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
- 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?
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?
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 are the 4 heart valves?
- Tricuspid (right)
- Mitral (left)
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.
First heart sound
Closing of the mitral and tricuspid valves
Indicates the beginning of systole.
Almost always synchronized with the carotid pulse
2nd heart sound
Closing of the aortic and pulmonic.
Indicates the beginning of diastole
- common in young children
- caused by increased fluid / increased atrial pressure / extra blood flow
CHF / JVD / edema
mitral or tricuspid regurgitation
During diastole, often heard at the apex
- common in elderly
- Caused by hypertension / extra peripheral pressure
End of diastole
What is a murmur?
- dysfunctional valves
- can be from stenosis / regurgitation /or both
- some are intermitted
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
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?
- posterior tibial
- dorsalis pedis
What is the pulse amplitude rating scale?
1+ Diminshed, barely palpable
3+ Full volume / bounding
4+ Full volume / increased
Palpable vibration over the precordium or artery: it feels like fine, palpable, rushing vibration. Associated with aortic valve stenosis
- 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
- 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.
Sympathetic Nervous System
- Releases Norepinephrine
- Increases HR, AV conduction, Contractility
- Due to stress/anxiety
- Release Acetylcholine
- Decreases Contractility, Conductivity, SA firing, and HR
- stimulates vagus nerve (by rectum or rubbing carotid artery)
Cardio subjective data
- Chest pain
- Cardiac history, Family cardiac history, Personal habits
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.
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
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.
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.
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
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
- 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.
- 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.
- 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.
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
- lymph node enlargement
- skin changes on arms or legs
Between pubis and anterior superior iliac crest
Frog like position, press firm then release.
Posterior Tibial (PT)
Groove between medial malleolus and achilles tendon
Curve fingers around medial malleolus
Manual Compression Test
- Compress vein on lower leg
- Feel for wave: no wave- competent valves, wave felt- incompetent valves
- Supine with knee flexed
- Sharply flex foot toward tibia
- Pain indicates: DVT, Tendinitis, Muscle injury, lumbosacral problems
- Auto-immune disorder
- blood vessels in the hands and feet appear to overreact to cold temperatures or stress
Aterial Vascular Symptoms
- 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?
Anterior, posterior, & midaxillary lines.
Four functions of respiratory system
- changing chest size during respiration
- 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 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?
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
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
- chronic bronchitis
- cystic fibrosis
- chronic interstitial lung disease,
When assessing the timing of a cough, what should the nurse ask the patient?
- 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?
- Dry / Moist?
Pink and Frothy Sputum
- Occurs with pulmonary edema
- blood & extra fluid
- usually too weak to cough
- from deep down
- comes out with tube insertion
-Leaning forward with the arms braced against the knees, against a chair, or against a bed.
- Suggests respiratory distress
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
- 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)
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, high-pitched crackling and popping noises (discontinuous sounds)
- Heard during the end of inspiration
- Not cleared by cough
- Medium pitched
- moist sound heard about halfway through inspiration
- Not cleared by cough
- Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration
- 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
- 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
- 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
What tests can the nurse perform to test for vocal resonance?
Bronchophony, Whispered Pectoriloquy, Egophony
- 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)
- 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)
- 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.
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)
- Funnel chest
- The sternum is indented above the xiphoid process
- Congenital abnormality
- many cases just cosmetic
- Marfan's Syndrome
- Spinal convexity
- Half the body: ribs close together, other half ribs are widely separated
- Reduced tactile vocal fremitus
- Reduced chest expansion
- Reduced airway
- Diminished BS
- Fluid within pleural space
- Increased tactile vocal fremitus
- Reduced expansion
- Dull perception
- Bronchial breathing
- Diminished BS
- Deviated trachea
- Reduced tactile vocal fremitus
- Reduced air entry
- Air in the pleural spaces; 3 different types: closed, open, and tension
- Deviated trachea
- Reduced tactile vocal fremitus
- Dull percussion
- Reduced air entry
- Poor air exchange
- Collapsed alveoli caused by external pressure from a tumor, fluid, or air in the pleural space or by removal of air from hypoventilation or obstruction by secretions.
- O2 levels may go below 90%.
- Diminished or absent breath sounds in affected lungs
- bed rest / immobility
- Infection of the terminal bronchioles and alveoli
- Caused by bacteria, fungi, viruses, mycoplasma, or aspiration of gastric secretions
- Important to get patients up after surgery to prevent this
When percussing the posterior and lateral thorax, what sound should you hear?
The sound should be resononant, which is loud in intensity, low in pitch, long in duration, and hollow in quality
- Movement of the diaphragm with maximum inspiration and expiration
- Allows the nurse to estimate the lower lung border during inspiration or expiration
What normal findings should the nurse see when measuring diaphragmatic excursion?
The diaphragmatic excursion should be equal bilaterally and measure at least 1-2 inches; in well conditioned individuals it may measure as much as 3 inches.
When palpating the trachea, what are normal findings?
- The trachea should be palpable, midline, and slightly movable
-abnormal: thorax mass / mediastinal shift / lung collapse / lung cancer / tracheal tumor
What are the normal/abnormal finding in palpating the anterior chest for thoracic expansion?
normal: thumbs should move apart symmetrically
abnormal: unequal movement can be the result from pain / fractured ribs / pneumonia / chest wall injury
Breast Subjective Data
- breast reduction
- breast augmentation
Use a circular, wedge, or vertical strip method to palpate for lumps throughout the breast, up to the chest, and through the tail of spence
If lump is present note....
- nipple retraction
- overlying skin
- lymphadenopathy (enlarged lymph)
What are the 4 quadrants the abdominal cavity is divided into?
What are the nine regions of the abdomen?
Right hypochondriac/ Epigastric/ Left hypochondriac
Right lumbar/ Umbilical/ Left Lumbar
Right Inguinal/ Hypogastric/ Left Inguinal
Abdominal / GI Subjective Data
What should you inspect the abdomen for?
Pulsations or surface movement
Upon inspection of the abdomen, what should you find?
Smooth surface characteristics, striae/scars/faint vascular network. Umbilicus should be centrally located.
Contour of the abdomen should be flat or slightly sunken
Peristalsis should not be visible. Smooth and even respiration movements.
What may cause an absence of bowel sounds?
Mechanical obstruction or paralytic ileus
Perotonitis and bowel obstruction
Technique used to listen to bowel sounds
Auscultate in all four quadrants. Also can use percussion to hear tymphany and dullness
When does a nurse not palpate?
When the patient is suspected to have:
True or False: The area of pulsations is not palpated because it may indicate an abdominal aneurysm, a weakening in the wall of the abdominal aorta.
How should the stoma appear on a patient with an ileostomy or colostomy?
Red and moist; the skin should appear well healed and without lesions, irritation, or areas of excoriation.
If the patient has an colostomy in the area of the descending or sigmoid colon, the stool is?
- Audible sounds produced hyperactive peristalsis
- Creates rumbling, gurgling, and high-pitched tinkling sounds.
- More intense and episodic sounds, associated with intestinal obstruction.
In what way should the nurse auscultate the abdomen?
Systematic way. Starting in the RUQ and progressing through clockwise.
What does CVA tenderness indicate?
Pyelonephritis, glomerulonephritis, or nephrolithiasis (kidney stones)
What 2 tests can the nurse perform if it is suspected that the patient has fluid within the abdomen?
Ask the pt to lie supine so that any fluid pools in the lateral (flank) area. Percuss the abdomen. Draw lines on the abdomen to indicate the midline tympany in contrast to lateral dullness. Then have the client turn to the right side and repeat percussion. Listen as the tympanic tone shifts to the upper side and the area of dullness rises toward the midline. FInally, have the client turn to the left lateral position and percuss. Listen as the dullness rises toward the midline. (+) Movement of dullness
Hypoactive Bowel Sounds
Reduced bowel sounds.
reduction in the loudness, tone, or regularity of the sounds. They are a sign that intestinal activity has slowed.
Normal during sleep, and also occur normally for a short time after the use of certain medications and after abdominal surgery. Decreased or absent bowel sounds often indicate constipation.
Hyperactive Bowel Sounds
Increase in intestinal activity.
Can occur with diarrhea, Crohn's disease, GI bleeding, ulcerative colitis
When percussing the abdomen what are the normal sounds heard?
Patterns of bowel and urinary elmination, problems with control, and use of assistive devices; also explores skin excretion
What are the 9 Ways to gain more information?
Data documented for use by health care team needs to be:
- Complete, accurate,descriptive data.
- Concisely, legibly, and without bias or opinion.
Using the hands to feel texture, size, shape, consistency, pulsations, and location of certain parts of the body.
Used to evaluate the size, borders, and consistency of internal organs, to detect tenderness, and to determine the extent of fluid in a body cavity.
Measures near vision; Chart made up of 3's, X's, and O's; Held 14 inches from client's face
Used to amplify sounds that are difficult to hear with an acoustic stethoscope. Uses ultrasonic waves to detect difficult to hear vascular sounds.
Costal angle meaning
Unilateral or unequal mvmt of expansion suggests asymmetry. This is related to pneumonia, atelectasis, or collapsed lung
What are the 8 functions of the liver?
- Bile production and secretion
- Transfer of bilirubin from the blood to the gallbladder
- Protein, carbohydrate, and fat metabolism
- Glucose storage in the form of glycogen
- Production of clotting factors and fibrinogen
- Synthesis of most plasma proteins
- Detoxification of a variety of substances, including drugs and alcohol
- Storage of certain minerals (iron and copper) and vitamin (A, B12, and other B-complex vitamins)
What are the main functions of the spleen?
- Storage of 1-2% of erythrocytes and platelets
- Removal of old or agglutinated erythrocytes and platelets
- Activation of B and T lymphocytes
- Production of erythrocytes during bone marrow depression
What are the five percussion tones?
1) Typany - loud, high pitched sound heard over abdomen
2) Resonance - heard over normal lung tissue
3) Hyperresonance - heard in overinflated lungs, as in emphysema
4) Dullness - heard over liver or heart
5) Flatness - heard over bones and muscle
What is an apical impulse?
A brief, early systolic outward thrust, followed by a late systolic retraction felt by the palpating finger when the LV contracts and rotates the LV apex and the adjacent interventricular septum hits against the chest wall.