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Class 6 PA: Thorax/Lungs/Heart/Vascular & Reproductive System
Treas & Wilkinson Ch. 21 pgs 552-564 Treas & Wilkinson Ch. 21 pgs 548-552, 591-600 TLO 3.1b
Terms in this set (35)
Order of Assessment for Thorax
3. Chest excursion
4. Tactile fremitus
5. Auscultation of lung sounds
Anterior Thorax & Lung Sounds (patient sitting)
1. Identify anterior lung borders
2. Inspect breathing pattern & effort, RR & depth, muscles used, & symmetry of respiratory movements.
3. Inspect chest shape: AP diameter vs transverse diameter
4. Inspect skin color & integrity
5. Palpate for chest wall tenderness, temp, moisture
6. Auscultate anterior lung sounds using diaphragm proceeding head to toe, side to side, bilateral comparisons; differentiate between bronchial, bronchovesicular, & vesicular breath sounds.
Posterior Thorax & Lung Sounds TEST-OUT STEPS
1. Identify posterior lung borders
2. Inspect breathing pattern etc. as with anterior chest
3. Inspect skin color & integrity
4. Palpate posterior chest wall for tenderness, temp, & moisture
5. Test chest expansion at T 10
6. Palpate tactile fremitus bilaterally
7. Auscultate posterior lung sounds preceding head to toe, side to side, bilateral comparisons.
8. Auscultate lateral lung sounds
Heart & Peripheral Vascular (Patient in bed at 45 degree) TEST-OUT STEPS
1. Palpate carotid pulses (one at a time)
2. Inspect & palpate precordium/point of maximal impulse (PMI)
3. Identify 5 listening posts for cardiac assessment; Mitral, Aortic, Tricuspid, Pulmonic, Erb's
4. Auscultate heart sounds in at each listening post with diaphragm & then bell, identifying S1 & S2
5. Take apical-radial pulse for one minute at Mitral listening post (instructor will assist)
Upper Extremities Circulation TEST-OUT STEPS
1. Inspect upper extremities for size, skin color, & symmetry.
2. Palpate upper extremities for size & temp
3. Palpate brachial, radial, & ulnar pulses bilaterally for strength & equality (grading scale for pulses)
4. Palpate capillary refill time (CRT)
Lower Extremities Circulation TEST-OUT STEPS
1. Inspect & palpate legs & feet for size, skin color, hair distribution, venous pattern, edema
2. Palpate legs & feet for temp, moisture, pretibial edema (use grading scale)
3. Palpate femoral & popliteal pulses, posterior tibial pulses, & dorsalis pedis bilaterally
4. Palpate for CRT
5. Examine for calf pain with dorsiflexion bilateral (Homan's Sign)
Anterior Lung Borders
Apex: 3-4 cm above the inner 1/3 of clavicle
Base: on diaphragm at 5th or 6th MCL
Lateral Lung Borders
Apex of axilla to 7th or 8th rib
Posterior Lung Borders
Apex: at C7
Base: at T10 (to T12 with deep inspiration)
Instructions for client for thorax auscultation
(client sitting upright)
1. Slow deep breaths-slightly deeper than normal
2. Breath with mouth slightly open
Vesicular lung sounds
soft breezy, low pitched; inspiration > expiration; heard over lung periphery; caused by air moving in small airways; normal
Bronchovesicular lung sounds
more blowing quality, medium pitch & intensity; inspiration=expiration; heard between scapula posterior. Anteriorly over bronchioles to sternum at 1st & 2nd intercostal spaces; caused by air moving through larger airways; normal
loud, high pitched & hollow, expiration > inspiration; normal to hear over trachea; caused by air rushing in through trachea; abnormal when heard in lung fields
added sounds over normal breath sounds; abnormal sounds--example: crackles, wheezes, rhonchi
Inspection & palpation of heart
Patient supine or elevated 30 degrees; inspect for visible pulsations, lifts & palpate for thrills at apex, left lower sternal border, & the base of the heart.
Located in center of chest (precordium); behind & to left of sternum.
Base of heart is up.
Apex of heart is down; touches anterior chest wall at 4th or 5th ICS medial to left MCL: PMI (point of maximal impulse); can be examined with inspection & palpation
(AORTIC ALWAYS ON RIGHT SIDE-2 INTERCOSTAL SPACES DOWN)
S1 "Lub" Heart Sound (First Heart Sound)
Caused by closure of AV valves (mitral & tricupsid); beginning of systole (ventricle contractions)
S2 "Dub" Heart Sound (Second Heart Sound)
Caused by closure of semilunar valves (aortic & pulmonic); beginning of diastole (filling)
Supine or 30/45 degree angle
PMI-apex of heart touches chest wall 4-5 ICS, just medial to left MCL
Look at PMI, palpate for pulsations, thrills, heaves (don't want to see thrills or hives, not normal)
Aortic: 2nd ICS right sternal border
Pulmonic: 2nd ICS left sternal border
Erbs point: 3rd ICS left sternum
Tricuspid: 4th ICS left sternum
Mitral: 5th ICS left sternum, 1/2 to MCL
(Use diaphragm of stethoscope for S1 & S2, press firmly; use bell for extra heart sounds, press lightly
Vascular Assessment Peripheral Pulses
Checking for circulation
Carotid-notch in neck (1 at a time)
Radial-next to thumb
Ulnar-hold hand up-next to pinky
Brachial-inside elbow-usually medial
Femoral-groin space (done on newborns)
Popliteal-back behind knee
Posterior tibial-back by ankle bone
Dorsalis pedis-top of foot (Edema can affect getting an accurate pulse)
ALWAYS COMPARING BOTH SIDES!!!!
Grading Scale for Strength of Pulses
0 = Absent Pulse
1+ = Diminished but palpable pulse
2+ = Normal Pulse
3+ = Full pulse, slight increase in strength
4+ = Strong, bounding pulse
Assess for edema (Skin Assessment)
Thumb pressed for 5 seconds; depression left indicates edema.
Grading +1 to +4 depending on the degree of pitting
+1 = 2 mm
+2 = 4 mm
+3 = 6 mm
+4 = 8 mm
Venous Insufficiency (Vascular Assessment)
Color: normal or cyanotic
Edema: often marked
Skin changes: brown pigmentation around ankles
**Elevation is more comfortable
Arterial Insufficiency (Vascular Assessment)
Color: pale---worse with elevation, dusky red when lowered
Pulse: decreased or absent
Edema: absent or mild
Skin changes: thin, shiny skin----decreased hair growth, thickened nails
**Pain when elevated
How many lobes do the lungs have?
Right has 3 lobes
Left has 2 lobes
Pain in calf of leg when client dorsiflexion of foot (possible sign of DVT)
Who should perform breast self-exam?
Woman 20 years & older
Best time to perform breast self-exam?
4-7 days after menstrual cycle; menopausal women should pick a date & do it at the same time each month
How is Inspection for breast self-exam done?
In front of mirror
Arms hanging loosely down
Inspect for discharge, puckering, dimpling, & scaling of the skin
Arms behind head, press hands on hips, bend over & inspect breast in these positions
Compare side to side, size, symmetry, contour
How is palpation done for breast self-exam?
1. Shower & lying down w/ small pillow
2. One arm behind head
3. Use pads of 3 fingers, clockwise circles from out to in, palpating entire breast
4. Tail of Spence
5. Compress nipple & look for discharge
6. Palpate both breast feeling for lump or mass under the skin; normal breast tissue is dense, firm & elastic
What is the scariest lump/bump to find on self breast exam?
One that doesn't move & is not painful
Painful & moveable
What men should exam their breasts at regular intervals?
Have a 1st degree relative w/ breast cancer (mother or sister)
What happens when a man's prostate is enlarged?
Causes urination problems
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