Nursing Health Assessment Exam 2

7/24/2019 Nursing Health Assessment Exam 2

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Chapter 18: Thorax and Lungs (pg. 413)

1. Position and Surface Landmarks

a. Anterior Thoracic Landmarks: Signposts for underlyingrespiratory structures.i. Suprasternal Notch:Hollow Ushaped depression

!ust a"o#e the sternum$ "etween cla#icles.ii. Sternum:%&"reast"one'( Has three parts: the

manu"rium$ the "ody$ and the )iphoid process.1. *alk your +ngers down the sternum until you

feel a distinct "ony ridge$ the sternal angleiii. Sternal Angle: %&Angle of Louis'( The articulation of

the manu"rium and the "ody of the sternum%continuous with the second ri"(.

1. Also marks the site of tracheal "ifurcation intothe right and left main "ronchi,. -orresponds with upper "order of the atria of

the heart. Lies a"o#e the fourth #erte"ra on the "ack

i#. Costal Angle: /ight and left costal margins form anangle where they meet at the )iphoid process.%Usually 0 degrees or less(

1


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1. Angle increases when ri" cage is chronicallyo#erin2ated %i.e. emphysema(

". Posterior Thoracic Landmarks: 3ore di4cult to countri"s and intercostal spaces "ecause of the surroundingmuscles.

,


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i. erte!ra "rom#nens: %-5( 6 the most "onyprominence when you 2e) your head.

1. 7f two #erte"ra seem e8ually prominent$ theupper on is -5

ii. Sp#nous "rocesses:9ote: -5T the spinous

process points outward$ after T the spinous processpoints downward o#erlying the ne)t #erte"ral "odyand ri" "elow.

iii. $n%er#or &order o% the Scapula:symmetrical ineach hemithora). Lower tip is usually at the 5thor ;thri".

i#. T'el%th #!:The tip is usually midway "etweensomeone


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erte!ral

%midspinal( =Scapular

Anter#orax#llar+,

#dax#llar+, ="oster#orax#llar+

,. The Thoracic -a#ity:i. 3ediastinum: 3iddle sectionii. Pleural -a#ities: right a left of the mediastinum

iii. Lung &orders: 7n the anterior chest$ the apex of thelung tissue is or cm a"o#e the inner third of thecla#icle. The !aserests on the diaphragm at a"outthe >thri" in midcla#icular line

1. Laterally: lung tissue e)tends from ape) ofa)illa to 5thor ;thri"

,. Posteriorly: -5 marks ape)$ T1 corresponds to"ase.

". Lo"es of Lungs: ?oth lungs are 9@T precisely symmetrical.1. /ight lung: shorter than left %"c Underlying

li#er on the right($ TH/BB lo"es %separated "y

+ssures(,. Left lung: narrower than the right %"c heart

"ulges to the left($ T*@ lo"esii. Anter#or: -ontains mostly upper and middle lo"es

1. -!l#ue (the ma/or or d#agonal) 0ssure:crossed the Cthri" in the mida)illary line andends at the >thri" in midcla#icular line


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,. or#2ontal (m#nor) 0ssure: Di#ides rightupper and middle lo"e. B)tends from Cthri"%right mida)illary( to rdintercostal space$ or th

ri" at the right sternal "order

iii. "oster#or: Almost ALL lower lo"es. Upper lo"es endat a"out T or T$ then lower lo"es "egin$ reachingall the way to T1 %e)piration( and T1, %inspiration(.

a. Right Middle Lobe (RML):does notpro!ect on the posterior chest.

,. Lo"es pro!ected in the posterior chest include:

Left upper lo"e$ Left Lower Lo"e$ /ight UpperLo"e$ /ight Lower Lo"e.

i#. Lateral: Lunges e)tend from ape) of a)illa to 5thor ;th

ri".

C


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#. TAEB A SPB-7AL 9@TB: points that often confuse"eginning e)aminers.

1. The left lung has no middle lo"e,. The anterior chest contains mostly upper and

middle lo"e with #ery little lower lo"e.

. The posterior chest contains almost all lowerlo"ec. "leurae: serous mem"ranes that form and en#elope

"etween the lungs and chest walli. #sceral pleurae: lines the outside of the lungs$

dipping down into the +ssures.1. -ontinuous with parietal pleurae

ii. "ar#etal pleurae: lines the inside of chest wall anddiaphragm

iii. Costod#aphragmat#c recess: pleurae e)tendappro)imately cm "elow the le#el of the lungs. This

is the potential spaceF when it a"normally +lls withair or 2uid it compromises lung e)pansion.

d. Trachea and ?ronchial Tree:i. Trachea: anterior to esophagus. 111 cm long in and

adultii. Trachea and "ronchi G ead Space%1C mL(

1. Transport gasses "etween en#ironment andlungs

iii. Ac#nus: unctional respiratory unit that consists ofthe "ronchioles$ al#eolar ducts$ al#eolar sacs$ andal#eoli

. 3echanics of /espiration:a. 4 ma/or %unct#onsof the respiratory system.

1. Supply o)ygen to the "ody for energyproduction

,. /emo#ing car"on dio)ide as a waste product ofenergy reactions

. 3aintaining homeostasis %acid"ase "alance( ofarterial "lood %maintains pH(

. 3aintaining heat e)change %less important inhumans(

". Control o% esp#rat#ons: controlled "y respiratory center

in the "rain stem %Pons and 3edulla( 6 normal stimulus to"reath is and increase car"on dio)ide in the "lood.

i. +percapn#a: increased car"on dio)ide in the "lood%increased respirations(

ii. +poxem#a: decreased o)ygen in the "lood %alsoincreases respirations$ "ut is less eIecti#e thanhypercapnia(

c. -hanging -hest SiJe:

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1. 7nspiration: inhale,. B)piration: e)hale

ii. B)pansion and -ontraction of the chest ca#ity$ altersthe siJe of the thoracic container in , dimensions:

1. The #ertical diameter lengthens or shortens$

which is accomplished "y downward or upwardmo#ement of the diaphragm,. The anteroposterior %AP( diameter increases or

decreases$ which is accomplished "y ele#ationor depression of the ri"s.

4. L-"NTAL C-"TNC:a. $n%ants and Ch#ldren:

i. /espiratory De#elopment in the etus.

Age e*elopmentur#ng the 0rst 5

'ee6s

Primiti#e lung "ud emerges

17 'ee6sThe conducting airways reach thesame num"er as the adult

3 'ee6sSur%actantis present in ade8uateamounts

&+ rthThe lungs ha#e 5 millionprimiti#e al#eoli ready to startrespiration

ii. /espiratory AL@9B does not function until "irth.iii. /espiratory de#elopment continues throughout

childhood1. 7ncreases in:

a. Diameter of airways". Length of airwaysc. SiJe of Al#eolid. 9um"er of Al#eoli % million "y

adolescence(i#. -onsider: -hildren


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c. Low "irth weightd. /isk of nicotine addictione. S7DS %"oth prenatal and

postnatal e)posure(f. Lower respiratory

illnessesg. Acute and chronic otitismedia$

h. ?reathlessnessi. Asthma!. Ad#erse lung function

throughout childhoodk. 7ncrease risk for ADHDl. 7ncrease risk for Depression in childhood

and adolescence". The "regnant 9oman: enlarging uterus ele#ates

diaphragm cmi. Decrease #ertical diameter of thoracic cageii. 7ncrease horiJontal diameter of thoracic cage %,cm(

1. 7ncrease BST/@KB9 le#els rela)es the chestcage ligaments to allow for trans#erse)pansion

,. -ostal angle widens. Total circumference of the chest cage increase

"y >cm. increase in Tidal Molume %e#en though

diaphragm is ele#ated$ it mo#es e#en more

during pregnancy(iii. Krowing fetus increase demand for o)ygen on the

mother %this is met easily "y increase in tidal#olume(

i#. 9o change in //#. "h+s#olog#c d+spnea%5C of women(: increased

awareness to "reath$ does 9@T alter ADLs$ and is9@T associated with cough$ wheeJing or e)ercise.

c. The Ag#ng Adult: more rigid and hard to in2atei. -ostal cartilages "ecome calci+es %thora) less

mo"ile(

ii. /espiratory muscle strength declines after age C1. Also a Decrease in elasticity in lungs,. Small airway closure

a. Decreased #ital capacity %ma) air on cane)pel(

". 7ncrease residual #olume %air left "ehindafter forceful e)piration(

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iii. Histologic -hanges: %i.e. gradual loss of intraal#eolarsepta and decreased num"er a al#eoli( 6 less surfacearea for gas e)change

1. 7ncreased risk for:a. Postoperati#e pulmonar+

compl#cat#ons". Postoperati#e atelectas#sc. $n%ect#onfrom a decrease a"ility to

cough$ loss of protecti#e airway re2e)es$and increased secretions

i#. Lung "ase "ecome less #entilated as a result ofclosing oI a num"er of airways

1. 7ncreased risk for d+spneaC. CLT AN ;NT$CS:

a. Tu"erculosis %T?(: 9um"er of cases declined for , years inthe U.S.

". Asthma: most common chronic disease in childhood with apre#alence of 0.C in children ages 15.

i. -ases ha#e increase in the U.S. since ,1.1. ;. %,11(,. 3ost common in lower income families. Pre#alence according to Bthnicity %,1(

ethnicity wide increase in pre#alence ofAsthma

a. *hite: 5.;". ?lack: 11.0c. Hispanics: 5.,

>. 79TB/M7B*: Health History and Su"!ecti#e Assessmenta.Cough:

i. Nuestions to askThings to Eeep in 3ind in aninter#iew:

1. Do you ha#e a coughO,. *hen did it startO Kradual or SuddenO

a. Acute #s. -hronic. How long ha#e you had a coughO

a. Acute Cough: , weeks". Chron#c Cough: o#er , months

. How often do you coughO Any special time ofdayO Does it wake you up at nightO

a. -ontinuous throughout the day: Acuteillness %e.g. respiratory infection(

". Afternoon e#ening %may"e e)posure toirritants at work(

c. 9ight: Post nasal drip %sinuses(

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d. Barly morning: -hronic "ronchialin2ammation of smokers

C. Do you cough of phlegm or sputumO HowmuchO *hat colorO

i. Chron#c &ronch#t#s: producti#e

cough$ months of a year$ lasts ,years". 9h#te or Clearmucoid: colds$

"ronchitis$ #iral infectionsc.


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,. B#er had any shortness of "reath or hard"reathing spellsO *hen did it STA/TO *hat"rings it onO Se#erityO How long does it lastO

. 7s it aIected "y positionOa. -rthopnea: di4culty "reathing when

supine. @ccur at speci+c timeO 9ightDayOa. "arox+smal nocturnal d+spnea

("N):awakening from sleep with S@?%Shortness @f ?reath( and needing to "eupright to achie#e comfort

C. S@? episodes associated with night sweats%diaphoresis(O

>. -ough$ chest pain or "luish color around lips ornails$ wheeJing soundO

5. Bpisodes seem to "e related to food$ pollen$

dust$ animals$ season$ emotion$ or e)erciseOa. Asthma aattacks occur with a speci+c

allergen$ e)treme cold$ an)iety%Descri"ed at &chest tightness'(

;. *hat do you do during an episodeO Takespecial position or purse lip "reathingO @)ygen$inhalers$ medicationO

0. How does S@? eIect your acti#itiesO Ketting"etter or worse or neitherO %Assessing ADLs(

ii. People with smoking history$ dyspnea$ and cough$you can use the short Citem 8uestionnaire to

identify who should "e asses with spirometry forchronic o"structi#e pulmonary disease %-@PD(. %pg.,(

9e#er

/arely

Sometimes

@ftenMery@ften

Score

o' o%ten do +ou cough=

C , 1

o' o%ten does +ourchest sound no#s+

('hee2+, 'h#stl#ng,

rattl#ng) 9hen +ou!reathe=

C , 1

o' o%ten do +ouexper#ence shortness o%!reath dur#ng ph+s#cal

act#*#t+=

C , 1

o' man+ +ears ha*e+ou smo6ed=

C , 1

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9hat #s +our age=

C , 1

c. Chest "a#n '#th &reath#ng:-aused "y musclesoreness from coughing$ or from in2ammation of pleurao#erlying pneumonia.

1. Eeep in mind: distinguish from cardiac pain orheart "urn of stomach acid

ii. Nuestions to Ask1. Any chest pain with "reathingO Point to

location.,. *hen did it startO -ontinuous$ intermittentO. ?urningO Sta""ingO. ?rought on "y respiratory infection$ coughing$

or traumaO Associated with fe#er$ deep"reathing$ une8ual chest in2ationO

C. *hat ha#e you done to treat it medication orheatO

d. #stor+ o% resp#rator+ #n%ect#ons: -onsiderseuelae %a condition that is the conse8uence of apre#ious disease or in!ury(after these conditions

i. Nuestions to askThings to consider:1. Any past history of "reathing trou"le or lung

diseases such a "ronchitis$ emphysema$

asthma$ pneumonia.,. Any unusually fre8uent or unusually se#erecoldsO

a. 3eaningful to ask a"out e)cess num"eror se#erity %"ecause e#eryone gets acold here and there(

e.Smo6#ng #stor+.i. Nuestions to AskThings to consider:

1. Do you smokeO *hat age did you startO Howmany packs a dayO

,. Ha#e you e#er tried to 8uiteO *hat happenedO

*hy do you think it didn


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,. Ad*#se.Ki#e clear$ non!udgmental$ andpersonaliJed suggestions for 8uitting.

. Assesseach person


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constriction(. Usuallycaused "y smoking.

%crackles o#er de2atedareas$ may ha#ewheeJe(

C-" S@? %e): after 2ightof stairs($ Barly

morning -ough %wsputum($

S: Hypertension$afe"rile$ H/ *DL$

ele#ated respirations%resting($ under weight$nspect#on: ?arrel-hest$ Tripod$ regularshallow respirations%accessory muscles($prolonged e)piration$S@? am"ulation$"alpat#on: minimal%symmetric( cheste)pansion$ Tactil

fremitus %"ilaterally($Auscultat#on:?Sdiminished$ wheeJe%e)piration$

mph+sema

-aused "y destructionof Pulmonaryconnecti#e tissueFcharacteriJed "ypermanentenlargement of airsacts distal to terminal"ronchioles andrupture ofinteral#eolar calls.7ncrease airwayresistance.Hyperin2ated lung$increase lung #olume.Smokers: ;0 ofcases

$nspect#on: 7ncreasedAP diameter$ ?arrelchest$ Acessorymuscles used$ Tripod$position$ S@?%especialyon e)ertion( resp.distress$ Tachypnea

"alpat#on: DecreaseTactile remitus andchest e)pansionAuscultat#on:Decreased ?reathsounds$ 3ay ha#eProlonged e)piration.3ued heart sounds$Ad#entitious Sounds%occationally a wheeJ(

Atelectas#s

-ollapsed shrunkensection of a#eoli orentire ung as a resultof:1( airway o"structionF

7nspection: -ough. Lagon e)pansion onaIected side increasedrepiratory rate andpulse. Possi"lecyanosisPalpation: -hest

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al#eolar air "eyondthe o"struction isgradually a"sor"ed"y the pulmonarycapillaries and

al#eolar walls ca#ein,( -ompression on

lung( Lack surfactant

e)pansion on aIectedside. Tactile remitusdecreased or a"sento#er area. Largecollapse could mean

tracheal shift towardaIected sideAuscultation ?reathsounds Decreased#esicular or a"sento#er aIected area.Ad#entitious sounds%none if "ronchuso"struction$ occasional+ne crackles if"ronchus is patent(

"neumon#a

Pneumocystis jiroveci%P. carinii( 6 #irulentform of pneumonia.ProtoJoal infection%associated with A7DS(

$nspect#on:An)iety$S@?$ dyspneaone)ertion$ malaise%common($ tachypnea$fe#er$ drynonproducti#e cough$intercostal retraction inchildren$ cyanosis"alpat#on:Decreasedchest e)pansionAuscultat#on:?S

decreased$ad#entitious sounds%crackles may "epresent 6 often a"sent(

Tu!erculos#s

-aused frominhalation of tu"ercle"acilli into the al#eolarwall:1( Acute

in2ammatoryresponse 6macrophagesengulf "acilli%don


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,( Scar tissue forms$lesion calci+es andshows on )ray

( /eacti#ation ofpre#iously healed

lesion. Dormant"acilli nowmultiply$producingnecrosis$ ca#iation$and caseous lungtissue %cheeselike(

( Destruction aslesion erodes into"ronchus$ formingair+lled acity

%ape) usually mostdamaged(

lo"es common persistfollowing full ecpirationand cough

Hyperresonance: Lower pitched$ "ooming sound %too much air ispresent(Anteroposterior %AP( diameter Q Trans#erse diameter %.5:.5C(3ore -onditions:

Cond#t#on e0n#t#on

"neumothorax

ree Air in Pleural space %causes hyperresonance(

"ulmonar+

emo!l#sm

Undissol#ed materials %throm"us$ air "u""les$ fat

glo"ules( origninating in legs or pel#is detach andtracel #ia #enous system$ return#ng !lood tor#ght heart,and lodge to occlude pulmonar+*essels.

;. Techni8ues for -ollecting -!/ect#*e ataa"out the Thora)%anterior and posterior(:

a.Anter#or:#. $nspect#on:

1. Shape and Con0gurat#on: ri"s sloping

downward$ symmetric interspaces$ costal anglewithin 0 degrees$ de#elopment of a"dominalmuscles %consistant with age$ weight$ andathletic condition(

,. @ac#al express#on: /ela)ed indicatesunconscious "reathing eIorts %that


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. Color and Cond#t#on: assess lipsnail"eds%look for cyanosis or unusual pallor($ nails%con+guration($ skin %lesionsO(

C. esp#rat#ons: 9ormal rela)ed "reathing$ nonoise$ symmetry$ note any localiJed lag on

inspirationa. 9ote use of accessory muscles to "reatheis a"normal$ unless in e)ercise$ one mayuse calene$ sternomastoid$ trapeJiusmuscles to enhance respiration.

>. esp#rator+ rate: occasional sighs normallypunctuate "reathing

##. "alpat#on:1. Symmetric -hest B)pansion: place hands along

costal margins$ point thum"s toward )iphoidprocess$ Ask person to "reathe deep$ watch

your thum"s mo#e apart,. Tactile %#ocal( remitus: Mi"rations

a. ?egin at lung apices %su"cla#icular areas(". -aompar #i"rations one side to the other

while patient say &00'c. A#oid female "reasts. The "reast tissue

damps the sound. "alpate anter#or chest 'allfor tenderness:

none should "e present###. Auscultat#on

1. Listen from apices to >thri"

,. 3easurement of Pulmonary unction Status:a. orced e)piratory time:

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". Handheld Sp#rometer: measures lunghealth in chronic conditions such asasthma.

i. Forces vital capacity%M-( 6 thetotal #olume of air e)haled

ii. Forced expiratory volume in 1second%BM1( the #olume e)halein the +rst measure second

iii. BM1M- ratio 5C or greater Gno o"struction

c. Pulse oximeter: Sp@,: 0500i. 3ust "e ele#ated in conte)t of

hemoglo"in le#el$ acid"ase"alance$ and #entilator staus

d. 6-minute walk test%> 3*T(: safer$simpler$ ine)pensi#e clinical measure of

gunctional status in aging adultsi. used in pulmonary reha"ilitationii. +nd a hallway with little tra4c and

make sure patient is wearingcomforta"le shoes and pulse o).

iii. Assess @,saturation as they arewalking

i#. ST@P if "elow ;C to ;; or upone)treme "reathlessness

!."oster#or:#. $nspect#on:

1. 9ote the shapeand con0gurat#on of chestwall

,. Spinous processes should "e in a straight line. Thora) is symmetric. Thora) elliptical shape$ downward sloping ri"s

%C degrees from spine(C. Scapulae symmetrical in each hemithora)>. AP diameter should "e less than trans#erse

diameter5. The neck and trapeJius muscles$ de#eloped

normally for age and occupation;. 9ote: position the person takes to "reathe

%including a rela)ed position(0. Skin -olor and condition

A?9@/3AL 79D79KS in 7nspection.

Skeletal deformities may limit thoracic cage e)cursion: scol#os#s$

6+phos#s %pg. ,(

AP is e8ual to Trans#erse Diameter %&arrel Chest(

o /i"s horiJontal$ chest appears as if held in continuous

inspiration

o ound 7n -@PD

C+anos#s

1;


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ii. "alpat#on:1. Assessing Symmetric -hest B)pansion: Place

hands sideways on the posterolateral chestwall with thum"s pointing together at the le#elof T0 or T1. Slide hands medially to pinch up a

small fold of skin "etween your thum"s

a. Ask the person to take a deep "reath

%9ote any lag in e)pansion(,. Assessing Tact#le %#ocal( @rem#tus%palpa"le

#i"ration(: Use palmar "ase of the +ngers orthe ulnar edge of one hand and tough theperson


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A?9@/3AL 79D79KS in Palpation:

Une8ual chest e)pansion: sign of atelectasis$ lo"ar pneumonia$ pleural

eIusion$ thoracic trauma %fractured ri"s or pneumothora)(o Asymmetry suggest dysfunction$ can "e assessed further with

the stethoscope ecreased @rem#tus: any "arrier that comes "etween the

sound and your palpating hand decreases fremitus %i.e.o"structed "ronchus$ pleural eIusion$ or thickening$pneumothora)$ or emphysema(

$ncreased @rem#tus: -ompression or consolidation of lung

tissue %i.e. lo"ar pneumonia( honchal @rem#tus:Palpa"le with thick "ronchial

iii. %Apparently we are skipping percussion(i#. Auscultat#on: Air that passes through the

tracheo"ronchial tree is an audi"le sound through

the chest wall.1. ?reath Sounds: B#aluate the presence and

8uality of 9ormal ?reath Soundsa. "os#t#on o% "at#ent: sitting$ leaning

forward slightly$ with arms restingcomforta"ly across the lap

". Tell patient to "reathe deep through themouth$ assure them they can stop if theystart to feel diJJy

%pg,0(

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,. 73P@/TA9T to "e aware of. There are C-ommon "ackground noises that are oftenconfused with lung sounds. They are:

a. B)aminer


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A?9@/3AL 79D79KS in Auscultation:

?reath sounds changed "y o!struct#onin the passageways or "y

d#seasein the lung parenchyma$ the pleura$ or the chest wall

Decreased or A!sent &reathsounds:

o *hen "rochial tree is o"structed %"y secretions$ mucus$ plug$ orforeign "ody(

o Bmphysema: loss of elasticity in lung +"ers and decreased force of

inspired air Lungs also already hyperin2ated 6 inhaled air does notmake

as much noiseo Anything %in the pleural space( that o"structs transmission of sound

"etween lung and stethoscope i.e. pleurisy$ leural thickening$ airRpheumothora)$ 2uid Rpeural eIusion

-rackles %Sign of Pulmonary edema$ pneumonia$ pulmonary$ +"rosis$ and

the terminally ill who ha#e a depressed cough re2e) Ad#entitious Sounds: added sounds that are not normally heard in the

lungs. Heard as "eing superimposed on the "reath soundso -aused "y mo#ing air colliding with secretions in the

tracheo"ronchial passageways or "y popping open of pre#iouslyde2ated airways

o Crac6les%rales( and'hee2e%rhonchi( are terms commonly used

"y most e)aminers. There are also sounds called str#dor%heard inthe lungs of children with the -roup( and @r#ct#on u!s%the soundof the plurae ru""ing together(.

-rackles: discontinuous popping sounds heard o#er inspiration

*heeJes: continuous musical sounds heard mainly o#ere)piration

0. /espiratory Patterns

,,


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1. 9ormal *o#ce sounds:-an "e auscultated o#er the chestwall %same pattern used for tactile fremitus(

a. Moice Sounds: not elicited routinely 6 only if you suspectlung pathology %"ased on earlier data(

i. Testing for: &ronchophone+$ egophone+$ and'h#spered pector#lou+

A?9@/3AL 79D79KS:1. ?ronchophoney: &00' is more distinct than normal,. Bgophoney: &e' sounds like &a' %in Say(

. *hispered pectorilo8uy: a whispered &1,' sounds #ery clearand close

. -onsolodation of lung tissue will enhance the #oice sounds$

11. De#elopmental -ompetence:a. 7nfants and -hildren

i. 7nspection:

,


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1. ?arrel -hest after > years lead to chronicasthma or cystic +"rosis

,. Apgar Scoring System

Card#o*ascular S+stem (ear Nec6 essels) "er#pheral ascular S+stem: Chapter 1B?("age 45B)

a. -ool acts:i. ?lood MolumeG C leters G >C 8uarts G1.C gallonsii. 1 hear "eat pumps >; ml %1 cup(iii. Heart pumps a"out ,$ gallons a day %>

litersmin(

,. "os#t#on and Sur%ace Landmar6s: -ardio#ascular system: theheart %muscular pump($ "lood #essels

a. "record#um: Area on anterior chest directly o#erlying theheart

". Heart and Kreat Meins located "etween lungs and in themiddle third of the thoracic cage %med#ast#num(

c. Heart e)tends from the ,ndto the Cthintercostal space

,


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i. /ight "order of sternum %?ase(Left mid cla#icularline

Descri"e where each heart sound is heard "est 6APBT3 %All Pigs Bat Too3uch(

1( Aort#c%/ight sternal "order$ ,nd 7-S(,( "ulmon#c %Left sternal "order$ ,nd 7-S(( r!>s %Left sternal "order$ rd 7-S(( Tr#cusp#d %Left sternal "order$ th 7-S(

C( #tral %Left midcla#icular line$ Cth 7-S(

,C


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"$ ("o#nt o% ax#mum $mpulse):Apical Pulse 6 at the Ape)%landmarks: midcla#icular line$ +fth intercostal space(.

Anatom+ and "h+s#olog+ o% C s+stem

d. Heart Mal#es

,>


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i. A (Atr#o*entr#cular):prevent return of blood toatrium chamber of the heart.

1. Tricuspid %right side( and mitral"icuspid %leftside( &Try "efor you ?uy'

a. @pen with Diastole %allow #entricles to +ll

from Atrium(". -losed with Systole %Pumping phase sono "ack2ow(

ii. Sem#lunar al*e: heart Mal#e$ shaped like halfmoonsFprevents blood from owin! back into theheart.

e. Card#ac C+cle: The rhythmic mo#ement of "lood throughthe heart %pg.>( 6 know when #al#es are open and whenthey are closed

i. #astole: The +lling phase 6 Mentricles are rela)ed 6AM open$ SL closed

1. , of cycle is +lling %longest(ii. S+stole: Pumping PhaseDMentricular contractionD

AM open$ SL closed1. Mentricular pressure is higher than atrial". AM #al#es swing shut %S1(: "eginning of systole

a. Pre#ents regurgitation into atria duringcontraction

#. All #al#es closeda. Mentricular walls contract %isometric

contraction( to "uild pressure inside the#entricles to a high le#el

b. Mentricle P V Aortai. Aortic #al#es open

iii. #astole%again(:Atria +lls with "lood1. All four #al#es closed$ #entricles rela)

%isometric rela)ation(a. Atria +lls with "lood deli#ered from lungsb. Atria Pressure V Mentricular Pressure

iv. $vents in the %i!ht and Left &ounds'1. S1: AM #al#es close+rst Heart sound %"egin

systole(a. 31: 3itral closes

b. T1: Tricuspid closesc. S1 is loudes at Ape)

". S: semilunar #al#es close %end systole(a. A,: Aortic closesb. P,: Pulmonic closesc. S, is loudest at ?ase

,5


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. B)tra Heart Sounds: ?ell is "est %pg. >(a. Third Heart Sound %S3(:in Diastole 6

comes after S,

i. Mentricles resistant to +lling%#olume too much$ "acking up andde#eloping Heart ailure or Mal#eregurgitation(

ii. Lu" du" da %&Een Tuck EBW'(". Diastole B)tra Heart Sound %S4(:in

Diastole 6 comes "efore S1i. Later resistant sound %#entricle too

full$ still wall$ heart damage 63yocardial infarction %37((

ii. Lu" Du" %&TB99 a see'(

. 3urmurs: Tu"ulent "lood 2owa. Kentle$ "lowing$ wishing sound". 3U/3U/S 6 documented

i. "#tch or @reuenc+%high$ low(ii. Loudness Kraded 1> loud or

soft %intensity(iii. T#m#ng%systolic or diastolic(i#. "attern%grows louder$ tapers$

peaks(#. Eual#t+%rum"ling$ musical$

"lowing harsh(

c. -onditions that cause 3urmurs: Don


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B)ample 3urmurB)ercise$ thyroto)icosis Melocity of "lood increases

Anemia Miscosity fo "lood decreases

A stenotic or narrowed #al#e$ anincompetent or regurgitant #al#e$dilated cham"er$ septal defect

Structural defects in the #al#es %astenotic or narrowed #al#e$ anincompetent or regurgitant #al#e($or unusual openings occure in thecham"ers %dilated cham"er$septal defect(

. BEK %-ham"er depolariJation and repolariJation(

. Su!/ect#*e ata%pg.51(a. -hest Pain: -@LDSPA

a. Ang#na: -hest Pain 6 7mportant cardiac symptom$occurs when heart


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i. -hest Pain @rigin my "e found in diIerent areas:%pg. 0(

1. Pulmonary,. 3usculoskeletal. Kastrointestinal

ii. Uni#ersal sign of chest pain: -lenched +st to thechest1. 3en: classic,. *omen: diIer %!aw pain$ "ack pain$ etc.(

". +spnea: shortness of "reathi. +spnea on exert#on%D@B( 6 Nuantify e)actly

%i.e. &after walking two "locks'( 6 Paro)ymal$-onstant or intermittent$ /ecum"ent

ii. "arox+mal nocturnal d+spnea%P9D(: occurswith Heart failure$ supine increases #olume ofintrathoracic "lood$ weakened heart cannot

accommodate1. Typically$ After , hours of sleep$ person

awakens with the need for fresh airc. Cough: Any sputum

i. Producti#e cough$ mucoid or purulent.ii. Hemoptysis: coughing up "lood

1. @ften pulmonary disorder,. Does occur with m#tral stenos#s

d. @at#gue: tiring easilyi. Unusual fati8ue is a topprodromal 37 symptom

for women

ii. Decrease cardiac output is worse in the e#eningiii. An)iety or depression occurs all day$ or worse in

morninge. dema: Swelling

i. Bdema: Dependent when caused "y heart failureii. Card#a edema: worse in e#ening

1. ?etter in morning %ele#ated legs all night(,. ?ilateralF unilateral swelling has local #ein

causef. C+anos#s or "allor: ?oth occurs with 37 or low cardiac

output decreased tissue perfussion

g. Noctur#a: waking up at night to urinatei. /ecum"ency at night promotes 2uid resorption

and e)cretionF this occurs with heart %a#lureinthe person who is am"ulatory during the day

h. "ast ealth #stor+#. @am#l+ Card#a #stor+/. L#%est+le ealth a!#ts


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i. 9utrition$ Smoking$ B)ercise$ S$ stress$weight$ cholesterol$ checkupO

C. Preparation for ascultating the heart: Should "e re#iew1. *ash hands,. -lean Steth

. *arm and 8uiet room. Pri#acyC. Access to chest 6 gown>. *atch with second hand5. Stethoscope;. Patient sitting upright

>. @"!ecti#e Data 7nspection anteriora. PT in upright sitting position". 9ot skin colorc. Base of /espirationsd. 9ot #isi#le pulsations in neck or chst

e. 9eck Messel Destintion %XMD(5. -arotid Artery: %pg. >>(

a. Kroo#e "etween Trachea andsternocleidomastoid muscle

". Palpation and Ausculation:i. Palpate gently and locate

1. Light$ apply "ell %light: #agalstimulation could decrease heartrate(

,. Listen for ?ruit %9ormal: none(a. &ru#t: ?lowing$ swishing

sound: tur"ulence. ?reathe: B)hale 6 Hold ?reath 6

?reathe

. ?ilateral ?ut *A/979K: @9B S7DBat a time

C. 9o percussion of arteries %DUH(

1


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;. Xugular Meins

a. -lues a"out riht side of hearti. 7nternal 6 deepii. B)ternal 6 more super+cial

". 7nspection %tells us heart e4ciency as a pump and #olumestatus(

i. Pt in supine position %face up(ii. Stand on the right side of the pation$ ask them to

turn their head slightly to the left1. 9ormal: 2attened %no XMD( with H@? ele#ated

%C degrees(,. 9ormal: no palpa"le #enous pulsation

. 7f Destension: Unilateral or "ilateralO. XMD can "e measured in cm

iii. 9ote: Misi"le neck #ein distension while patient islying 2at is 9@/3AL

1. /aise the head of the "ed$ it should disappearB. The "record#um

a. $nspect#on:Anterior -hest Precordium

,


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i. Pulsation: 3ay "e a"le to see apical impulse %left#entricle rotating against the chest wall duringsystole(.

1. thor Cthintercostal space at or insidemidcla#icular line

,. Basier to see in children. A"normal:ea*eor l#%t: sustained forcefulthrusting of #entricle during systole

a. Mentricle hypertrophy %increasedworkload(

". /ight Mentricular Hea#e: seen at sternal"order

c. Left Mentricular Hea#e: seen at ape)". "alpat#on: Precordium

i. Apical 7mpulse %can "e palpated in ,C adults 6C5 in left lateral position( 6 palpate with one

+nger.1. Ask Patint to e)hale and hold

ii. Palpation across the Precordium: using palmaraspects

1. plapate the ape)$ left sternal "orde$ and the"ase %searching for any other pulsations(

A?9@/3AL 79D79KS:1) Card#ac enlargement,( Le%t *entr#cular d#lat#on%#olume o#erload( displaces impulse

down and to left and increases siJe more than one space

%Diameter cm or greater G dilated(a. @ccurs in Heart failure". @ccurs in -ardiomyopathy

( Susta#ned $mpulse: increased force and duration "ut nochange in location occurs in left #entricular hypertrophy and nodilation %pressure o#erload(

( Palpa"le #i"rations %Thr#ll(

c. Percussion: 9ot on the heartd. Ausculatation

i. Auscultor+ Areas


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1. eart @a#lure:%pg 0C( &i!ns and &ymptomsa. Shortness of ?reath". Ad#entitious Soundsc. Dissiness

d. Tiredness %fatigue( = weaknesse. /apid or irregular H/$ Sf. Swelling in ankles$ legs and a"domen and weight gaing. @ther: 9ausea$ palpitations$ -hest pain$ waking suddenly

at night una"le to "reath %P9D($ changes in sleep patternsh. YY Suggest aspirin

11. De#elopmental -onsiderations:a. 7nfants and -hildren %pg. >5(

i. Listen whene#er you can %sleeping$ 8uiet(ii. unctional %innocent( murmurs common

1. Usually change or disappear with position

change,. /BB/ ALL 3U/3U/Siii. -heck heart and femoral pulse simultaneously in

infant for delay %coarctation(i#. Signi+cant History indings in 7nfants and -hildren:

1. 3other. re8uent respiratory infection

5. amily history". Blderly: -onsider

i. Slow position changes in elderly: /isk orthostat#ch+potens#on%sudden drop in ?P(

ii. ?P gradual systolic rise with ageiii. -arefully listen for S and Si#. @ccasional irregular "eats common#. Enown cardiac/espiratory historyO


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#i. 3edications#ii. Bn#ironment

1,. Accurately document +ndings to determine your patientZscardio#ascular status. % see e)amples at the end of thechapter(

Chapter : "er#pheral ascular S+stem andL+mphat#c S+stem ("g. 5B)

-ool act: if laid in line an adult


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". Takes e)tra 2uid to "lood stream%drainage system(

c. Lymph nodes 6 clumps of tissuesurrounded "y the #essels

d. Super+cial and deep

e. Super+cial 6 cer#ical$ a)illary$epitrochlear$ and inguinalf. HBB9T = K7 class

( Peripheral Mascular Assessment:a. Su!/ect#*e: History

#. Leg "a#n or cramps1. Peripheral #ascular

disease %PMD(: "lood2ow cannot matchdemand during

e)ercise %musclefatigue or pain whenwalking 6 claudation(

,. -laudation Distance:num"er of "lockswalked or stair climedto produce pain.

##. S6#n Changes on arms orlegs

1. -olor change,. Hair loss

. Temp %symm(. Soresulcers %leg ulcers with chronic arterial

and #enous disease(###. S'ell#ng #n arms or legs

1. Bdema: "ilateral when the cause is generaliJed%heart failure(

a. Unilateral when it is the result of localo"structionin2ammation

i#. L+mph node enlargement: occur with infection$malignancies$ and immunologic disease

#. ed#cat#onsO

1. 3ay cause hypercoagula"le state,. Lowdose aspirin or clopidogrel are used to

pre#ent "lood clots in selected people#i. Smo6#ngO

1. To"acco -auses all of the followinga. constricts arteries". increases coagula"ilityc. in!ures endothelium

>


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d. promotes in2ammation,. Strongest risk for PAD. Starting 1> yrs and under$ ,) risk

!. -!/ect#*ei. $nspect and palpate the Arms:

1. 9ote color skin and nail "edsF temperature$te)ture$ and turgor of skinF present of anylesions$ edema or clu""ing

a. Lift "oth patient. -ollateral -irculation:

a. Allen Test %e)plained later(##. $nspect and palpate the Legs

1. Symmetry:a. 7nspect "oth legs together: note color$

hair distri"ution$ #enous pattern$ siJe%swellingatrophy($ any lesionsulcers

i. A"normal:1. Pallor: #asoconstriction,. Brythema: #asodilation

. -yanosis: decrease tissueperfusion

. 3alnutrition: thin$ shiny$atrophic skinF thick ridgednails$ loss of hairF ulcersFgangrene

a. Pallor$ coolness%arterial insu4ciency(

5


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". 3easure circumference %note location ofany a"normality(

i. Asymmetry:1. 1cm: mild lymphedema,. Ccm: moderate

lymphedema. VCcm: se#ere lymphedemac. Temperatured. Pulses:

i. emoral %groin(1. A"normal:"ruit occurs with

tur"ulen "lood 2ow %indicatespartial occlusion(

ii. Popliteal %"ehind knee(\patientsupine or prone

iii. Posterior ti"ial %posterior to ankle(

i#. Dorsal pedis pulse %on the tarsals(e. Preti"ial edema: A"normal

i. Krading1. 1[$ 3ild pitting$ slight

indentation$ no percepti"leswelling of the leg

,. ,[$ 3oderate pitting$indentation su"sides rapidly

. [. Deep pitting$ indentationramins for a short time$ leglooks swollen

. [$ Mery deep pitting$indentation lasts a long time$leg is grossly swollen anddistorted

ii. 7f !#lateral: e)amine neck #eins1. Distention of neck #eins:

peripheral edema may "erelated to heart disease

,. 9ormal neck #eins: othercomplications %i.e. li#erdisease$ nephrosis$ chronic

#enous insu4ciency$antihypertensi#e or hormonalmedication(

###. Color changes1. 7f you suspect arterial de+cit$ raise legs a"out

cm %1, inches( 6 drains oI #enous "lood soyou can inspect coloration due to arterial"lood.

;


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a. 9ormal:i. Light skinned: little pale "ut still

should "e pinkii. Dark skinned: soles should re#eal

e)treme color change

i#. The oppler ultrason#c "ro!e%pg. C,C(1. @nly way to "e sure of Maricosities.a. Palpation is unrelia"le "c #aricosities

occure "elow or "etween e#encompetent #al#es

#. The Ankle and ?rachial 7nde) %don


40/45

neuromuscular#asculartissue damage(

Y9europathic: pain and sensation decrease

( Assessing Pulses

a. -arotid". ?rachialc. /adiald. emorale. Poplitealf. Posterior Ti"ial %medial(g. Dorsalis pedis %lateral to tendon

of "ig toe(C( Assessing e)tremities:

a. 7nspection:i. -olor

ii. SiJeiii. Symmetryi#. 9ails#. Hair

#i. Maricosities#ii. ?ulges#iii. Mascular patternsi). Lesions or ulcers

". Palpation:i. -ompare ?ilaterallyii. Symmetry in siJe$ shape$ color

iii. Temperature %"ack of hand(i#. -ondition %skin$ nail "ed$ hair distri"ution(#. Pulses

#i. Bdema %see skin assessment(#ii. 3easurements#iii. -apillary /e+ll %Q, seconds(

>( PMS Assessment 3neumonic:a. &Please 3ake Sure To -hart'

i. Pulsesii. 3o#ementiii. Temperature

i#. -olor and or -apillary /e+ll". Always look for symmetry

5( Bdema:a. -heck for preti"ial edema$ Press +rm for C seconds$ release

i. 9ormal: no indentation". Pitting Bdema %pg C,(

i. ?ilateral %generaliJedF 2uid o#erload(ii. Unilateral %o"struction or in2ammation(


41/45

;( Allen Test:Used to e#aluate the ade8uacy of collateralcirculation

a. Prior to arterial stick %check for ade8uacy of collateralcirculation(

". A?9@/3AL: Pallor persistes$ or sluggish reutn to colorsuggests occlus#on%reduced "lood 2ow due toatherosclerosis( of the collateral arterial 2ow. A#oid radialartery annulation until ade8uate circulation is shown.

13. lcers: enous *s. Arter#alenous Stas#slcer

Arter#al ($schem#c) lcer

Su!/ect#*e ata

Aching Pain

"elow knee

*orse standing$

may itch

Deep muscle pain$

lower calf or foot

Pain with walking

%claudication(-!/ect#*e ata

irm$ ?rawny

edema

9ormal Pulses

Ulcer une#en

edges

-ool$ pallor$ diminished

pulses

Thin$ shiny skin$ hairless

toe

Thick nails

Ulcer: well de+ned

edges$ punched outlook

1


42/45

a.enouse Stas#s lcer: After Acute or chronic incompetent#la#es in deep #eins. Menous ulcers account for ; oflower leg ulcers

#. @ccur at medial malleolus and are

##. Character#2ed !+: "leeding$ une#en edges.%"ecause "lood is getting there$ "ut not o)ygen(!.Arter#al ($schem#c) lcer: ?uildup of fatty pla8ues on

intima %atheroscleros#s6 chronic gradual "uild up of%att+ strea6s$0!ro#d plaue, calc#0cat#on o% *essel'all$ and throm!us %ormat#on6 in that order( plusharden$ calci+cation of arterial wall %arteriosclerosis(

###. @ccur at toes$ metatarsal heads$ heels$ and lateralankle.

i. Character#2ed !+: Pale ischemic "ase$ well de+nededges and no "leeding %"c decreased tissueperfusion(

1. T%Deep Mein Throm"ophle"itis(a. Mein occlusion "y throm!us %clot(". #s6: ?edrest %V days($ trauma$ #aricositiesc. Su!/ect#*e: sudden onset$ sharp$ deep muscle paind. -!/ect#*e: *armth$ swelling$ redness$ tender to palpation

i. #s6: em"olism

1C. Aneur+sm%pg. CC(i. A sac formed "y dilation in the artery wall

,


43/45

ii. Atheroclerosis %most common cause( weaken middlelayer %media( of #essel wall

iii. Stretches inner and outerlayers %intima andad#entitia(

i#. BIect of "lood pressurecreates !alloonenlargement

". 3ost -@33@3 sites: Aorta or-ere"ral

c. Highest at risk:i. 3en o#er CCii. *omen o#er 5

d. Symptoms #aryi. Serious: can "e deadly

1>. -ommon A?9@/3AL7TW: "hle!#t#s Throm!ophle!#t#s

a. Throm!ophle!#t#s:in2ammation of the wall of a #ein withassociated throm"osis$ often occurring in the legs duringpregnancy.

". "hle!#t#s:7n2ammation o f #eini. 7M in+ltration or irritationii. @ften with throm"osis %clot( (hrombophlebitis

1G.Throm!ophle!#t#s *s T:


44/45

a. Throm"ophle"itis: more super+cial". DMT: Deep

1;. De#elopmental -onsiderations %children and aging adult( 6PMS and Lymphatic system:

a. $n%ants and Ch#ldren: Pulse force should "e normal andsymmetric %same in upper and lower e)tremeties(

i. Palpa"le lymph nodes: often in healthy infants andchildren

1. Small$ +rm$ mo"ile$ nontender

,. 3ay "e se8uelae froma. past infection". #accines

. Still not location and characterics %local orgeneraliJed(

A?9@/3AL 79D79KS:

9ea6pulses: #asoconstriction of diminished cardiac output

@ull, !ound#ngpulses occur with patent ductus arteriosus from

the large lefttoright shunt

#m#n#shed or A!sent%femoral Pulse(: while upper e)tremity

pulses are normal %coarctation of aorta( nlarged Tender Nodes: current infection

b. Aging adult: DP and PT pulses may "ecome more di4cul to+nd.

i. Trophic changed associated with arterial insu4ciency

1.Thin

2. Shiny skin


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3.Thickridged nails

4. Loss of hair on lower legs

ii. All occur normally with Aging.

A?9@/3AL 79D79KS: ;eneral#2ed dema: suggests heart disease

+pertens#on: suggests preeclampsia %dangerous o"stetric

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Nursing Health Assessment Exam 2