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Nursing 314: Assessing and Promoting Wellness > Exam 2: Heart & Lungs Assessment > Flashcards

Exam 2: Heart & Lungs Assessment Flashcards

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1
Q

Technique and sequence of physical assessment for heart and lungs

A

Inspection
Palpation
Percussion
Auscultation

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2
Q

When assessing for heart and lungs, also consider diagnostics such as

A

X-rays, MRIs, CT scan, EKGs, etc.

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3
Q

Pulmonary assessment subjective data

A
  • Cough, sputum, SOB, pain
  • History or respiratory diseases (Asthma, Croup, cystic fibrosis)
  • Self care (immunizations, influenza, TB test)
  • Environmental exposure
  • Habits (smoking)
  • Injuries
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4
Q

Pulmonary assessment objective data: anterior/posterier

A

Inspect…

  • facial expression
  • LOC (Level of consciousness)
  • ease of breathing
  • Skin color and nail beds
  • use of accessory muscles
  • respiratory rate
  • Sternal formation
  • – Pectus carinatum
  • –Pectus excavatum
  • Shape and configuration
  • —Downward sloping of ribs
  • —muscle and skeletal structures
  • —-posture
  • AP diameter of chest 2:1
  • kyphosis/scoliosis/lordosis
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5
Q

inspection includes

A

Visual examination

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6
Q

Palpation includes

A

Using hands to feel

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7
Q

Percussion includes

A

Light tapping to assess underlying structures

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8
Q

Auscultation includes

A

listening to sounds produced by body

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9
Q

Pectus carinatum

A

sternal production

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10
Q

Pectus excavatum

A

sternal concavity

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11
Q

AP diameter of chest —-> anterior posterior diameter is

A
  • Approximately 1/2 of transverse diameter or 1:2 ratio

- rounding from chronic COPD can cause a barrel chest look

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12
Q

pulmonary assessment objective: palpate posterior

A
  • Symmetric expansion

- Assess for tenderness with percussion over kidneys: costal vertebral angle

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13
Q

how to do to symmetric expansion

A

Thumbs along spinal processes
2 inch apart @ 10th rib
palms resting lightly on lateral chest
tell patient to take several deep breaths
note bilateral outward movement of thumbs
—- thumbs should life symmetrically

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14
Q

Costal vertebral angle tenderness indicates a need for

A

renal assessment

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15
Q

does costal vertebral angle assess respiratory?

A

No! since we are already behind conducting pulmonary assessment, a renal assessment is good

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16
Q

When auscultating lungs, individuals should breathe through

A

their mouth

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17
Q

When auscultating lungs, start at

A

top to bottom comparing sides, then compare laterally

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18
Q

Normal lung sounds

A
  • vesicular
  • Bronchovesicular
  • Bronchial
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19
Q

vesicular lung sound

A

Soft, breezy, low pitched

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20
Q

Bronchovesicular lung sound

A

Blowing, medium pitch/intensity

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21
Q

Bronchial lung sound

A

Loud high pitched

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22
Q

Where to hear vesicular lung sounds

A

small airways: periphery of lung

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23
Q

Where can you hear bronchial lung sounds

A

Trachea: heard only over the trachea

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24
Q

Where to hear Bronchovesicular lung sound

A

Large airways: Between scapulae, over bronchioles lateral to sternum

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25
Q

Abnormal sounds

A 
Atelectasis 
Crackles 
Wheezes 
Rhonchi
Stridor 
Pleural Friction Rub 
Absent
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26
Q

Atelectasis

A

Collapsed alveoli: small area or large

Will most likely not hear, but inspiration !!

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27
Q

Minor atelectasis may not be detected

A

early

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28
Q

Major atelectasis is when

A

entire lobe/lung collapses

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29
Q

Crackles

A

popping open of deflated alveoli on INSPIRATION

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30
Q

Where in the lungs does fluid usually collect

A

Lower lobes

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31
Q

Can crackle sound be cleared by a cough?

A

Nope!

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32
Q

Fine crackles sound similar to

A

the sound of a wood fireplace

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33
Q

Coarse crackles

A

Velcro separating/ cellophane crumpled

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34
Q

Wheeze

A

High velocity airflow through narrowed/obstructed airways with many causes

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35
Q

Where can you hear a wheeze?

A

Heard in all lung fields

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36
Q

Can coughing mitigate wheeze?

A

Nope, there is nothing to cough or move

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37
Q

Wheeze sounds like

A

High pitches, continuous musical sound/squeaking

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38
Q

When can you hear a wheeze?

A

Inspiration AND/OR expiration

–usually louder on expiration

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39
Q

Rhonchi

A

Spasm, fluid/mucus in airways = turbulence

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40
Q

Where can you hear rhonchi

A

Mostly over trachea and bronchi with mucus present

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41
Q

Can rhonchi be cleared with a cough

A

yes, clear after coughing usually, BUT not always

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42
Q

Rhonchi sounds like

A

Loud, low pitched, rumbling, continuous coarse sounds, snore

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43
Q

When can you hear rhonchi

A

inspiration and/or expiration

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44
Q

Stridor

A

Air moving over partially obstructed airway/larynx

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45
Q

stridor can become

A

emergent

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46
Q

Stridor can be caused by

A

Inhaled object, infection, throat swelling, laryngospasm

— frequent in children

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47
Q

you can only hear bronchial sounds

A

anteriorly

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48
Q

Where can you hear stridor

A

Through, it’s loud and do not need stethoscope

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49
Q

When can you hear stridor

A

High pitch musical sound heard on INSPIRATION

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50
Q

Pleural friction rub

A

Inflamed pleura rubbing against raw visceral pleural

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51
Q

When can you hear pleural friction rub

A

Dry, rubbing or grating on inspiration AND expiration

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52
Q

where can you hear pleural friction rub

A

Hear over anterior lateral lung fields

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53
Q

What does pleural friction rub sound like

A

Rubbing leather together, walking

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54
Q

Absent lung

A

Pneumothorax (collapsed lung)

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55
Q

Absent lung =

A

No air movement in the identified area

56
Q

Subjective data for cardiac assessment

A 
Smoking/alcohol/caffeine 
Prescribed medication/OTC 
History of Cardiac diseases 
family medical HX 
report discomfort : OLDCART 
cardiac procedures 
Reporting palpitations, fatigue, cough, dyspnea
peripheral symptoms: leg pain, cramp, edema, cyanosis, nocturia 
dizziness, SOB, orthopnea 
Lifestyle
57
Q

When can you hear atelectasis

A

Inspiration

58
Q

Objective anterior cardiac assessment

A

Inspect

  • Skin: oxygenation/lesions
  • Heave/lift at apical pulse
  • —-hypertrophy of ventricle

Palpate -valves

  • Aortic, pulmonic, tricuspid, mitral
  • Apical pulse (PMI) - mitral
  • – Location, size, amplitude, duration
  • — 5th intercostal space
  • – may need to roll or learn to left to help increase amplitude
59
Q

Objective auscultate of heart (APETM)

A 
Aortic valve 
Pulmonic valve 
Erb's point 
Tricuspid Valve 
Mitral Valve
60
Q

Aortic valve

A

2nd right intercostal

61
Q

Pulmonic valve

A

2nd left intercostal space

62
Q

Erb’s point

A

3rd intercostal space

63
Q

Is era’s point a valve?

A

Nope

64
Q

Tricuspid valve

A

4th or 5th left intercostal

65
Q

Mitral valve

A

5th intercostal space

  • midclavicular line
  • at base of breast tissue, move bra out of way if present
66
Q

When auscultating heart, start

A

at base and move in Z to apex

67
Q

When auscultating heart, listen with

A

both the diaphragm and the bell of stethoscope

68
Q

When auscultating the valves of the heart, you listen

A

to not the ACTUAL anatomical locations of the valve, but where the valve sound is heard best

69
Q

S1: “lub” is louder at

A

apex

70
Q

In QRS, S1 represents

A

carotid pulsation and the “R” wave

71
Q

S1 is the closure of

A

AV valves

72
Q

S2 “dub” is louder

A

At base

73
Q

S2 “dub” is the closure of

A

semilunar valves

74
Q

When assessing neck vessels, inspect

A

For obvious pulsation/bulging

75
Q

When palpating the carotid artery, massaging vigorously can cause

A

Syncope

76
Q

When palpating carotid arteries, can you do both?

A

No! Only one side at a time to prevent obstructed blood flow to brain

77
Q

When auscultating carotid arteries use the ___ of a stethoscope

A

Bell and have patient hold breath

78
Q

Normal carotid arteries sound is

A

no sounds

79
Q

Carotid artery sound: Bruit

A

Blowing, swishing sound (narrowing_)

80
Q

Carotid bruit

A

Narrowed blood vessel: arteriosclerosis

  • Creates turbulence
  • Blowing/swishing
81
Q

Assessing for Jugular venous distention

A

Place patient in supine position (bulge is normal when flat)
Raise torso to 45 degrees

82
Q

after raising horse to 45 degrees, if JV is still bulging

A

There is JVD which means venous and rich atrium pressure is elevated
– heart failure, fluid volume overload/hypervolemia

83
Q

When assessing peripheral arteries, assess

A

ELASTICITY
STRENGTH
EQUALITY

84
Q

Peripheral arteries can be graded on 4 point scale

A 
4- bounding 
3- full and brisk 
2- NORMAL
1- weak
0- absent
85
Q

Light pressure is on the

A

Bell

86
Q

Firm pressure is

A

Diaphragm

87
Q

Modifiable risk factors for CV disease

A 
Hyperlipidemia 
Hypertension 
excessive weight 
physical inactivity 
smoking 
psychological stress 
diabetes
88
Q

Non-modifiable factors

A

family history

genetics

89
Q

Lab values to assess cardiac system

A
  • Complete blood count
  • Lipids
  • Serum electrolytes
  • BNP: elevated in heart failure
  • Creatine kinase
  • Troponin/myoglobin
90
Q

Values listed for complete blood count

A

numerous components

91
Q

Values listed for lipids

A

cholesterol
triglycerides
HDL
LDL

92
Q

HDL =

A

good

93
Q

LDL = bad

A
94
Q

Values listed for serum electrolytes

A

C-reactive protein: inflammation

Peaks 18+ hours

95
Q

Values listed for Creatine Kinase

A

Heart muscle injury: Inexpensive
Elevated in 4+ hours after injury
Can pick up skeletal muscle injury

96
Q

Values listed for troponin/myoglobin

A

evidence of cardiac damage

elevated in 3-4 hours

97
Q

Murmurs

A

A blowing swishing sound from turbulent blood flow in the heart or great vessels
— you will feel a thrill when palpating

98
Q

murmurs are often abnormal or normal?

A

Abnormal, however, some people live with murmurs without symptoms

99
Q

Timing of murmurs

A

Systolic and diastolic murmurs without symptoms

100
Q

Loudness of murmurs are graded

A

1-6, soft to loud

101
Q

Murmur pitch

A

high, medium, low

102
Q

Developmental considerations of infants for cardiac and pulmonary assessment

A
  • Smaller diaphragm/bell
  • Higher heart rates
    • —- Harder to count and evaluate for murmurs
103
Q

Feeling turbulence is known as

A

feeling a thrill

104
Q

Developmental considerations of children for cardiac and pulmonary assessment

A
  • Extra cardiac signs of heart diseases
  • -clubbing of fingers
  • – cyanosis: fingers, lips, etc.
  • Activity level
  • Weight gain: Fluid retention, immobility due to low activity tolerance
105
Q

You can feel a ____

or hear a _____

A

Feel a thrill, hear a bruit

106
Q

Developmental considerations of pregnant women for cardiac and pulmonary assessment

A
  • Pulse increased 10-15 BPM
  • heart displaced to upper left and rotates
  • PMI is higher
  • Increased blood volume
  • Systolic murmurs - 90% disappear after delivery
107
Q

Changes with aging

A
  • Harder to hear sound with increased AP diameter
  • cardiac valves degenerate: Especially mitral and aortic—- murmurs
  • conduction: pacemaker cells decrease in number —- dysrhythmias, ectopic bears
  • left ventricle: size increases and more fibrotic — decrease cardiac output
  • Aorta and large vessels: Thicken —- increase systolic BP
  • baroreceptors: Become less sensitive —- orthostatic hypotension
108
Q

Right side heart failure

A

Function of R ventricle or increased pulmonary vascular resistance

109
Q

Function of R ventricle or increased pulmonary vascular resistance can cause

A
  • Peripheral congestion/backup
    • –Hepatomegaly
    • –splenomegaly
    • –dependent edema
      - – weight gain
  • Distended neck vein
    • – JVD
110
Q

Left side heart failure

A

Function of L ventricle

  • cardiac output
    • – fatigue
    • – dizziness
    • – confusion
  • Pulmonary congestion
  • – crackles
  • – SOB
  • – Dyspnea
  • – Breathlessness
111
Q

The right side of the heart receives

A

From the periphery

112
Q

If right side of heart fails,

A

The blood backs up into where it was coming from

113
Q

The left heart receives from the

A

lungs

114
Q

if the left side fails

A

the blood backs up into the lungs

– ALSO circulates to everything, so everything is getting LESS oxygen and nutrients

115
Q

Factors affecting Oxygenation:

A

Alterations in respiratory function

  • respiratory
    • – Hypo/Hyperventilatoin
    • – Anoxia
116
Q

Anoxia

A

Absence of oxygen

117
Q

Physiological factors affecting oxygenation

A

Decreases O2 carrying capacity

  • hypovolemia/decreased circulating blood volume
  • oxygen concentration
    • –airway obstruction
    • –decreased environmental oxygen
    • –hypoventilation
  • increased metabolic rate
  • decreased O2 carrying capacity

Chest wall movement

  • pregnancy
  • obesity
  • musculoskeletal alterations in thoracic region
  • trauma
  • neuromuscular
  • central nervous system
118
Q

decreased O2 carrying capacity:

A

Low hemoglobin/anemia

119
Q

Increased metabolic rate:

A

Increases oxygen demand

120
Q

Hypoxia

A

Inadequate oxygenation of the TISSUE

121
Q

Hypoxemia

A

Inadequate oxygenation of the BLOOD

122
Q

Is hypoxia measurable

A

Nope, but comes as a result of hypoxemia

123
Q

Is hypoxemia measurable

A

YES!

  • Pulse oximetry
  • arterial blood assess
  • other respiratory tests
124
Q

First signs of hypoxemia

A

Restlessness and confusion

125
Q

Factors affecting oxygenation

A

Alterations in cardiac function
Lifestyle factors
Environmental factors

126
Q

Examples of alterations in cardiac function

A

Conduction
Altered cardiac output
Valves
Myocardial ischemia: Blood flow to heart is insufficient

127
Q

Myocardial ischemia

A

Blood flow to heart is insufficient

128
Q

Lifestyle factors affecting oxygenation

A 
nutrition 
exercise 
smoking 
substance abuse 
stress
129
Q

Developmental considerations for infants: Pulmonary

A
  • Count respiratory rate 1 full minute
  • irregular with some apnea normal
  • crackles are common in newborns
  • distress
  • —– nasal flaring
  • —– substernal and intercostal retractions
130
Q

Developmental considerations for elderly: Pulmonary

A
  • Increased AP diameter (especially COPD)
  • kyphosis
  • Less mobile thorax
  • fatigue easily during auscultation (pace your assessment)
  • fragile bones (broken ribs or spine)
131
Q

Clubbing of nails

A

building of tissues at the nail bas

132
Q

Clubbing of nails is caused by

A

Insufficient oxygenation at the periphery

pulmonary OR cardiac

133
Q

Most common causes of clubbing of nails

A

Emphysema and congenital heart disease are the most common causes

134
Q

How to calculate smoking habits: Pack years

A

years smoked * # packs smoked/day = ___ pack years

135
Q

pulmonary/oxygenation NANDA nursing diagnosis

A 
Impaired gas exchange 
fatigue 
ineffective airway clearance 
ineffective breathing pattern 
activity tolerance 
risk for acute confusion 
decreases cardiac output 
actor pain 
risk fo infection
136
Q

interventions for pulmonary/oxygenation

A

Airway: Coughing. suctioning, physiotherapy maintenance
Hydration: Humidifiers, fluid intake orally, through GI tracts or IV
Nebulizers: breathing treatments w/ medications added as well as humidity
Cough/deep breathing
Pursed-lip breathing: Helps leep alveoli open
Noninvasive ventilation
Invasive mechanical ventilation
ambulation/positioning
chest tubes
oxygen therapies

137
Q

Are crackles common in infants?

A

yes due to the fact that lungs have not developed

Nursing 314: Assessing and Promoting Wellness (26 decks)

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