Foundations Exam 2 Flashcards
components of the integumentary system include…
hair, skin, nails, sweat glands
body’s largest organ system
skin
functions of the skin
waterproof, protective barrier body temperature regulation vitamin D synthesis sensory perception non verbal communication & identity wound repair waste excretion
three main layers of the skin
epidermis (most superficial), dermis, subcutaneous tissue (deepest)
components of the epidermis
most superficial layer
thin (just a few cells thick)
avascular
two layers: outer (dead keratinized cells) and inner (cell layer where melanin, keratin formed)
components of dermis
vascular
connective tissue
sebaceous and sweat glands
hair follicles
components of subcutaneous tissue
adipose/fatty tissue
directly below dermis–loose later (inc. mobility over underlying structures)
fat for: energy, temp regulation, cushioning
4 pigments that contribute to normal skin colors
melanin, carotene, oxyhemoglobin, deoxyhemoglobin
melanin
brownish pigment
amount genetically determined
amount inc. with more sun exposure
carotene
golden yellow pigment
in subQ fat and heavily keratinized areas (palms, soles)
oxyhemoglobin
bright red pigment
predominates @ arteries, capillaries
blood flow through skin: more (reddening), less (pale pallor)
deoxyhemoglobin
darker bluish pigment
increase amount @ cutaneous vessels: bluish color (cyanosis)
abnormal skin pigments
jaundice, cyanosis
jaundice
yellow color pigment
bilirubin deposits @ skin
secondary to liver disease, biliary duct obstruction, and increased destruction of RBCs
first seen: hard/soft palate junction, sclera of eyes, then @ skin over rest of body
best way to assess jaundice?
in direct natural sunlight
where is jaundice first seen?
junction of hard and soft palate and sclera of eyes
cyanosis
bluish color pigment
nonspecific sign
peripheral (dec. cutaneous blood flow, normal arterial O2 levels–possibly normal response to cold, anxiety)
central (arterial O2 levels low)
hard to assess in people with darker pigmented skin
how do you identify decreased oxygenation in lighter vs darker pigmented persons?
lighter: cyanosis
darker: rely on clinical signs of dec. oxygenation @ brain
skin turgor is….. and it measures…
skin elasticity (ability to promptly return to place when released), hydration status.
sign of decreased skin turgor
tenting when pinched
causes of decreased skin turgor
age (thinning of dermis, reduced elastin)
dehydration
examination of skin, hair, nails is _________ throughout the rest of the comprehensive examination
integrated…not a separate step!
major components of skin assessment:
color, color change, temperature, moisture, thickness, texture, mobility/turgor, edema, lesions, pressure ulcer risks, skin cancer
skin color assessment
general pigmentation, skin tone even, consistent with genetic background, increase/loss of pigmentation, color change (pallor, redness, central/peripheral cyanosis, jaundice, carotene)
high levels of carotene will present as a _______ pigment in the _______ (areas of the body)
yellow color; palms, soles, face
how do you assess skin temperature?
use the backs of hands
check bilaterally
skin should be warm and equal bilaterally
how do you assess skin moisture?
look & touch
should be dry to touch without flaking or cracking
perspiration/ diaphoresis
check mucosal membranes for dehydration (usually smooth, moist)
normal skin texture
smooth and firm with an even surface
a callous forms in response to…
excessive pressure exerted on certain areas (palms, soles)
arterial insufficiency leads to what skin findings?
very thin, shiny (atrophic) skin
skin mobility
the ease with which it lifts
skin turgor
the speed with which it returns to place
where do you usually assess skin turgor?
anterior chest under clavicle (preferred)
back of the hand
pitting edema
fluid in interstitial spaces is displaced when pressure is applied to the surface area with a finger, leaving a depression or “pit”.
usually assessed along the shin
nonpitting edema
cause by plasma proteins “leaking” out of capillaries and into tissues, drawing water with them
see with burns, localized reaction (bee sting, for example), or trauma
scale for pitting edema + corresponding depression depth: 1+ 2+ 3+ 4+
1+ = 2mm (mild, disappears rapidly) 2+ = 4mm (moderate; disappears 10-15s) 3+ = 6mm (moderate-severe; lasts 1+min) 4+ = 8mm (severe; lasts 2+ min)
characteristics of lesions to note
anatomical location, distribution (localized, generalized), patterns, shapes, types, color, elevation
macule
flat, non-palpable skin color change (brown, white, tan, purple, red)
patch
flat, non-palpable skin color change (brown, white, tan, purple, red)
> 1 cm, may have irregular border
papule
elevated, palpable, solid mass with circumscribed border
plaques
elevated, palpable, solid mass with circumscribed border
> 0.5 cm
e.g. psoriasis, actinic keratosis
nodule
elevated, solid, palpable mass that extends deeper into the dermis that a papule
- 5-2 cm and circumscribed
e. g. lipoma, squamous cell carcinoma, poorly absorbed injection, dematofibroma
tumor
elevated, solid, palpable mass that extends deeper into the dermis that a papule
> 1- 2 cm and doesn’t always have sharp borders
e.g. larger lipomas, carcinoma
vesicle
circumscribed, elevated, palpable mass containing serous fluid
bulla
circumscribed, elevated, palpable mass containing serous fluid
> 0.5 cm
e.g. pemphigus, contact dermatitis, large burn blisters, poison ivy, bullous impetigo
wheal
elevated mass, transient borders, often irregular, size/color vary, caused by serous fluid moving into dermis, doesn’t contain free fluid
e.g. hives (urticaria), insect bites
pustule
pus-filled vesicle or bulla
e.g. acna, impetigo, furuncles, carbuncles
cyst
encapsulated, fluid-filled or semi-solid mass located in the subcutaneous tissue or dermis
e.g. sebaceous cyst or epidermoid cyst
primary vs. secondary skin lesions
primary skin lesions are original lesions arising from previously normal skin.
secondary skin lesions originate from primary lesions.
erosion
loss of superficial epidermis
does not extend to dermis
depressed, moist area
e.g. ruptured vesicle, scratch marks, aphthous ulcer
ulcer
skin loss extending past epidermis
necrotic tissue loss
bleeding, scarring possible
e.g. stasis ulcer (venous insufficiency), pressure ulcer
scar
(aka cicatrix)
skin mark left after healing of wound, lesion
injured tissue replaced by connective tissue
young = red, purple; mature = white, glistening
e.g. healed wound or surgical incision
fissure
linear cracks in skin
may extend to dermis
e.g. chapped lips or hands, athlete’s foot
skin and mobility: discuss
patients with decreased mobility are at an increased risk for pressure ulcers, skin breakdown. pressure because not moving + circulation problems.
stage 1 pressure ulcer
non-blanching redness
stage 2 pressure ulcer
involves epidermis + dermis
stage 3 pressure ulcer
involves subcutaneous tissue
stage 4 pressure ulcer
involves muscle, bone, tendons
assessment tool for determining risk for skin breakdown, ulcers?
braden scale. Categories: sensory perception, moisture, activity level, mobility, nutrition, friction/shear. Lower score (6) = higher risk. Higher score (23) = lower risk.
three major types of skin cancer
basal cell carcinoma, squamous cell carcinoma, melanoma
basal cell carcinoma
arises in the basal layer of epidermis
80% of skin cancers
appear pearly white, translucent. grow slowly and rarely metastasize. mostly in sun-exposed areas @ head, neck
squamous cell carcinoma
arise in upper later of epidermis
16% skin cancers
appear crusted, scaly, red, inflamed/ulcerated
can metastasize
melanoma
arise from melanocytes in epidermis (produce melanin)
4% skin cancers, but most lethal type (cause 75% of deaths)
can spread rapidly
ABCDEs of examining moles for melanoma
A: asymmetry
B: borders (irregular)
C: color variation/change (esp black, blue)
D: diameter 6+mm or diff from others
E: evolving (diff from rest, changing over time)
risk factors for melanoma
sun exposure (UV radiation) hx previous melanoma older than 50 years male 1-4 atypical moles light colored eyes, skin severe blistering as child (2nd degree)
most commonly recommended screening method for skin cancer
self-examination
skin cancer prevention strategies
avoid sun exposure(10a-2p), wear sun screen, wear long sleeves/pants/hat, regular self exam
what’s included in hair assessment?
hair color, quantity, distribution, texture, scalp, body, axillae, pubic hair
hair color
results from melanin production. graying occurs with reduction of melanin.
hair quantity
varies from person to person, decreases with age in both men and women. male patterned baldness = normal change. abnormal = patchy or uneven balding
hair texture
fine, thick, straight, curly, kinky
hair distribution
may be diminished in certain populations (asian). look for normal hair distribution @ genital region.
scalp assessment
look for lesions, flaking, parasites
body/axillae/pubic hair assessment
look for changes, unusual patterns, ask pt what is normal, what is different for them
loss of hair on legs is an indication of…
peripheral artery disease
hirsutism
excessive facial hair on women due to elevated testosterone levels
two types of hair
vellus: short, fine, covers body (“peach fuzz”)
terminal: coarser, thicker, conspicuous. scalp, armpits, eyebrows, pubic hair)
function and parts of fingernails
protect distal ends of fingers and toes, prevent infection.
nail plate, lanula, cuticle
how to assess nails?
inspect, palpate
look @ color, shape, any lesions
Beau’s lines
horizontal ridges
indicate acute illness
early & late clubbing
180 degrees + @ nail bed. indicates oxygen deficiency. More clubbing = more chronic hypoxia.
spoon nails
indicates iron deficiency anemia
pitting @ nails
indicative of psoriasis
paronychia
swelling proximal to cuticle. indicative of local infection.
sebaceous glands
oil glands that lubricate skin, hair
reduces water loss @ skin
sweat glands
2 types
eccrine: widely distributed, open directly to surface, body temp control
apocrine: axillary and genital areas, stimulated by emotional stress, body odor
describe the flow of blood @ heart, lungs, body
from body, low O2 blood travels through vena cavas into right atrium. from right atrium through the tricuspid valve and into right ventricle. from right ventricle through pulmonic valve to pulmonary arteries to lungs where blood is oxygenated and returned to left atrium via pulmonary veins. from left atrium through bicuspid/mitral valve to the left ventricle. from left ventricle through aortic valve to the aorta and out to body to deliver O2 and collect waste.
describe the pericardial sac/pericardium
a double walled sac containing the heart and roots of the great vessels. consists of two layers (serous and fibrous) with pericardial fluid between to prevent friction/rubbing.
if pericardial fluid is limited/diminished, what sound might you hear @ auscultation?
pericardial rub
upper chamber, lower chamber, and septum @ heart (describe)
upper: right and left atria, thinner walls
lower: right and left ventricle, thicker walls
septum: separates right and left sides
AV valves
tricuspid and mitral valves. closing of these creates the S1 heart sound.
semilunar valves
pulmonic and aortic valves. closing of these creates the S2 heart sound.
location of the heart
under the sternum between the 2nd and 5th intercostal space (ICS).
Aprox. 2nd ICS = base of heart
Aprox. 5th ICS = apex of heart
pericordium
area of the anterior chest over the heart and great vessels
detrocardia
heart is oriented the wrong way/ on the opposite side in the thorax. aka “flipped heart”
electrical activity @ heart
SA node (60-100) > AV node (40-60) > Bundle of His > Purkinje fibers
what are the different phases of an ECG wave?
P wave: atrial depolarization (impulse conduction through atria)
QRS complex: ventricular depolarization (impulse conduction through ventricles)
T wave: ventricular repolarization (“recovery phase”)
one of most important symptoms to assess during interview, subjective data collection…
chest pain. can be a wide variety of things, but assume it’s cardiac until you can prove otherwise.
“Time is muscle.” Explain.
the longer people go without care during cardiac events, the greater the damage to heart muscle. 1st: ischemia, loose O2 @ heart muscle. then, cardiac muscle dies, cannot regenerate.
CHEST mnemonic
causes of chest pain C: cardiac disorders H: heartburn, hiatal hernia E: esophageal and gastric disorders S: stress T: trauma
common symptoms associated with chest pain
dyspnea, diaphoresis, pallor, nausea, vomiting, weakness, palpitations, disorientation, anxiety, “fear of impending doom.”
prodromal/initial symptoms of heart disease in women
common: fatigue, anxiety, indigestion, achy chest, SOB esp with exercise, sleep difficulties
less common: discomfort @ shoulder, dizziness, changes in headache, vision probs
cardiac risk factors
smoking, nutrition, stress, alcohol use, exercise
patient positions for cardiac exam
supine, left lateral, leaning forward
assessment of precordium and heart sounds (steps)
inspect for pulsations palpate apical impulse palpate for abnormal pulses auscultate heart rate (apical) and rhythm if you detect an irregular rhythm, auscultate for pulse deficit (radial pulse rate minus apical pulse rate) id and listen to S1 and S2 auscultate for extra heart sounds auscultate for murmurs auscultate w/ client in other positions
palpate apical pulse (location/what to assess)
location: use palm over area around 5th ICS, then switch to fingers for finer assessment.
Note location, diameter, amplitude, duration
what position should the patient be in to assess apical pulse?
supine
midsternal, midclavicular line
midsternal: down middle of sternum
midclavicular: middle of clavicle down (near nipple)
most useful characteristic for identifying left ventricular hypertrophy
apical pulse duration
what sound does the opening of heart valves produce?
none. just the closing produces sound.
S1 heart sound
“lub” of “lub dub.” produced by closing of bicuspid (mitral) and tricuspid. heard the loudest @ apex of heart (near 5th ICS). correlates to the beginning of systole.
S2 heart sound
“dub” of “lub dub.” produced by closing of semilunar valves (aortic and pulmonic). head loudest @ the base of heart (near 2nd ICS). correlates to beginning of diastole.
what heart sound marks the beginning of systole? diastole?
systole: S1
diastole: S2
what are split heart sounds?
when the valves in question (bi/tricuspid for S1 and semilunar for S2) don’t close at the exactly the same time, you get a split S1 or S2 sound.
APE TO MAN
Aortic > Pulmonic > Erb’s point > tricuspid > mitral (order for listening to heart sounds)
Location for listening to aortic valve?
right 2nd ICS
Location for listening to pulmonic valve?
left 2nd ICS
Location for listening to Erb’s point? what is Erb’s point?
left 3rd ICS. Location where you can hear S1 and S2 relatively equally.
Location for listening to tricuspid valve?
lower left sternal border @ 4th ICS
Location for listening to mitral valve?
left 5th ICS medial to midclavicular line
S3 heart sound
heard early in diastole immediately after S2.
produced by large amount of blood hitting compliant left ventricle b/c rapid ventricular filling. low frequency, dull sound. indicates ventricular dysfunction or overload.
most sensitive indicator of ventricular dysfunction
presence of S3 heart sound
ventricular gallop aka…
S3 heart sound
when is the presence of a S3 heart sound considered normal?
in young children, people with high cardiac output, and during 3rd trimester of pregnancy
S4 heart sound
heard late in diastole just before S1. indicates a reduction in ventricular wall compliance (resulting from conditions causing ventricular hypertrophy). “Ten-nes-see.” Low pitch sound best heard with bell of stethoscope.
atrial gallop aka…
S4 heart sound
when is the presence of a S4 heart sound considered normal?
sometimes in athletes or elderly.
pericardial friction rub
caused by inflammation @ pericardial sac. rubbing together of two layers (parietal and visceral layers). best heard @ 3rd ICS to left of sternum. high pitched scratchy sound (inc. with exhalation, leaning forward). Have pt. hold breath to hear better.
conditions that contribute to heart murmurs
increased blood velocity, structural valve defects, valve malfunction, abnormal chamber openings (septal defects)
heart murmur sound are made by______ and sound like….
turbulent blood flow; swooshing or blowing during auscultation.
systolic murmur is heard…
between S1 and S2
diastolic murmur is heard…
between S2 and S1
how do you characterize hear murmurs?
timing (midsystolic, pansystolic, diastolic), intensity (1 softer to 6 louder scale), location where hear it best, pitch, and quality (blowing, swooshing, rumbling, rushing, musical), and shape/pattern (intensity from beginning to end).
jugular venous pressure reflects…
the pressure @ right atria (i.e. central venous pressure)
carotid artery pulse location
@ groove between trachea and sternocleidomastoid muscle
how do you assess jugular venous pulsation?
sit patient in supine position, 30-45 degree incline of torso, ask patient to turn head slightly to left, shine light to help.
how do you assess for jugular venous distention ?
patient supine, start @ 30 deg > 45 deg > 90 deg. turn head to left/right and look for distended jugular vein. evaluate both sides.
what does JVD indicate?
indicates right arterial pressure. if distended, likely right sided weakness and blood “backing up” @ heart.
also could indicate tension pneumothorax (blood can’t get back to heart as well) and pericardial tamponade
auscultate the arteries using which end of the stethoscope?
use the bell to listen for bruits
bruits are caused by…
turbulent blood flow cause by increased stenosis @ artery.
steps for examining blood vessels @head/neck?
auscultate 1st (have pt hold breath briefly)! then palpate, one at a time so don’t occlude both carotid arteries and blood O2 to brain.
what should you note when assessing blood vessels @ head, neck?
amplitude, elasticity, thrills (feels like cat purring softly)
An early systolic bruit is associated with….?
a 50% decrease in the diameter of the carotid artery lumen
A pansystolic bruit is associated with…?
a 60% reduction in the diameter of the carotid artery lumen
A pansystolic bruit that extends into early diastole is associated with…?
a 70-80% reduction in the diameter of the carotid artery lumen
chest pain can radiate to what other areas?
jaw, neck, back, shoulder, down arm
aggravating factors for chest pain?
eating, physical exertion, position change, motion of arms/neck/jaw, deep breathing or coughing, elimination, emotional upset/stress, sexual intimacy/activity, weather extremes (hot/cold)
alleviating factors for chest pain?
rest, change position, shallow breathing, temp change, heating pad or ice pack depending, reduce/eliminate stressors, medications, analgesics, OTCs, Rxs, antacids, H2 blockers, PPIs, nitroglycerin
arteries carry what? (and exception)
oxygen rich blood from heart to body tissues (via capillaries).
exception: pulmonary arteries carry deoxygenated blood from heart to lungs
major arteries of arm?
brachial, radial, ulnar
major arteries of leg?
femoral, popliteal, dorsalis pedis, posterior tibial
veins carry what? (and exception)
deoxygenated blood from body back to heart/lungs
exception: pulmonary veins carry oxygenated blood from lungs back to heart.
major veins?
femoral, popliteal, saphenous veins
the lymphatic system includes…
lymph, lymphatic capillaries, lymphatic vessels, and lymph nodes
lymphatic system forms a connection between…
arterioles and venules
what allows the circulatory system to maintain vital equilibrium?
the lymphatic system
peripheral vascular symtoms to note during subjective data collection…
skin changes, leg pain/heaviness/aching, leg veins (appearance, feel), leg sores or open wounds, swelling @ legs/feet, sexual activity changes (men), swollen glands/nodules.
arterial ulcers generally present where?
in toes (result from arterial insufficiency @ legs)
venous ulcers generally present where?
on ankles (venous insufficiency @ legs)
when assessing peripheral vessels, what should you always do?
compare bilaterally!
how do you grade pulses and what do the grades mean?
0: absent
1+: palpable, thready, weak, easily obliterated
2+: normal, easily identified, not easily obliterated
3+: increased pulse, moderate pressure for obliteration
4+: full pulse, bounding, cannot obliterate
arms: inspection and palpation steps
inspection: size, edema, venous patterning, skin color, clubbing @ fingertips
palpation: fingers/hands/arms for temp, capillary refill time, pulses (radial, ulnar, brachial), epitrochlear lymph nodes, allen’s test
legs: inspection and palpation steps
inspection: skin color, hair distribution, lesions/ulcers, edema
palpation: temperature, capillary refill, femoral pulse (auscultate for bruits), popliteal/dorsalis pedis, posterior tibial pulses
how to assess popliteal pulse?
flex knee partially
thumbs on anterior knee while press fingers firmly @ popliteal fossa @ back of knee
how to assess dorsalis pedis pulse?
have pt dorsiflex foot
apply light pressure to + along side of extensor tendon of big toe
how to assess posterior tibial pulse?
palpate behind and just below medial malleolus (in groove between ankle and achilles tendon)
dependent position food turns red
arterial ulcerations/insufficiency
dependent position food turns cyanotic
venous insufficiency
Raynaud’s
vascular disease caused by vasoconstriction and vasospasm of fingers and/or toes
breasts
paired mammary glands, produce/store milk, aid in sexual stimulation
lymphatic system
remove interstitial fluid from tissues, absorb/transport fatty acids as chyle from digestive system, transports WBCs to/from lymph nodes into bones
axillary tail of spence
fatty breast tissue extending up into armpit
BP & mastectomy
don’t take BP on side with mastectomy. removed lymph nodes. swelling, damage from BP cuff.
external anatomy of breast
nipple, areola, montgomery glands, four quadrants
internal anatomy of breast
glandular, fibrous, and fatty tissues
major axillary lymph nodes
risk factors for breast cancer
female, age (older), 1st degree relative with dx of bc, dense breast tissue, start menstruation before 12, menopause after 55, radiation to chest
modifiable risk factors for breast cancer
drinking alcohol, overweight/obesity, physical activity level (get at least 150 min moderate or 75 min intense per week), having children, taking birth control
hormone replacement therapy: the current word…?
okay for short-term replacement, but not safe for long-term tx
breast cancer and antiperspirants, bras, breast implants,
no hard evidence of link between these things and breast cancer
breast inspection includes…
palpation includes…
inspection: size/shape, color/texture, superficial venous pattern, bilateral color/size/shape/texture of areolas, bilateral size/direction of nipples
palpation: texture, elasticity, tenderness, temperature, masses, mischarge (only normal with lactation), mastectomy or lumpectomy
characteristic late sign of breast cancer
peau d’orange. skin peel looks like an orange. not good prognosis.
breast cancer symptoms
lump, pulled in nipple, dimpling, dripping, redness/rash, skin changes
best time to do self breast exam
immediately after menstruation, which can make boobs tender
expected changes in aging female breast tissue
decrease in size, firmness
glandular tissue decreases
fatty tissue increases
current screening guidelines
vague.
average risk: 40-44 (choice to get annual exams), 45-54 (yearly mammograms), 55+ (mammograms every 2 years)
higher risk: yearly MRI
thorax
base of neck to diaphragm
lungs, distal trachea, bronchi
thoracic cage…what is it? what’s it do?
sternum, 12 rib pairs, 12 thoracic vertebrae, muscles, cartilage
function: protects heart, lungs, great vessels
supports shoulders, upper limbs
attachment for many neck, back, chest muscles
uses IC muscles to lift, depress the thorax during breathing
thoracic cavity
respiratory components
retraction
when you can see the IC muscles assisting with the WOB. see a lot in kids (RSV, bronchiolitis) and adults with asthma
sternum angle
aka angle of Louis. location of 2nd pair of ribs and reference point for counting ribs/ICSs.
costal angle
angle where right and left costal margins meet the xiphoid process. usually less than 90 degrees, but will be increased with chronically overinflated lungs (emphysema, barrel chest)
posterior landmarks
right and left scapular lines and vertebral line
lateral landmarks
anterior and posterior axillary lines and midaxillary line (middle of armpit down)
anterior landmarks
midsternal line and right, left midclavicular line
mediastinum
trachea, bronchi, esophagus, heart, great vessels. lungs sit on either side of mediastinum.
trachea
flexible surface lying anterior to esophagus
begins @ cricoid cartilage @ neck
10-12 cm long in adults
made up of C shaped hyaline cartilage rings
bronchi
right, left main bronchi are @ oblique position in the mediastinum. right main bronchus is shorter, more vertical than left.
which bronchus is more likely to be involved during aspiration?
right bronchus because straighter down, more likely for material to go down it than the left bronchus. right bronchus goes straight into right middle lobe, so listen there for aspiration lung sounds
respiratory “dead space”
bronchi and trachea
where do you listen for aspiration sounds?
right middle lung, so listen @ armpit/axillary region.
lungs
two cone shaped, elastic structures suspended in the thoracic cavity
apex of lungs
extends slightly above the clavicle
base of lungs
@ level of diaphragm
@ anterior surface, the lungs extend down to what level? laterally? @ posterior surface?
6th rib; 8th rib; 10th rib
where does TB like to live in the lungs?
@ the apex (near clavicle).
lobes @ left lung
two
lobes @ right lung
three
where do you assess upper lobes of lungs? lower lobes? right middle lobe?
anteriorly for upper lungs; posteriorly for lower lungs; axillary area
alveoli are responsible for…?
gas exchange
the purpose of respiration
to maintain adequate oxygen level in blood to support cellular life
ventilation
the mechanical act of breathing
chest expands vertically and horizontally, creating negative pressure in the lungs to draw in air (inspiration). Expiration is passive, occurs with relaxation of IC muscles and diaphragm.
what are some things that alter breathing patterns?
cellular requirements, hormonal regulation, changes in O2 and CO2 levels in blood, changes in hydration status and pH
control centers of breathing?
medulla, pons, hypothalamus, sympathetic nervous system,
strongest stimulus for breathing
under normal circumstances, hypercapnia (high levels of CO2 in blood)
CHEST PAIN mnemonic
C: cardiac H: heartburn, hernia E: esophageal and gastric disorders S: stress T: trauma P: pulmonary A: aneurism I: inflammation N: neurological disorders
cough: what to evaluate
productive or non-productive?
wheezing?
three major respiratory concerns for patients traveling outside country?
TB, SARS, MERS
pulmonary inspection
nasal flaring
color of face, lips, chest
look for clubbing @ nails
inspect shape, configuration of chest
normal anterioposterior to transverse ratio?
should be 1:2. measures chest anteriorly and compares to lateral size of chest
what part of stethoscope do you use to assess breath sounds?
diaphragm, not bell.
if listening to breast sounds through clothing, might mistakenly hear…?
crackles
increased WOB looks like….?
use of accessory muscles, tripod position, pursed lip breathing
pectus excavatum
“hole” in sternum
pectus carinatum
sternum protrudes outward
scoliosis
curvature of spine. note by looking for one shoulder shifting lower than other when pt bends forward.
kyphosis
“hump back”
lordosis
“sway back”
lordosis is normal in what populations?
toddlers, pregnant women
palpation @ pulmonary
measure chest expansion
hyper resonance upon percussing will be heard with what…?
emphysema or pneumothorax
diaphragmatic excursion
helps you determine if lungs functioning the same on both sides. as pt to exhale, percuss down until hear dull sounds. have pt inhale and repeat.
what pattern do you use to auscultate lungs?
“ladder pattern” from one side to the other as you move downward/distally
crackles, rales
can be fine or coarse. fine: high pitched, popping sound not cleared by coughing (associated with pneumonia, CHF, bronchitis, asthma, emphysema). coarse: low pitched, bubbling “velcro sound” (associated with pneumonia, pulmonary edema, pulmonary fibrosis)
pleural friction rub
low pitched, dry grating sound that occurs with inspiration and expiration (associated with pleuritis)
wheeze (sibilant)
high pitched musical sound heard primarily during expiration but may also be heard @ inspiration (associated with acute asmtha or chronic emphysema)
wheeze (sonorous)
low pitched snoring, moaning sounds heard during expiration that often clear with coughing (associated with bronchitis, single obstruction, snoring w/ sleep apnea)
stridor
harsh, honking/wheezing noise heard with severe broncholaryngospasm (like w/ croup)
when do you use voice sounds to assess pulmonary function? what does it test for?
if you hear abnormally located bronchovesicular or bronchial breath sounds.
tests for presence of bronchophony, egophony, and whispered petriloquy (changes with consolidation–clearer over consolidation). “ninety nine” as move down back.
bronchophony (“99”)
indicates indicates increased density, sounds are louder and clearer
Egophony (“eee”)
indicates area of consolidation, sound is louder and sounds like A
Whispered petriloquy (whisper “99”)
indicates areas of consolidation or compression, whispered words are louder, clearer
health promotion counseling
tobacco cessation, immunizations (flu, pneumococcal pneumonia)
