Exam 2 Blueprint Flashcards
What is Stage 1 of a pressure ulcer?
Stage 1: skin is unbroken but inflamed; nonblanchable erythema of intact skin
AV valves - location and function
Tricuspid valve - between RA and RV
Mitral Valve - between LA and LV
What is Stage 4 of a pressure ulcer?
Stage 4: ulcer extends to muscle or bone; undermining is likely; exposed bone, tendon, or muscle
What are the focused questions for the lymphatic system?
- have you noticed any swollen glands or lumps?
– where are they located?
– how long have you had them?
– is the swelling continuous or occasional?
– what makes the swelling better or worse? - any recent changes in size?
- how do they feel to you: hard, soft?
- are any of the swollen glands associated with pain or local infection?
Normal breath sounds - description and location
B, BV, V
Bronchial: over trachea and large bronchi; tubular sound; high pitched hollow sounds
Bronchovesicular: medium-pitched sounds
Vesicular: inspiration louder and longer than expiration, low pitched sounds
Auscultation: Carotid Artery
How to do it
use the bell of stethoscope: better for higher grade stenosis
- place bell near upper end of thyroid cartilage, below angle of the jaw
have client take a breath, exhale, and hold briefly while you listen for <10 seconds
- listening for bruits
Arteries of arms and legs: pulse descriptions and grading of pulses
Grade force (amplitude) of pulse on a three-point scale:
0: absent
+1: diminished, weak, thready
+2: brisk, normal
+3: full, bounding
What is the acute wound classification?
Healing time: days to weeks
Edges well-approximated (can see are closing together)
Decreased risk of infection
Thorough healing process without delay
What is a deep tissue pressure injury?
Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration
What are ABCDE-EFG Lesions on Skin assessment
A - asymmetry
B - border
C - color
D - diameter
E - evolving
E - elevated
F - firm to palpation
G - growing progressively over several weeks
Palpation - cardiovascular assessment: Carotid artery
Info on carotid artery, how to palpate
carotid artery is a central artery
- palpate pulse, carotid upstroke, amplitude and contour, presence or absence of thrills
- timing closely coincides with ventricular systole (beginning of S1)
- located in groove between trachea and SCM muscle; medial to and along side it
provides information about cardiac function (aortic valve stenosis and regurgitation)
palpate bilaterally - avoid excessive pressure and palpate one at a time
**height of pulsations unchanged by position and not affected by inspiration
**
to palpate:
- patient should be supine with head of bed at 30 degrees
- inspect for visible pulsations - often just medial to SCM muscle
- index and middle fingers in lower third of neck and palpate
- want equal bilaterally, smooth contour, brisk
– decreased pulsations: decreased stroke volume from shock or MI and local atherosclerotic narrowing or occlusion
Focused questions to ask during respiratory assessment - continued
Smoking:
- packs per day (PPD)
- when did you start? cough with it? what kind?
Environment:
- work
- animals
- chemicals
Medications:
- some can cause a cough
- inhaler
Allergies:
- do you have any allergies?
- reactions to allergens?
Self-care behaviors?
- mask when cleaning? fragrances?
What is Stage 2 of a pressure ulcer?
Stage 2: skin is broken to epidermis or dermis; partial-thickness skin loss - shallow, open ulcer
Developmental Considerations for peripheral vascular assessment - pregnant women
edema: expect diffuse bilateral pitting edema in the LEs, especially at the end of the day and into the 3rd trimester
varicose veins: often seen in 3rd trimester
- veins are dilated and tortuous
- vein walls may feel somewhat thickened
Focused questions to ask during respiratory assessment for an aging adult
Have you noticed any SOB or fatigue with your daily activities?
Tell me about your usual amount of physical activity.
History of COPD, lung cancer, or TB
- how are you getting along each day?
- any weight change in the last 3 months? increase or decrease? how much?
How is your energy level? Do you tire more easily? How does your illness affect you at home and at work?
Do you have any chest pain with breathing?
Do you have any chest pain after a bout of coughing or after a fall?
Developmental considerations - cardiovascular assessment:
Infants and children: average heart rates
Years 1-2; Years 2-6; Years 6-10
Years: 1-2
– average rate: 110-120
– range: 88-155
Years: 2-6
– average rate: 100-110
– range: 65-140
Years: 6-10
– average rate: 75-90
– range: 52-130
Nail Assessment - integumentary system
Clubbing
Beau’s lines: transverse depressions that appear as white lines across the fingernails
– sign of acute severe illness; malnutrition
– or sign of systemic disease, trauma, or coronary occlusion
Splinter Hemorrhage: linear bleeding under a nail resembling a splinter
– seen after trauma and in bacterial endocarditis
Pitting: small punctate indentations in nails; often result of psoriasis
Pleural friction rub
What is it and sound
- inflammation of the lung tissues
- raspy breathing sound
Aging adult skin considerations
Elasticity - loses elasticity, skin folds and sags
Sweat and sebaceous glands - decrease in number and function; leaving skin dry
Skin breakdown due to multiple factors - cell replacement is slower; wound healing delayed
Senile purpura - discoloration due to increasing capillary fragility
Hair matrix - functioning melanocytes decrease, leaning to gray fine hair
Keratoses - raised thickened area of pigmentation, crusty or warty in appearance
Skin tags - overgrowth of skin with a stalk
Auscultation: Heart sounds - where to listen
Identify auscultatory areas: four traditional valve areas and Erb’s point
– valve areas are not over actual anatomic locations on valves but sites on chest wall where sounds are best heard
sound radiates with blood flow direction
“All people eat taco meat”
aortic valve area: 2nd right ICS; S2
pulmonic valve area: 2nd left ICS; S2
Erb’s point: 3rd left ICS; S1=S2
tricuspid valve area: 4th left ICS; S1
mitral valve area: 5th left ICS @ MCL; S1
Structure and more functions of the skin
Epidermis: outer highly differentiated layer
– Basal cell layer forms new skin cells - contains keratin
— melanocytes: derivation of skin color
– Outer horny cell layer of dead keratinized cells (outer layer)
— replaced every 4 weeks
Dermis: inner supportive layer
– connective tissue (collagen)
– elastic tissue
Subcutaneous: adipose tissue
Focused questions for cardiovascular - continued
- chest pain: do you have any chest pain or chest discomfort
- dyspnea: any shortness of breath?
- orthopnea: how many pillows do you sleep with? comfort or breathing?
- cough: when does it occur?
- edema: in feet or legs? socks/shoes tight?
- syncope: any LOC or dizzy getting up?
- nocturia: getting up to pee at night?
- cyanosis: changes in lips or fingertip color - blue?
What is the chronic wound classification?
Do not move through normal sequence of repair (remains in inflammatory phase)
Edges often not approximated (not closing or connected)
Increased risk of infection
Healing time delayed
What are complications of wounds
Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation
Developmental considerations: Aging changes of skin
Decreased ___
- thinner, more easily damaged
- decreased sensation of pressure
- decreased sweat gland activity - drier skin
- decreased cell renewal - delayed healing
- decreased melanocytes - gray/white hair and uneven pigmentation of skin
Developmental considerations - cardiovascular assessment: Pregnancy
Blood volume increases by 30-40% during pregnancy
- most rapid expansion occurs during 2nd trimester
- creates an increase in stroke volume and cardiac output and increased pulse rate of 10-15 bpm
- despite increased cardiac output - arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation
– BP drops to lowest point during 2nd trimester then rises after that - BP varies with person’s position
Developmental considerations for peripheral vascular assessment for aging adults
DP and PT pulses may become more difficult to find
trophic changes associated with arterial insufficiency may be seen:
- thin, shiny skin
- thick, ridged nails
- loss of hair on lower legs
What are primary skin lesions
They are the immediate result of specific causative factor; develop on previously unaltered skin
Respiratory assessment considerations with illness
may need to roll from side to side
limits comparison
Rate and rhythm of breathing
Normal: 10-20 breaths per minute, even pattern, normal depth (sticking to 10-20 for this class even though book says 12)
Tachypnea: >25 per minute, rapid, shallow
Bradypnea: <10 per minute
Apnea: periods of not breathing
Hyperventilation: increase rate and depth
Hypoventilation: irregular, shallow
Adventitious breath sounds
JVP (jugular venous pressure)
reflects the right side of the heart
assess filling pressure and volume status
- volume and pressure increases when right side of heart fails to pump efficiently
- gives info about the right side of heart because no cardiac valve to separate superior vena cava from right atrium
empties unoxygenated blood directly into superior vena cava
two jugular veins on each side of neck - internal and external
JVP is the highest oscillation point; at what level do pulsations stop? when can you no longer see jugular venous pulse?
- the higher the venous pressure, the higher the position you need
- jugular veins correspond to central venous pressure
- elevate JVP correlates with acute and chronic HF: tricuspid stenosis, chronic pulmonary HTN, superior vena cava obstruction, cardiac tamponade, constrictive pericarditis
considered elevated when JVP is >3cm above sternal angle or more than 8cm in total distance above RA
S2 and where in the cardiac cycle
S2 occurs when semilunar valves close
signals end of systole
heard over all of precordium - loudest at base
Palpation - respiratory assessment - assessing chest expansion
- place thumbs at the level of the 10th ribs, fingers loosely grasping and parallel to the lateral rib cage
- position hands and slide them medially just enough to raise a loose fold of skin between thumbs over spine
- ask patient to inhale deeply
- watch distance between your thumbs as they move apart during inspiration
- feel for the range and symmetry of the rib cage as it expands and contracts
What is the Ankle-Brachial Index?
it assesses for peripheral arterial disease (PAD); is the ratio of BP measurements in the foot and arm
- two measurements taken and then average is used as the recorded pressure
ABI = (systolic ankle pressure)/(highest systolic brachial pressure)
Pediatric Auscultation in respiratory assessment
Differences in this assessment because it’s pediatric
Bowel sounds are easily heard in the chest
Use smaller pediatric diaphragm end piece; or bell over infant’s interspaces and not over ribs
Bronchovesicular breath sounds in peripheral lung fields of infant and young child up to ages 5/6 years old
Fine crackles are commonly heard in immediate newborn period from opening of airways and clearing of fluid
Palpation in respiratory assessment: tactile fremitus findings
Decreased, increased, crepitus and what to assess
Decreased/absent: voice is higher pitched or soft
- something obstructs the transmission of vibration
- COPD, pleural effusion, fibrosis, pneumothorax, infiltrating tumor, emphysema
Increased:
- compression or consolidation of lung tissue
- lobar pneumonia
Crepitus:
- coarse, crackling over skin surface
- subQ emphysema (when air is in tissue and can feel it; can happen with chest tubes)
Assess:
- temperature
- lesions
- masses
- wounds
Posterior ribs landmarks
Vertebrae
Spinous processes
Scapulae
12 ribs
Developmental considerations - respiratory assessment: Older Adult
Less mobile thoracic cavity: calcified costal cartilages
Decreased elastic properties within lungs (decreases recoil)
Increased risk of pneumonia
Decreased number of alveoli: less surface area available for gas exchange
Lung bases become less ventilated as a result of closing off of a number of airways
Focused questions to ask during respiratory assessment?
Shortness of breath (SOB) or dyspnea:
- Have you had any difficulty breathing?
- Rest, exertion, how much exertion
- Supine (orthopnea) or at night (paroxysmal nocturnal dyspnea), relieved by sitting
Cough:
- what brings on a cough?
- Hemoptysis: do you cough up blood?
– what does it look like, what brings it on, when did it start, quantity?
- do you have any allergies? What kind and what happens?
Chest pain (CP) with breathing:
- do you have any chest pain or chest discomfort?
Respiratory infection:
- have you had any respiratory infections? often?
Developmental considerations - cardiovascular assessment: aging adult continued
amount of collagen in heart increases and elastin decreases
– affect the contractile and distensible properties of the myocardium
heart valves become thick and stiff
increased need for pacemakers
– SA node fails
risk of orthostatic hypotension
increase incidence of CAD, HTN, and HF
Palpation - integumentary system
Temperature:
- use backs of hands
- should be warm and temperature equal bilaterally
- warmth suggests normal circulatory status
- hands and feet may be slightly cooler in cooler environment
Moisture:
- diaphoresis
- dehydration
Texture
Thickness
Edema (1-4)
Mobility and Turgor
Heart murmurs - descriptions
descriptions based on blood flow
are the result of turbulent blood flow
can be stenotic - valve opening progressively decreases in size and forward flow of blood is restricted
can be regurgitation - valve does not completely close; backflow into chamber causing overload and dilation
What are the stages of edema
Measures the severity of pitting edema, determined by applying pressure to the affected area of skin
1+: Barely detectable impression when finger is pressed
into skin. May have mild pitting, slight indent, no
perceptible swelling of legs
2+: Slight indentation; 15 seconds to rebound
3+: Deeper (pitting) indentation, 30 seconds to
rebound, leg looks swollen
4+: >30 seconds to rebound, leg is severely swollen
What is the lymphatic system
forms a completely separate vessel system; drains excess fluid from body tissues/interstitial spaces and returns it to the venous circulation
- empties into the venous system at the subclavian veins
includes the spleen, thymus, lymph nodes, and lymph channels; tonsils and adenoids
Fine Crackles
- softer, higher pitched
- more frequent per breath than coarse
- mid to late inspiration; dependent areas of the lungs, varies with positioning - Fluid shift
Percussion - respiratory assessment
advanced assessment
- producing audible sound and palpable vibrations
- establish whether underlying tissues are air-filled, fluid-filled, or consolidated
- normal: resonance
- abnormal: hyperresonance (COPD); dull (pneumonia)
anteriorly:
- heart produces dullness to the left of the sternum from the 3rd-5th ICS
- gently displace the breast in women
What are the node locations in UE and LEs?
UE:
- axillary lymph nodes drain most of the arm
- epitrochlear nodes: ulnar surface of the forearm and hand, 3rd/4th fingers, adjacent surface of middle finger
LE:
- lymphatics are both deep and superficial systems
- superficial nodes are palpable
- superficial inguinal nodes:
– horizontal group
– vertical group
What is the intentional wound classification?
Result of planned invasive therapy or treatment
Wound edges are clean and bleeding is usually controlled
Decreased risk for infection
Healing is facilitated
Inspection - integumentary system
THings to note about appearance
Color - know baseline
General pigmentation, freckles, moles, birthmarks
Widespread color change:
- note color change over entire body
- white (pallor): reflects anemia
- red: erythema
- blue: cyanosis
- yellow-orange: jaundice
