Exam 2 Flashcards
Explain the mechanics of respiration:
- Bronchi split at base of trachea with one entering each lung and divide into tiny passages called bronchioles
*Alveoli’s (air sacs) at the end of each bronchiole have capillaries filled with RBC’s containing hemoglobin
*Diffusion occurs between O2 in alveoli and CO2 in capillaries
*O2 rich hemoglobin is transported though the bloodstream
*CO2 is exhaled
*Lung infections
*SOB
*Low oxygen level
*Abnormal breathing patterns
What subjective data would you collect regarding respiratory health?
*PQRSTU: Provocation, quality, region, severity, timing, understanding
*Cough
*SOB
*Chest pain
*History of respiratory health
*Smoking history
*Environmental conditions
*Self-care behaviors
*Privacy considerations
How do you protect client modesty during a respiratory assessment?
*Keep them as covered as possible during examination
*Maintain privacy
What is a normal breathing pattern?
10-20 breathes per minute with even pattern
What are the abnormal breath sounds (Adventitious Sounds)?
*Crackles
*Pleural Friction Rub
*Wheeze
*Stridor
What are crackles?
Popping sound heard over inspiration when there’s fluid in the lungs
*Fine Crackles: Short, high pitched crackling not cleared by coughing and heard during early or late inspiration
*Course Crackles: Loud, low pitched bubbling and gurgling early in inspiration
What is a pleural friction rub?
Course, low pitched with grating quality of two pieces of leather rubbing together. Heard on inspiration and expiration when pleurae become inflamed and lose normal lubricating fluid.
What is wheezing?
*High Pitched Wheezing: During expiration and caused by diffuse airway obstruction from acute asthma of chronic emphysema.
*Low Pitched Wheezing: During expiration, somewhat cleared by coughing and caused by bronchitis or single bronchus obstruction from airway tumor.
What is stridor?
High pitched inspiratory crowing sound that is louder in neck than over chest. Comes from larynx or trachea and is upper airway obstruction from swollen inflamed tissues or legged foreign object.
Tachypnea:
Rapid shallow breathing with respiratory rate of 24 breaths per minute or faster.
*Normal response to fever, fear, or exercise or with respiratory insufficiency, pneumonia, alkalosis, pleurisy, lesions
Bradypnea:
Respiratory rate less than 10 breaths per minute
*Can be from drug induced depression of respiratory center of medulla, increased intracranial pressure, or diabetic coma
Hyperventilation:
Increased rate and depths of breathing. Occurs with fear, anxiety, diabetic ketoacidosis, hepatic coma, salicylate overdose, lesions of the midbrain, alteration in blood gas concentration
Hypoventilation:
Irregular shallow breathing pattern caused by overdose, narcotics, anesthetics, prolonged bed rest or splinting of chest
Cheyenne-Stokes:
Respirations gradually wax and wane in regular pattern increasing in rate and depth then decreasing. Breathing periods last 30-45 seconds with apnea up to 20 seconds. Common cause is heart failure, renal failure, meningitis, drug overdose, increased intracranial pressure.
Chronic Obstructive Breathing:
Normal inspiration and prolonged expiration to overcome increased airway resistance.
*Chronic Obstructive Lung Disease: Any situation calling for increased heart rate may lead to dyspneic episodes because person doesn’t have enough time for full expiration.
What are the different chest shapes and their clinical significance?
*Elliptical Shape: Normal
*Barrel Shape: Ribs horizontal instead of downward slope - aging, COPD, asthma - hyperinflation of the lungs
*Kyphosis: Exaggerated posterior curvature of thoracic spine (humpback) - aging, postmenopausal osteoporotic women
*Scoliosis: S shaped curvature of thoracic and lumbar spine
What is a healthy percussion note?
*Low pitched, clear, hollow sound for healthy lung tissue
*Flat sound over scapula
*Dull over organs
Bronchial Sounds:
*Heard over trachea and larynx
*Expiration is heard longer than inspiration and are not heard on the posterior side
Bronchiovesicular Sounds:
*Heard over the main bronchi
*Inspiration and expiration are about equal in loudness and time
Vesicular Sounds:
*Heard over peripheral lung fields where air flows through the smaller bronchi
*Inspiration is heard louder and longer than expiration
Pleural Effusion:
Excess fluid in inter pleural space with compression of overlying lung tissue
CM: Dyspnea, increased respirations, absent breath sounds, crackle or pleural rub, dull percussion
Pulmonary Embolism:
Undissolved material that originates in leg or pelvis, detaches, and travels in venous system occluding pulmonary vessels.
CM: Chest pain worse on inspiration, dyspnea, restless, anxiety, mental status change, cyanosis, tachypnea, cough, pulse oximetry less than 80%, crackles, and wheezing
Heart Failure:
CM: Increased respiratory rate, dyspnea on exertion, orthopnea, paroxysmal, nocturnal dyspnea, nocturia, ankle edema, pallor - S3 sounds and crackles
Vital Capacity:
Maximum amount of air a person can expel from lungs after first filling the lungs to maximum
Tidal Volume:
Amount of air that moves in or out of lungs with each respiratory cycle
Inspiratory Volume:
Amount of air that can be forcibly exhaled after a normal tidal volume
Blood flow through the heart:
*Body
*To Superior and inferior vena cava returning unoxygenated blood
*To right atrium
*Through tricuspid valve
*To right ventricle
*Through pulmonary valve
*To pulmonary arteries
*To the lungs
*To pulmonary vein which returns oxygenated blood
*To left atrium
*Through mitral valve
*To left ventricle
*Through aortic valve
*To Portia
*To body
What are the phases of the cardiac cycle?
Diastole and Systole
What is the protodiastolic phase?
First part of diastole, when all chambers of the heart are relaxed and blood fills the ventricles with passive filling. AV (Tricuspid and Mitral) valves are open and semilunar valves (Aortic and Pulmonary Valves) are closed - S3 sound
What is diastole?
Occurs when ventricles relax and fill with blood
*Made up of Protodiastolic phase and Atrial Systoles of Pre-Systole Phase
What are the atrial systoles of the pre systole phase?
Second part of diastole, when atria contract and push last amount of blood into ventricles. Active filling. AV valves open and semilunar valves closed - S4 sound.
What is systole?
Heart muscle contracts and pumps blood from the chambers to the arteries.
What are the phases of systole?
*Begins when blood pressure in ventricles causes AV valves to shut - creating S1 sound.
*Ventricular isovolumetric contraction: When all 4 valves are closed ventricles begin to contract which raises ventricular pressure even more until pressure is high enough to open semilunar valves.
*Ejection: When semilunar valves open and blood is ejected from ventricles to body via aortic valve and aorta or to the lungs via pulmonic valve and pulmonary artery. Come blood falls back towards semilunar valves triggering them to shut, this ends systole - S2 sound heard.
What subjective data would you gather in cardiovascular assessment?
*Chest pain
*Cough
*Fatigue
*Cyanosis
*Pallor
*Nocturia
*Past Cardiac History
*Risk Factors
*Family History
S1 Heart Sound:
When A/V valves close at the beginning of systole - lub sound loudness at apex of heart
S2 Heart Sound:
When semilunar valves close at end of systole - dub sound loudest at base of heart - split S2 can be normal
S3 Heart Sound:
Sound of ventricular filling in early diastole - heard beast at apex of heart with bell of stethoscope
S4 Heart Sound:
Also heard during ventricular filling but in late diastole - head best at apex of heart with bell of stethoscope - occurs due to decreased compliance of the ventricles as well as stiffened heart muscles
Points of Auscultation:
APE To Man
*A: Aortic Valve (S2 Louder)
*P: Pulmonic Valve (S2 Louder)
* E: Erb’s Point (S1=S2)
*To: Tricuspid Valve (S1)
*Man: Mitral Valve (S1)
Cardiovascular Inspection:
Inspect anterior chest wall for pulsation or movement and check apical pulse
Hemodynamic Changes with Aging:
*Increased in systolic BP due to stiffening arteries
*Decrease of diastolic BP
*Decreased ability for heart to adapt to cardiac output
*Supraventricular and ventricular dysrhythmias
Ectopic Heart Beats (Extra or skipped beats)
*Increased risk of cardiovascular disease
Health Promotions for the Cardiovascular System:
*BP Screenings
*Not Smoking
*Maintain Healthy BMI
*No drug use
*Heart healthy diet
*Maintain healthy blood sugar
*Early Screenings
*Regular aerobic exercise
*Low dose aspirin
What is the modified Allen’s Test?
Measure’s how well blood flows in the ulnar artery.
*Occlude radial and ulnar arteries
*Have client open and close hand 10 times
*Client should open hand without hyperextending it
*Stop occluding one of the arteries
*Normal Result: Blood returns to hand within 5 seconds.
*If doing other hand release opposite artery
*Abnormal Result: If blood doesn’t return to hand within 5 sec then that artery doesn’t have sufficient blood supply
Radial Pulse:
Wrist - same time
Brachial Pulse:
Crook of elbow - same time
Carotid Pulse:
Neck - separately
Popliteal Pulse:
Behind knee - can do together or separately
Posterior Tibial:
Inner ankle near bony prominence - same time
Dorsalis Pedis:
Top of foot - same time
Cervical Lymph Nodes:
Drain head and neck
Axillary Lymph Nodes:
Drain breast and upper arm
Epitrochlear Lymph Nodes:
Drain the hand and lower arm
Inguinal Lymph Nodes:
Drain most lymph of lower extremity, external genitalia, and anterior abdominal wall
Brachial Artery:
In biceps-triceps furrow of upper arm
Radial Artery:
Medial to radius at wrist on thumb side
Ulnar Artery:
Medial to ulna on pinky side of hand but deeper and harder to find than radial
Femoral Artery:
Travels down thigh
Popliteal Artery:
Behind knee
Anterior Tibial Artery:
Travels down front of leg onto dorm
Dorsalis Pedis Artery:
Top of foot
Posterior Tibial Artery:
Felt on inside of ankle by medial malleolus
Deep Veins (Femoral, Popliteal):
If these remain intact then superficial veins can be excised without harming circulation
Superficial Veins (great saphenous vein, small saphenous vein):
Only have one way valves that route blood from superficial Ito the deep veins and prevent back flow to superficial veins
Pulmonary Veins:
Carry the blood from the lungs back to the heart after the blood is reoxygenated
Normal lymph node findings:
Moveable, non-tender, and relatively soft
what is lymphedema?
Condition in which protein rich lymph builds up in interstitial spaces
Peripheral Vascular Lymphatic Assessment: Normal changes of aging?
*Arteriosclerosis: Blood vessels grow more rigid
*Atherosclerosis: Deposits of fatty plaques in arteries
*Loss of lymphatic tissue
*Enlargement of intramuscular calf veins
Peripheral Arterial Disease (PAD):
*Not enough blood in extremities
*6 P’s: Pain, pallor, pulselessness, paresthesia, poikilothermic (cold), paralysis
*Dependent rubor (red or blue) when legs are in independent position but not when they’re elevated
*Shiny skin
*Thick rigid nails
*Hair loss on lower legs
*Pain in calf or foot that’s worse with elevation
*No edema
*Treatment: Dangle extremities to get blood back to them
Peripheral Venous Disease (PVD):
*Blood stuck in extremities
*Lower leg edema
*Pain in calf/lower leg that’s worse with prolonged sitting/standing
*Normal pulses
*Brown pigment discoloration
*Warm leg
*Venous stasis ulcers: shallow and irregular
*Treatment: Elevate veins to get blood back to heart
Reynauds Disease:
When a person has episode of abrupt, progressive, tricolor change on fingers in response to cold, vibration, and stress.
3 color changes of Reynauds disease:
- Whiteness from deficit blood supply
- Blue from slight relaxation of spasm that allows slow trickle of blood through capillaries and increased O2 extraction from hemoglobin
- Redness or rumor in heel of hand caused by return of blood intro dilated capillary bed or reactive hyperemia
Subjective data for abdominal assessment:
*Appetite
*Dysphagia
*Food intolerance/allergies
*Abdominal pain
*Nausea/vomiting
*Bowel habits
*Medications
*Bloating
*Over 50: colon cancer screening
*24 food recall
Relaxation techniques for abdominal exam:
*Have client empty bladder beforehand
*Comfortable room temp.
*Client lays on back with knees bent
*Warm hands
*Distract client with conversation
*Save painful areas for last
Objective data for abdominal assessment:
Save painful areas for last!!
*Inspect
*Auscultation: RLQ>RUQ>LUQ>LLQ
*Percussion
*Light palpation
*Deep palpation
Recommended frequency of a mammogram?
For women 40 and up: Annual mammogram
*Mammogram device squeezes breasts and can be painful
Tips for getting a mammogram:
- No deodorant, cream, lotion, or powder on underarms or breasts
*Avoid caffeine
*Bring previous mammograms
*Schedule when breasts aren’t tender
If lump on breast is reported:
*Note location
*Measure size
*Note shape
*Assess consistency
*Assess mobility
*Note distinctness
*Examine nipple
*Note skin over lump
*Assess tenderness
*End with lymphadenopathy
What findings would be concerning on breast exam?
*Nipple discharge
*Mass
*Skin changes
Head, face, and neck subjective data:
*Headaches
*Head injury
*Dizziness
*Neck pain
*Lumps or swelling in the neck
*Smoking
*Alcohol use
*Thyroid issues
*Surgery history
Head, face, and neck normal changes with aging?
*Facial bones and orbital more prominent
*Facial skin sags due to decreased elasticity
*Decreased subcutaneous fat
*Decreased moisture in skin
What is a goiter?
A visibly enlarged thyroid
What is PERRLA?
Pupils equal round reactive to light and accommodation
Snellen Chart:
Most commonly used accurate measurement of visual acuity
Consensual pupillary response:
Change in pupil size in eye opposite to the eye which the light is directed
Direct pupillary response:
Change in pupil size in eye to which the light is directed
Corneal Light Test:
*Assesses for parallel alignment of eyes
*Shine light tot persons eye and have them stare straight ahead as you hold light 12 inches away - note reflection o flight on the corneas
Cover/Uncover Test:
*Follow up for abnormal results of corneal light test
*Have client stare straight ahead at your nose, cover one eye with opaque card and watch uncovered eye. Should have a steady fixed gaze.
Uncover and observe eye - should still be staring straight ahead.
6 Cardinal Fields of Gaze:
*Hold finger 12 inches away from face and move it in a cat whisker pattern of 6 points.
*Both eyes should move parallel to the test.
Confrontation Test:
*Peripheral vision test
*Position yourself 2 ft away from client at eye level. Client looks straight at you, cover on eye with opaque card. Hold wiggling finger as target midline and slowly advance it from periphery in several directions. Estimate angle where object is first seen.
Aging considerations of the eyes:
*Loss of depth perception or central vision
*Decreased tear production
What is diplopia?
*Double vision
What is nystagmus?
Jerky movements of the eye
What is strabismus?
Deviation in axis of the eye
