^Ch. 29 Thorax Heart Abdomen Flashcards
Midsternal line
is through the center of the sternum
midclavicular line
is through the midpoint of the clavicle
anterior axillary line
is through the anterior axillary folds
midaxillary line
is through the apex of axillae
posterior axillary line
is through the posterior axillary fold
the right and left scapular lines
are through the inferior angle of scapula
vertebral line
is along the center of the spine
Dysrhythmia
occurs when the heart fails to beat at a regular successive interval
Gallops
are extra heart sounds.
ventricular gallops
occurs after S2 sounds like Ken-tuck-y
Arterial gallop
occurs before S1 sounds Ten-es-see
Murmurs
are audible when blood volume in heart increased or its flow is impeded or altered
systolic murmurs
occur just after S1
Diastolic murmur
occur just after S2
percussion
compare sounds from side to side
-percussion of the thorax elicits resonance
unexpected finding percussion
dullness- fluid or solid tissues, this can indicate pneumonia or a tumor
-hyper-resonance: in the presence of air, this can indicate pneumothorax or emphysema
Auscultation Bronchial sounds
loud, high pitched, hollow quality, expiration longer than inspiration over the trachea
Auscultation Broncho vesicular
medium pitch, blowing sounds and intensity with equal inspiration and expiration times over the larger airways
Auscultation vesicular
soft, low pitched breezy sounds inspiration three times longer than expiration over most of the peripheral areas of the lungs
Crackles or rales
fine to coarse bubbly sounds (not clear with coughing) as air passes through fluid or re-expands collapsed small airways
wheezes
high pitched whistling, musical sounds as air passes through narrowed or obstructed airways usually louder on expiration
rhonchi
coarse loud low pitched rumbling sounds during either inspiration or expiration resulting from fluids or mucus can clear with coughing
pleural friction rub
dry, grating or rubbing sounds as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration
Absence of breath sounds
from collapsed or surgically removed lobes
S1 sound
closure of mitral and tricuspid valve signals signals the beginning of ventricular systole (contraction)
S2 sounds
closure of the aortic and pulmonic valves signals the beginning of ventricular diastole (relaxation)
S3 sounds
ventricular gallop
indicates rapid ventricular filling and can be an expected finding in children and young adult
S4 reflects
a strong atrial contraction and can be an expected finding in older and athletic adult and children
Thrills
are palpable vibration that can accompany murmurs or cardia malformation
Bruits
are blowing or swishing sounds that indicate obstructed peripheral blood flow
Auscultatory sites of the heart
Aortic pulmonic Erb's point tricuspid apical/mitral
Peripheral vascular system
inspect jugular system
Jugular venous pressure (JVP)
measure at less than 2.5 cm (1in) above the sternal angle
Apical pulse or Point of maximal impulse
Can be visible just medial to the left midclavicular line at the forth or fifth ICS
Halves (lifts)
are unexpected, visible elevations of the chest wall that indicate heart failure and are often along the left sternal border or at PMI
Thrills
use the palm of the hand to feel for vibration similar to that of purring kitten (unexpected finding)
bruits
are blowing or swishing sounds that indicate obstructed peripheral blood flow
Auscultatory sites for the heart
Aortic pulmonic Erb's point Tricuspid Apical/mitral
Peripheral vascular system assess for bruits
- Carotid arteries
- abdominal aorta
- renal arties: above umbilicus
- iliac arteries: below the umbilicus
- femoral arteries: femoral pulses
assess skin for
- lesions: bruising, rashes
- scars: location length
- silver striae or stretch marks
- dilated veins
- Jaundice, cyanosis ascites
assess skin for shape or contour
- flat
- convex: rounded
- concave: a sunken appearance
- distended: a large protusion of the abdomen due to fat, fluid flatus.
Distended fluid
flanks also protrude and when the client turns onto one side the protrusion is mainly midline and there us no change in the flanks
distended hernias
protrusion through the abdominal muscle wall are visible, especially when the client flexes the abdominal muscles
distended flatus
the protrusion is mainly midline and there is no change in the flanks
Peristalsis
wavelike movement visible in thin adults or in pts who have intestinal obstruction
pulsations
regular beats of movement midline above the umbilicus are expected finding in thin adults. BUT pulsating mass is unexpected
expected bowl sounds in tummy
5-35/min
Seven key chest landmarks
- Midsternal line
- midclavicular line
- anterior axillary
- midaxillary line
- posterior axillary line
- R L scapular lines
- Vertebral lines
a nurse is performing a breast examination for an older adult who is post menopausal. which of the following finding should the nurse expect?
Smaller nipples
more pendulous
nipple inversion
A nurse is auscultating and percuss a thorax. which finding should the nurse expect
- Resonance
- Broncho vesicular sounds
Nurse listens on the left midclavicular line at the 5th ICS. which data is the nurse attempting to auscultate
- closure to mitral valve
- apical heart rate
nurse auscultate and percuss a clients abdomen. what finding should the nurse expect
Tympany
high pitched clicks
