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Health Assessment > Test 3 Review > Flashcards

Test 3 Review Flashcards

1
Q

Precordium Assessment

A

The area on the anterior surface of the body overlying the heart, great vessels, pericardium and some pulmonary tissue:

  1. Inspection
  2. Palpation
  3. Auscultation (Use both bell and diaphragm)
    - systematic manner
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2
Q

Assessment of the Periphery

A
  • Inspection of the jugular venous pressure (JVP)
  • Inspection of the HEPATOJUGULAR REFLUX
  • Palpation and auscultation of the ARTERIAL PULSES
  • Inspection and palpation of the PERIPHERAL PERFUSION
  • Palpation of the EPITROCHLEAR NODE
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3
Q

5 Cardiac Landmarks:

A
  1. Aortic area
  2. Pulmonic area
  3. Midprecordial area
  4. Tricuspid area
  5. Mitral area
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4
Q

Aortic Area

A

2nd intercostal space (ICS) to the right of the sternum

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5
Q

Pulmonic Area

A

2nd ICS to the left of sternum

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6
Q

Midprecordial Area

-Erb’s Point

A

3rd ICS to the left of the sternum

-Both aortic and pulmonic murmurs may be auscultated

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7
Q

Tricuspic Area

A

5th ICS to the left of the sternum

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8
Q

Mitral Area

A

5th ICS at the left midclavicular line

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9
Q

Angina

A
  • The heart’s vascular supply cannot keep up with metabolic demand
  • The pain of angina is characterized as burning, squeezing, or aching, heaviness in the chest which may be relieved by rest
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10
Q

Palpitations

A

Irregular heartbeats or the sensation of a rapidly fluttering, pounding, or throbbing heart.

Quality:
-Skipped heart beats, throbbing, pounding, fluttering
Associated Manifestations:
-Anxiety, weakness, nausea, SOB, chest pain, perspiration, fainting
Aggravating Factors:
-Smoking, caffeine, exercise 
Alleviating Factors:
-Rest
Setting
-Resting, smoking, exercising, drinking or eating food w/ caffine
Timing
-After exercise or at rest
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11
Q

Aortic (Thoracic) Dissection

A

Pain:
-Sudden, sharp, and tearing, and radiates to shoulders, neck, back, and abdomen

Neurological Complications:

  • Hemiplegia, sensory deficits secondary to carotid artery occlusion
  • May present w/ a new murmur, bruits, or unequal blood pressure in upper extremities
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12
Q

Thorax

A

The thorax is a cone-shaped structure (narrower at the top and wider at the bottom) that consists of bones, cartilage, and muscles.

  • On the anterior thorax, these bones are the 12 pairs of ribs and the sternum
  • Posteriorly, there are 12 thoracic vertebrae and the spinal column

Normal adult ratio: 1:2 ratio

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13
Q

Barrel Chest

A

Ration AP:TD = 1:1

  • Circular or barrel shaped
  • COPD - barrel due to air trapped in alveoli - hyperinflation
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14
Q

Auscultation of S1

A
  • S1 is heard loudest in the mitral area
  • S1 is caused by the closure of the mitral and tricuspid valves.
  • S1 corresponds to the lub sound in the phonetic “lub-dub”
  • S1 heealds the onset of systole
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15
Q

Intensity of S1 depends on:

A
  1. Adequacy of the A-V cusps in halting the ventricular blood flow
  2. Mobility of the cusps
  3. Position of the cusps and the rate of ventricular contraction
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16
Q

Auscultation of S2

A
  • S2 is caused by the closure of the semilunar valves
  • S2 corresponds to the “dub” sound in the phonetic “lub-dub”
  • S2 heralds the onset of diastole
  • S2 is heard loudest at the Aortic landmark
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17
Q

Distinguishing S1 from S2

A

Palpate the carotid artery w/ the hand closest to the head while auscultating the mitral landmark

-You will hear S1 with each carotid pulse beat

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18
Q

S3

A

Mitral and tricuspid areas auscultated for low-pitched sounds, specifically S3

Ventricular diastolic gallop

  • extra heart sound
  • heard louder during inspiration
  • Use BELL of the stethoscope
  • Early diastolic filling sound that originates in the ventricles and is thus heard best at the apex of the heart
  • Sounds like Kentucky - S1 Ken S2 Tuc S3 ky
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19
Q

S3 cont…

A
  • An S3 heart sound can be normal or abnormal
  • Physiological S3 is heard in children and young adults
  • After age 30, a physiological S3 is very infrequent
  • An S3 can also be normal in high-output states like 3rd trimester of pregnancy
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20
Q

S4

A
  • Bell and Diaphragm over Mitral and tricuspid areas
  • Auscultate for 15 seconds
  • Late diastolic filling just before S1
  • Atrial contraction
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21
Q

S4 cont…

A
  • S4 is low-frequency vibration caused by atrial contraction
  • Precedes S1 of the next cycle and is known as atrial diastolic gallop
  • S4 heart sound is a late diastolic filling sound
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22
Q

Normal Blood Pressure

A

Under 120/80

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23
Q

Past Health History

A

Medical History:

  • Cardiac specific: AAA, angina, cardiogenic shock, chest trauma
  • non cardiac specific

Surgical History:
-Previous cardiovascular procedures

Communicable diseases:
-Rheumatic fever, untreated syphilis, viral myocarditis

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24
Q

Past Health History (cardiovascular)

-Allergies

A
  • Aspirin
  • IVP dye
  • Seafood

Before cardiac catheterization, it is a PRIORITY to notify PCP of an allergy to iodine-containing substances such as shellfish

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25
Q

Pulsations on Inspection

A

Normal findings

-No visible pulsations Except for the PMI (point of maximum intensity or apical pulse) in the MITRAL AREA

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26
Q

Pulsation in Aortic area

A

Abnormal and is possibly caused by the presence of an aortic root aneurysm.

-Aortic regurgitation can cause a pulsation or thrill palpable in the aortic area

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27
Q

Pulsations in tricuspid area

A

abnormal and can result from a right ventricular enlargement or hypertrophy

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28
Q

Thrills

A
  • Use Palmar surface/ball of hand

- Vibrations feel like the throat of a purring cat

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29
Q

Heaves

A

Palmar surface/ball of hand

Lifting of cardiac area secondary to increased workload and force of left ventricular contraction.

A heave is also referred to as a lift

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30
Q

Auscultation of the heart

A

Diaphragm of the stethoscope is used to auscultate high-frequency or high-pitched sounds.

Diaphragm is used to auscultate for murmurs in the aortic, pulmonic, mitral, and tricuspid areas

Bell of the stethoscope is used to assess for bruits. Bell is for relatively lower pitched sounds.

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31
Q 
Social History (cardiovascular)
-Alcohol Use
A

Excessive alcohol intake:
-Increases risk for cardiomyopathy, angina, CAD, HTN, dysrhythmias, stroke

Prolonged use of alcohol can interfere w/ the normal pumping function and electrical activity of the heart, leading to:
-Cardiomegaly, poor left ventricular contractility, ventricular dilatation, palpitations, peripheral edema, and fatigue

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32
Q

Positioning the Pt during routine heart assessment

A

Pt should be positioned flat, supine, or sitting
-For more thorough auscultations of the heart, the pt may need to be in positions other than flat, supine, or sitting

MURMUR of mitral stenosis and S1 and S2 sometimes can be heard only when Pt is on LEFT SIDE

MURMUR of aortic regurgitation can sometimes be heard only when pt is leaning forward in sitting position

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33
Q

Positioning Pt

-Murmur of mitral stenosis and S1 and S2

A

position pt on the left side

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34
Q

Positioning Pt

-Murmur of aortic regurgitation

A

Position Pt leaning forward in the sitting position

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35
Q

Murmur

A

Produced by turbulent blood flow in these situations:

  • Flow across partial obstruction
  • Increased flow through normal structures
  • Flow into dilated chamber
  • Backward regurgitation across incompetent valves
  • Shunting of blood out of a high pressure chamber or artery through an abnormal passageway
36
Q

Murmur Classification

A
  1. Innocent
    - Systolic - not associated w/ abnormalities
  2. Functional
    - High output states
  3. Pathological
    - Structural abnormalities
37
Q

Murmur Configuration

A

The configuration of a murmur is the pattern that the murmur makes over time

  • Crescendo (soft to loud)
  • Decrescendo (loud to soft)
  • Crescendo-decrescendo (soft to loud to soft)
  • Plateau (sound is sustained)
38
Q

Bruits

A

Blowing sounds heard when blood flow becomes turbulent as it rushes past an obstruction
-Ask pt to hold his or her breath during auscultation of the carotid pulse because respiratory sounds can interfere w/ auscultation

-Use the BELL of the stethoscope to assess

39
Q

Homan’s

A

Homans sign is elicited by bending the pt’s knee slightly, and sharply dorsiflexing the foot toward the tibia

There should be no complaints of calf pain when evaluated.
-positive homans sign is present when pt complains of pain in calf when foot is dorsiflexed toward the tibia

A positive Homans’ sign may indicate the presence of a thrombophlebitis or deep venous thrombosis (DVT).

40
Q

Positive Homans sign

A

May indicate the presence of a thrombophlebitis or deep venous thrombosis (DVT)

41
Q

Pectus Carinatum

A

Pigeon Chest

  • Increases AP diameter of thorax
  • Respiratory difficulty

Rickets - Vitamin D deficiency

  • bones become weak
  • Intercostal muscles pull ribs and sternum forward
42
Q

Pectus Excavatum

A

Funnel Chest
-depression in sternum

AP diameter decreases

  • can compress heart and cause myocardial disturbances
  • respiratory insufficiency from lung compression
43
Q

Kyphosis

A

Humpback

-Curving of the spine that causes a rounding of the back

44
Q

Scoliosis

A

Lateral curvature of thorax or lumbar vertebrae

Usually consists of 2 curves:
1-Original abnormal curve
2-compensatory curve in opposite direction

Having one shoulder higher than another indicates the presence of scoliosis

45
Q

Retractions

A

Occur when the muscles between the ribs pull in during inspiration.
-abnormal and usually occurs during INSPIRATION

Conditions that obstruct the free inflow of air can lead to retractions:

  • emphysema, asthma, tracheal or laryngeal obstruction
  • presence of a foreign body or tumor that compresses the respiratory tract
46
Q

Eupnea

A

12-20 breaths per minute

47
Q

Tachypnea

A

> 20 breaths per minute

48
Q

Bradypnea

A

<12 breaths per minute

49
Q

Apnea

A

no respiration for 10 or more seconds

50
Q

Accessory Muscles

A

Attempt to create an extra respiratory effort to inhale needed oxygen.
-pt’s experiencing hypoxic evens such as COPD, pneumonia, etc., usually present w/ accessory muscle use.

51
Q

Alcohol and lung disease

A

Alcohol decreases the efficiency of lung defense mechanisms and predisposes the pt to aspiration pneumonia.

Pt’s w/ emphysema in the late stage have carbon dioxide retention which makes them more sensitive to alcohol’s depressant effect

52
Q

Orthopnea

A

Labored breathing that occurs when lying flat and is relieved by sitting up.

Classic symptom of LEFT VENTRICULAR HEART FAILURE but may also be present in COPD and pulmonary edema

53
Q

Pursed Lip Breathing

A

Positive pressure breathing. To prevent alveolar collapse
-performed by pt’s with COPD

Less energy is expended w/ each breath because the alveoli do not completely collapse after expiration

54
Q

Sputum

A 
Color
-clear or light yellow 
Amount
-excessive w/ pulmonary edema 
Consistency 
-thick or thin. Dehydrated = thicker
55
Q

Sputum characteristics

A

Anaerobic infections produce foul-smelling sputum that is yellow or green in color

Lung cancer is associated w/ sputum that is rust of blood tinged

Viral infections can result in sputum that is white or clear mucoid

56
Q

Crepitus

A

Coarse crackling sensation palpable over the skin surface

Also referred to as subcutaneous emphysema

Condition that interrupts integrity of pleura and lungs can lead to crepitus:
-pneumothorax, chest trauma, thoracic surgery

57
Q

Tactile Fremitus

A

Normal fremitus is felt as a buzzing on the ulnar aspect of the hand

58
Q

Anterior Thoracic Percussion

A

Place pt in an UPRIGHT SITTING POSITION w/ shoulders back

59
Q

Posterior Thoracic Percussion

A

Place Pt in upright sitting position w/ slight forward tilt.
Have Pt bend the head down and fold the arms in front at the waist

60
Q

Lateral Thoracic Percussion

A

Place Pt in an upright sitting position w/ hands and arms raised overhead

61
Q

Syncope

A

the abrupt loss of consciousness resulting from decreased oxygen or glucose supply to the brain.

62
Q

Paresthesia

A

Abnormal sensation such as numbness, prickling, or tingling

63
Q

Vertigo

A

Vertigo is the sensation of moving in space or the sense that objects are moving

It is often described as dizziness or lightheadedness

64
Q

Broca’s aphasia

A

result of a motor cortex lesion in Broca’s area and is characterized by slow, hesitant speech w/ difficulty in selecting and organizing words

65
Q

Reticular Activating System (RAS)

A

Conscious behavior requires arousal, or wakefulness, which is controlled by the RAS

RAS is involved w/ arousal and consciousness and functions to maintain wakefulness and alertness

Sleep wake cycle

66
Q

Glasgow Coma Scale

A

Assesses 3 parameters of consciousness:

  1. Eye opening
  2. Verbal response
  3. Motor response

Record the Pt’s best response
Highest score of responsiveness is 15 (Fully Alert)
Lowest score is 3
A score of 3 to 6 indicates a coma

67
Q

Dysarthria

A

Disturbance in muscular control of speech

  • due to ischemia affecting motor nuclei of CN X and CN XII;
  • defects in the premotor or motor cortex that provide motor input for the face, throat, and mouth; or cerebellar disease
68
Q

Dysphonia

A

Difficulty making laryngeal sounds.

-abnormal and can lead to aphonia (total loss of voice)

69
Q

Apraxia

A

Inability to perform purposeful movements despite preservation of motor ability and sensation.

Inability to reproduce figures on paper
-Lesions of pre-central gyrus/frontal lobe

70
Q

Agnosia

A

Inability to recognize form and nature of objects.
-unable to recognize or name familiar objects

Lesions on non-dominant parietal lobe 
-self in relation to environment
Occipital lobe lesions
-Visual agnosia 
Temporal Lesion
-Auditory agnosia
71
Q

Stereognosis

A

ability to IDENTIFY objects by manipulating and touching them

Pt should be able to identify a coin, key, safety pin, by holding it in the hand

72
Q

Astereognosis

A

Inability to recognize the nature of objects by touch manipulation
-abnormal

73
Q

Anesthesia

A

absence of touch sensation

74
Q

Dysesthesia

A

abnormal interpretation of a stimulus such as burning or tingling from a stimulus such as touch or superficial pain

75
Q

Paresthesia

A

Numbness, tingling, or a pricking sensation

76
Q

Cognitive Function

-Attention

A

Pronounce list of numbers slowly start w/ 2 numbers

  • progress up to 5 or 6 numbers
  • Ask pt to repeat in correct order
  • If they miss give them a new set of numbers / stop after 2 misses

Dementia, neurological injury or disease, mental retardation

77
Q

Cognitive Function

-Long Term Memory

A
  • Name of spouse
  • Spouses birthday
  • Name of President
  • Mothers maiden name

-Long-term memory is memory that is retained for at least 24 hours

78
Q

Cognitive Function

-Immediate Recall and Attention Span

A

Give list of 3 items that pt is to repeat in 5 minutes

  • repeat to check initial understanding
  • converse for 5 minutes
  • At the end of 5 min. ask pt to repeat
  • Record number of objects remembered over number given 3/3

Infection, trauma, stroke, tumor, alzheimer’s

79
Q

Depression

A

described as an abnormal emotional state characterized by feelings of sadness, despair, and discouragement

80
Q

Abstract Reasoning

A

Pt should be able to give the abstract meanings of proverbs, fables, or metaphors w/in their cultural understanding

Ex.
Squeaky wheel gets the grease
rolling stone gathers no moss

Dementia, frontal tumors, schizophrenia

81
Q

Sensory Assessment

-Light Touch

A

Exteroceptive Sensation

  • skin and mucous membranes
  • light touch, superficial pain, temperature

LIGHT TOUCH:

  • begin distal and move proximally
  • test hand, lower arm, abdomen, foot, leg
  • instruct pt to respond when they fell the touch
82
Q

Proprioceptive Sensation

A

Grasp pt index finger w/ thumb and index finger

  • hold finger at sides
  • pt shuts eyes
  • show what up and down feel like
  • Gentle slow movements
  • both hands

Peripheral neuropathies, lesions

83
Q

Cranial Nerve

-Taste

A

CN 7 -Taste

  • tip of tongue sweet and salty
  • borders sour
  • back of tongue is bitter
  • test both sides
  • Rinse between tests
84
Q

Decorticate Posturing

A

Elbows, wrists and fingers flexed
-Legs extended and rotated inward

Decorticate rigidity is characterized by:
-hyperflexion of the arms (flexion of the arm, wrist, and fingers, and abduction of the arms), hyperextension and internal rotation of the legs, and planter flexion

Sign of SEVERE BRAIN DAMAGE
corticospinal and rubrospinal tract disrupted

85
Q

Decerebrate posturing

A

Brain stem damage
-Involuntary extension of the upper extremities in response to external stimuli:

  • head is arched back
  • arms are extended by sides
  • legs are extended
  • HALLMARK SIGN IS EXTENDED ELBOWS
86
Q

Pronator Drift

A

Pt extends arms out in front w/ palms up for 20 seconds

  • observe for drift downward
  • There should be none

Stroke

87
Q

Romberg Test

A

Stand erect feet together arms at side eyes open then closed.
-note ability to maintain balance

Should be able to balance for 20 seconds w/ minimal swaying
-POSITIVE = Pt unsteady and tends to fall when eyes are closed

Cerebellar disease
-remains unsteady w/ eyes open and closed

Posterior column disease
-becomes unsteady w/ eyes closed

Health Assessment (8 decks)

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