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Health Assessment > Exam 2: Respiratory, Cardiac, Immunizations > Flashcards

Exam 2: Respiratory, Cardiac, Immunizations Flashcards

1
Q

Cardiac: What do you listen for with the client in LLD?

A

mitral stenosis, S3, S4 - with bell

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2
Q

Cardiac: What do you listen for with the client leaning forward?

A

Aortic regurgitation murmurs - with diaphragm. “breathe in, breathe out, hold”

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3
Q

What heart sounds do you hear with the diaphragm?

A

high pitched: S1, S2, murmurs of AR and MR, AS, friction rubs, VSD

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4
Q

What heart sounds do you hear with the bell?

A

low pitched: S3, S4, diastolic murmurs (e.g. MS)

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5
Q

Cardio: what are the characteristics of sounds to be described?

A

Frequency (pitch) Intensity (loudness) Duration Timing (systole, diastole)

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6
Q

What are the valves of the heart?

A

Atrioventricular: tricuspid & mitral/bicuspid Semilunar: pulmonic & aortic

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7
Q

Name the areas of the heart

A

RV is most of anterior chest

Base is superior aspect of heart at R & L 2nd IS

Xiphoid process is good landmark for RV.

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8
Q

Tell me about a normal PMI

A

4th or 5th interspace, 7-9cm lateral to midsternal (at or just medial to midclavicular)

Supine diameter: 1-2.5 (about a quarter)

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9
Q

Tell me about an abnormal PMI

A

Larger than 2.5cm (evidence of LVH, or enlargement, as seen in HTN and AS)

Lateral to midclavicular or >10cm lateral to midsternal (LVH)

Xiphoid/epigastric area (COPD)

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10
Q

Sinus arrhythmia

A

varies with respiration

normal HSs, though S1 may vary with the HR

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11
Q

Atrial or nodal premature contractions

A

Rhythm: atrial/nodal beat before next expected heart beat. Pause. Rhythm resumes

Heart Sounds: S1 may differ in intensity from normal S1. S2 may be decreased.

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12
Q

PVC (sporadic or regularly irregular)

A

Rhythm: ventricular beat comes before next expected beat. Pause. Rhythm resumes.

Heart Sounds: S1 may differ from normal, S2 may be decreased. Both likely split.

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13
Q

Afib & Aflutter w/varying AV block (Irregularly irregular)

A

Rhythm: ventricular rhythm is totally irregular, though possible short runs of regular-seeming

Heart Sounds: S1 varies in intensity

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14
Q

Paradoxical Pulse

A

decrease in pulse’s amplitude on quiety inspiration (st palpable, but possibly need BP cuff)

Systolic pressure decreases >10mmHg during inspiration

Causes: pericardial tamponade, exacerbatins asthma & COPD, st in constrictive pericarditis

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15
Q

pulsus alternans

A

pulse alternates in amplitude beat to beat even though rhythm is basically regular (must be).

Indicates LV failure, usually accompanied by S3

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16
Q

Normal Pulse Pressure

A

~30-40 mmHg pulse pressure

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17
Q

small, weak pulse

A

Pulse pressure diminished, upstroke may feel slowed, peak prolonged

causes: decreased SV (HF, hypovolemia, severe AS); increased peripheral resistance (exposure to cold and severe HF)

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18
Q

Large, bounding pulse

A

pulse pressure increased, rise and fall may feel rapid, peak brief

Causes: increased stroke volume, decreased peripheral resistance, or both (fever, anemia, hyperthyroidism, AR, AV fistulas, PDA); increased stroke volume d/t slow HRs (bradycardia, complete heart block); decreased compliance/increased stiffness of aortic walls (aging, atherosclerosis)

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19
Q

Systolic click

A

Usually MVP (systolic ballooning into LA from both leaflet redundancy & elongations of chordae tendineae)

Mid to late systolic

High pitched, often followed by MR murmur

several positions recommended: supine, seated, squatting, standing (squatting delays click & murmur, standing moves them closer to S1)

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20
Q

Opening snap

A

very early diastolic sound

stenotic mitral valve

listen with diaphragm medial to apex along lower left sternal border

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21
Q

intermittently irregular beats

A

e.g., ectopic beats - PAC, PVC

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22
Q

Continuously irregular beats

A

a.k.a. “regularly irregular”

Afib: palpittions that warrant ECG

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23
Q

Superior view of heart valves

A
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24
Q

What happens during diastole (+atrial kick)

A

AV valves open, passive flow (about 75% of volume) move into relaxed ventricles, then atria contract & active flow accounts for about 25% into ventricles (atrial kick)

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25
Q

isovolumic phase of ventricular systole

A

interval between closing of AV valves and opening of semilunar valves

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26
Q

ECG: define p, qrs, t, u

A

p: atrial depolarization
qrs: ventricular depolarization
t: ventricular repolarization
u: ventricular diastole

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27
Q

ECG leads

A

6 limb leads, 6 precordial leads

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28
Q

CAD risk factors for women

A

DM, smoking, HTN, obesity

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29
Q

questions you ask if chest pain

A

O: when did pain start? having pain now?

L: where is pain located? Does it radiate?

D: how long have you had pain?

C: what does it feel like? Pressure, tightness, heaviness, stabbing? Associated symptoms?

A: aggravates/alleviates? rest? Nitro?

R: travel to any part of your body?

T: when did you notice? Intermittent or persistent?

characteristics: squeezing, discomfort, burning, stabbing

Associated symptoms: cough

Relieved by: rest or nitrogylcerin

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30
Q

Special considerations on pediatric cardiac exam

A

Listen in at least 2 positions

S3 heard through thin chest walls

S4 indicates poorly compliant ventricles - always abnormal

murmurs: should disappear when supine, be systolic, not be assoc w/clicks, rubs, or other sx

school age: may disappear w/sitting

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31
Q

What causes S3?

A

passive flow of blood from atria

slight resistance to filling d/t ventricular overload and/or systolic dysfunction

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32
Q

What causes S4?

A

vigorous atrial ejection of blood d/t resistance to filling at end of diastole (presystole): decreased ventricular compliance

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33
Q

Normal vs abnormal S3

A

Normal: young adults, children, increased HR, late pregnancy

abnormal: older adult, HTN, volume overload (CHF), MR, high output states (thyroid, anemia)

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34
Q

Listening for S3

A

“Kentucky”

Hooked on back of S2 (after opening snap)

low pitch - apex, LLD, bell

does not vary w/respiration, persists when sitting upright, increases w/isotonic exercise (e.g., sit-ups)

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35
Q

Normal vs abnormal S4

A

Normal: trained athletes, elderly (ventricles become stiff)

Abnormal: systemic or pulmonary HTN, CAD/ischemia, AS/cardiomyopathy, delayed conduction

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36
Q

Listening for S4

A

“Tennessee”

Hooked on front of S1

Low pitch: LLD, bell

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37
Q

What is Split S2?

A

widening of normal interval beween aortic and pulmonic components of S2 - A valve closes before P valve

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38
Q

Normal vs Abnormal S2 - who and on exam

A

Physiologic: who - athletes, <40yo; on exam - pulmonic area, on inspiration, louder on reclining, disappears during slow breathing or holding breath

Pathologic: who - >40; on exam - appears or persists during expiration. May indicate pulmonary stenosis, ASD, RT BBB

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39
Q

Squatting valsalva and its effect on murmurs

A

Increases LV volume & increased vascular tone

MVP: delays click, murmur shortens (dec prolapse, harder to hear)

hypertrophic cardiomyopathy: Decreases intensity of murmur (dec outflow obstruction)

Aortic stenosis: increases intensity (inc blood volume ejected into aorta)

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40
Q

Standing valsalva and its effect on murmurs

A

decreseased LV volume, decreased vascular tone

MVP: click earlier, murmur longer (inc prolapse)

hypertrophic cardiomyopathy: increased intensity of murmur (inc outflow obstruction)

Aortic stenosis: decreased intensity of murmur (dec blood volume into aorta)

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41
Q

Physiologic murmurs: example causes

A

exercise, fever, hyperthyroidism, pregnancy, children, anemia

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42
Q

Grading of Heart Murmurs

A
  1. Very faint
  2. Quiet but heard immediately w/stethoscope on chest
  3. Moderately loud
  4. Loud, w/palpable thrill
  5. Very loud, w/thrill. May be heard w/stethoscope partly off chest
  6. Very loud, w/thrill. May be heard w/stethoscope off chest
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43
Q

What type of murmur might you hear in each area of the heart?

A
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44
Q

Systolic murmurs: mid, holo, and late

A

Midsystolic: AS, PS, ASD, HOCM*

Holosystolic: MR, TR, VSD

Late systolic: MVP

*Hypertrophic obstructive cardiomyopathy - most common cause of MIs in pediatric population

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45
Q

Diastolic murmurs: early, mid/late, other

A

Early diastolic: AR, PR, Austin-flint

Mid/late diastolic: MS, TS

Other/rare: PDA

46
Q

Murmurs in infants and children

A

S3 common - be concerned if increased intensity

Murmurs common in newborns until 48h of age - if <grade></grade>

<p>Most common cause: CHD. Acquired - rheumatic fever</p>

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47
Q

Benign pediatric murmurs

A

Still’s murmur: vibratory, groaning, musical. Heard best btwn LLSB and apex. 3-7yo.

Pulmonary: harsh systolic ejection at 2nd/3rd left IS

Venous Hum: continuous humming. Heard best at upper right sternal border in sitting position. Decreases/disappears supine.

48
Q

Vesicular breath sounds

A

inspiratory longer than expiratory

Soft intensity of expiratory

Relatively low pitch

covers most of both lungs

49
Q

Bronchovesicular breath sounds

A

inspiratory & expiratory about equal

intermediate intensity of expiratory

intermediate pitch

located 1st & 2nd ICS anteriorly & between scapulae

50
Q

Bronchial

A

Expiratory longer than inspiratory

loud intensity of expiratory

relatively high pitch

heard over manubrium, larger proximal airways

51
Q

Tracheal breath sounds

A

Inspiratory & expiratory about equal

very loud expiratory intensity

relatively high pitch

heard over trachea

52
Q

At what gestational age do alveolar cells secrete surfactant?

A

24-26 weeks

53
Q

Newborns/Infants & respiration

A

Newborns: Thorax barrel shaped (shaped like adult at 6yo)

chest & head circumference match

obligate nose-breathers x4 weeks

irregular breathing patterns (apnea 10-15sec)

crackles may be normal

**Newborns & infants: **thin chest wall, little musculature, ribs soft & pliant, some abd breathing (if increased - possible pulm dz). Chest circumference 30-36cm; Respiratory tree - bifurcation of distal trachea at T3 (adults T4-5)

54
Q

Pregnant women & Respiration

A

Dyspnea: breathes more deeply but not more frequently

asthma - worse or unaffected

Functional residual capacity decreases

55
Q

Types of immunity

A

Active Natural: had the dz. Life long immunity

Active Artificial: immunization via altered dz antigen against which body made antigens (most IZs)

Passive Natural: maternal - infant. Short lifespan - infant unprotected at about 2-3mths.

**Passive Artificial: **Preformed Abs - immune globulins or dz specific globulins. Human or animal products - protect 1-2mths.

56
Q

Types of Vaccines

A

Live Attenuated: live weakened strain injected. Stimulates memory B and T cells. Immunity typically long-term. E.g., MMR, Varicella

Inactivated: bacteria or virus isolated & inactivated using heat or chemicals. Can’t cause infection , buts stimulates B cells to produce Abs. Usually need several doses or booster shots. E.g., polio, hep A

**Subunit/conjugate: **also inactivated. Use only part of pathogen that evokes immune response. E.g., HIB, pertussis

57
Q

Vaccines for Health Care Workers

A

**HEp B: **3 doses (1 now, 2 in one month, 3 approx 5 months after dose 2)

Tdap: single dose + booster q10y

Influenza: annually

MMR: 1-2 doses if born after 1957

Varicella: 2 doses, 4w apart

Meningococcal: if routinely exposed to N. meningitidis

58
Q

Required record keeping for IZs

A

Edition & date of VIS

Date VIS is provided (date of IZ)

Office address & name of person who administers

Date vaccine administered

Vaccine manufacturer & lot #

59
Q

Diptheria

A

Transmitted respiratory droplets (or on objects)

Sx: weakness, sore throat, fever, swollen glands in neck

Thick coating builds up on throat or nose in 2-3 days (pseudomembrane - formed from dead tissue) making it hard to breath

Prognosis: may cause damage to heart, kidneys, and nerves, paralysis. 1 in 10 w/Tx die. W/o 1 in 2 die.

**Diagnosis: **throat swab or skin lesion

Tx: isolation 48hrs, antitoxin & antibiotics (erythromycin), respiratory support & airway mgmt

*give diptheria toxoid booster to all close contacts

60
Q

Tetanus

A

**Transmission: **not person-person. Bacteria found in soil, dust, manure, enters body through break in skin

Sx: HA, jaw cramping, sudden involuntary muscle tightening, trouble swallowing, seizures, fever

Dx: clinical exam

Tx: medical emergency - hospitalization, immediate human tetanus immune globulin or equine antitoxin, tetanus vaccine, drugs to control muscle spasm, aggressive wound care, Abx, supportive care (possible intubation)

61
Q

Pertussis

A

“Whooping cough”

**Transmission: **air droplets, most contagious up to 2 weeks after cough starts

S/s: w/in 5-10 days post exposure, runny nose, low grade fever, violent rapid cough, vomiting, exhaustion, apnea

**Prognosis: **most sever in infants/children. May last 10+weeks

**Dx: **swab secretions at back of throat or nasopharyngeal flush

Tx: strongly recommended before test results. Antibiotics if >1 yo w/in 3weeks cough onset. <1 y and pregnant w/in 6 weeks of cough onset. Azithromycin, clarithromycin, erythromycin, trimethoprim-sulfamethoxasole; vaporizer, suctioning. cough syrup will NOT help

62
Q

Haemophilus Influenza Type B (HIB)

A

Types: bacteremia, meningitis, cellulitis

Transmission: droplets, cough

Risk: sickle cell, asplenia, HIV, chemo, radiation, post transplant

S/s: fever, cough, SOB, chills, sweating, HA, muscle pain, excessive tiredness, anxiety, alt MS

**Dx: **one or more lab tests: blood, spinal fluid

**Tx: **Antbx 10 days

**Prognosis: **even w/tx, 3-6% chldren w/meningitis die

63
Q

Measles

A

“Rubeola”

**Transmission: **droplet 4 days before & 4 days after rash; incubation 7-21 days, lives on objects 2 hours

S/s: classic prodrome of fever (up to 105F), malaise, three Cs - cough, coryza (inflammation mucous membranes & loss of smell), conjunctivitis, & pathognomonic enanthema (koplic spots - white sposts in mouth) followed by maculopapular rash

complications: pneumonia, hearing loss, enchepalitis

Dx: serology lab confirmation, throat, nasopharyngeal swab

**Tx: **isolation, supportive care

*post exposure prophylaxis: vaccine w/in 72hrs, IG w/in 6 days

*hcp must report to health dept w/in 24 hours

64
Q

Mumps

A

**Transmission: **droplet. Incubation 12-25 days

S/s: fever, HA, muscle aches, tiredness, loss of appetite, swelling of salivary glands

**complications: **encephalitis/meningitis, oophoritis and mastitis

**Dx: **serologic testing

**Tx: **isolation for 5 days after glands swell, supportive care

65
Q

Rubella

A

“german measles”

**Transmission: **droplet

**S/s: **rash starting on face, spreads to body, low fever, lasting 2-3 days; older persons swollen glands

Complications: birth defects: deafness, heart defects, mental retardation

66
Q

Hep B

A

**Transmission: **body fluids

S/S: fever, fatigue, loss of appetite, nausea, emesis, abdominal pain, dark urine, clasy-colred stool, joint pain and jaundice. Appear 90 days after exposure, but can occur 6 weeks to 6 months, lasting 6 months

**Dx: **serologic testing (HBsAg, anti-HBs, etc)

**Tx: **acute: supportive; chronic: close surveillance (infx dz f/u, hepatologist, VA clinics)

Prognosis: can cause lifelong infxn, cirrhosis, liver cancer, liver failure, death

67
Q

Hep A

A

Transmission: fecal matter- even microscopic

S/s: jaundice, tiredness, stomach ache, loss of appetite, nausea, joint pain

**Dx: **serologic testing

**Tx: **supportive, fluids, rest

68
Q

Polio vaccine

A

**Transmission: **person to person

**S/s: **72% have none. Some have fever, nausea, HA, stiffness in back. <1% permanent paralysis of limbs, of those 5-10% die

69
Q

Pneumococcal

A

**Transmission: **air droplets

**S/s: **fever, chills, cough, rapid breathing, chest pain, stiff neck

**Complications: **meningitis, bacteremia, pneumonia

**Dx: **serum, spinal fluid

**Tx: **based on severity. Antibx, caution w/resistance

*immunocompromised, chronic illness, cochlear implants are high risk - should get 23 (can’t get 23 until 2y - get 13

70
Q

Influenza vaccines

A

Shot: inactivated

Nasal spray: live attenuated (5-49yo, healthy immune system)

71
Q

Who should not get certain flu shots

A

Anyone not feeling well

Inactivated: anyone with Guillai-Barre syndrome

Nasal: long term health problems, received other vaccines w/in 4weeks, age <2, >50, long term aspirin tx, people who care for immunocompromised pts, allergy to eggs

72
Q

Meningococcal Dz

A

Risks: community settings (e.g., college dorms)

Transmission: close contact w/throat secretions, spit, kissing; sx present 3-7 days after exposure

S/s: N/V, photophobia, altered MS, neck pain, HA

**Dx: **serum testing, blood or lumbar puncture, CSF

**Tx: **antibx (before test results)

**Prognosis: **10-15% die even w/tx; 11-19% of survivorshave long term disabilities, loss of limbs, deafness, brain damage

73
Q

Herpes Zoster

A

“Shingles”

Transmission: can spread by direct contact. caused by virus reactivation - greater risk w/dec immune function

S/s: blistering clear rash in dermatome, pain. Lesions usually crust over/heal in 2-4 weeks

Complications: postherpetic neuralgia (PHN), ophthalmic involvement (medical emergency!), bacterial superinfection, cranial nerve palsy

74
Q

Rabies

A

Transmission: saliva or brain/nervous system tissue

S/s: flu-like, fever, HA, cerebral dysfunction, delirium, confusion, agitation

**Onset: **acute 2-10 days, once signs of rabies appear, nearly always fatal

Dx: locate animal & euthanize, examine brain tissue; in humans ante-mortem - serum, spinal fliud, need more than one. Post-mortem - brain biopsy

**Tx: **wash wounds immediately. Give passive Ab & vaccine

75
Q

Rotovirus

A

**Transmission: **fecal-oral

S/s: severe acute gastroenteritis, watery diarrhea, vomiting, abdominal pain, dehydration, lasts several days

**Tx: **supportive care

do not give vaccine to severe combined immunodeficiency or intususseption

76
Q

Pregnancy Vaccinations

A

Hep A

Hep B

HPV

Influenza IIV, LAIV (live)

MMR (live)

Meningococcal (polysaccharide, conjugate)

Pneumococcal (polysaccharide)

Tdap (toxoid/inact)

Tetanus/diptheria TD (toxoid)

Varicella (live)

77
Q

Pregnancy vaccinations - BEFORE

A

Influenza IIV

Influenza LAIV (live)

If indicated: the rest

*Avoid conception 4 weeks for all LIVE

78
Q

Pregnancy Vaccinations - DURING

A

Influenza IIV

Tdap 27-36 weeks gest, each pregnancy

(or Tetanus/diptheria Td, but prefer Tdap)

If indicated: meningococcal, pneumococcal, Hep A/B

Contraindicated: Influenza LAIV, HPV, MMR, Varicella, Zoster

79
Q

Pregnancy Vaccinations - AFTER

A

Influenza IIV & LAIV

If indicated: the rest (avoid conception 4 weeks for all live)

Special Considerations: MMR immediately PP if not rubella immune; Tdap immediately PP if not given before, Varicella immediately PP if not immune

80
Q

Adult Vaccinations - GENERAL

A

Influenza annually

Tdap: one time Tdap then booster Q10y

Varicella: 2 doses

81
Q

Adult Vaccinations 19-21 yo

A

HPV 3 doses M &F

MMR 1 or 2 doses

82
Q

Adult Vaccinations 22-26 yo

A

HPV 3 doses, females

MMR 1 or 2 doses

83
Q

Adult Vaccinations 27-49 yo

A

MMR 1 or 2 doses

84
Q

Adult Vaccinations 50-59yo

A

MMR 1 or 2 doses (to about 55yo)

85
Q

Adult Vaccinations 60-64yo

A

Zoster 1 dose

86
Q

Adult vaccinations >= 65yo

A

Zoster (1 dose)

Pneumococcal polysaccharide (PPSV23) 1 dose

87
Q

Vaccinations immunocompromised (except HIV)

A

Influenza IIV

HPV Males & Females through 26yo

Pneumo 12 or 23

*Hib if post-HSCT

C/I’d: varicella, zoster, MMR

88
Q

Vaccinations HIV

CD4 count <200

A

Influenza IIV

HPV through 26yo (M & F)

Pneumo 13 or 23

Hep B

C/I’d: varicella, zoster, MMR

89
Q

Vaccinations HIV

CD4 >200

A

Influenza IIV

Varicella

HPV through 26yo (M & F)

MMR

Pneumo 13 or 23

Hep B

No C/I

90
Q

Vaccinations MSM

A

HPV through 26 yo

Hep A/B

91
Q

Vaccinations: Kidney Failure

A

Influenza IIV

Zoster

MMR

Pneumo 13 or 23

Hep B

92
Q

Vaccinations: Heart Dz, Chronic Lung Dz, Chronic ETOH

A

Influenza IIV

Zoster

MMR

Pneumo 23

93
Q

Vaccinations asplenia

A

Influenza IIV

Zoster

MMR

Pneumo 13 or 23

Meningococcal

Hib

94
Q

Vaccinations Chronic Liver Dz

A

Influenza IIV

Zoster

MMR

Pneumo 23

Hep A/B

95
Q

Vaccinations: Diabetes

A

Influenza IIV

Zoster

MMR

Pneumo 23

Hep B

96
Q

Vaccinations: Birth

A

Hep B 1

97
Q

Vaccinations: 1 mth

A

Hep B2 (1-2mo)

98
Q

Vaccinations: 2 mo

A

Hep B2 (1-2mo)

Rotavirus 1

DTaP 1

Hib 1

PCV13 1

IPV 1

99
Q

Vaccinations 4 mo

A

Rotavirus 2

DTaP 2

Hib 2

PCV13 2

IPV 2

100
Q

Vaccinations: 6mo

A

Hep B3 (6-18mo)

Rotavirus 3 (if necessary)

DTaP 3

Hib 3 (depending)

PCV13 3

IPV 3 (6-18mo)

Influenza IIV

101
Q

Vaccinations: 9mo

A

Hep B3 (6-18 mo)

IPV 3 (6-18mo)

Influenza IIV

102
Q

Vaccinations: 12 mo

A

Hep B3 (6-18 mo)

Hib 3/4 (12 - 15)

PCV13 4 (12 - 15)

IPV 3 (6-18mo)

Influenza IIV

Varicella (12-15)

MMR (12-15)

Hep A 2 doses (12-23mo)

103
Q

Vaccinations: 15 mo

A

Hep B3 (6-18 mo)

DTaP 4 (15-18mo)

Hib 3/4 (12 to 15)

PCV13 4 (12 to 15)

IPV 3 (6-18mo)

Influenza IIV

Varicella (12-15)

MMR (12-15)

Hep A 2 doses (12-23mo)

104
Q

Vaccinations: 18mo

A

Hep B3 (6-18 mo)

DTaP 4 (15-18mo)

IPV 3 (6-18mo)

Influenza IIV

Hep A 2 doses (12-23mo)

105
Q

Vaccinations: 19-23 mo

A

Influenza IIV​

Hep A 2 doses (12-23mo)

106
Q

Vaccinations: 2-3yo

A

Influenza IIV or LAIV

107
Q

Vaccinations: 4-6yo

A

Influenza IIV or LAIV

DTaP 5

IPV 4

MMR 2

Varicella 2

108
Q

Vaccinations: 7-10

A

Influenza IIV or LAIV

109
Q

Vaccinations: 11-12

A

Influenza IIV or LAIV

Tdap

HPV (3 doses)

Meningococcal 1

110
Q

Vaccinations: 13-15

A

Influenza IIV or LAIV

111
Q

Vaccinations: 16-18

A

Influenza IIV or LAIV

Meningococcal booster at 16yo

Health Assessment (14 decks)

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