Exam #2 Nursing 203

sternal angle

"angle of Louis", articulation of the manubrium and body of sternum, continuous with second rib. helps to count ribs starting with 2nd rib. helps localize a respiratory finding horizontally. each intercostal space is numbered by rib above it. you can palpate easily down to the tenth.

sternum

'breastbone", 3 parts - manubrium, body, xiphoid process.

diaphragm

'floor", a musculotendinous septum that separates the thoracic cavity from the abdomen.

Direct observation

BEST technique but most expensive. detect problems not readily identified through standard nutrition interviews. someone monitors.

Costal angle (angle of louis)

R and L costal margins form an angle where they meet at the xiphoid process. Usually 90 degrees or less, this angle increases when rib cage is chronically overinflated (emphysema).

Optimal nutritional status

achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands due to growth, pregnancy, or illness.

adventitious sounds

added sounds that are not normally heard in the lungs.

advantage of 24-hour recall

advantage is that it can elicit specific info about diet intake over specific time.

atelectatic crackles D

airways crack open but disappear. sounds like fine crackles but do not last and are pathologic during INSPIRATION

Auscultate the posterior chest

ask patient to breath in deeply and listen in 9 areas (18 spots total) for breathing Listen to at least one full respiration in each location side-to-side comparison is most important Standing behind back, listen from C7 to T10- axilla down to 7th or 8th rib Ask: What am I hearing over this spot? What should I EXPECT to be hearing?

background noise

examiners breathing on stethoscope tubing stethoscope tubing bumping together patient shivering patient's hairy chest rustling of paper gown

vertebral prominens

flex head, 1st bony prominent spur is c7

comprehensive nutritional assessment

for those individuals at nutritional risk during screening. it includes dietary history and clinical info, physical exam for clinical signs.

tactile fremitus

fremetis - a palpable vibration. use either palmar base (the ball) of fingers or ulnar edge of one hand. Touch back of person's chest when he says resonant phrases "ninety-nine" or "blue moon". palpate side to side (5 rows = 10 spots). vibrations should feel symmetric, except between scapulae (stronger on R because of bronchial bifurcation). avoid palpating over scapulae (bone dampens sound transmission).

Bronchial (tracheal) breath sound

high pitch loud inspiration < expiration harsh, hallow, tubular Trachea & larynx

stridor

high-pitched, monophonic, crowing sound= louder in neck INSPIRATION

fine crackle D

high-pitched, short crackling, POPPING sounds heard during INSPIRATION that are not cleared by coughing

lung apex

highest point, 3-4 cm above inner third of the clavicles.

sternal notch

hollow U-shaped depression just above sternum, in between clavicals

reference lines

important for charting purposes ANTERIOR: midsternal (middle of sternum) midclavicular (middle of clavical) anterior axillary line (armpit) POSTERIOR: scapular (shoulderblade) vertebral (down vertebra- back bone) LIFT PERSON'S ARM 90 degrees - divide chest: anterior axillaruy= pectoralis major poterior axillary= latissimus dorsi midaxillary= apex of axilla and lies between 2

hypercapnia

increase of carbon dioxide in blood. most effective stimulus to make us breathe

BMI

indicator of obesity or undernutrition <18.5 underweight 18.5-24.9 normal weight 25-29.9 overweight 30-39.9 obesity >40 extreme obesity

Undernutrition

nutritional reserves are depleted and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands.

costochondral junctions

points at which the ribs join their cartilages. not palpable.

24-hour recall

questionaire, recall everything eaten in last 24 hours.

hyperventilation

rapid, deep breathing. causes carbon dioxide to be blown off.

Food diaries

records ask the individual or family member to write down everything consumed for a certain period of time. 3 days. 2 weekday + 1 weekend

factors that affect normal intensity of tactile fremitis

relative location of bronchi to chest wall thickness of chest wall pitch and intensity (loud, low-pitched voice generates more than soft, high)

lateral chest

see all three (R) or two (L) lobes from lateral side

Pleurae (visceral and parietal)

thin, slippery= allowing for smooth movement. serous membranes that form an envelope between lungs and chest wall.

trachea and bronchi

transports gases between enviornment and lung parenchyma. constitute 'dead space' or space that is filled with air but is not available for gaseous exchange

abnormalities in symmetric chest expansion

unequal chest expansion occurs with marked atelectasis, lobar pneumonia, pleural effusion; with thoracic trauma, such as fractured ribs; or with pneumotorax (air in aircavity). Pain accompanies deep breathing when pleurae are inflamed.

inspiration

uses external intercostal muscles (in- ex)

BMI Calculation

weight (pounds) / height (inches) X 703

decreased fremitus

when anything obstructs transmission of vibrations- air isn't getting through for vibration

alveolar duct/ alveoli

where gaseous exchange occurs across respiratory membrane

Obesity BMI

30+

State the purpose of a nutritional assessment

1) identify individuals who are malnourished, or are at risk for developing malnutrition, 2) provided data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition, and 3) establish baseline data for evaluating the efficacy of nutritional care.

disadvantages of 24-hour recall

1) may not be able to recall type of food or amt eaten, 2) intake may be atypical of usual intake, 3) may alter truth of intake, 4) snakc items or condiments may be underreported

4 major functions

1) supplying oxygen for energy production, 2) removing co2 as waste, 3) maintaining homeostasis, 4) maintaining heat exchange

ribs

1-7 directly attached to sternum 8,9, 10- costal cartilage 11, 12- "floating", free palpable tips

3 points that commonly confuse examiners

1. left lung - no middle lobe (only 2 lobes) 2. anterior chest contains mostly upper and middle lobe with very little lower lobe 3. posterior chest contains almost all lower lobe

Overweight BMI

25+

Describe the role cultural heritage and values may play in an individual's nutritional assessment

Each person has unique cultural heritage that may affect nutritional status. Occupation ,class, religion, gender, and health awareness have a great bearing on eating customs. New immigrants may be at nutritional risk because they frequently come with limited food supplies caused by poverty, poor sanitation, war, or political strife. Other factors include: new country with a new language, culture, and society. Faced with unfamiliar foods, food storage, food preparation, and food-buying habits. Many familiar foods are difficult or impossible to obtain. Low income may also limit their access to familiar foods. Borderline deficiencies or adverse nutritional consequences may result. American standard tables of weight, age, height may not work to evaluate immigrants. 24 hour diet recall & 3 day food record inadequate too. Food preferences are interrelated with religious dietary beliefs and practices. Use food for celebrations & rituals.

thoracic cage

bony structure with a conical shape, which is narrower at top. defined by sternum , 12 ribs, 12 vertebrae

expiration

chest recoils. uses intercostal muslces (ex-in)

normal breath sounds

clear, equal bilaterally in all lobes. person is sitting, leaning forward slightly, arms resting comfortably across lap 3 types: bronchial (tracheal), bronchovesicular, vesicular

increased fremitus

compression or consolidation of lung tissue (lobar pneumonia).

Palpate posterior chest

confirm symmetric chest expansion - place warmed hands on posterolateral chest wall with thumbs T9/T10. Slide hands medially to pinch up small fold of skin between thumbs. Ask person to take deep breath. Your thumbs should move apart symmetrically. Note any lag. Palpate the entire chest wall- note areas of tenderness, skin temp, moisture, lumps, masses, lesions.

posterior chest

contains almost all lower lobes (T3-T10/12)

pleural cavities

contains lungs

subjective data

cough shortness of breath chest pain with breathing history of respiratory infections smoking history environmental exposure self-care behaviors class notes: Last TB test? X-ray? Weight change? Normal activities? Shortness of breath? Ask kids: allergies, child-proof home (anything that fits into a toilet paper roll is too small and could get into airway)

crepitus

course, crackling sensation palpable over the skin surface. occurs in subcutaneous emphysema when air escapes from the lung and enters subcutaneous tissue, as after open thoracic injury/surgery.

hypoxemia

decrease of oxygen in the blood

Percuss the posterior chest

determine predominant note over the lung fields. start at apices and percuss band of resonant tissue across tops of shoulders. percuss in interspaces- make side-to-side comparison all the way down lung region. Percuss at 5cm intervals. Avoid damping effect of scapulae and ribs. percussion used over the outer 5-7 cm of tissue (no deeper). Abnormal finding must be 2-3 cm wide to yield abnormal percussion note. Lesions smaller than that are not detectable by percussion.

Subjective data for nutritional assessment

eating patterns, usual weight, changes in appetite, recent surgery, chronic illnesses, vomiting/diarrhea/constipation, food allergies, medications, self-care behaviors, alcohol, exercise, family history

Describe unique nutritional needs for various developmental periods throughout the lifecycle

infants/children- increase length and brain size. Breastfeed recommended. No cow's milk, no low-fat/skim. Need fatty acids. adolescence- rapid growth & endocrine & hormonal changes. Calorie/protein increase for bone and growth and muscle development. Calcium & Iron. 3 meals + snacks pregnancy- for synthesis of maternal and fetal tissues: increase calories, protein, vitamins, minerals (iron, folate, zinc). adult- growth and nutrient needs stabilize. lifestyle factors may lead to problems of hypertension, obesity, atherosclerosis, cancer, diabetes. Prevent/delay onset of disease. aging adult- increased risk for undernutrition or over nutrition. protein, vitamins, minerals (vit D & calcium), nutrient-dense food.

Food frequency questionaire

info collected on how many times per week or month individuals eat certain food. drawbacks: doesn't always quanitify amt intake and relies on memory

brainstem (pons and medulla)

involuntary control of respirations mediated by the respiratory center

parietal

lines inside of chest wall and diaphragm

visceral

lines outside of lungs, dipping down into fissures.

coarse crackle (coarse rales) D

loud, low-pitched, bubbling and gurgling sound during INSPIRATION

Vesicular breath sound

low pitch soft inspiration > expiration rustling, like sound of wind in the trees over peripheral lung fields where air flows through smaller bronchioles and alveoli

Resonance

low-pitched, clear, hollow sound that predominates healthy lung tissue in the adult. May be modified in athlete with heavy muscular chest or obese person.

wheeze - low-pitched C

low-pitched, monophonic SNORING EXPIRATION

lung base

lower border, rests on diaphragm (about 6th rib). drops with angle of diaphragm. T10 usually corresponds to the base. deep inspiration takes it to T12.

inferior border of scapula

lower tip is usually in 7th or 8th rib

Hyperresonance

lower=pitched, booming sound found when too much air is present, such as in emphysema or pneumothorax.

angle of louis

marks the site of the tracheal bifurcation into the R and L main bronchi; corresponds with the upper border of atria of heart, and lies above 4th throacic vertebra on the back.

mediastinum

middle section of thoracic cavity. esophagus, trachea, heart, and great vessels

12th rib

midway between spine and person's side to identify its free tip.

Bronchovesicular breath sound

moderate pitch & amplitude inspiration= expiration mixed quality bronchi, between scapulae, upper sternum, intercostal space

wheeze - high-pitched C

musical squeaking sound. air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors EXPIRATION long E sound

left lung

narrower than right because of heart. 2 lobes: upper and lower. all lobes stack diagonally separated by fissures that run obliquely through chest

Inspect posterior thoracic cage

shape & configuration - spinous process should appear in straight line. thorax is symmetric, in an elliptical shape, with downward sloping ribs, about 45 degrees relative to the spine, scapulae are symmetric. anteroposterior diameter should be less than transverse diameter. Ratio should be 1:2 to 5:7 (front to back is smaller than side to side). Neck muscles and trapezius should be developed normally for age & occupation. Note position when breathing- relaxed posture, able to support weight comfortably Skin color & condition- color should be consistent with person's genetic background. No cyanosis or pallor present. note lesions. inquire about changes in nevus

right lung

shorter than left because of underlying liver. 3 lobes: upper, middle, lower

Abnormal thoracic cage inspection findings

skeletal deformities: scoliosis: a lateral S-shaped curve of thoracic and lumbar spine, usually with involved vertebrae rotation. kyphosis: exaggerated posterior curvature of the thoracic spine (humpback) Barrel chest- Anteroposterior to transverse diameter equal Pectus excavatum- depression at second intercostal space Pectus carinatum- forward protrusion of sternum

hypoventilation

slow, shallow breathing. causes carbon dioxide to build up in blood

dull note

soft, muffled thud= signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

pleural friction rub D

sounds like sandpaper. coarse, low-pitched, sounds like crackles, during INSPIRATION and EXPIRATION

pleural cavity

space fillled only with a few mm. of lubricating fluid. vacuum that holds lungs tightly against chest wall.

spinous processes

spinous processes align with their same numbered ribs only down to T4. after T4 the spinous processes angle downward from their vertebral body

Overnutrition

the consumption of nutrients, especially calories, sodium, and fat, in excess of body needs. Leads to obesity and risk factor for type 2 diabetes, hypertension, stroke, gallbladder disease, sleep apnea, certain cancers, and osteoarthritis.

Nutritional status

the degree of balance between nutrient intake and nutrient requirements. Affected by factors, including physiologic, psychosocial, developmental, cultural, and economic.

Nutrition screening

the first step in assessing nutritional status, is required for all patients in all healthcare settings within 24 hours of admission. Quick, easy way to identify individuals at nutrition risk, such as those with weight loss, inadequate food intake, or recent illness. Parameters include weight & weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. Examples, Malnutrition Screening Tool was validated for use in adult acute care patients and Mini Nutritional Assessment (MNA) was designed for use in older adults in long-term care and community settings.

Cultural stereotyping

the tendency to view individuals of common cultural backgrounds similarly and according to a preconceived notion of how they "ought" to behave.