Health/ H2T Assessment- Respiratory/ Cardiac/ Extremities

Question 1

What do you INSPECT for in respiratory assessment

Answer 1

Look for breathing pattern & rate (respirations, labored vs nonlabored effort)
Look at shape of the chest (normal, barrel, etc)
Flaring nostrils (in infants & children)

Question 2

How do document normal chest sounds?

Answer 2

Lungs are clear
Good Air exchange

Question 3

Adventitious Breath Sounds mean …
Examples

Answer 3

Abnormal breath sounds
Ex:
Wheezing (high pitch sounds from inflammation)
Bronchi (snoring sounds)
Pleural rub (grating sound)
Rails/Crackles (rice krispy/crackling sound due to fluid)
Absence of breath sounds

Question 4

breathing that is difficult or requires more effort than normal

Answer 4

labored breathing

Question 5

What do you auscultate in a respiratory assessment?

Answer 5

Chest sounds (anterior listening)
Breath sounds (posterior listening)
*Listen for quality and intensity(

Question 6

How to auscultate anterior chest sounds

Answer 6

• Assist pt with sitting upright*
• Ask pt to take SLOW, DEEP BREATHS through the mouth
• Start 1 inch below R mid clavicle over the intercostal space and listen to 1 FULL inspiration and expiration. Do to L side
• Begin 1.5- 2 inches below origin point R mid clavicular and listen to 1 FULL again. Repeat on L side
  -Move down to midclavicular 5th intercostal space and repeat process on both R & L sides

Question 7

How to auscultate posterior chest sounds

Answer 7

Tell pt to lean forward and cross there arms
- Start at 2 inches below shoulder and 2 inch into the right of the spine. listen to 1 FULL inspiration and expiration. Do to L side
-Repeat on both sides about 2 inches from origin point.
-Repeat
-End just below scapula on both sides

Question 8

PMI

Answer 8

Point of Maxium Impulse
where steth is placed to hear heart sounds the best

Question 9

Where is PMI?

Answer 9

L mid-clavicle 5th intercostal space

Question 10

Normal Heart sounds

Answer 10

S1 and S2 Lub Dub

Question 11

Systole

Answer 11

Ventricular Contraction

Question 12

Diastole

Answer 12

Ventricular Relaxation

Question 13

Abdominal Assessment

Answer 13

Assess the abdomen in four quadrants
Pt should be laid flat
Inspect Auscultate Percuss Palpate

Question 14

Why do we auscultate before palpate when assessing abdomen?

Answer 14

We do not want to disrupt or create sounds that did not exist prior to palpating before listening

Question 15

Anything done rectally, pt should

Answer 15

be on their left side

Question 16

Grading Scale for Pulses

Answer 16

0- Absent
1- Diminished, thready
2- Normal, not easily obliterated
3- Increased full volume
4- Bounding

Question 17

How many arterial pulse sites are there?

Answer 17

12

Question 18

When assessing the extremities,

Answer 18

always compare both sides
you inspect and palpate; check
arterial pulses
capillary refill
veins
Edema
Joint mobility/ ROM
Muscle strength
Color, Movement, Temp
CMS

Question 19

Normal capillary refill documentation

Answer 19

Capillary refill < 3 seconds

Question 20

Abnormal capillary refill documentation

Answer 20

Capillary refill > 3 seconds

Question 21

Capillary refill is a good test to check for

Answer 21

circulation

Question 22

How is edema measured and checked?

Answer 22

measured from +0-4
*Make indentation w/ finger
Count in seconds for indentation to return to normal

Question 23

Hyperactive bowel sounds aka

Answer 23

Borborygmi

Question 24

Best area to check apical pulse

Answer 24

The mitral area aka apical area of the heart located 5th intercostal space L mid-clavicle

Question 25

Example of a Normal breath sounds that are lough and high pitched, compared to sound of air blowing through a pipe

Answer 25

Bronchial

Question 26

Example of a Normal breath sound that is soft and breezy

Answer 26

vesicular

Question 27

example of a normal breath sound that are medium pitched and soft

Answer 27

Broncho vesicular

Question 28

What are some causes for adventitious breath sounds?

Answer 28

Inflammation of airways, air passing through fluid, and narrowed airways

Question 29

How is edema measured?

Answer 29

pressing thumb into skin and noting how long the tissue remains indented

Question 30

Edema measurement scale

Answer 30

+1 pitting edema- barely detectable/ immediate rebound
+2 pittind edema- a few seconds to rebound
+3 pitting edema- 10 to 12 seconds to rebound
+4 pitting edema- more than 20 seconds to rebound
+5 branwy edema- no pitting, tissue is firm; skin warm and mosit- skin discoloration

Question 31

Difference between pitting and non pitting edema

Answer 31

Pitting edema- cause is excess water in the tissue, can usually resolve e/ diuretics and elevation

Non pitting- cause can be other than extra fluid, can be salts, proteins and drainage is more difficult

Question 32

The BELL of a stethoscope is to listen to _____ ; the diaphragm of stethoscope is to listen to _____

Answer 32

heart murmurs; breath sounds

Question 33

Dependent areas of bedridden patients;

Answer 33

back and sacrum.

Question 34

CMS stands for

Answer 34

Circulation, Motion, Sensation