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Health Assessment > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

What is the precordium

A

area on anterior chest directly overlying heart and great vessels

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2
Q

What is the pericardium or pericardium sac

A

protective, fluid-filled sac with 2 layers that surrounds your heart and helps it function properly, helps with friction free movement of heart muscle

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3
Q

What is the myocardium

A

muscular wall of heart that does the pumping

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4
Q

What is the endocardium

A

thin layer of endothelial tissue that lines inner surface of heart chambers and valves

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5
Q

What is the mediastinum

A

heart and great vessels located between lungs in the middle third of thoracic cage

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6
Q

Where does the heart sit

A

2nd to 5th intercostal space and from right border of sternum to left midclavicular line

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7
Q

Where is the apex of the heart located

A

5th intercostal space left midclavicular line

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8
Q

Where is the base of the heart located

A

2nd intercostal space across midline of the sternum

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9
Q

Describe in order the circulation of heart blood flow

A

-vena cava
-right atrium
-tricupsid valve
-right ventricle
-pulmonic valve
-pulmonary arteries
-unoxygenated blood to lungs
-lungs oxygenate blood
-pulmonary vein
-left atrium
-mitral valve
-left ventricle
-aortic valve
-aorta

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10
Q

Describe how fetal circulation is different

A

-lungs non functioning

-blood pumped from placenta to right side of heart

-two openings shunt (bypass lungs) directly to aorta and systemic circulation

-shunts: foramen ovale and ductus arteriosus

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11
Q

Where is the aortic valve located

A

2nd intercostal space immediately to right of sternal border

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12
Q

Where is the pulmonic valve located

A

2nd intercostal space immediately to left of sternal border

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13
Q

Where is the tricuspid valve located

A

4th or 5th intercostal space immediately to left of sternal border

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14
Q

Where is the mitral valve located

A

5th intercostal space midclavicular line

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15
Q

What does S1 represent closure of

A

AV valves

-tricupsid and mitral valves

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16
Q

What does S2 represent closure of

A

semilunar valevs

-pulmonic and aortic valves

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17
Q

Where is S1 loudest at

A

apex

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18
Q

Where is S 2 loudest at

A

base

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19
Q

Where does S1 begin

A

systole

-lub sound

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20
Q

Where does S2 begin

A

diastole

-dup

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21
Q

How and where to get the apical pulse

A

5th intercostal space left midclavicular line

-palpate one finger

-have pt exhale and hold breath

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22
Q

What does displaced apical pulse indicate

A

-heave or lift

-Enlarged Heart

-Volume Overload

-CHF

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23
Q

What is the order of auscultation of heart sounds

A

aortic

pulmonic

tricuspid

mitral

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24
Q

What is an S3 murmur

A

right after S2 when AV valves open and atrial blood first pours into ventricles

-due to the vibration of ventricles that resist early, rapid filling

This is often an indicator of heart failure

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25
Q

What is an S4 murmur

A

before S1 (presystole), ventricle resistant to filling, atria contract and push blood into noncompliant ventricle

-CAD

-can be common in adults older than 40-50 and are normal

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26
Q

How to assess for pulse deficit

A

-palpate carotid artery

-auscultate apical heart rate

-compare, equal “no pulse deficit”

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27
Q

How to assess for carotid bruits

A

whooshing sound, blood flow turbulence, can indicate atherosclerotic disease

-use bell over 3 spots on carotid artery

  • pt exhale and hold breath

-do bilaterally

-normal “no bruits noted”

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28
Q

What is heave or lift

A

sustained forceful thrusting of the ventricle during systole

-ventricular hypertrophy result of increased workload

-find from inspecting precordium

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29
Q

What is a thrill

A

palpable vibration

-like the throat of purring cat

-signifies turbulent blood flow

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30
Q

Describe the clinical portrait of heart failure

A

Dilated pupils, skin pale, gray or cyanotic, dyspnea, orthopnea, crackles, cough, decreased BP, N&V, ascites, pitting edema, anxiety, falling O2 sat, confusion, JVD, MI, fatigue, S3 gallop, enlarged spleen, decreased urine output, weak pulse.

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31
Q

What is dyspnea

A

difficulty breathing, shortness of breath

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32
Q

What is dyspnea on exertion

A

shortness of breath with exertion (DOE after walking two level blocks)

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33
Q

What is paroxysmal nocturnal dyspnea (PND)

A

person awakens from sleep with perception of needing fresh air

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34
Q

What is angina

A

chest pain

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35
Q

What is orthopnea

A

need to assume a more upright position to breathe. exact number of pillows used can indicate how severe the orthopnea is

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36
Q

What is nocturia

A

wake up in the night needing to pee

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37
Q

What is pallor

A

paleness

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38
Q

What is orthostatic hypotension

A

Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions

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39
Q

What causes jugular vein distention

A

right sided heart failure

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40
Q

What are questions we would ask when getting a cardiac history

A

-chest pain
-dyspnea
-orthopnea
-cough
-fatigue
-cyanosis or pallor
-edema
-nocturia
-past cardiac history
-family cardiac history

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41
Q

What are risk factors for cardiac troubles

A

-nutrition

-smoking

-alcohol

-physical activity

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42
Q

Which ethnic groups are at a greater risk for cardiovascular failure

A

-prevalence of hypertension (contributes to coronary heart disease) in black americans is highest in the world

-higher rate of stroke, death from heart disease

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43
Q

What is stenosis

A

-The area through which blood moves out of the heart to the aorta is narrowed

calcification of valve restricting forwards flow of blood

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44
Q

What is regurgitation

A

-valves dont close completely

back flow of blood

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45
Q

What is heart failure

A

a chronic condition in which the heart is unable to pump out all of the blood that it receives

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46
Q

How do we grade pulses

A

0=absent

1+= weak

2+= normal

3+= increased, full bounding

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47
Q

How do we assess for pretibial edema

A

depress skin over tibia for 5 secs and release, should leave no indentation

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48
Q

How do we grade pitting edema

A

1+, Mild pitting, slight indentation, no perceptible swelling of the leg

2+, Moderate pitting, indentation subsides rapidly

3+, Deep pitting, indentation remains for a short time, leg looks swollen

4+, Very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted

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49
Q

How to perform a capillary refill test

A

hands near level of heart, depress and blanch nail beds, release and note time of color return

-normal: <3 secs

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50
Q

Describe the characteristics of an artery

A

-heart pumps oxygenated blood through arteries to tissues

-pulse

-strong, tough, dense

-stretch and recoil

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51
Q

Describe the characteristics of a vein

A

-absorb CO2 and waste products from periphery and carry back to heart

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52
Q

How does venous flow occur

A

-moves forward by contraction of skeletal muscles and one way values not allowing blood to go backwards

53
Q

What is the purpose of the lymphatic system

A

retrieve excess fluid and plasma protein from interstitial spaces and returns to blood stream

54
Q

Name 3 functions of the lymphatic system

A
  1. conserve fluid and plasma proteins that leak out of capillaries
  2. form major part of immune system that defends body against disease
  3. absorb lipids from small intestine
55
Q

What is claudication

A

Cramping pain in legs induced by exercise. Typically caused by artery obstruction. Assessed by number of blocks walked or stairs climbed to produce pain

56
Q

What do the cervical nodes drain

A

head and neck

57
Q

What do the axillary nodes drain

A

breast and upper arm

58
Q

What do the epitrochlear nodes drain

A

hand and lower arm

59
Q

What do the inguinal nodes drain

A

lower extremity, external genitalia, anterior abdominal wall

60
Q

Where are radial pulses and what supplies them

A

medial to radius at wrist

-radial artery supplies blood

61
Q

Where are the brachial pulses and what supplies them

A

above elbow crease

-brachial artery supplies blood

62
Q

What is a deep vein thrombosis (DVT)

A

deep vein occluded by thrombus blocking venous return

-acute, unilateral painful swelling, warmth, redness, cyanosis

-causes: immobility, history blood clots, estrogen therapy (birth control), trauma, infection

63
Q

Where is the femoral pulse and what supplies it (we only verbalize for assessment)

A

below inguinal ligament, between pubis and inferior superior iliac crest

-deep femoral artery supplies blood

64
Q

Where is the popliteal pulse and what supplies it (we only verbalize for assessment)

A

leg extended, anchor thumbs on the knee and curl fingers around into popliteal fossa

-superficial femoral artery becomes popliteal artery and supplies blood

65
Q

Where is the posterior tibial pulse and what supplies it

A

Between medial malleolus and the achilles tendon

-posterior tibial artery supplies blood

66
Q

Where is the dorsalis pedis pulse and what suplpies it

A

lateral to and parallel the the extensor tendon of the big toe

-anterior tibial artery supplies blood

67
Q

How do we use a doppler ultrasonic probe

A

detects weak peripheral pulse, magnifies pulsatile sounds from heart and blood vessels

-place drop of coupling gel on end of handheld device , use light pressure over pulse site

-swishing swooshing sounds are normal

68
Q

List 8 acute arterial symptoms

A

-sudden onset
-throbbing
-pain
-pallor
-pulselessness
-paresthesia
-poikilothermia (coldness)
-paralysis

69
Q

List 8 chronic arterial symptoms

A

-onset gradual
-cramp
-numbness and tingling
-feeling of cold
-low ankle brachial index
-cool pale skin
-diminished pulses
-pallor on elevation

70
Q

List 3 acute venous symptoms

A

-sharp deep calf muscle tender to touch

-sudden onset

-red, warm, swollen leg

71
Q

List 5 chronic venous symptoms

A

-aching, tiredness, feeling of fullness

-chronic pain, increases at end of day

-edema

-varicosities

-weeping ulcers at ankle

72
Q

What is a venous stasis ulcer

A

After acute DVT or chronic incompetent valves in deep veins

-medial malleolus and tibia bleeding, uneven edges, develops into an open wound

-itching, brown pigments, petechiae

73
Q

What is an aneurysm

A

sac formed by dilation in artery wall

-cause: arthrosclerosis (plaque builds up in artery)

74
Q

Where is the carotid pulse and what supplies it

A

pulse felt on either side of the neck, over the carotid artery.

-carotid artery supplies blood

75
Q

Describe the homan’s sign test

A

the individual’s knee should be in a flexed position. The examiner will then forcibly and abruptly dorsiflex the individual’s ankle and observe for pain behind the knee, which constitutes a positive Homan sign (presence of thrombosis).

-tests for DVT

76
Q

Where is the apex of the lungs

A

top of lung location. anterior: 3-4cm above clavicles

77
Q

Where is the base of the lungs

A

bottom of lung location. -anterior: rests on diaphragm

-posterior: T10: T12 with inspiration

78
Q

Describe the right lung

A

-shorter than left (room for liver)

-3 lobes

79
Q

Describe the left lung

A

-narrower than right (room for heart)

-2 lobes

80
Q

Describe the posterior lung

A

almost all lower lobe

81
Q

Where is the pleural cavity

A

either side of mediastinum (left or right)

-contains lungs !

82
Q

What are the four main functions of the respiratory system

A
  1. supplies oxygen for energy production
  2. removes carbon dioxide (CO2)
  3. maintains homeostasis (acid base balance) of arterial blood
  4. maintains heat exchange, stabilizes body temp
83
Q

How are respirations controlled

A

-involuntary control

-pons and medulla (part of brain stem)

84
Q

Describe hypercapnia as a respiratory drive

A

-primary drive to breathe

-increases in CO2 levels in the blood stimulate us to breathe

85
Q

Describe hypoxemia as a respiratory drive

A

-not as strong as hypercapnia

-COPD pt use as main drive

-decrease of O2 in the blood stimulate us to breathe

86
Q

What are the normal muscles of respiration

A

diaphragm and intercostal muscles

87
Q

What are the accessory muscles of respiration

A

-neck shoulders and abdomen

-sternal and intercostal retraction

-abdominal muscles contract and push diaphragm up squeezing lungs

88
Q

Why do we use accessory muscles for respiration

A

occur as a result of forced inspiration with intense exercise or respiratory distress

89
Q

What is the angle of louis and where is it located

A

at secondary rib

-indentation between manubrium and body of sternum

-marks tracheal bifurcation (division) into right and left main bronchi

90
Q

What is the APGAR scoring system

A

newborns respiratory assessment at 1 min and 5 mins after birth

-scored on: heart rate, respiratory effort, muscle tone, reflex irritability, color

-2,1 or 0 score

-score of 7-10 indicated good condition, needing only suction of nose and mouth

91
Q

What are we assessing for when inspecting respirations

A
  • rate (12-20)
  • depth (moderate: easy rise and fall. shallow: hardly see breaths. deep: really working for breath)

-use of accessory muscles

92
Q

What are we assessing for during inspection of the thorax

A

-symmetry: transverse diameter should be 2:1. 1:1 indicates barrel chest, respiratory disease, lungs hyperinflated

-lesions

-scars

-hair pattern: females fine villus hair

-hair color compared to rest of body

93
Q

What are we assessing for during inspection of lips and mucous membranes

A

-lips: pink and moist, no cyanosis

-buccal mucosa: pink and moist, no cyanosis

94
Q

What are we assessing for during inspection of nails

A

-shape and contour: slightly convex, pink nail beds, no cyanosis

-angle: less than 160 degrees, make diamond

-capillary refill: push down nail bed, <3 secs

95
Q

What are we assessing for during palpation of thorax

A

-anterior and posterior: no crepitations

-place hands butterfly on ribs, take deep breath, do anterior and posterior, smooth, symmetrical, and equal chest expansion anterior and posterior

96
Q

How do we auscultate lungs vesicular and what are expected findings

A

use diaphragm

-over peripheral lung fields

-low pitch

-soft inspiration greater than expiration anterior and posterior

97
Q

How do we auscultate the lungs bronchovesicular and what are expected findings

A

use diaphragm

-over major bronchi

-moderate pitch and amplitude

-inspiration equal to expiration anterior and posterior

98
Q

How do we auscultate the lungs bronchial and what are expected findings

A

use diaphragm

-over trachea and larynx

-high pitch

-loud inspiration less than expiration anterior only

99
Q

What do adventitious breath sounds sound like

A

-crackles indicating pneumonia

-wheezing indicating asthma

100
Q

What does resonance in the lungs sound like and where can we expect to find it

A

-clear hollow sound

-low pitch

-healthy lung tissue

101
Q

What does hyper resonance in the lungs sound like and where can we expect to find it

A

-booming sound

-lower pitch

-normal over childs lung and abnormal in adult indicating emphysema or pneumothorax

102
Q

What does dullness in the lungs sound like and where can we expect to find it

A

-soft muffled thud

-abnormal density in lungs: pneumonia, pleural effusion, atelectasis, tumor

-can be normal in athlete with muscular chest wall or obese adults with subcutaneous fat

103
Q

What id diaphragmatic excursion and what can it indicate

A

percussion measuring outer 5-7cm of tissue

-abnormal finding must be 2-3 cm wide

-indicates lung disease, COPD

104
Q

How do we assess for tactile fremitus

A

-palpable vibration

-use ball of fingers and touch chest while they repeat “ninety nine” or “blue moon”

-vibrations should feel same on both sides

105
Q

What is a barrel chest and where do we expect to find it

A
  • equal anteroposterior to transverse diameter, 1:1 ratio

normal aging, chronic emphysema and asthma

106
Q

Describe adventitious breath sounds: crackles (rales) and what can it indicate

A

-short popping sounds

-heard more on inspiration

-not cleared with coughing

-indicates pulmonary edema, pneumonia

107
Q

Describe adventitious breath sounds: wheeze (rhonchi) and what can it indicate

A

-high pitches, musical, squeaking sounds

-inspiration or expiration as air is compressed through narrow passageways

-indicates tumors, asthma, bronchitis, emphysema

108
Q

Describe adventitious breath sounds: stridor and what can it indicate

A

-high pitch crowing sound

-louder in neck than chest

-inspiration and/or expiration

-obstruction or swollen upper airway

-indicates epiglottitis, croup

109
Q

What is a pleural friction rub

A

-coarse low pitched grating quality that sounds like two pieces of leather being rubbed together, crackles close to ear

-caused when pleurae become inflamed and lose normal lubrication!

110
Q

What is tachypnea and what can cause it

A

rapid shallow respirations >20-24

-fever, exercise, respiratory distress

111
Q

What is bradypnea and what can cause it

A

slow <10

-drug induced, increased ICP, coma

112
Q

What is hyperventilation

A

blowing out too much CO2

-increase in depth and rate

113
Q

What are kussmuals respirations and when does it occur

A
  • increased rate, depth in attempt to compensate for acidosis
  • occur in diabetic ketoacidosis
114
Q

What are cheyne stokes

A

-waxing/waning respiration pattern

-increasing rate and depth then decreasing

-normal in infants

-increased ICP, drug overdose, meningitis, renal failure

115
Q

Describe the development variations in lungs and thorax in the elderly

A

-calcified costal cartilages (less mobile thorax)

-decreased strength respiratory muscles

-lungs rigid, hard to inflate

-decreased ventilation of lung bases

-fewer alveoli

-kyphosis: hump in curvature of spine

116
Q

What is crepitus

A

coarse, crackling sensation palpable over the skin when air abnormally escapes from the lung and enters the subcutaneous tissue, subcutaneous emphysema!

117
Q

What is emphysema

A

-destruction of pulmonary connective tissue

-indications: barrel chest, accessory muscles used with respiration, SOB on exertion, tachypnea, respiratory distress

118
Q

What is atelectasis

A

the collapse of part or all of a lung, is caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the lung

119
Q

What are retractions

A

Skin pulling around the ribs or above the clavicles during inspiration, sinks in

120
Q

What is chronic obstructive pulmonary disease (COPD)

A

airflow limitation caused by airway narrowing and/or obstruction, loss of elastic recoil, or both.

121
Q

The electrical stimulus of the cardiac cycle follows which sequence

A

At SA node - AV node - bundle of His - bundle branches

122
Q

When listening to heart sounds, the nurse knows that the S1:

A

Is louder than the S2 at the apex of the heart

123
Q

When listening to heart sounds the nurse knows the valve closures that can be heard best at the base of the heart are

A

mitral and tricuspid

124
Q

When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true

A

Blood can flow into the left side of the heart through an opening in the atrial septum

125
Q

If the nurse hears extra heart sounds in the infant at 48 hours after birth, the nurse should:

A

Make sure the advanced practitioner is aware of this finding before discharge

126
Q

What is tactile fremitus produced by

A

sounds generated from the larynx

127
Q

What best describes the normal mechanism of respiration in relation to the diaphragm

A

During inspiration the diaphragm descends and flattens

128
Q

What is the normal diaphragmatic excursion in an adult patient

A

3-5 centimeters

Health Assessment (5 decks)

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