Jen ch 30 Part II Flashcards
Crackles
Caused by random, sudden reinflation of groups of alveoli or disruptive passage of air through small airways. Canned be described as fine, medium, or course
When assessing thorax and lungs:
Inspect for deformities, position of the spine, slope of the ribs, retraction of intercostal spaces during inspiration, bulging of intercostal spaces, and rate and rhythm of breathing
Rhonchi
Low pitched, continuos sounds caused by muscular spasm, fluid, or mucus in larger airways; or new growth or external pressure causing turbulence
Wheezes
High pitched continuous squeak during inspiration or expiration. Louder on expiration; often heard in asthma
Pleural friction
Dry rubbing or grating sound caused by inflamed pleura: parietal pleura rubbing against visceral pleura
PMI
Point of maximal impulse for palpating of heart similar placement to apical pulse
S1, S2, S3, S4
S1 and S2 “lub/dub” S1 hearts chambers fill with blood, S2 chambers empty of blood, S3 can be heard when heart attempts to fill already distended ventricle, S4 occurs when atria contract to enhance ventricular filling (S4 not normally heard in adults)
Six anatomical landmarks of heart:
Aortic, pulmonic, second pulmonic, tricuspid, mitral, epigasric (Ape 2 man?)
Atrial gallop
S4
Assessing vascular system:
Carotid arteries, jugular veins, peripheral arteries, peripheral veins, tissue perfusion, lymphatic system
BP Readings between arms
Right arm tends to be higher - always record highest measurement
Do not _____ the carotid artery and why
Do not palpate or massage the carotid artery vigorously because carotid sinus located at bifurcation of common carotid arteries in upper third of neck and sinus sends impulse to vagus nerve - stimulation causes reflex drop in heart rate and BP (can cause syncope or circulatory arrest.)
Occlusion
Blockage
Jugular vein
Most accessible, right internal JV best to examine because has more direct path to right atrium of heart, when lying down ext. JV will distend and easily visible, if distended when sitting can be a sign of heart disease
Lack of pulse
Can indicate arterial issues
Ulnar pulse used when
Evaluating arterial insufficiency to the hand
Phlebitis
Irritation of vessels
Variscosities
Superficial veins that become dilated, esp. when legs in dependent position
Abdomen inspection
Inspect, palpate, auscultate, check liver, stomach, uterus, ovaries, kidneys, bladder, umbilicus, contour and symmetry, enlarged organs or masses, movements or pulsations
Abdomen auscultation
Bowel motility (peristalsis, borborygmi), vascular sounds (bruits)
Abdomen palpation
Detect tenderness, distention, masses, aortic pulsation
musculoskeletal system general inspection
Gait, postural abnormalities, age related changes
Crepitus
Joint sounds - rice krispys
ROM, AROM, PROM
Range of motion, active and passive
Neurological assessment
Variables considered: LOC (level of consciousness), physical status, chief complaint, mental and emotional status, cultural considerations
MMSE
Mini-Mental State Examination- measures orientation and cognitive function
Delirium
Acute mental disorder, characterized by confusion, disorientation, and restlessness
Glasgow Coma Scale
Objective measurement of consciousness on a numerical scale for patients with lower consciousness
Intellectual function assessment
Memory (recent, immediate, past), knowledge, abstract thinking, association, judgment
Motor function assessment
Tests: coordination, higher and lower extremity/fine-motor control, balance, gross motor function
Clonus
muscular spasm involving repeated, often rhythmic, contractions.
After the exam:
- Record findings
- Give patient to dress (assist if needed)
- talk to doc before patient if serious issues
- ensure exam room cleaned
- review assessment for accuracy
- communicate significant findings w/ patient
