Test 3 Review Flashcards
Precordium Assessment
The area on the anterior surface of the body overlying the heart, great vessels, pericardium and some pulmonary tissue:
- Inspection
- Palpation
- Auscultation (Use both bell and diaphragm)
- systematic manner
Assessment of the Periphery
- 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
5 Cardiac Landmarks:
- Aortic area
- Pulmonic area
- Midprecordial area
- Tricuspid area
- Mitral area
Aortic Area
2nd intercostal space (ICS) to the right of the sternum
Pulmonic Area
2nd ICS to the left of sternum
Midprecordial Area
-Erb’s Point
3rd ICS to the left of the sternum
-Both aortic and pulmonic murmurs may be auscultated
Tricuspic Area
5th ICS to the left of the sternum
Mitral Area
5th ICS at the left midclavicular line
Angina
- 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
Palpitations
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
Aortic (Thoracic) Dissection
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
Thorax
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
Barrel Chest
Ration AP:TD = 1:1
- Circular or barrel shaped
- COPD - barrel due to air trapped in alveoli - hyperinflation
Auscultation of S1
- 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
Intensity of S1 depends on:
- Adequacy of the A-V cusps in halting the ventricular blood flow
- Mobility of the cusps
- Position of the cusps and the rate of ventricular contraction
Auscultation of S2
- 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
Distinguishing S1 from S2
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
S3
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
S3 cont…
- 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
S4
- Bell and Diaphragm over Mitral and tricuspid areas
- Auscultate for 15 seconds
- Late diastolic filling just before S1
- Atrial contraction
S4 cont…
- 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
Normal Blood Pressure
Under 120/80
Past Health History
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
Past Health History (cardiovascular)
-Allergies
- Aspirin
- IVP dye
- Seafood
Before cardiac catheterization, it is a PRIORITY to notify PCP of an allergy to iodine-containing substances such as shellfish
Pulsations on Inspection
Normal findings
-No visible pulsations Except for the PMI (point of maximum intensity or apical pulse) in the MITRAL AREA
Pulsation in Aortic area
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
Pulsations in tricuspid area
abnormal and can result from a right ventricular enlargement or hypertrophy
Thrills
- Use Palmar surface/ball of hand
- Vibrations feel like the throat of a purring cat
Heaves
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
Auscultation of the heart
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.
Social History (cardiovascular) -Alcohol Use
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
Positioning the Pt during routine heart assessment
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
Positioning Pt
-Murmur of mitral stenosis and S1 and S2
position pt on the left side
Positioning Pt
-Murmur of aortic regurgitation
Position Pt leaning forward in the sitting position
Murmur
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
Murmur Classification
- Innocent
- Systolic - not associated w/ abnormalities - Functional
- High output states - Pathological
- Structural abnormalities
Murmur Configuration
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)
Bruits
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
Homan’s
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).
Positive Homans sign
May indicate the presence of a thrombophlebitis or deep venous thrombosis (DVT)
Pectus Carinatum
Pigeon Chest
- Increases AP diameter of thorax
- Respiratory difficulty
Rickets - Vitamin D deficiency
- bones become weak
- Intercostal muscles pull ribs and sternum forward
Pectus Excavatum
Funnel Chest
-depression in sternum
AP diameter decreases
- can compress heart and cause myocardial disturbances
- respiratory insufficiency from lung compression
Kyphosis
Humpback
-Curving of the spine that causes a rounding of the back
Scoliosis
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
Retractions
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
Eupnea
12-20 breaths per minute
Tachypnea
> 20 breaths per minute
Bradypnea
<12 breaths per minute
Apnea
no respiration for 10 or more seconds
Accessory Muscles
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.
Alcohol and lung disease
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
Orthopnea
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
Pursed Lip Breathing
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
Sputum
Color -clear or light yellow Amount -excessive w/ pulmonary edema Consistency -thick or thin. Dehydrated = thicker
Sputum characteristics
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
Crepitus
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
Tactile Fremitus
Normal fremitus is felt as a buzzing on the ulnar aspect of the hand
Anterior Thoracic Percussion
Place pt in an UPRIGHT SITTING POSITION w/ shoulders back
Posterior Thoracic Percussion
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
Lateral Thoracic Percussion
Place Pt in an upright sitting position w/ hands and arms raised overhead
Syncope
the abrupt loss of consciousness resulting from decreased oxygen or glucose supply to the brain.
Paresthesia
Abnormal sensation such as numbness, prickling, or tingling
Vertigo
Vertigo is the sensation of moving in space or the sense that objects are moving
It is often described as dizziness or lightheadedness
Broca’s aphasia
result of a motor cortex lesion in Broca’s area and is characterized by slow, hesitant speech w/ difficulty in selecting and organizing words
Reticular Activating System (RAS)
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
Glasgow Coma Scale
Assesses 3 parameters of consciousness:
- Eye opening
- Verbal response
- 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
Dysarthria
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
Dysphonia
Difficulty making laryngeal sounds.
-abnormal and can lead to aphonia (total loss of voice)
Apraxia
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
Agnosia
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
Stereognosis
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
Astereognosis
Inability to recognize the nature of objects by touch manipulation
-abnormal
Anesthesia
absence of touch sensation
Dysesthesia
abnormal interpretation of a stimulus such as burning or tingling from a stimulus such as touch or superficial pain
Paresthesia
Numbness, tingling, or a pricking sensation
Cognitive Function
-Attention
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
Cognitive Function
-Long Term Memory
- Name of spouse
- Spouses birthday
- Name of President
- Mothers maiden name
-Long-term memory is memory that is retained for at least 24 hours
Cognitive Function
-Immediate Recall and Attention Span
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
Depression
described as an abnormal emotional state characterized by feelings of sadness, despair, and discouragement
Abstract Reasoning
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
Sensory Assessment
-Light Touch
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
Proprioceptive Sensation
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
Cranial Nerve
-Taste
CN 7 -Taste
- tip of tongue sweet and salty
- borders sour
- back of tongue is bitter
- test both sides
- Rinse between tests
Decorticate Posturing
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
Decerebrate posturing
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
Pronator Drift
Pt extends arms out in front w/ palms up for 20 seconds
- observe for drift downward
- There should be none
Stroke
Romberg Test
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
