Exam 2: Heart & Lungs Assessment Flashcards
Technique and sequence of physical assessment for heart and lungs
Inspection
Palpation
Percussion
Auscultation
When assessing for heart and lungs, also consider diagnostics such as
X-rays, MRIs, CT scan, EKGs, etc.
Pulmonary assessment subjective data
- Cough, sputum, SOB, pain
- History or respiratory diseases (Asthma, Croup, cystic fibrosis)
- Self care (immunizations, influenza, TB test)
- Environmental exposure
- Habits (smoking)
- Injuries
Pulmonary assessment objective data: anterior/posterier
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
inspection includes
Visual examination
Palpation includes
Using hands to feel
Percussion includes
Light tapping to assess underlying structures
Auscultation includes
listening to sounds produced by body
Pectus carinatum
sternal production
Pectus excavatum
sternal concavity
AP diameter of chest —-> anterior posterior diameter is
- Approximately 1/2 of transverse diameter or 1:2 ratio
- rounding from chronic COPD can cause a barrel chest look
pulmonary assessment objective: palpate posterior
- Symmetric expansion
- Assess for tenderness with percussion over kidneys: costal vertebral angle
how to do to symmetric expansion
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
Costal vertebral angle tenderness indicates a need for
renal assessment
does costal vertebral angle assess respiratory?
No! since we are already behind conducting pulmonary assessment, a renal assessment is good
When auscultating lungs, individuals should breathe through
their mouth
When auscultating lungs, start at
top to bottom comparing sides, then compare laterally
Normal lung sounds
- vesicular
- Bronchovesicular
- Bronchial
vesicular lung sound
Soft, breezy, low pitched
Bronchovesicular lung sound
Blowing, medium pitch/intensity
Bronchial lung sound
Loud high pitched
Where to hear vesicular lung sounds
small airways: periphery of lung
Where can you hear bronchial lung sounds
Trachea: heard only over the trachea
Where to hear Bronchovesicular lung sound
Large airways: Between scapulae, over bronchioles lateral to sternum
Abnormal sounds
Atelectasis Crackles Wheezes Rhonchi Stridor Pleural Friction Rub Absent
Atelectasis
Collapsed alveoli: small area or large
Will most likely not hear, but inspiration !!
Minor atelectasis may not be detected
early
Major atelectasis is when
entire lobe/lung collapses
Crackles
popping open of deflated alveoli on INSPIRATION
Where in the lungs does fluid usually collect
Lower lobes
Can crackle sound be cleared by a cough?
Nope!
Fine crackles sound similar to
the sound of a wood fireplace
Coarse crackles
Velcro separating/ cellophane crumpled
Wheeze
High velocity airflow through narrowed/obstructed airways with many causes
Where can you hear a wheeze?
Heard in all lung fields
Can coughing mitigate wheeze?
Nope, there is nothing to cough or move
Wheeze sounds like
High pitches, continuous musical sound/squeaking
When can you hear a wheeze?
Inspiration AND/OR expiration
–usually louder on expiration
Rhonchi
Spasm, fluid/mucus in airways = turbulence
Where can you hear rhonchi
Mostly over trachea and bronchi with mucus present
Can rhonchi be cleared with a cough
yes, clear after coughing usually, BUT not always
Rhonchi sounds like
Loud, low pitched, rumbling, continuous coarse sounds, snore
When can you hear rhonchi
inspiration and/or expiration
Stridor
Air moving over partially obstructed airway/larynx
stridor can become
emergent
Stridor can be caused by
Inhaled object, infection, throat swelling, laryngospasm
— frequent in children
you can only hear bronchial sounds
anteriorly
Where can you hear stridor
Through, it’s loud and do not need stethoscope
When can you hear stridor
High pitch musical sound heard on INSPIRATION
Pleural friction rub
Inflamed pleura rubbing against raw visceral pleural
When can you hear pleural friction rub
Dry, rubbing or grating on inspiration AND expiration
where can you hear pleural friction rub
Hear over anterior lateral lung fields
What does pleural friction rub sound like
Rubbing leather together, walking
Absent lung
Pneumothorax (collapsed lung)
Absent lung =
No air movement in the identified area
Subjective data for cardiac assessment
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
When can you hear atelectasis
Inspiration
Objective anterior cardiac assessment
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
Objective auscultate of heart (APETM)
Aortic valve Pulmonic valve Erb's point Tricuspid Valve Mitral Valve
Aortic valve
2nd right intercostal
Pulmonic valve
2nd left intercostal space
Erb’s point
3rd intercostal space
Is era’s point a valve?
Nope
Tricuspid valve
4th or 5th left intercostal
Mitral valve
5th intercostal space
- midclavicular line
- at base of breast tissue, move bra out of way if present
When auscultating heart, start
at base and move in Z to apex
When auscultating heart, listen with
both the diaphragm and the bell of stethoscope
When auscultating the valves of the heart, you listen
to not the ACTUAL anatomical locations of the valve, but where the valve sound is heard best
S1: “lub” is louder at
apex
In QRS, S1 represents
carotid pulsation and the “R” wave
S1 is the closure of
AV valves
S2 “dub” is louder
At base
S2 “dub” is the closure of
semilunar valves
When assessing neck vessels, inspect
For obvious pulsation/bulging
When palpating the carotid artery, massaging vigorously can cause
Syncope
When palpating carotid arteries, can you do both?
No! Only one side at a time to prevent obstructed blood flow to brain
When auscultating carotid arteries use the ___ of a stethoscope
Bell and have patient hold breath
Normal carotid arteries sound is
no sounds
Carotid artery sound: Bruit
Blowing, swishing sound (narrowing_)
Carotid bruit
Narrowed blood vessel: arteriosclerosis
- Creates turbulence
- Blowing/swishing
Assessing for Jugular venous distention
Place patient in supine position (bulge is normal when flat)
Raise torso to 45 degrees
after raising horse to 45 degrees, if JV is still bulging
There is JVD which means venous and rich atrium pressure is elevated
– heart failure, fluid volume overload/hypervolemia
When assessing peripheral arteries, assess
ELASTICITY
STRENGTH
EQUALITY
Peripheral arteries can be graded on 4 point scale
4- bounding 3- full and brisk 2- NORMAL 1- weak 0- absent
Light pressure is on the
Bell
Firm pressure is
Diaphragm
Modifiable risk factors for CV disease
Hyperlipidemia Hypertension excessive weight physical inactivity smoking psychological stress diabetes
Non-modifiable factors
family history
genetics
Lab values to assess cardiac system
- Complete blood count
- Lipids
- Serum electrolytes
- BNP: elevated in heart failure
- Creatine kinase
- Troponin/myoglobin
Values listed for complete blood count
numerous components
Values listed for lipids
cholesterol
triglycerides
HDL
LDL
HDL =
good
LDL = bad
Values listed for serum electrolytes
C-reactive protein: inflammation
Peaks 18+ hours
Values listed for Creatine Kinase
Heart muscle injury: Inexpensive
Elevated in 4+ hours after injury
Can pick up skeletal muscle injury
Values listed for troponin/myoglobin
evidence of cardiac damage
elevated in 3-4 hours
Murmurs
A blowing swishing sound from turbulent blood flow in the heart or great vessels
— you will feel a thrill when palpating
murmurs are often abnormal or normal?
Abnormal, however, some people live with murmurs without symptoms
Timing of murmurs
Systolic and diastolic murmurs without symptoms
Loudness of murmurs are graded
1-6, soft to loud
Murmur pitch
high, medium, low
Developmental considerations of infants for cardiac and pulmonary assessment
- Smaller diaphragm/bell
- Higher heart rates
- —- Harder to count and evaluate for murmurs
Feeling turbulence is known as
feeling a thrill
Developmental considerations of children for cardiac and pulmonary assessment
- 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
You can feel a ____
or hear a _____
Feel a thrill, hear a bruit
Developmental considerations of pregnant women for cardiac and pulmonary assessment
- Pulse increased 10-15 BPM
- heart displaced to upper left and rotates
- PMI is higher
- Increased blood volume
- Systolic murmurs - 90% disappear after delivery
Changes with aging
- 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
Right side heart failure
Function of R ventricle or increased pulmonary vascular resistance
Function of R ventricle or increased pulmonary vascular resistance can cause
- Peripheral congestion/backup
- –Hepatomegaly
- –splenomegaly
- –dependent edema
- – weight gain
- Distended neck vein
- – JVD
Left side heart failure
Function of L ventricle
- cardiac output
- – fatigue
- – dizziness
- – confusion
- Pulmonary congestion
- – crackles
- – SOB
- – Dyspnea
- – Breathlessness
The right side of the heart receives
From the periphery
If right side of heart fails,
The blood backs up into where it was coming from
The left heart receives from the
lungs
if the left side fails
the blood backs up into the lungs
– ALSO circulates to everything, so everything is getting LESS oxygen and nutrients
Factors affecting Oxygenation:
Alterations in respiratory function
- respiratory
- – Hypo/Hyperventilatoin
- – Anoxia
Anoxia
Absence of oxygen
Physiological factors affecting oxygenation
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
decreased O2 carrying capacity:
Low hemoglobin/anemia
Increased metabolic rate:
Increases oxygen demand
Hypoxia
Inadequate oxygenation of the TISSUE
Hypoxemia
Inadequate oxygenation of the BLOOD
Is hypoxia measurable
Nope, but comes as a result of hypoxemia
Is hypoxemia measurable
YES!
- Pulse oximetry
- arterial blood assess
- other respiratory tests
First signs of hypoxemia
Restlessness and confusion
Factors affecting oxygenation
Alterations in cardiac function
Lifestyle factors
Environmental factors
Examples of alterations in cardiac function
Conduction
Altered cardiac output
Valves
Myocardial ischemia: Blood flow to heart is insufficient
Myocardial ischemia
Blood flow to heart is insufficient
Lifestyle factors affecting oxygenation
nutrition exercise smoking substance abuse stress
Developmental considerations for infants: Pulmonary
- Count respiratory rate 1 full minute
- irregular with some apnea normal
- crackles are common in newborns
- distress
- —– nasal flaring
- —– substernal and intercostal retractions
Developmental considerations for elderly: Pulmonary
- Increased AP diameter (especially COPD)
- kyphosis
- Less mobile thorax
- fatigue easily during auscultation (pace your assessment)
- fragile bones (broken ribs or spine)
Clubbing of nails
building of tissues at the nail bas
Clubbing of nails is caused by
Insufficient oxygenation at the periphery
pulmonary OR cardiac
Most common causes of clubbing of nails
Emphysema and congenital heart disease are the most common causes
How to calculate smoking habits: Pack years
years smoked * # packs smoked/day = ___ pack years
pulmonary/oxygenation NANDA nursing diagnosis
Impaired gas exchange fatigue ineffective airway clearance ineffective breathing pattern activity tolerance risk for acute confusion decreases cardiac output actor pain risk fo infection
interventions for pulmonary/oxygenation
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
Are crackles common in infants?
yes due to the fact that lungs have not developed
