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
Inspection - respiratory assessment - 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
Developmental considerations - cardiovascular assessment: Infants and children
- fetal heart begins to beat after 3 weeks’ gestation
- right and left ventricles equal in weight and muscle wall thickness and both pumping into systemic circulation
- inflation and aeration of lungs at birth produces circulatory changes
- at birth and after, blood is oxygenated through lungs rather than through placenta
- at birth and after, the left ventricle has greater workload of pumping into systemic circulation
Developmental considerations - respiratory assessment: Infants and children
Infant: body systems develop in utero
Respiratory system alone does not function until birth
Children: respiratory development continues throughout childhood
Thoracic landmarks
Thoracic cage
- sternum
- ribs: 12 pairs
– ribs 1-7: attach to sternum - costal cartilages
– ribs 8, 9, and 10: attach to costal cartilage above
– ribs 11 and 12: floating
– costochondral junctions (joint): connect the ribs to the costal cartilage
Thoracic vertebrae - 12
Diaphragm
What are the classifications of wounds
Intentional
Unintentional
Open wound
Closed wound
Acute
Chronic
Inspection - respiratory assessment
Usually starting back and working towards the front
- symmetry, deformities
- muscle retraction: intercostal spaces during inspiration
- lag: delay
- chest shape: normally wider than it is deep
- anteroposterior diameter (AP) to the lateral chest (AP:L): want 1:2; increases with age
- patient’s position
- skin: cyanosis, pallor, clubbing of fingers
Risk factors for skin integrity to note during skin assessment
IV drug use
Prolonged sun exposure
Body piercing
Increased age
Dehydration and Malnutrition
Reduced sensation
Diabetes
GI preparations for testing - dehydration
Bedrest - pressure ulcers
Casts - breakdown unseen; pressure
Medications
Radiation therapy
What is an unstageable pressure ulcer?
Unstageable: base of ulcer covered by slough and/or eschar in wound bed
Heart Murmur locations
aortic area: right 2nd ICS
pulmonic area: left 2nd ICS
erb’s point: 3rd left ICS
tricuspid area: 4-5th ICS left sternal border
mitral area: 5th ICS MCL
Focused questions for cardiovascular
- chief complaint present illness
- past medical/health history
- medications: current and past, and reason
- surgery or treatments
- lifestyle management
- family medical history
– cardiac history
– immediate family members: age, current health status, cause of death, age of death - nutrition
- cholesterol screenings: LDL (want low), VLDL, HDL (want higher)
Blood flow through the heart
right heart: deoxygenated blood
- enters the heart through the superior vena cava from upper body; inferior vena cava from lower body
- goes into the right atrium
- tricuspid valve opens and blood flows from RA to RV
- RV contracts and pumps blood to the lungs
- pulmonary valve opens and blood flows from RV to pulmonary artery
- pulmonary artery carries deoxygenated blood to the lungs
Left Heart: oxygenated blood
- returns to the heart through the pulmonary veins
- pulmonary veins allows blood to enter LA
- LA: oxygenated blood flows from LA to LV through mitral valve
- LV pumps the oxygenated blood to the aorta, passing through aortic SL valve
- aorta distributes oxygenated blood to the rest of the body (systemic circulation)
Ankle-Brachial Index Values
ABI value greater than 1.4:
– calcification/vessel hardening
– refer to vascular specialist
ABI value 1.0-1.4:
– normal
– no recommendation
ABI valve 0.9-1.0:
– acceptable
– no recommendation
ABI value: 0.8-0.9:
– some arterial disease
– treat risk factors
ABI value 0.5-0.8:
– moderate arterial disease
– refer to vascular specialist
ABI value less than 0.5:
– severe arterial disease
– refer to vascular specialist
What are Cheyne-Stokes respirations?
periods of deep breathing alternating with periods of apnea
in a severe state; can be seen when a patient is dying
Percussion - cardio assessment (advanced assessment)
advanced. no notes in PPT.
More Heart Murmur descriptions - what they can be described by
timing: systolic or diastolic
duration: short or long
location: where it is the loudest, radiates
position patient: left lateral decubitis or sitting up
shape: crescendo, decrescendo, or holosystolic
grading and intensity
- pitch: low, medium, or high
- quality: blowing, harsh, rumbling, or musical
Abnormal assessment findings in respiratory assessment
- Shortness of breath (SOB) or dyspnea
- Cough
– mucus, pus, blood
– allergens: dust, foreign bodies, hot or cold air - Chest pain (CP) w/ breathing
- Respiratory infection
– viral upper airway, bacterial infection
– pneumonia - Orthopnea - supine
- Cheyne-Stokes respirations
- Biot’s (Ataxic) Breathing
- Abnormal vocal sounds (advanced assessment)
– egophony, bronchophony, whispered pectoriloquy
What are focused questions regarding skin, hair, and nails?
Past history of skin disease, allergies, hives, psoriasis, or eczema?
Change in pigmentation or color?
Change in mole size, shape, color, tenderness?
Excessive dryness or moisture?
Pruritus or skin itching?
Excessive bruising?
Rash or lesions?
Medications: prescription and OTC?
Hair loss?
Change in nail shape, color, or brittleness?
Environmental or occupational hazards? Chemicals or sun?
Self-care behaviors: tanning, lotions, fragrances, ointments?
What are lesions - shapes and configurations - on skin assessment?
Annular or circular
Confluent - growing into each other
Discrete - one area
Grouped - little groups
Target or Iris “Bulls Eye” - Lymes
Linear - common in shingles
Zosteriform - herpes
Stridor
- high-frequency, high-pitched musical sound produced during airflow through a narrowing in the upper respiratory tract
- obstruction - foreign body
Anterior Chest Wall Landmarks
Suprasternal Notch
Sternum
– Manubrium
– Body
– Xiphoid process
Sternal Angle-angle of Louis
Costal Angle
Anterior ribs landmarks and intercostal spaces
What are functions of the skin?
skin is waterproof, protective, and adaptive
- protection from environment
- body temperature regulation
- prevents penetration
- perception
- temperature regulation
- psychosocial
– identification
– communication
- sensation
- vitamin D production
- immunologic
- absorption
- elimination
- wound repair
Palpation - cardiovascular assessment
- carotid artery
- PMI (apical pulse)
- pericardium
Adventitious sounds - wheezing
- continuous musical sounds
- occur during rapid airflow when bronchial airways are narrowed
- heard throughout the lung
- inspiratory, expiratory, or biphasic
- asthma, mucous plug, tumor
Infant Auscultation in respiratory assessment
Diaphragm is newborn’s major respiratory muscle
count respiratory rate for 1 full minute
normal rates 30-40 breaths (may spike up to 60)
most accurate respiratory rate is when the infant is asleep
Brief periods of apnea (less than 10-15 seconds) are common
– is more common in premature infants
Peripheral vascular assessment - focused questions
- chief complaint present illness
- do you have any leg pain or cramps?
- have you noticed any skin changes on your arms or legs?
- have you noticed any swelling/edema anywhere on your body?
- have you noticed any swelling/enlargement of your lymph nodes?
- medications: current and past, and reason
- smoking: PPD
What is the closed wound classification for wounds?
Results from a blow, force, or strain caused by trauma
Skin surface is not broken
Soft tissue damage, internal injury, and hemorrhage (may occur)
Older adult respiratory considerations
When doing assessment
Tire easily - be care to not hyperventilate them
Typically see an increase in AP diameter
SL valves - location and function
Pulmonic valve - between RV and pulmonary artery
Aortic valve - between the LV and the aorta
What do mucous membranes do?
- line body cavities (digestive tract, respiratory passages, urinary and reproductive tracts)
- secrete mucous
- have receptors that offer protection
- insensitive to temperature, but sensitive to pressure
- absorb substances from surface
What is Stage 3 of a pressure ulcer?
Stage 3: ulcer extends to subcutaneous fat layer; full-thickness skin loss - subcutaneous fat may be visible
What are abnormal findings of peripheral vascular disease (PVD)?
Arms:
- Raynaud phenomenon
- lymphedema
Legs:
- arterial-ischemic ulcer
- venous (stasis) ulcer
- superficial varicose veins
- deep vein thrombophlebitis
aneurysms
occlusions
AV valves - when do they open and close as it pertains to the cardiac cycle
During diastole - the AV valves are open, filling phase as ventricles fill with blood
During systole - the AV valves are closed as this is pumping phase - prevents blood from backing into the aorta (regurgitation)
What are secondary skin lesions
They result from a change in a primary lesions from the passage of time; an evolutionary change
Debris on skin surface
- crust
- scales
Break in continuity of skin surface:
- fissures
- erosions
- ulcers
- excoriations: abraded skin
- scars
– atrophic scars: cannot regenerate tissue correctly
– keloids: thick raised scar
Peripheral Arterial Disease
peripheral arterial disease (PAD) is form of CV disease that manifests primarily in LEs:
- deep muscle pain
- injuries often go unnoticed by patient
classic symptoms of PAD - intermittent claudication:
- ischemic muscle pain that is caused by constant level of exercise
- resolves within 10 minutes or less with rest
- reproducible
Coarse crackles
- popping sound
- are heard over any lung region
- do not vary with body position
- early inspiration and last throughout expiration
What is Biot’s (Ataxic) breathing?
severe, IRREGULAR Cheyne-Stokes
periods of apnea alternating with regular deep breaths which stop suddenly for short intervals
Palpation - respiratory assessment - tactile fremitus
- assess for symmetry
- use ball or ulnar surface of hand
- ask patient to repeat words “99” or “one one one”
- initially used for side-by-side comparison
- both hands to palpate and compare symmetry
- identify and locate any areas of increased, decreased or absent fremitus
- for women: gently displace the breasts anteriorly
anteriorly: fremitus is usually decreased or absent over the precordium
Afterload
afterload is the force against which the heart has to contract to EJECT THE BLOOD
- afterload is the opposing pressure that the ventricle must generate to open the aortic valve -
degree of vascular resistance which the left ventricle must pump (contraction)
What are abnormal findings of the lymphatic system
Lymphedema: buildup of lymphatic fluid in the body, obstructed lymphatic drainage, is usually not compressible
Lymphadenopathy: enlarged/swollen lymph nodes, with or without tenderness
– can be local or generalized
– can be caused by bacterial, viral, or fungal infections
What is the open wound classification for wounds?
Result of intentional or unintentional trauma
Skin surface is broken
Bleeding, tissue damage, infection, delayed wound healing (possible)
S1 and where in the cardiac cycle
S1: closure of AV valves and signals beginning of systole
can hear S1 over all precordium - loudest at apex
AV valves close to prevent any regurgitation of blood back up into atria during contraction
Edema: Pitting scale
Measures the severity of pitting edema, determined by applying pressure to the affected area of skin
THERE IS NO ZERO
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
Inspection - cardio assessment
- general appearance and vital signs
- skin color, temperature
- edema
- diaphoresis
- BP: normal range or abnormal
- extremities: perfusion
- pulses: brisk and easily palpable
- JVP: normal range
- lower extremities for edema
What is the unintentional wound classification?
Result of accidental occurrence such as unexpected trauma
Wound edges often jagged and bleeding uncontrolled
Increased risk for infection
Increased healing time
Palpation - cardiovascular assessment: Pericardium
use palmar aspects of four fingers; palpate apex, left sternal border, and base
note if any other pulsations; if present - note timing (should not be any)
use carotid artery pulsation as your guide
Preload
When does it happen
preload is the volume of blood in the ventricles AT THE END OF DIASTOLE
- preload is venous return, which build during diastole -
stretching of the cardiac cells PRIOR to contraction; how well ventricular muscle can stretch at end of diastole
the greater the stretch, the stronger the heart’s contraction
What are debris on skin surface - secondary skin lesions?
Crusts - drying of plasma or exudate on the skin
Scales - flakes representing compacted desquamated layers
What are the signs of infection in wounds
- Purulent and increased drainage
- pain, redness, swelling
- Increased body temperature
- Increased WBC
- Delayed healing
- Discoloration of granulation tissue
What is a pressure ulcer?
A wound with a localized area of injury to the skin and/or underlying tissue
Can be acute or chronic
Underlying cause is pressure
Most develop when soft tissue is compressed alone or in combination with shear and/or friction
AKA decubitus ulcer, pressure sore, bed sore
Auscultation: Heart sounds - set up
have the patient supine
follow a “Z” pattern
- begin with diaphragm then move to bell of stethoscope
identify S1 and S2
- determine if there are abnormal heart sounds
- S3 or S4
are the sounds regular or irregular?
assess for pulse deficit - apical and radial pulses should match
– if they don’t match: not every beat is reaching the peripheral vascularization
Peripheral vascular assessment - pulses and arteries
Arteries of the arm:
- brachial artery
- radial artery/pulse
- ulnar artery
Peripheral arterial pulses:
- femoral artery
- popliteal
- pedal pulses:
– dorsalis pedis (DP) pulse
– posterior tibial (PT) pulse
Structure and function of hair
Hair:
- vellus hair
- terminal hair (adult stage)
Sebaceous glands secrete sebum
Sweat glands are important for fluid balance and thermoregulation
- eccrine glands
- apocrine glands
Developmental considerations - cardiovascular assessment: Aging adult
Lifestyle, BP, HR
as we age, the process is closely tied to lifestyle, habits, and diseases
- lifestyle: diet, exercise, alcohol, smoking, drug use, stress all influence coronary artery disease
- lifestyle affects the aging process; cardiac changes once thought to be due to aging due to sedentary lifestyle accompanying aging
– moving improves aging process - systolic BP increases: thickening and stiffening of the arteries
- diastolic BP decreases or no change
- LV wall becomes thicker, usually the size of the heart does not change
- no change in resting HR or cardiac output at rest
- decreased ability of heart to adjust cardiac output with exercise
Chest circumference: Lines
Midsternal line: vertical along the sternum
Midclavicular line: vertical from the midpoint of the clavicle
Anterior axillary line: vertical from the anterior axillary fold
Midaxillary line: vertical from the apex of the axilla
Posterior axillary line: vertical from the posterior axillary fold
Scapular line: from the inferior angle of the scapula
Vertebral line: overlies the thoracic spinous processes
What are examples of breaks in continuity of skin surface in secondary skin lesions?
Fissures - linear cleavage of skin
Erosions - slightly depressed areas
Ulcers - necrosis
Excoriations - abraded skin
Scars - permanent fibrotic changes
– Atrophic scars: skin cannot regenerate tissue correctly
– Keloids: thick raised scar
Lichenification: thick and leathery skin; can be irriting
– more scratching – gets bigger and spreads
Chambers of the heart
Four chambers: right atrium, right ventricle, left atrium, and left ventricle
Lymph Nodes
Lymph nodes are round, oval, or bean-shaped lymphatic tissue (structures) located along the vessel
Vary in size according to their location
Only the superficial lymph nodes are accessible to inspection and palpation.
- Cervical nodes
- Axillary nodes
- Nodes in the arms and legs
SL valves- when do they open and close as it pertains to the cardiac cycle
during systole - valves are open; pumping phase – blood is ejected from the heart
during diastole - SL valves are closed, ventricles are relaxed, pressure inside drops, preventing blood from flowing back into the heart
Adventitious sounds - description and location
Added sounds: caused by moving air colliding with secretions in tracheobronchial passageways or by popping open of previously deflated airways
Types:
- crackles (rales)
- wheezes
- rhonchi
- stridor
- diminished/decreased, absent
- pleural friction rub
- abnormal vocal sounds
What are the risk factors of pressure ulcers
- Immobility
- Malnutrition and dehydration/excess fluid
- Exposure to moisture
- Altered level of consciousness
- Advancing age
- Chronic illnesses
What are the stages of pressure ulcers
Stage 1: skin is unbroken but inflamed; nonblanchable erythema of intact skin
Stage 2: skin is broken to epidermis or dermis; partial-thickness skin loss - shallow, open ulcer
Stage 3: ulcer extends to subcutaneous fat layer; full-thickness skin loss - subQ fat may be visible
Stage 4: ulcer extends to muscle or bone; undermining is likely; exposed bone, tendon, or muscle
Unstageable: base of ulcer covered by slough and/or eschar in wound bed
Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration
What are clinical manifestations of peripheral arterial disease (PAD)?
- paresthesia: numbness or tingling in the toes or feet
- loss of pressure and deep pain sensation
- thin, shiny, and taut skin
- loss of hair on lower legs
- diminished or absent pulses (lesion) at any point in LE circulation
– ulcers develop from inadequate circulation
– high risk for gangrene - pallor of foot with leg elevation
- pain at rest
– occurs in the foot or toes
– aggravated by limb elevation
– occurs from insufficient blood flow
– occurs more often at night
Adventitious sounds - crackles
Discontinuous nonmusical, early inspiratory (COPD); late inspiratory (pulmonary fibrosis), or biphasic (pneumonia)
Popping sound - inspiration
Deflated - expiration
Fine Crackles
Coarse Crackles
Skin, hair and nail assessment? Not v specific - is spread through the cards so just adding some objective stuff here
Vascularity or bruising:
- cherry angiomas
- multiple bruises at different stages
- note tattoos
- note any needle marks or tracks
Promote health and self-care:
- self-inspection
- sunscreen
- hats, clothing
Emollients/lubricants
Developmental considerations - respiratory assessment: Pregnancy
Diaphragm elevated 4cm
Decreased vertical diameter thoracic cage
Increased horizontal diameter, increased tidal volume
Focused questions to ask during respiratory assessment: Infants and children - questions directed at parents
Any colds? Frequency? Are they severe colds?
Allergy history?
- children under 2 years old: at what age were new foods introduced? breastfed or bottle-fed? any allergies?
Cough or congested? Noisy breathing or wheezing?
- Mucus production, color, how much? What kind of cough?
Does anyone smoke in home and/or in the car with the child?
Environmental or household hazards:
- carbon monoxide monitor, pet dander, dust, mold; roaches can cause asthma attacks
Has anyone taught you emergency care measures in case of accidental choking or a hard-breathing spell?
- Heimlich; smacking infant’s back
Rhonchi
- variant of wheezes; same mechanism
- lower in pitch
- disappear with coughing
Palpation - respiratory assessment
- tenderness
- intercostal tenderness: over inflamed pleurae
- crepitus: fractures
- bruising (can be from disorders, meds, injections, falls, abuse)
- sinus tract: inflammatory, tube-like structures opening onto the skin (infection)
- chest expansion
- tactile fremitus (“99”)
What is the function of the lymphatic system?
- continuously filters blood
- filters foreign material: engulf cellular debris and bacteria and produce antibodies
- form a major part of immune system that defends body against disease
– serves as a reservoir for T-cells and B-cells - conserve fluid and plasma proteins that leak out of capillaries
- absorb lipids from intestinal tract
Palpation - cardiovascular assessment: Apical Pulse (PMI)
represents the brief early pulsation of the LV as it moves anteriorly during systole and makes contact with the chest wall
palpable in about half of adults; not in those obese or with thick chest walls
– displaced to the left in heart failure
– if can’t find: ask person to exhale and hold; ask patient to roll partly onto left side
high cardiac output:
- apical impulse increase in amplitude and duration
- anxiety, fever, hyperthyroidism, anemia
What are the types of wound drainage?
Serous: clear watery
Sanguineous: bright red or pink
Serosanguineous: combination of blood and the clear fluid
Purulent: foul odor, white, yellow, green, pink, or brown
Auscultation - respiratory assessment
Assessing air flow through the tracheobronchial tree
Listening for:
- breath sounds
- adventitious (added) sounds
- abnormalities
Diaphragm on chest wall
Listen to one full respiration; side to side
- C7 to T10
- lateral from axilla to 7th rib
What are examples of primary skin lesions?
Macules: flat
Papules: solid, raised
Pustules: pus
Vesicles/Bulla: trapped fluid under skin
Urticaria (Hives): red, itchy welts
Cyst: benign, round, dome-shaped encapsulated lesion containing fluid or semi-fluid material
Nodule: solid, elevated, hard, or soft
Wheal: superficial raised, transient and reddened, irregular shape from edema
What are the developmental stages of the integumentary system - Infants
Under the age of 2 - the skin is thinner, but becomes increasingly resistant to injury and infection as children age
Newborn infants:
lanugo - fine downy hair of newborn infant
Vernix caseosa - thick, cheesy substance at birth
Sebum - holding water in the skin producing “milia”
