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NURS 3100 Health Assessment Exam 2 Study Guide:
*Remember, the end result of REALLY learning material is that you will be an expert & confident practitioner. You will identify problems early, minimize complications, provide comfort, & even Save Lives!
· 55 Multiple Choice Questions. This list covers the most important topics, but may not cover every possible test item.
· Using power points, lecture notes, and text book, familiarize yourself with the following concepts:
· Respiratory System:
· Signs of respiratory distress (flaring, use of accessory muscles, retractions, cyanosis)
· Flaring= labored respiratory; hypoxia
· Use of accessory muscles= facilitate inspiration in chronic airway obstruction or atelectasis
· Retractions= when the area between neck and ribs sinks due to not getting enough air and struggling to breathe
· Cyanosis= cold or hypoxia
· Observe chest wall for deformities (AP vs Transverse dimensions & significance of). Know how to assess for equal expansion, trachea midline, equal scapulae
· Normal chest= AP< lateral (1:2 ratio)
· Barrel Chest= AP> lateral (1:1 ratio)
· Pectus excavatum = funnel chest
· Pectus carinatum = pigeon chest
· Tactile fremitus: findings, possible interpretations (when this would be decreased or increased)
· Fremitus- vibrations of air in bronchial tubes
· Use hand to palpate as client repeats “99”
· Should be symmetrical and easily felt in upper lobes
· Normal to diminish toward base of lungs
· Percussion findings: (when might hear hyper-resonance, dullness over lungs?)
· Resonance- low-pitched, normal over lungs
· Tympany- drum-like, normal over abdomen
· Dullness- fluid or solid, normal over heart and liver
· Consolidation, pleural effusion, tumor if heard over lungs
· Hyper resonance- trapped air
· COPD, emphysema, pneumothorax if heard over lungs
· Know lung sounds: Where you expect to hear, pitch, significance/what to do for abnormals:
· Vesicular- low pitched, normally over peripheral lung fields
· Bronchial (tracheal)- over trachea, loud, harsh
· Broncho-vesicular- by sternum & between scapulae
· Fine Crackles- (Fine Rales); high pitched, (rubbing hair by ear, fire)
· Coarse Crackles- (Coarse Rales): loud, low pitched, bubbling; may clear with coughing. Inhaled air collides with secretions in trachea & large bronchi
· Wheezes- high, musical whistling; air passing thru constricted airway (asthma)
· Stridor- inspiratory wheeze associated with obstruction of airway
· If you hear abnormal breath sounds, ask the client to cough as this can clear the airways. Then listen again and note any change.
· Respiratory signs such as clubbing, cyanosis, barrel chest, pursed-lip breathing, tri-pod positioning
· Auscultation of lungs- location/# of lobes, use diaphragm, pattern, compare side to side for symmetry. Know steps of respiratory assessment.
· Right lung: 3 lobes
· Left lung: 2 lobes
· Palpate, percuss, auscultate
· Move in a ladder pattern
· How to assess chest expansion, including normal findings & significance
· Place hands on back with thumbs pointing in toward spine
· Patient breathes in and your hands should move apart
· How to perform voice transmission tests-normal findings & significance
· Listen while patient says 99 and E
· As you move toward base of lungs sound should diminish
· Should be hard to understand what they are saying
· If you can hear what they are saying, something is abnormal
· Discuss signs of pleural effusion, pneumothorax, pneumonia, asthma, COPD
· Pleural Effusion
· Collection of excess fluid in intrapleural space with compression of lung
· fluid settles in bottom of thoracic cavity
· fluid subdues lung sounds
· tachypnea, dyspnea, tachycardia, cyanosis, tactile fremitus
· percussion- dull; no diaphragmatic excursion on affected side
· auscultation- breath sounds decreased or absent, crackles
· Pneumothorax
· Air in the pleural cavity resulting in partially or completely collapsed lung
· Usually unilateral
· Caused by trauma to chest wall or spontaneous rupture
· Causes unequal chest expansion
· Tachypnea, cyanosis, apprehension, anxiety
· Breath sounds decreased or absent
· Tactile fremitus absent or decreased
· Hemothorax- same symptoms but its blood instead of air
· Pneumonia
· Infection in lung causing alveolar membranes to fill with fluid/pus which replaces space for air exchange
· Tactile fremitus- INCREASED
· Percussion- dull over affected lobe
· Auscultation- loud bronchial breathing, diminished lung sounds in some cases
· Cough, fever, tachycardia, dyspnea, pleural pain, respiratory distress
· Asthma
· Retractive Airway Disease
· Triggers activate inflammatory response- bronchospasm, edema in bronchioles, secretion of highly viscous mucus, increase in airway resistance
· Symptoms:
· Increased respiratory rate, sob, wheezing, accessory muscles used, retractions, labored and prolonged expiration
· Palpation- tactile fremitus decreased
· Percussion- resonance
· Auscultation- diminished air movement, breath sounds decreased, wheezing
· COPD
· Chronic Airflow Limitation
· Emphysema and chronic bronchitis
· Symptoms
· Easily fatigued, frequent respiratory infections, use of accessory muscles to breathe, thin, fingernail clubbing, chronic cough, pursed lip breathing, wheezing, barrel chest
· Know risks of lung cancer & education to provide to patient on decreasing risk
· LEADING CAUSE OF DEATH IN THE US & EUROPE
· Risk Factors:
· Cigarette smoking (self or 2nd hand)
· Genetic predisposition
· Exposure to toxins (asbestos, radon, environmental factors)
· Workplace pollutants
· Poor diet
· Decrease Risk:
· Stop smoking! Avoid 2nd hand smoke!
· Check for occupational or home exposure to asbestos or radon
· Seek care for prolonged cough or pain in chest area
· Affects more men than women
· Black men have more incidence and mortality rates
· Affects mainly elderly patients (over 60)
· Respiratory assessment landmarks (sternal angle, costal angle, sternal notch, C7 (vertebral prominens)
· Sternal angle- bony ridge a few centimeters below the suprasternal notch; also called angle of Louis
· Costal angle- angle between ribs
· Sternal notch- u shaped indention on top of sternum
· C7- sticks out on back of neck
· Cardiac, Neck Vessels, Peripheral Vascular:
-Know basic landmarks (expected location of heart, midclavicular lines, apex, base, aortic, pulmonic, erb’s point, tricuspid, mitral) “All People Enjoy Time Magazine”
· Heart is between left 2nd and 5th intercostal space
· Apex is bottom of heart
· Base is top of heart
· Aortic valve = 2nd right intercostal space
· Pulmonic valve = 2nd left intercostal space
· Erb’s point = 3rd ICS at left sternal border
· Tricuspid valve = 4th or 5th ICS at left sternal border
· Mitral valve = 5th ICS at left midclavicular line
-Know which intercostal spaces the valves are heard best over
· See above
-Know which heart sounds correspond with which valve closures
· S1 – “LUB”; Tricuspid and Mitral valves (R&L AV valves)
· S2- “DUB”; Aortic and Pulmonic valves (R&L SL valves)
-Heart sounds (Normal vs. Abnormal): S1, S2- what makes sound? Where heard loudest? What is S3, S4, Murmurs (what are they, how to grade; Technique/sequence to auscultate). Is S3 ever normal and/if in who?
· S1 and S2 are normal
· Makes lub dub sound
· S1 loudest at apex
· S2 loudest at base
· S3 Ventricular Gallop
· Vibrations from resistance to ventricular filling heard over the chest
· Occurs immediately after S2
· Can be a normal finding in young athletes
· Otherwise it is abnormal
· S4 Atrial Gallop
· At the end of diastole, just before S1
· Occurs in a non-compliant ventricle: CAD, hypertension, cardiomyopathy
· Abnormal
· Murmurs
· Swishing or blowing sound caused by turbulent backflow of blood
· Can be caused by
· Increased blood velocity (exercise, thyrotoxicosis)
· Narrow or incompetent valve
· Decreased blood viscosity (thickness, as in anemia)
· Abnormal chamber openings
· Grading Murmurs
· I – difficult to hear; experienced examiner and quiet environment are needed
· II – can be heard upon laying stethoscope on chest, but it is very quiet; examiner must listen closely
· III – requires no effort to hear; is readily heard when stethoscope is placed on chest
· IV – loud with a thrill
· V – very loud; easily palpated thrill
· VI – audible with stethoscope only near chest
-Capillary refill- purpose, how & where to check, what does it indicate
· If the refill takes longer than 1-2 seconds it indicates poor circulation
· Press nail bed, blanch, let go, color should return within 1-2 seconds
-Sequence of Cardiovascular exam: inspect, palpate, percuss, auscultate
· Inspect
· Auscultate
· Palpate
· Percuss
-Define bruit & thrill; Where do you assess for these & how; indicates what?
· Bruit- a blowing, swishing sound indicating blood flow turbulence
· Auscultation over carotid artery
· Indicates plaque build-up in artery
· Thrill- purr-like vibration feeling indicating turbulent blood flow
· Palpate over apex, left sternal border, and base of heart
-Know signs/how to identify MI, heart failure, Allen’s test, Homan’s Sign
· Myocardial Infarction (MI)
· Coronary Artery Occlusion
· Crushing chest pain that does not subside
· Heart Failure
· Cough- pink, frothy sputum
· JVD
· Pitting edema
· Falling O2 saturation
· Crackles or wheezes
· Dyspnea
· Orthopnea
· Stress/Anxiety
· Allen’s test
· Occlude radial and ulnar pulses and have patient pump hand
· Let go of ulnar pulse
· Color should return to pinky side of hand within 2-5 seconds
· This shows whether or not the patient has good circulation in that artery
· Homan’s sign
· Used to test for deep vein thrombosis (DVT)
· Dorsiflexion of foot will cause pain in the back of knee
· Be careful with this as it can let loose a blood clot
-Pulses- Be able to locate/name all. Assess for rate, regularity, and amplitude.
-Cautions for examining carotids
· Only feel one at a time
· Never take pulse bilaterally; could cut off blood flow to brain
· Palpate GENTLY
· Pulse amplitude and strength should be the same bilaterally
-How to locate & assess apical pulse, how to locate & palpate apical impulse
· Position client supine or on left lateral side
· Use 1-2 finger pads to palpate in the mitral area
· Feels like a gentle tap
· 5th left ICS and midclavicular line
-Be able to trace/list the proper sequence of blood flow through the heart
·
· Sup VC Right Atrium Tricuspid (R AV) valve Right Ventricle Pulmonic (R SL) valve Pulmonary artery Lungs Pulmonary veins Left Atrium Bicuspid/Mitral (L AV) valve Left Ventricle Aortic (L SL) Valve Aorta Body
-Know what defines Jugular Venous Distention
· Bulging jugular vein
· Sign of increased central venous pressure in vena cava
-What occurs during diastole? Systole?
· Diastole- ventricles relax, AV valves open, SL valves shut, fill with blood
· 2/3 of cardiac cycle
· Systole- ventricles contract, AV valves snap shut, SL valves open, pump blood out
· 1/3 of cardiac cycle
-Characteristics of Arterial versus Venous systems
· Arteries
· Carry OXYGENATED, nutrient-rich blood from the heart to the capillaries
· High pressure
· Maintain BP by constricting or dilating in response to the parasympathetic nervous system
· Veins
· Carry DEOXYGENATED, nutrient-depleted blood from tissues back to heart
· Much lower pressure
· Act as a reservoir for extra blood
·
-Define pulse deficit and lymphedema
· Lymphedema- high protein swelling of limb
· Lymph builds up in interstitial spaces after a surgical removal of lymph nodes
· Pulse deficit- difference in palpable pulse and heart rate
· Usually seen in atrial fibrillation
-Know how Ankle Brachial Index is calculated and what normal results include
· Systolic blood pressure taken using a doppler ultrasound and cuff from arm and ankle on both sides
· Highest number for each is kept
· Ankle divided by arm
· .9-1.9 is normal and means circulation is good
· Tests for PAD- a condition where arteries in arms and legs are narrowed or blocked by plaque
-Characteristics & risks of venous versus arterial ulcers/skin appearance
· Venous Insufficiency/ PVD
· Inadequate return of venous blood from legs to heart
· Tired/heavy legs
· Cramping/aching in legs
· Pain worsens with standing
· Pain improves with elevation
· Venous (stasis) Ulcer
· Shallow ulcer with irregular border
· Bleeding
· Seen on legs
· Thin and blue surrounding skin
· Darkening of legs
· Arterial Insufficiency/ PAD
· Narrowing of arteries commonly the pelvis and legs
· Cramping
· Worsens with exercise
· Subsides with rest
· Arterial (ischemic) Ulcer
· Have a punched out appearance
· Tendons, bones, underlying joints exposed
· Covered with minimal granular tissue
· Pallor, dry skin, loss of hair, fissuring of nails
· Usually on toes and ankles
· Can be on legs
-Risk factors for cardiovascular disease (modifiable versus non-modifiable)
· Modifiable- things you can control/change; modify (smoking, weight, cholesterol, nutrition, exercise, alcohol, drugs, etc.)
· Non-modifiable- things you cannot change (age, race, gender, etc.)
· Breast Exam:
· Breast exam-method of assessment and palpation techniques, including what to do if a lump is found.
· All lumps should be further assessed and referred
· Inspection
· Palpation
· Patient lays supine
· Palpate for texture and elasticity: look for thickening from tumor
· Tenderness and temperature
· Masses: location, size in cm, shape, mobility, consistency, tenderness
· Nipples: wear gloves, compress nipple gently
· Mastectomy or lumpectomy site
· Use a sensitive but matter of fact approach
· Wedge technique, circular or vertical strip
· Have client lay supine with arm overhead. Place small pillow under breast being palpated. Use flat pads of 3 fingers to palpate breasts in one of 3 patterns. Palpate every square inch in each level of pressure (light, medium, firm)! Use bimanual technique if there are large breasts.
· Know what abnormal lymph node findings can be associated with breast cancer.
· Lumps
· Swelling
· Redness
· Warmth
· Dimpling
· Pain
· Prominent or asymmetric pattern
· Retraction
· Be familiar with Tail of Spence and how to document locations on breast (quadrants)
·
· Know the site of most breast tumors
· UPPER OUTER QUADRANT
· Know signs of breast cancer (dimpling, bloody nipple discharge, retraction, lump, etc)
· Retraction- when nipple starts out as raised but begins to pull inward
· Dimpling- dimpling of breast tissue
· Discharge
· Know signs of Paget’s, Peau D’orange
· Paget’s Disease
· Redness and flaking of nipple
· Late signs are tingling, itching, sensitivity, burning, discharge, and pain
· Underlying invasive ductal carcinoma
· Peau D’orange
· Inflammatory cancer
· Accumulation of excess lymph fluid inside breast tissue cause pores to enlarge due to edema
· HEENT Exam:
· Cervical lymph nodes: Normal vs. worrisome (How to assess, Lymphadenopathy, characteristics to check)
· Swelling and tenderness are abnormal
· Assess by feeling, palpating
· Lymphadenopathy:
· Thyroid: Know the steps on how to assess (how to palpate, how/when to auscultate)
· Usually nonpalpable, nontender
· Reach from behind the client to palpate
· Auscultate for bruits if enlarged
· Auscultate only if enlargement is seen
· Headaches: Cluster vs. Tension vs. Migraine vs. Sinus
· Cluster Headache:
· Stabbing, sudden onset at same time of day
· may have reddened eye/drooping,
· in orbit of eye
· more common in young males
· Tension Headache:
· Dull/tight/diffuse pattern
· Occur with stress and anxiety
· Aching
· More common in women
· Migraine:
· Severe throbbing, may have N/V
· Sensitive to light; aura (visual changes associated with migraines)
· One spot where the pain is
· More common in women
· Can last for days
· Sinus:
· Pressure, tenderness on face
· May have nasal drainage/bad breath
· Worse when bending over
· Tumor related:
· May worsen with cough/sneeze
· May have neurologic symptoms
· Commonly occurs in the morning
·
· Characteristics of Pharyngitis (Strep vs viral sore throat)
· Strep is caused by bacteria; can see white patches on throat and tonsils
· Viral is caused by virus
· PERRLA: Know what each letter stands for & how to assess each test
· PERRLA = Pupils Equal, Round, Reactive to Light, Accommodation
· Corneal light reflex test- have patient look at a penlight. The light reflex should fall within the pupils bilaterally equal
· Esotropia- light reflex is in the interior of a pupil
· Exotropia- light reflex is toward outer edge of pupil
· Know how to check of mydriasis, anisocoria, miosis-what do these indicate?
· Mydriasis- dilated pupils
· Anisocoria- unequal pupils
· Miosis- pinpoint pupils; seen with narcotic usage
· How to check Visual acuity testing (Snellen) & what documentation means (Ex: 20/20 vs 20/80)
· Person stands 20 feet away from the chart
· 20/40 or worse = need corrective lenses
· 20/80 means that a person can read at 20 ft what a person with normal eyesight could read at 80 ft away
· Terms- Ptosis, chalazion, hordeolum, conjunctivitis, ectropion, cataracts (what will red flex look like if cataracts are present?)
· Ptosis- droopy eyelid, can be born with it or can be caused by tumor
· Ectropion- eyelid is pulling away from eye so you can see the inside of eyelid; no treatment unless patient is uncomfortable
· Hordeolum- (aka sty) infected external eyelid gland
· Chalazion- similar to hordeolum; occurs UNDER eyelid, inflamed sebaceous (Meibomian) gland
· Conjunctivitis- (AKA Pink Eye) inflammation of the conjunctiva; can be due to allergies or bacteria
· Cataract- leading cause of blindness worldwide, Black spots or spokes against the background of the red light reflex is indicative of cataracts.
· Define Consensual reaction, Presbyopia, Corneal light reflex
· Presbyopia- age related change in the eyes in which the lens can’t accommodate for near vision
· Corneal light reflex- use pen light to observe parallel alignment of light reflection in corneas
· Consensual reaction- when light is shined in the right eye, the left eye pupil should also react and vise versa
· Otoscopic exam: (such as positioning & what you are expected to visualize): normal and abnormal findings of tympanic membrane, outer ear, how to hold otoscope
· Inspection
· Inspect the external auditory canal for discharge, color, consistency of cerumen, canal walls, and nodules
· Inspect the tympanic membrane for shape, consistency, and landmarks
· Tympanic membrane should be a pearly gray color if normal
· Terms: pinna, tragus, otitis media, otitis externa, presbycusis, types of hearing loss & signs of each
· Pinna- auricle, basically the outer ear
· Otitis media- infection of middle ear
· Otitis externa- infection of outer ear
· Presbycusis- hearing loss associated with aging, hard to heat high pitched sounds
· Conductive hearing loss- something blocks or impairs the passage of vibrations from getting to the inner ear
· May result in bone conduction being better than air conduction in the affected ear and the Weber would lateralize to that side)
· Sensorineural (perceptive) hearing loss- damage is located in the inner ear
· Due to a disease process
· AC>BC and Weber lateralized to non-affected side
· Can be congenital or acquired
· Know how to conduct Rinne & Weber tests (expected findings related to air and bone conduction)
· Weber Test
· Strike the tuning fork
· Use tuning fork placed on the center of the head or forehead
· Ask whether the client hears the sounds better in one ear or the same in both
· Rinne Test
· Use the tuning fork and place at the base of clients mastoid process
· When the client can no longer hear the sound, note the time interval and move the tuning fork in front of the external ear
· Note how long they can hear the sound
· Expected to hear the sound longer in front of ear than when tuning fork was on bone bc air conduction is better than bone
· Know how to conduct Romberg test; what it means & what a positive test is
· Have client stand with feet together and arms at side, close eyes for 20 seconds
· Check for swaying
· Tests equilibrium
· If the patient loses their balance or sways, it is a positive test
· Sinuses-how to assess in steps; know signs of sinus infection
· Palpate for tenderness and crepitation
· Percussion and transillumination for air vs. fluid or pus
· Mouth: Signs of Abnormal findings (fungal infection like yeast; leukoplakia) vs. normal findings (soft, spongy palate)
· Abnormal
· Cheilosis- sides of mouth cracking and sore
· Carcinoma of lip or tongue- cancer
· Leukoplakia- thick white patches in your mouth from smoking
· Fungal infection- black hairy tongue
· Gingivitis
· Smooth, red, shiny tongue- vitamin B12 deficiency
· Normal
· Soft, spongy palate
· Pink
· No receding gums
· Has all teeth
· Know how to grade tonsils
· 1+, 2+, 3+, 4+
·
·
· Know signs & risks of oral cancer
· Risks
· Tobacco products!!!
· Heavy alcohol use
· HPV infection
· Poor oral hygiene
· Poor diet/nutrition
· Weak immune system
· Age 55+
· Use of mouthwash with alcohol content
· Signs
· Sores that do not heal
· Lump
· Red or white patch on inside of mouth or tongue
· Ulcers
· Bad breath
· Pain
· Know how to locate and name lymph nodes in head and neck
· Preauricular nodes- in front of ears
· Postauricular nodes- behind ears
· Occipital nodes- posterior base of skull
· Tonsillar nodes- angle of mandible, on the anterior edge of the sternocleidomastoid muscle
· Submandibular nodes- medial border of the mandible
· Submental nodes- a few centimeters behind the tip of the mandible
· Superficial cervical nodes- superficial to the sternomastoid muscle
· Posterior cervical nodes- posterior to the sternocleidomastoid muscle and anterior to the trapezius in the posterior triangle
· Supraclavicular nodes- hook fingers over clavicles and feel deeply between the clavicles and sternomastoid muscle
·
·
· Know where and how to assess the TMJ
· Should be nontender without crepitation or swelling
· Mouth should open/close fully and jaw move smoothly laterally
· Should not hear any popping or clicking
· Fingers in front of ears, instruct patient to open and close jaw
· Know facial abnormalities (signs of Parkinson’s, Acromegaly, CVA)
· Acromegaly- enlargement of facial bones; can be seen in feet and hands too
· Parkinson’s- mask-like facial appearance, shuffling gate and diminished reflexes
· CVA (cerebrovascular accident)- stroke; can be caused by a clot or by bleeding on the brain (hemorrhage); paralysis or droopiness on one side of face