S1-S2-S3
- common in young children
- caused by increased fluid / increased atrial pressure / extra blood flow

may indicate:
CHF / JVD / edema
mitral or tricuspid regurgitation

Ken-Tuck-y
During diastole, often heard at the apex

S4

S4-S1-S2
- common in elderly
- Caused by hypertension / extra peripheral pressure

End of diastole
Ten-ness-ee

What is a murmur?

- dysfunctional valves
- can be from stenosis / regurgitation /or both
- some are intermitted

Systolic Murmur

A murmur occurring during the ventricular ejection phase of the cardiac cycle.
Caused by obstruction of the outflow of the Semilunar valves or by incompetent AV valves; structural deformities of the aorta or pulmonary arteries, anemia, and thyrotoxicosis

Diastolic Murmurs

A murmur occurring in the filling phase of the cardiac cycle.
Caused by: Incompetent semilunar valves or stenotic AV valves; dilation of the valvular rings
Indicates heart disease.

When a nurse finds a murmur, how should he/she document?

Quality
Location
Radiation
Posture
Timing
Loudness
Pitch
Pattern

Pulse points

- temporal
- carotid
- apical
- brachial
- radial
- femoral
- popliteal
- posterior tibial
- dorsalis pedis

What is the pulse amplitude rating scale?

0+ Absent
1+ Diminshed, barely palpable
2+ Normal
3+ Full volume / bounding
4+ Full volume / increased

Stenosis

Valve does not open properly

Regurgitation

Valve does not close properly

Thrill

Palpable vibration over the precordium or artery: it feels like fine, palpable, rushing vibration. Associated with aortic valve stenosis

Lift

A more sustained thrust than an expected apical pulse and is felt during systole

Heave

More prominent thrust of the heart against the chest wall during systole.

Preload

- Amount of myocardial fiber stretch at the end of diastole
- Determined by left ventricular end-diastolic volume (LVED)
- Starling's Law
- Excessive filling= excessive LVED volume & pressure= decreased CO

Afterload

- Pressure ventricles must overcome to eject blood into the peripheral blood vessels
- Amount of resistance is directly related to arterial B/P and the diameter of the blood vessels.
- Impedance: the pressure the heart must overcome to open the aortic valve; amount depends on compliance and total systemic vascular resistance.

Starling's Law

The more the heart is filled during diastole the more forcefully it contracts

Preload decreases/increases with?

- decreases with Diuretics

- increases with fluids

Sympathetic Nervous System

- Releases Norepinephrine
- Increases HR, AV conduction, Contractility
Vasoconstriction
- Due to stress/anxiety

Parasympathetic System

- Release Acetylcholine
- Decreases Contractility, Conductivity, SA firing, and HR
- stimulates vagus nerve (by rectum or rubbing carotid artery)

Cardio subjective data

- Chest pain
- Dyspnea
- Orthopnea
- Cough
- Fatigue
- Cyanosis/pallor
- Edema
- Nocturia
- Cardiac history, Family cardiac history, Personal habits

Orthopnea

Dyspnea becomes worse when lying down.
A person must stand or sit up to breathe easily.
The number of pillows necessary to relieve this problem.

Hemoptysis

Coughing up blood
Symptom of mitral stenosis

Syncope

A brief lapse of consciousness.
Fainting

When palpating the carotid artery, what should the nurse do?

Palpate one artery at a time. This stops the nurse from cutting off the oxygen and blood supply to the brain when palpating both carotids at the same time.

Hows does the nurse inspect the jugular vein for pulsations?

- Elevate the head of the bed to semi-fowlers position
- Use a penlight and observe for pulsations
- The vein itself should not be visible, only the pulsations

When taking blood pressure in both arms, what should you find?

A difference of 5-10mm Hg systolic between the 2 arms.

How long should it take for capillary refill? What does a greater time indicate?

- Less than 2 seconds

- Poor perfusion

Clubbing of nails

- chronic hypoxia
- common with cystic fibrosis or COPD
- Nail bed angle is greater than 180 degrees

Retraction

a visible sinking in of tissues between and around the ribs.

Where do you palpate the apical apex of the heart?

The 5th intercostal space, left midclavicular line. This is the Point of Maximal Impulse.

Where do you auscultate for heart sounds?

1. Aortic Valve
2. Pulmonic Valve
3. Erb's Point
4. Tricuspid Valve
5. Mitral Valve

What happens when the mitral and tricuspid valves do not close at the same time

S1 sounds as if it were split into 2 sounds instead of 1.

Splitting is often heard?

Tricuspid area with deep inspiration

What is the 1st sign of Coronary Artery disease

Dyspnea

Paroxysmal Nocturnal Dyspnea

Shortness of breath that awakens the individual in the middle of the night, usually in a panic with the feeling of suffocation.

How do you auscultate the carotid arteries for bruits?

With the bell of the stethoscope

Bruits

Low-pitched blowing sounds usually heard during systole that indicate occlusion of the vessel.

How does the nurse estimate the jugular venous pressure?

- Identify the highest level at which jugular vein pulsations are visible, and then identify the angle of Louis.
- Use a ruler to create an imaginary line from the highest venous pulsation to the angle of Louis. Measure the vertical distance between the ruler and the angle of Louis.
- The pressure should not rise above 1 in (2.54cm) above the sternal angle

What does an EKG assess?

Rate and rhythm of the heart

How do you palpate the epitrochlear lymph nodes?

- Flex the client's arm to a 90 degree angle and palpate below the elbow posterior to the medial condyle of the humerus
- There should be no palpable lymph nodes

What are lymphatic ducts highly influenced by?

infection or cancer

Trandelenburg's Test

- Test competence of venous valves in patients with varicose veins
- Have pt lay in supine position, lift one leg above the level of the heart to allow veins to empty, then assist the client to stand.
- If veins are competent, veins fill slowly
- Fill too rapidly = valves may be incompentent, and varicose veins may be present.

What is the preferred position for cardiac palpation?

Supine

Allen's Test

- Important when drawing arterial blood
- Check to see if patient has good circulation through the ulnar artery. (Collateral circulation)
- Raise arm above patients head and hand in a fist for about 30 seconds. Pressure is put on the radial and ulnar arteries, then have the patient open fist, which should be pale. Ulnar pressure is released and color should return in 7 seconds.
- If color does not return in 7-10 seconds, the test is considered positive & the ulnar artery supply is not sufficient.

What are some immune related organs?

- Tonsils
- lymph nodes
- thymus gland
- spleen
- bone marrow

Lympadema

- No cure / lifetime of problems
- Swelling that generally occurs in one arm or leg but may be both
- Caused by a blockage in lymphatic system. The blockage prevents lymph fluid from draining well, and as the fluid builds up, the swelling continues.

What is the number 1 cause of preventable deaths in hospitalized patients?

Pulmonary Embolism

Venous Insufficiency

More pain when legs are dangling, blood pools - does not return

Arterial Insufficiency

Dependent rubor, no hair, shiny skin, thick toe nails, pale feet
Circulation: pallor, mottling (spotting), due to cold
Treatment: Increase O2

What is the Pitting Edema Scale?

1+ A barely perceptible pit, 2mm
2+ A deeper pit, rebounds in a few seconds, 4mm
3+ A deep pit, rebounds in 10-20 seconds, 6mm
4+ A deeper pit, rebounds in >30 seconds, 8mm

When assessing edema, what should the you do?

Push on bony prominences
Trace edema - push down then drag finger along

Deep Vein Thrombophlebitis

- a blood clot (thrombus) in one or more of the deep veins, usually in the legs
- Can cause leg pain, but often occurs without any symptoms.
- can happen from sitting for a long period of time
-can travel to lungs causing pulmonary emboli
- to prevent use stockings
- don't use stockings or massage legs if suspected DVT

Vascular Subjective Data

- leg pain or cramps
- swelling
- medications
- lymph node enlargement
- skin changes on arms or legs

Femoral Arteries

Between pubis and anterior superior iliac crest
Frog like position, press firm then release.

Popliteal Arteries

Lateral to medial tendon of knee
Curl hand around knee, press hard

Posterior Tibial (PT)

Groove between medial malleolus and achilles tendon
Curve fingers around medial malleolus

Dorsalis Pedis

Parallel with tendon of big toe
Light touch

Manual Compression Test

- Compress vein on lower leg
- Feel for wave: no wave- competent valves, wave felt- incompetent valves

Homan's Sign

- Supine with knee flexed
- Sharply flex foot toward tibia
- Pain indicates: DVT, Tendinitis, Muscle injury, lumbosacral problems

Raynaud's Syndrome

- Auto-immune disorder
- blood vessels in the hands and feet appear to overreact to cold temperatures or stress

Aterial Vascular Symptoms

- Claudication
- Pain with exercise or at rest
- Decrease or absent pulses
- Thin, shiny, hairless skin
- Cool skin temperature
- Ulcers on pressure points of feet

Venous Vascular Symptoms

-Pain increases when legs dependent
- Lower extremity edema
- Brown discoloration of skin
- Ankle Ulcerations-meaty
- Skin temperature normal
- Pulses present, but difficult to palpate due to edema
- Pain when dangling legs

What are the reference lines of the thoracic cage?

Midsternal Line
Midclavicular line
Scapular line
Vertebral Line
Anterior, posterior, & midaxillary lines.

Four functions of respiratory system

- changing chest size during respiration
- inspiration
- expiration
- control of respiration

Thorax and Lungs Subjective Data

• Cough (productive?)
• Shortness of breath
• Chest pain with breathing
• History of respiratory infections
• Smoking history (packs/years)
• Environmental exposure
• Self‐care behaviors (flu shot)

The posterior back is made up mostly of what lobes of the lungs?

The lower lobes

Ventilation

The process of moving gases in and out of the lungs by inspiration and expiration

Diffusion

The process by which oxygen and carbon dioxide move from areas of high concentration to areas of low concentration.

What regulatory agency has guidelines and regulations to reduce the amount of occupational exposure to respiratory irritants?

OSHA

What are the primary muscles of inspiration?

The diaphragm and the intercostal muscles

What are the 3 functions of the upper airway in respiration?

- to conduct air to the lower airway
- to protect the lower airway from foreign matter
- to warm, filter, and humidify inspired air

When is a cough considered acute?

When its onset is sudden and it lasts less than 3 weeks

When is a cough considered chronic?

When it lasts longer than 3 weeks

What are common causes of acute cough?

- Viral infections
- allergic rhinitis
- acute asthma
- acute bacterial sinusitis
- environmental irritants

What are common causes of chronic cough?

- Postnasal drip
- GERD
- asthma
- chronic bronchitis
- bronchiestasis
- cystic fibrosis
- chronic interstitial lung disease,
- smoking
- sarcoidosis

When assessing the timing of a cough, what should the nurse ask the patient?

- Continuous?
- Afternoon/evening? Night? Morning?
- 3 months per year for 2 years?

When assessing a dry v/s moist cough, what should the nurse ask the patient?

- Hacking?
- Barking?
- Dry / Moist?
- Congested?

White/Clear Sputum

Occurs with colds, viral infections, allergy or bronchitis

Yellow/Green Sputum

Occurs with bacterial or viral infections

Black Sputum

Occurs with smoke/dust inhalation

Rust-colored Sputum

Occurs with tuberculosis or pneumococcal pneumonia (blood)

Pink and Frothy Sputum

- Occurs with pulmonary edema
- blood & extra fluid
- usually too weak to cough
- from deep down
- comes out with tube insertion

Tripod position

-Leaning forward with the arms braced against the knees, against a chair, or against a bed.
- Suggests respiratory distress

Eupnea

Normal respiratory rate

What is a normal respiratory rate for an adult?

12-20 breaths per minute

Men use what kind of breathing?

Abdominal Breathing

Women use what kind of breathing?

Thoracic breathing

Tachypnea

Respiratory rate more than 20 BPM

Bradypnea

Respiratory rate less than 12 BPM

Hyperventilation

Increased rate and depth of respiration

Anteroposterior (AP) diameter of the chest should be approxiamately?

- Half the lateral diameter, or 1:2 ratio of AP to lateral diameter

- ribs should slope down at about 45 degrees relative to the spine

Barrel Chest

- Costal angle greater than 90 degrees
- Associated with COPD & pulmonary disease

Vocal fremitus

- Instruct patient to recite: one-two-three or 99 while the you systematically palpate the chest wall

- fremitus should feel bilaterally equal

- enhanced vibrations = lung tissue is congested or consolidated (pneumonia/tumor)

- decreased vibrations = blocked (emphysema, pleural effusion, pulmonary edema, or bronchial obstruction)

Breath sounds should be?

Clear to Auscultation (CTA)

What are the 3 normal types of breath sounds in the thorax?

Vesicular, bronchovesicular, bronchial

Where are bronchial breath sounds commonly heard?

- Over the trachea & immediately above manubrium

- expiration louder & longer than inspiration
- pause between

Where are bronchovesicular breath sounds normally heard?

- Main stem bronchi
- 1st and 2nd intercostal spaces at sternal border anteriorly; T4 medial scapula posteriorly

-louder inspiration & expiration

Where are vesicular breath sounds normally heard?

- Peripheral lung fields

- expiration is quieter than inspiration
- no pause between

What sounds should be heard over almost all of the posterior lung fields and all the lateral surfaces?

Vesicular breath sounds

When observing the patient's breathing, what should you note?

Breathing is smooth, even respiratory depth.
Chest wall should symmetrically rise and expand and relax without effort

Adventitious Breath sounds

Crackles, wheezes, and rhonci
Extraneous sounds that are superimposed on the breath sounds.

What should you do if you hear an adventitious breath sound?

- Identify the type of sound
- location of the sound (R/L lung, bilaterally; upper/lower lobes; anterior/posterior)
- phase of breathing in which it is heard

What causes crackles?

- sudden opening of very small airways
- extra fluid
- static sound
- could be congested heart failure

Fine crackles

- Fine, high-pitched crackling and popping noises (discontinuous sounds)
- Heard during the end of inspiration
- Not cleared by cough

Medium crackles

- Medium pitched
- moist sound heard about halfway through inspiration
- Not cleared by cough

Coarse Crackles

- Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration

Wheeze

- High-pitched, musical sound similar to a squeak
- heard more commonly during expiration, but may also be heard during inspiration
- narrowing of airways
- could be asthma or congested heart failure

Rhonci

- Sonorous Wheeze
- Low-pitched, coarse, loud, low snoring or moaning tone
- Actually sounds like snoring
- Heard primarily during expiration, but may also be heard during inspiration
- Due to passage of air through a narrowed bronchus
Coughing may clear

Pleural Friction Rub

- superficial, low-pitched, coarse rubbing or grating sound
- Sounds like 2 surfaces rubbing together
- Heard throughout inspiration and expiration
- Loudest over the lower anterolateral surface
- Not cleared by cough
- Creaking noise
- Movement of visceral pleura over parietal pleura
- lung cancer

Respiratory Stridor

- Harsh, high-pitched sound associated with breathing that is often caused by laryngeal or tracheal obstruction
- Emergency Situation
- Croup, no lung sounds
- may be heard without stethoscope
- Usually louder in the neck than the chest

Atelectatic Crackles

- collapsed small alveoli
- cleared by cough or a couple deep breathes

What tests can the nurse perform to test for vocal resonance?

Bronchophony, Whispered Pectoriloquy, Egophony

Bronchophony

- To assess vocal resonance
- Have pt repeat 99, listen with the diaphragm of the stethoscope, systematically auscultate the posterior thorax
- Listen to the response. The expected response is a muffled tone such as "nin-nin"
- Abnormal: if sound is louder and clearer (pneumonia)

Whispered Pectoriloquy

- Referred to as an exaggerated bronchophony
- Ask pt to whisper, "one-two-three"
- Systematically auscultate the posterior thorax, listening for the quality of the whispered tones
- Normal: response is muffled "1-2-3"
- Abnormal: Increased clarity and loudness of the sounds (consolidation or compression of the lung / pneumonia/fluid)

Egophony

- Evaluates the intensity of the spoken voice
- Instruct the patient to say "e-e-e", as you auscultate the posterior thorax
- Normal: Expected sound if the muffled "e-e-e"
- Abnormal Findings: Changes in intensity and pitch, sounds more like and "a-a-a"

Biot Breathing pattern

Irregularly interspersed periods of apnea in a disorganized and irregular pattern, rate, or depth.

Cheyne-Stokes

Intervals of apnea interspersed with a deep and rapid breathing pattern.

Air Trapping

Abnormal respiratory pattern frequently seen in clients with COPD

When palpating a patient, what should you observe?

Symmetric expansion of the chest
Tactile (vocal) fremitus
Palpate the entire chest wall

Diminished or absent breath sounds are common in patients with?

Emphysema, atelectasis, severe asthma attack

What techniques should the nurse use to auscultate the patient?

- Use the diaphragm of the stethoscope
- Mouth open
- Breathing deeply and fairly rapidly
- Systematic approach over several areas
comparing both sides

What are ways to measure pulmonary function status?

Forced expiratory time
Pulse oximeter (norm above 95%)
6 minute distance walk (300 meters)

Pectus carinatum

- Pigeon Chest
- Prominent Sternum
- either cosmetic or genetic diseases

Pectus excavatum

- Funnel chest
- The sternum is indented above the xiphoid process
- Congenital abnormality
- many cases just cosmetic
- Marfan's Syndrome

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