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Health Assessment Test 3

Terms in this set (98)

Hypercapnia
Increased amounts of carbon dioxide in your blood.
Hypocapnia
Decreased carbon dioxide in the blood.
Four major functions of the respiratory system
Supplying the body with oxygen for energy production
Riding the body of Carbon Dioxide as a bi-product of energy formation
Maintaining oxygen and carbon dioxide balance in the arterial blood controls acid base balance or homeostasis
Maintain heat exchange
Anterior Chest Landmarks
Midsternal line
Midclavicular line
Anterior axillary line
Lateral or axillary Landmark
Anterior axillary line
Midaxillary line
Posterior axillary line
Posterior Chest Landmark
Vertebral Line
Midscapular Line
Tactile Fremitis
Have the patient say "99" while palpating their anterior and posterior chest
Should feel the vibrations and should be symmetrical bilaterally.
Diaphragmatic excursion
Percuss the patients posterior chest for lung field during inspiration and separately for expiration
Mark with pen when there is no resonance heard for inspiration and expiration
Measure with a ruler to determine value
Egophony
Have the patient say "e" while auscultating the chest
Normal sounds will be heard as "e"
Abnormal sounds will be heard as "ayyy"
Whispered Pectoriloquy
Have the patient whisper "99" while auscultating the chest
Normal sounds should not be heard
Abnormal sounds will be heard as a normal talking voice, not a whisper
Auscultation; which side?
DIAPHRAM
Subjective data overview
Chief complaint
Present Illness
Past medical history/surgery/social
Pertinent History
Diagnostics
Past medical history
pack years
number of packs per day x number of years
Pertinent history
Cough: Productive (phlegm) vs nonproductive (dry)
Dyspnea: Breathing trouble. Activity, nonactive or laying down
Sputum: color, consistency, amount
Voice: hoarseness
Allergies: meds, foods, environment
Medications: cough producer
Family history
Vaccines: immunity vs susceptibility
Lifestyle: smoking, occupational exposure (work effect your lungs?), living situation
Diagnostics
Pulse oximetry
Chest X-ray
Pulmonary function tests: how much air the lungs can inspire/expire and how efficiently oxygen goes into the blood
Arterial blood gas
Bronchoscopy: visual probe used to see the inside
CT scan
MRI
Labs: Hemoglobin, WBC
Objective Inspection data
Orthopnea Position vs Tripod position
Retractions: involuntary movement of the chest
Rate, Rhythm, Depth, Effort of breathing
Color of chest
Clubbing or barrel chest
Normal respiratory rate
12-20 breaths per minute for adults
Tachypnea
>20 breaths per min in adult
Bradypnea
<12 breaths per min in adult
Agonal breathing
irregular rate and depth
Apnea
Absent respiratory effort
Breathing in men vs women
Men: abdominal or diaphragmatic breathing
Women: Thoracic breathing
Shallow breathing
Caused by pain, fatigue and/or neurologic reasons
Hyperventilation
Increased work of breathing
Caused by exercise or anxiety
Cheyne-Stokes Breathing
Hyperventilation with periods of apnea
NOT A GOOD SIGN
Biot's
Irregular periods of apnea
Disorganized and irregular pattern
Caused by brain damage
Kyphosis
Objective Palpation data
Symmetric Expansion
Crepitus: crackling due to air in the subcutaneous tissue. Occurs with chest trauma such as pneumonia
Percussion of the lungs
(Sounds)
Resonance
Hyper-resonance
Dullness
Resonance
Hollow
Part air part tissue
Normally heard over lungs
Hyper-resonance
Booming
More air
Normal lung sound in infant
Lung emphysema
Dullness
Thud
More solid tissue
Atelectasis
Pneumonia
Pleural effusion
Rules of auscultation
Patient breath through mouth
Minimize outside noise
NOTE where abnormalities occur
Listen with the diaphragm
Scope to skin
Use a pattern and compare bilaterally
Bronchial breath sounds
On trachea and larynx
Harsh, hollow tubular
High pitch and loud amp
Inspiration < expiration
Bronchovesicular breath sounds
Between scapula and upper sternum
Mixed sounds
moderate pitch and amp
inspiration = expiration
Vesicular breath sounds
peripheral lung fields
Rustled like wind in trees
low pitch and soft amp
Inspiration > expiration
Adventitious breath sounds
NOT NORMAL
DO SOMETHING
Crackles
fluid in the airway or collapsed alveoli
Wheezing
Narrow airways
Musical sounds
Rhonchi
Crackles that subside with coughing
Pleural friction rub
Loud and rough grating sound
Pleura is rubbing together
Heard on lateral lung fields
Associated with pleurisy (inflammation of the pleura) and lung cancer
Stridor
Upper airway obstruction
Pleural effusion
Excess fluid build up in the pleural cavity
Pneumonia
Build up of fluid in the alveoli
Inflammation of one or both of the lungs
Pneumohemothorax
Blood and gas in the pleural cavity
Alveolar Atelectasis
Complete or partial collapse of the alveoli
Acute conditions of the lungs
Pleural effusion
Pneumonia
Pneumohemothorax
Alveolar Atelectasis
Chronic conditions
Cystic Fibrosis
Emphysema
Lung Cancer
Asthma
Chronic Bronchitis
Asthma
Bronchospasm (constriction) and inflammation
Emphysema
Permanent enlargement of the air sacs
Caused by destruction of pulmonary tissue
Chronic bronchitis
excessive mucous secretion
partial obstruction due to inflamed bronchi
Elderly
More susceptible to chronic bronchitis and pneumonia
Protective cough reflex less sensitive
Cough reflex does not trigger as readily
Cough not as forceful
Cilia lining airways decreased cannot move mucus up & out of airway
Nose & breathing passages secrete less of antibody IgA
Nursing Diagnoses
Ineffective airway clearance
Impaired Gas exchange
Impaired breathing pattern
Excess fluid volume
Cardiovascular Physiology
Transports oxygen and nutrients to the tissues
Transports waste products to the kidneys and lungs

At different times the body may need different amounts of blood.
Vasoconstriction or vasodilation
Alters cardiac output: how much blood the heart is pumping out
Cardiovascular anatomy
Heart
2 loops: vascular circulation and systemic circulation
Tough and tensile arteries
Maintain blood pressure by vasoconstriction and vasodilation
smaller
arterioles
Can undergo extreme amounts of pressure do to myocardial contraction
Venules
Low pressure compared to arteriole circulation
Valves keep blood flowing towards the heart
Passive smaller veins
Increased amount results in reservoir for blood to decrease workload on the heart
Lymphatic system
Fluid is clear, mostly water with some albumin protein
Arm, groin and leg nodes are the most important to peripheral vascular system
Removes fluid from interstitial spaces and transports it to the nodes
Epitrochlear Nodes
Not palpable
On the upper arm medial to the body
Receive fluid from the ulnar, radial and median lymphatic vessels
Inguinal Nodes
Drainage from great and small saphenous vessels in the legs
Upper thigh
Superficial
How does the lymph fluid flow?
Skeletal muscle contractions
Pressure changes secondary to breathing
Contraction of lymph vessel wall
What are the big 5 health history questions to ask about the peripheral vascular and lymphatic systems?
Do you have any heart or vascular problems?
Any other medical problems?
DIABETES AND LUNG DISEASE
What medications are you taking?
Include prescribed, OTC, vitamins and herbal supplements
What type of allergies do you have?
Explain reaction
Alcohol or recreational drugs?
Questions to ask particularly for general cardio and peripheral vascular systems
Any heart disease?
High cholesterol?
High blood pressure?
Chest pain/discomfort?
Trouble breathing?
With or without activity?
Orthopnea? How many pillows do you use?
Cough?
Fatigued or tire easily?
Cardio and peripheral vascular system questions pertaining to the extremities.
Cold?
Pain?
Pallor?
Pulslessness?
Paresthesias? Numbness/tingling
Paralysis?

Leg

Itching?
Cramping?
Aching?
Heaviness?
Throbbing/burning?
Ankle swelling?
Hard to put shoe on?
Pain walking or at rest?
Personal history
Cocaine?
Drugs?
Alcohol?
Smoke?
How much/what kind/how often
Work out?
how often/what do you do
Personality type?
stress/relaxation
Diet?
red meat/whole grains/caffeine
Symptoms suggesting cardiac problems
Chest pain
Dyspnea
PND
Cough
Fatigue
Edema
Changes in extremities
Nocturia: peeing a lot at night
Syncope: fainting
Palpitations
Questions required for chest pain
Where is the chest pain?
Is it localized or radiating?
When did it start?
Is it constant or intermittent?
What symptoms are you experiencing with the pain?
Sweating?
Pale/grey?
Vomiting?
Anxiety?
Skipping beats or racing?
SOB?
What were you doing before the pain started?
Rest/exercise/highly emotional/sex
What makes pain worse?
What makes pain better?
rest/nitroglycerine/how many tabs of nitroglycerine
Questions required for SOB
How long have you had it?
Do you have it now?
When does it occur?
How often?
How long does it last?
Interfere with ADLs?
Any other symptoms associated?
What makes it worse?
stairs/orthopnea
What makes it better?
Questions required for a cough
When did the cough start?
How often do you cough?
DO you cough anything up?
What does it look like?
Does your position effect your cough?
Do you cough more laying down?
Anxiety?
Talk/activity?
What makes your cough worse?
What make your cough better?
Questions required for nocturia
(Peeing a lot at night)
How long has this been happening?
How many times a night?
How have you tried to prevent this?
How has the prevention methods worked for you?
What should you know about the heart and its past history?
Elevated lipid levels
Hypertension
Murmur
Cardiac catheterization
Congenital heart disease
Diseases requiring meds/surgery
Last ECG
Stress ECG
Questions required for fatigue
When did you notice it?
How long does it occur?
Sudden or gradual onset?
Effecting ADLs?
Iron pills?
High iron diet?
Heavy menstrual flow?
Symptoms associated with fatigue?
Headache/increased heart rate/pale
What makes it better?
What makes it worse?
Unusual feelings in hands/feet
Trouble thinking?
Muscle weakness?
Questions required for fainting
What were you doing before?
Did you lose consciousness?
Were there any associated symptoms before?
Chest pain/dizziness/nausea/confusion
evaluation of the heart
Inspect
Palpate
Percuss
Auscultate
Inspection of the heart
Apical impulse
Heaving/lifting:
Pulsations
Palpation of the heart
Apical impulse
Thrills, heaves, lifts
Percussion of the heart
Optional to determine size
Auscultation of the heart
All five sites
Aortic/pulmonic/erbs point/tricuspid/mitral
What are you looking for during auscultation of the heart?
Rate/rhythm
S1: the end of diastole, initiation of systole. Heard best at the apex. "Lub"
S2: the end of systole, beginning of diastole. Heard best at the base. "dub"
Splitting S2: the aortic and pulmonic valves do not close at the same time. "t-dub" Will not hear if breath is held
S3: Ventricular gallop
S4: Atrial gallop
Any extra heart sounds
thrill/friction rub
Symptoms suggesting peripheral vascular system
swelling
aching in limbs
sensation/skin changes
Fatigue
Arteriole Occlusion Assessment
Diminished blood flow to the tissues may indicate the site, severity, ability to cope
Intermittent Claudication
Cramping of the legs while walking due to decreased blood flow to the legs
Cramping subsides with rest
Contour types
Flat
Scaphoid
Rounded
Protuberant
Hyperactive sounds
Loud
High pitch
Tinkling
Suggest increased movement
Hypoactive sounds
Absent sounds
Happens after surgery
Arterial Insufficiency
Comes on during exercise
Goes away with rest shortly after
Ascites
Edema in the abdomen
S3
Kentucky
Normal in children
Goes away when sit up
AV valves close
S4
Tennessee
Right before diastole
Decreased ventricular compliance
Ventricular compliance
Atrium contracts and squeezes blood into a stiff ventricle
Murmur
Turbulence, viscosity and velocity of blood flow is heard over the heart
Murmur Scale
1: barely audible
2: Clearly audible
3: moderately audible
4: Loud with palpable thrill
5: palpable thrill and can be heard with stethoscope partially on chest
6: thrill and can be heard with stethescope off of the chest
Bruit
Turbulent blood flow heard over an artery
Venous hum
Blood turbulence heard over the jugular veins
Common in healthy children
Louder when standing
Can stop by pushing on jugular veins
Innocent murmur
Soft and musical
Goes away when sit up
No cardiac symptoms are associated
Functional murmur
Due to increased blood flow
Mammary soufflé
Murmur when the mother is near term or lactating
Stops with pressure
Pregnant Woman
Blood pressure lowers during beginning of pregnancy
Gradually raises throughout
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