NUR 3029: Health Assessment Final Exam: Study Guide
NUR 3029: Health Assessment Final Exam: Study Guide
The comprehensive examination will contain
... [Show More] 100 multiple questions. Please refer to your course syllabus regarding examination policies, the Activities & Assignments for reading assignments, previous study guides, and class schedule. The following study guide is intended to assist you in preparing for the examination and may not be all-inclusive. Students are expected to apply concepts from pre-requisite courses. Examination preparation should include attending class lectures, reading assignments, and web-based activities.
Introduction to Health Assessment
• Understanding the components of the Nursing Process
• Nurse’s role in environmental assessment
• Communication for assessment of multiple populations (adult/elderly)
• Cultural sensitivity in Health Assessment
Health History
• Communication during the physical examination and obtaining health history
• Obtaining subjective and objective information during the health history
• Components of the Health History
Assessment Techniques
> Parts of the stethoscope and assessment of sounds (bell vs diaphragm)- the bell is used for soft, low pitched sounds such as extra heart sounds or murmurs and diaphragm used for high-pitched sounds such as, breathe, bowel, and normal heart sounds.
> Inspection, palpation, percussion, auscultation (order changes in abdominal assessment.
> Appropriate sequence of assessment (infant, child, adult)- the same for each- head to toe
General Survey
Assessment of vital signs (normal vs abnormal, routes & locations of vital signs)
1) Temperature-
> normal oral temp: 96.8 degrees F; normal range: 35.8 to 37.3 degrees C (96.4-99.1 degrees F)- most accurate and convenient
> normal rectal temp: 0.4 to 0.5 degrees C higher (0.7 to 1 degree F)- only used when other routes are not practical
> TMT- temperature checked by ear (used mostly in children)
2) Pulse- palpating the peripheral pulse gives the rate and rhythm of the heartbeat, as well as local data on the condition of the artery; counting for 30 seconds and multiplying by 2 is the most accurate but if rhythm is irregular, count for the full minute; assess for rate, rhythm, and force
> bradycardia- rate less than 50 bpm
> tachycardia- rate greater than 90 bpm
> 3+ full, bounding; 2+ normal; 1+ weak, thready; 0 absent.
3) Respirations- for a neonate 30-40 breaths per min is normal; for an adult 10-20 is considered normal but 10 should be a concern.
4) Blood pressure- Can be checked in the arm or the thigh (brachial pulse, popliteal pulse)
> Normal: 120/80 or less
> Prehypertension: 120-139/80-89
> Stage 1 hypertension: 140-159/90-99
> Stage 2 hypertension: >160/>100
Assessment of changes in BP (orthostatic BPS and nurse’s role)
> take serial measurements when you suspect volume depletion; when the person is known to have hypertension or is taking antihypertensive medication; or when the person reports fainting or syncope.
> have person rest supine for 2 to three minutes and take baseline readings of pulse and BP, and then repeat the measurements with the person sitting, then standing (for person too busy to stand, assess supine and then sitting with legs dangling. Normally when the position is changed from supine to standing, there is a slight decrease (les than 10 mmHg) in systolic pressure.
> orthostatic hypotension- drop in systolic pressure of more than 20 mmHg or orthostatic pulse increases in 20 bpm standing position.
> nurse must record the BP for each position, the arm used, and the cuff size if different from standard adult; also record the pulse rate and rhythm.
* If BP cuff is too narrow for the arm, it will result in a false high BP reading and if it is too loose or uneven it will result in a false low reading.
Pain Assessment and Vital Signs interpretation
>infants and children use the face pain scale
>PQRSTU
- Provocative/palliative
- Quality
- Region/Radiation
- Severity, 0-10
- Time
- Understands
* BP tends to be higher when a person is in acute pain; in persons with chronic pain BP is not normally affected.
Integumentary Assessment
Normal vs abnormal changes in the skin (infant, child, adult, older adults)
> test for skin turgor (tenting), which signifies dehydration- abdomen on infant, hand on an adult
> newborns nail beds may be cyanotic for the first few hours of life, then turn pink.
> adolescents experience acne; appear in children 7 to 8 years of age but usually peak at age 14 to 16 years in girls, and at 16 to 19 years in boys.
> skin for aging adult is much thinner
> acrochordons or “skin tags” occur frequently on eyelids, back, and axillae and trunk.
> hair growth decreases in aging adult and the amount of decrease in axillae and pubic areas. After menopause, women develop brisk hair on chin or upper lip; in men coarse terminal hairs develop in ears nose and eyebrows but beard is unchanged; male pattern alopecia is a genetic trait (gradual receding in a symmetric W shape); in males and females, hair begins to change white due to loss of melanocyte function.
> with aging the nail growth rate decreases and surface may be brittle and sometimes yellowed; toe nails are thickened- make sure it is normal and not due to peripheral vascular disease
Abnormal skin and hair changes and descriptions
> pallor occurs with anemia, shock, arterial insufficiency, albinism (absence of melanin), and vitiligo (destruction of melanocytes)
> cyanosis in light skinned people- blue, in dark skinned- check conjuctiva, oral mucosa, and nail beds
> jaundice – yellow in sclera, hard palate, mucous membranes, skin; check palms and soft palate in dark persons; light gray colored stool and dark golden urine.
> skin smooth with hyperthyroidism, skin dry in hypothyroidism
> in endocrine disorders cause excessive hair or hair loss
> tinea capitis- brittle scalp hair, dull, and coarse
> jagged nails- nervous picking habits; chronically dirty- poor self-care; clubbing of nails occurs with congenital cyanotic heart disease and pulmonary disorders (nail is > 180 degrees with a spongy nail base)
> nails are thickened and rigid with arterial insufficiency
> alopecia- a condition in which hair is lost from some or all areas of the body, usually from the scalp.
> wheal- superficial, raised, transient, and erythematous; slightly irregular shaped due to edema; (ie. mosquito bite, allergic reaction; dermographism).
> bulla- larger than 1 cm diameter; usually single chambered; superficial in epidermis; thin walled so it ruptures easily; (ie. friction burn, dermatitis, burns).
> papules- solid, elevated, and circumscribed, less than 1 cm in diamete, caused by superficial thickening in the epidermis (ie. mole, wart).
> nodule- solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than a papule.
Changes in skin turgor and associated conditions
> urticaria- “hives”; when wheals coalesce to form extensive reaction, intensely pruritic
> fissure- linear crack with abrupt edges, extends into the dermis, dry or moist. Ex: cheilosis- at corners of mouth due to excess moisture; athlete’s foot.
Head & Neck
Sinuses
> using thumbs press the frontal sinuses by pressing up and under the eyebrows and over the maxillary sinuses below the cheekbones- person should feel firm pressure, but no tenderness/pain.
> Abnormal: person feels tenderness in presence of acute infection (sinusitis) or with chronic allergies
Nasal passages-
> lift up the tip of the nose with finger before inserting otoscope head; view nasal cavities with the head erect and then with the head tilted back; Inspect he mucosa noting normal red color and smooth, moist surface.
> observe the septum for deviation- a deviated septum is common and not significant unless air flow is obstructed; also note any perforation or bleeding in the septum
> inspect the turbinates- the superior one will not be viewable, but the middle and inferior appear the same light red color as the nasal mucosa; turbinate’s are tender.
> Abnormal: Rhinitis- nasal mucosa is swollen and bright red; discharge is common with rhinitis and sinusitis, varying form watery to thick, purulent, and green-yellow; With chronic allergy, mucosa looks swollen, boggy, pale, and gray*; perforation is seen as a spot of light from a penlight shining in the other naris and occurs with cocaine use; epistaxis- nose bleeding; polyps are smooth, pale gray, avascular, mobile and nontender.
Oral mucosa-
> The inside of the mouth looks pink, smooth, and moist, hard palate white with irregular transverse rugae and the posterior soft palate is pinker, smooth, and upwardly moveable; leukoedema- a benign milky bluish, white opaque areas- is normal.
> Abnormal: dappled brown patches are present with addisom’s disease; hard palate appears yellow with jaundice; oral Kaposi sarcoma is the most common early lesion in people with AIDS; candida infection will usually rub off, leaving a raw denuded area; leukoplakia- chalky white raised patch; gums bleed with slight pressure indicating gingivitis
Thyroid gland
> is difficult to palpate; supply person with a glass of water and inspect the neck as the person takes a sip and swallows- thyroid tissue should move up.
> Thyroid posterior examination:
- to palpate behind, ask person to stand up straight and bend the neck and slightly to the left and then use your left hand to push the trachea slightly to the right. The right hand will then palpate between the trachea and the sternocleidomastoid muscle. Reverse the procedure for the left side. You should not be able to palpate the thyroid on a normal adult
> Thyroid anterior examination:
- alternate/best method of palpating thyroid. Stand facing the person ask him or her to tip the head forward and to the right. This time use your right thumb to displace the trachea slightly to the person’s right. Next, hook the left thumb and fingers around the sternocleidomastoid muscle and feel for lobe enlargement when person swallows.
Assessment of the Throat
> uvula should be midline and when person says ah note the soft palate and uvula rise midline- tests one function of cranial nerve X, vagus.
> tonsils should be same color pink as oral mucosa and surface peppered with indentations or crypts; tonsils are graded as 1+ visible, 2+ halfway between tonsilar pillars and uvula, 3+ touching the uvula, 4+ touching each other- tonsils will be enlarged with acute infection
> touch the posterior wall with a tongue blade elicits a gag reflex. This tests cranial nerve IX and X, the glossopharyngeal and vagus- with damage to these nerves patient may experience dysphagia- occurs with pharyngitis, gastroesophageal reflux disease, stroke, and esophageal cancer.
> halitosis- breath odor
> diabetic ketoacidosis has a sweet, fruity, breathe odor
> hoarseness of the larynx has many causes- overuse of the voice, upper respiratory tract infection, chronic inflammation, lesions, or a neoplasm.
Eye Assessment (internal/external)
Acuity/Snellen eye chart
Most commonly used and accurate measure of visual acuity; It consists of lines of letters arranged in decreasing size; Person positions 20 feet from the chart and read the chart to the smallest line possible while shielding one eye.
> Normal visual acuity is 20/20; the larger the denominator, the poorer the vision- poorer than 20/30 refer to an opthalmologist or optometrist.
Diagnostic positions test
Leading the eyes through six cardinal positions of gaze will elecit any muscle weakness during movement. Ask the person to hold the head steady and to follow the movement of your finger, pen, or penlight only with the eyes. Hold the target about 12 inches and move it to each of the six positions, then back to the center. Check for nystagmus- involuntary eye movement and also lid lag- upper eyelid continues to overlap the superior part of the iris.
> Normal response is parallel tracking of the object with both eyes.
> Abnormal eye movement is not parallel. Failure to follow in a certain direction indicates weakness of an extraocular muscle or dysfunction of a cranial nerve innervating it; Nystagmus occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis, or brain lesions; lid lad occurs with hyperthyroidism.
Pupillary light reflexes
Darken the room and ask the person to gaze into the distance. Advance a light in from the side and note the response. Resting size pupil of an adult is 3 to 5 mm. 5% of people normally have pupils of two different sizes anisocoria
> Normal- you will see constriction of the same-sided pupil (a direct light reflex) and simultaneous constriction of the other pupil (a consensual light reflex); record normal findings of all maneuvers as PERRLA- Pupils, Equal, Round, React to Light, and Accommodation.
> Abnormal- absence of constriction; unequal-size pupils calls for a consideration of central nervous system (anisocoria); blind eyes do not respond to light
Corneal light reflex
assess the parallel alignment of the eye axes by shining a light toward the person’s eyes. Direct the person to stare straight ahead as you hold the light about 30 cm (12 in) away. Note the reflection of the light on the corneas.
> Normal- it should be in exactly the same spot on each eye.
> Abnormal- asymmetry of the light reflex indicates deviation in alignment from eye muscle weakness or paralysis. If you see this perform the cover test.
Macular degeneration- The macula is in the center of the retina, the light-sensitive layer of tissue at the back of the eye. The macula is responsible for central vision (straight-ahead vision). Degeneration of the macula occurs most often after the age of 60 years and is termed age-related macular generation (AMD)- results in a loss of vision in the center of the visual field
Cataracts- clouding of the lens inside the eye which leads to a decrease in vision; appears as opaque black areas against the red reflex.
**In whites over 40 years, the leading cause of blindness is age-related macular degeneration (54%), followed by cataracts (9%).
Extra abnormal findings: swilling of lacrimal gland is a visible bulge in the outer part of the upper eyelid; scleral icterus- even yellowing of the sclera extending up to the cornea, indicating jaundice; ptosis- drooping of the upper eyelid; presbyopia- decrease in power of accommodation with aging; cyanosis in the lower lids or pallor in the outer canthus of the lower lid may indicate anemia; arcus senilis- normal finding in old people which is due to a deposition of lipid material; phoria- mild weakness noted only when fusion is blocked; tropia- more severe- a constant malalignment of the eyes; amblyopia- lazy eye; esophoria- eye drift inward, exophoria- outward eye drift; diplopia- perception of two images of a single object; photobia- inability to tolerate light
Aging Adult
> Lacrimal glands involute, causing decreased tear production and feelings of dryness/burning
> skin loses elasticity which causes drooping and wrinkling
> Pupil zise decrease, lens loses elasticity becoming hard and glasslike, which decreases the lens ability to change shape to accommodate for near vision presbyopia
> at 70 years of age, fibers of the lens thicken and yellow, beginning senile cataract.
> aging person needs more light for reading because of decreased adaptation to darkness.
> cataracts, glaucoma (increased intraocular pressure), and macular degeneration (breakdown of cells in the macula of the retina) are the most common causes of decreased visual acuity in older patients.
Ear Assessment
Normal and abnormal assessments
* Virus/bacteria from upper respiratory tract infection may migrate up the Eustachian tube to involve the middle ear.
otalgia- earache/pain
otorrhea- discharge in ear that suggest infected canal or perforated eardrum
Presbycusis- gradual onset over years whereas a trauma hearing loss is often sudden; not associated with upper respiratory tract
tinnitus- ringing, crackling or buzzing in your ears. Originates within the person; accompanies some hearing or ear disorders
> a sticky yellow discharge accompanies otitis externa and may indicate otitis media if the drum is ruptured;
> enlarged, tender lymph nodes in the region indicate inflammation of the pinna or mastoid process
> Impacted cerumen is a common cause of conductive hearing loss
> frank blood or clear watery drainage after trauma suggests basal skull fracture and warrants immediate referral. CSF feels oily and is positive for glucose on TesTape.
> Check for any polyps furuncle, exostosis etc.
> Use of otoscope: hold otoscope upside down with the dorsa of your hand along the persons cheek; insert the specula slowly and carefully along the axis of the canal and avoid touching the inner “bony” section of the canal wall; rotate slightly to visualize the entire eardrum; do this before hearing examination to see if impacted with cerumen.
> tympanic membrane: normally shiny and translucent, with a pearl gray color
- yellow-amber drum color occurs with otitis media with effusion (serous) and sometimes air bubbles behind drum; red color with acute otitis media.
> eardrum is flat and slightly pulled in at the center, and flutters when person performs valsalva maneuver or holds the nose and swallows- avoid doing so with upper respiratory infection because it could propel infectious matter into the middle ear
Hearing assessment/Hearing Testing
Your screening for hearing deficit begins during the history; how well does the person hear conversational speech? Ask the person directly if he or she thinks there is a hearing difficulty. If the answer is yes, perform audiometric testing or refer for audiometric testing. If the answer is no, screen using the whispered voice test.
1) Whispered Voice Test- test one ear at a time while masking hearing in the other ear to prevent transmission around the head and shield the lips or stand behind the person so they cannot read your lips. Standing 1 to 2 ft away whisper slowly a set of 3 random numbers, letters, or even words. Normally the person should be able to repeat each one directly after you say it. A passing score is correct repeating of at least 3 out of 6.
> abnormal: person is unable to hear whispered items. A whisper is a high frequency sound and is used to detect high tone loss.
2) Tuning Fork Tests- measures hearing by air conduction or bone conduction, in which the sound vibrates through the cranial bones to the inner ear.
> Weber Test- executed by hitting the tuning fork and then holding it in the middle of the patient’s forehead. If the patient is unable to hear the tuning fork in this position, it can also be placed on the nasal bone or in the middle of the front two teeth. The patient is then asked to determine where the sound is heard the best. A normal result is when the sound is the same in both ears.
> Rinne Test- air conduction and bone conduction tested; first strike the tuning fork then hold it next to the persons ear to see if he or she can hear it; next place the base of the tuning fork on bone in front of ear and test if person can feel the vibration.
*both tests used to evaluate the Vestibulocochlear nerve (cranial nerve VIII)
Aging Adult
> An aging adult may have pendulous earlobes with linear wrinkling because of loss of elasticity of the pinna
> Coarse wiry hairs may be present at the opening of the ear canal.
> eardrum may be whiter in color and more opaque, duller than in the younger adult.
> A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. This condition is revealed in difficulty hearing whispered words in the voice test and in difficulty hearing consonants during conversational speech. The aging adult feels that “people are mumbling” and feels isolated in family or friendship groups.
> impacted cerum is common in aging adults which blocks conduction in those wearing hearing aids and accounts for 70% of malfunction in hearing aids returned to the manufacturer. Cerum should be removed if it interferes with full assessment of the ear.
Lymphatic System
Cardiac Assessment
Anatomical Landmarks, Cardiac Cycle
> Precordium- area anterior chest directly overlying the heart and great vessels.
> Heart and great vessels are located between the lungs in the middle of the thoracic cage (mediastinum).
> top if the heart is the base, bottom is the apex (landmark for apical pulse)
> right side of heart is anterior and the left is posterior; left ventricle lies behind the right ventricle; right atrium forms right border, left ventricle forms part of left border.
> great vessels lie at the base of the heart; pulmonary arteries leave the right artrium carrying deoxy blood to lungs; pulmonary veins located in the left atrium bring back oxygenated blood from the lungs back to heart; aorta sends blood to rest of body.
Inspection of Anterior chest: you may or may not see an apical pulse; a heave or a lift is a sustained forceful thrusting of the ventricle during systole; it occurs in ventricular hypertrophy as a result of increased workload.
Palpation of anterior chest: palpate the apical impulse; a thrill is a palpable vibration; it feels like the throat of a purring cat; it signifies turbulent blood flow and accompanies loud murmurs.
For auscultation of anterior chest:
Aortic Area- Right 2nd intercostal space
Pulmonic Area- left 2nd intercostal space
Erb’s point- left of sternum 3rd intercostal space
Tricuspid area- 5th left intercostal space
Mitral area- 5th left intercostal space mid clavicular/nipple line
Assessment of Neck Vessels
*yield important information on heart function
1) Palpate the carotid artery
> medial to the sternomastoid muscle. Avoid excessive pressure b/c excessive vagal stimulation slows down heart; palpate only one at a time; Normal contour is smooth with rapid upstroke and slower downstroke and normal strength Is 2+.
> carotid sinus hypersensitivity is a condition in which pressure over the carotid sinus leads to decreased HR, BP, and cerebral ischemia with syncope (occurs in older people with hypertension or occlusion of carotid).
2) Auscultate
> middle-aged or older persons who show signs of CVD auscuultate each carotid artery with the bell for presence of a bruit (blowing, swishing sound indicating blood turbulence)
> 3 different locations: angle of the jaw, midcervical area, and base of neck; ask person to take a huge breath, exhale, and hold the breath while you listen so tracheal breath sounds are not present.
> carotid bruit only heard when vessel is ½ or 2/3 occluded; once fully occluded bruit disappears so absence of a bruit doesn’t ensure absence or a carotid lesion.
3) Inspect Jugular Venous Pulse-
> external overlies sternocleidomastoid muscle, internal in the sternal notch (deep and medial to sternocleidomastoid muscle)
> from jugular veins you can asses central venous pressure and judge the hearts efficiency as a pump. (head of bed 30-45 degree angel, the higher you are the more the pressure falls)
> unilateral distension of external jugular veins is due to local cause (kinking or aneurysm); full distended external jugular veins signify increased CVP as with heart failure
The Aging Adult
> with aging there is an increase in the systolic blood pressure (which increases pulse pressure) due to stiffening of the large arteries which in turn is due to calcification of vessel walls.
> left ventricular wall thickness increases to accommodate the vascular stiffening mentioned earlier that creates an increased workload on the heart.
> there is a decreased ability of the heart to augment cardiac output with exercise (decreased max heart rate).
> no change in cardiac output at rest or resting heart rate wit age
> presence of dysrhythmias increases and ectopic beats are common
> tachydysrhythmias may not be tolerated b/c myocardial wall is thicker and less compliant
> prolonged P-R interval (first degree AV block) and prolonged Q-T interval
> greater risk for CVD and CAD
Cultural and Genetic Considerations
> Higher percentage of men than women experience hypertension until age 45; After age 64 years women have a much higher percentage of hypertension.
> Prevelance of hypertension in blacks is among the highest in the world: 31.8% African Americans, 25.3% American Indians, 23.3% in whites, and 21% for Hispanics and Asians.
> Nicotine increases rates of MI and stroke by causing increase in O2 demand and decrease in Oxy supply, an activation of platelets and fibrinogen, and adverse change in lipid profile
> High levels of LDL add to lipid core of thrombus formation in arteries resulting in MI and strokes; high risk cholesterol level 240mg/dL, 200-239 are borderline.
> prevelance for high cholesterol: 51.1% Mexican-American men and 49% women, 45% white men 48% women, 40.2% African American mean 57.7% women
> prevelance for obesity: 74.8% Mexican American men 73% women, 73.7% African American men 77.7% women, and 72.4% white men 57.5% women
> CVD risk is two-fold greater among persons with DM (strong genetic factor); most prevelant in Africa 11%.
>hypertension is 2 to 3 times more common among women taking oral contraceptives especially obese and older women
Heart Sounds (Normal, Extra, & Murmurs)
> First heart sound S1- beginning of systole ; av valve closure
> Second heart sound S2- end of systole, beginning of diastole; closure of semilunar valves (loudest at the base)
> S3- normally is silent but occurs when ventricles are resistant to filling during the early rapid filling phase; occurs immediately after S2 when the av valves open and the atrial blood first enters ventricle;
> S4- occurs at end of diastole, presystole, when the ventricle is resistant to filling; the atria contract and push blood into a noncompliant ventricle, which creates these vibrations; S4 occurs just before S1.
> midsystolic click- associated with mitral valve prolapse is the most common extra sound
> ejection click- occurs early in systole at the start of ejection because it results from opening of the semilunar valves; short and high pitched, with a click quality.
* S3 (ventricular gallop, Kentucky) and S4 (atrial gallop, Tennessee) both occur in diastole.*
> Mitral prosthetic valve sound- iatrogenic sound, gives an early diastolic sound an opening click just after S2.
Murmurs:
> when certain conditions create turbulent blood flow and collision currents; murmur is a gentle blowing swooshing sound that can be heard on the chest wall
> Following causes of murmurs:
Velocity of blood increases
Viscocity of blood decreases
Structural defects in the valves or unusual openings occurring in the chambers (wall defect)
Systolic (midsystolic ejection murmurs)
> aortic stenosis /pulmonic stenosis
> mitral regurgitation/tricuspid regurgitation
Diastolic rumbles of AV valves
> mitral stenosis/tricuspid stenosis
> aortic regurgitation/pulmonic regurgitation
Respiratory Assessment
Normal versus abnormal respiratory assessment findings/definitions/lung sounds
Assessment findings:
> tactile fremitus- palpable vibration; sounds generated from the larynx that are transmitted through patent brochi to chest wall. Touch person’s chest while asking them to say “blue moon” or “ninety nine”. Obstruction will decrease fremitus and compression or consolidation (lobar pneumonia) causes an increase in fremitus.
> crepitus- coarse, crackling sensation palpable over the skin surface.
> check for bilateral chest expansion- unequal occurs with atelectasis, pneumothorax, or fractures ribs
> hyperresonance- lower-pitched booming sound found when too much air is present such as in emphysema or pneumothrax.
> dullness- soft muffled thud which signals abnormal density in the lungs, as with pneumonia, pleural effusion, tumor, or atelectasis- should only be heard when percussing over the liver area
Respiratory patterns:
> tachypnea- rapid, shallow breathing. Increased rate, >24 per minute. This is a normal response to fever, fear, or exercise.
> hyperventilation- increase in both rate and depth; occurs with extreme exertion, fear, or anxiety.
> bradypnea- slow breathing. A decreased but regular rate <10 per minute, as in drug-induced depression of the respiratory center in the medulla, increased intracranial pressure, and diabetic coma.
> hypoventilation- an irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bedrest or conscious splinting of the chest to avoid respiratory pain.
> cheyne-stokes respiration- cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds) alternating cycle- normal in infants and aging persons during sleep.
> chronic obstructive breathing- normal inspiration and prolonged expiration to overcome increased airway resistance (emphysema/COPD)
Adventitious lung sounds:
> Crackles- fine (discontinuous high pitched, short crackling popping sound heard upon inspiration and not cleared by coughing; caused in pneumonia, heart failure, chronic bronchitis, asthma and emphysema) or coarse (loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration; decreased after coughing or suctioning; sounds like Velcro; found in pulmonary edema, pneumonia, and pulmonary fibrosis)
> Pleural friction rub- superficial sound is coarse and low-pitched; grating quality as if two pieces of leather are being rubbed together; sounds like crackles but close to the ear; inspiratory and expiratory; caused by pleuritis and accompanied by pain with breathing
> wheeze- result of passage narrowed or airway obstruction; common in asthma or chronic emphysema; high-pitched (occurs in both inspiration and expiration) or low-pitched (expiration).
> stridor- high-pitched, inspiratory, crowing sound, louder in neck than overall chest
Assessment of conditions (asthma, COPD/emphysema, infections)
=Patients with COPD/emphysema normally have a barreled chest; Person with pneumonia will normally experience crackles; a person with asthma or emphysema will normally experience wheezing.
Distinguish between lung sounds and location
> Bronchial- high pitched, loud, harsh and hallow, location: trachea
> Bronchovesicular- moderate pitched, moderate amplitute, mixed sounds, location: over bronchi, between scapulae, around upper sternum 1st and 2nd intercostal spaces
> Vesicular- Low pitched, soft, rustling like the sound of wind in trees, location: peripheral lung fields where smaller bronchioles and alveoli are located.
Abdominal Assessment
Internal Anatomy of all 4 Quadrants
Right Upper Quadrant:
Liver
Gallbladder
Duodenum
Head of Pancreas
Right kidney and adrenal
Hepatic flexure of colon
Part of Ascending and transverse colon Left Upper Quadrant:
Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney and adrenal
Splenic flexure of colon
Part of transverse and descending colon
Right Lower Quadrant:
Cecum
Appendix
Right ovary and tube
Right ureter
Right spermatic cord Left Lower Quadrant:
Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
Special Procedures
> Rebound Tenderness AKA “Blumber Sign”- assess for rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. Choose a site away from painful area. Hold hands perpendicular to abdomen; push down slowly and deeply then lift up quickly (perform at end of examination). Positive response confirms peritoneal inflammation, which accompanies appendicitis.
> Inspiratory Arrest AKA “Murphy Sing”- In a person with inflammation of the gallbladder (cholesystitis) pain occurs. Hold fingers under the liver border and ask person to take a deep breath. Patient should be able to complete a deep breath without pain; If in extreme pain person will immediately stop inhalation; less accurate in patients older than 60 because they don’t have abdominal tenderness.
> Iliopsoas Muscle Test- Perform when acute abdominal pain of appendicitis is suspected. While person is in supine position, life the right leg straight up, flexing at the hip then push down over the lower part of the right thigh as the person tries to hold up the leg. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant.
> Fluid wave test- used to differentiate ascites from gaseous distension. Firm stride with the hand. [Show Less]