Focused Assessment II: Cardiac, Respiratory, Anxiety, Depression

When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What does this finding indicate? A. Secretions in the lungs B. Fluid in the airways C. Normal breath sounds D. Narrowed airways

D Rationale: Wheezes are musical or squeaking high-pitched, continuous sounds heard as air passes through narrowed airways. Rhonchi are low-pitched, continuous sounds with a snoring quality that occur when air passes through secretions. Crackles are bubbling, cracking or popping, low- to high-pitched, discontinuous sounds that occur when air passes through fluid in the airways.

Abnormal findings during the auscultation phase of a cardiovascular assessment:

Murmurs, extra sounds or clicks/rubs/bruits

Wheezes (sibilant)

Musical or squeaking High-pitched, continuous sounds Auscultated during inspiration and expiration Air passing through narrowed airways

Eupnea

Normal breathing

Expected thorax/respiratory findings during inspection:

Symmetric, no barrel chest Breathing pattern, respiratory rate, musculature, color

Expected thorax/respiratory findings during palpation:

Symmetrical expansion No tenderness/masses Fremitus

How is edema graded?

-1+: 2mm depression, barely detectable. Immediate rebound. -2+: 4mm deep pit. 10-15 seconds. -3+: 6mm deep pit. 1 minute. -4+: 8mm: very deep pit more than 2 minutes.

Bronchial breath sounds

Loud, high-pitched, hollow quality, expiration longer than inspiration over the trachea; expected finding

Pleural friction rub

Rubbing or grating Loudest over lower lateral anterior surface Auscultated during inspiration and expiration Inflamed pleura rubbing against chest wall

Bruits

Blowing or swishing sounds that indicate obstructed peripheral blood flow (use bell of the stethoscope to auscultate)

Panic

Fourth level of anxiety; experiencing dread and terror. "Fight or flight". Not able to function, learn, or participate in conversation. Can lead to exhaustion and death.

Absence of breath sounds

From collapsed or surgically removed lobes

I report to oncoming RN that edema is 2+. What does this translate to?

4 mm

Which type of chest configuration is typical of the patient with COPD? A. Barrel chest B. Pigeon chest C. Flail chest D. Funnel chest

A Rationale: In patients with COPD who have a primary emphysematous component, chronic hyperinflation leads to the "barrel chest" thorax configuration. This configuration results from a more fixed position of the ribs in the inspiratory position (due to hyperinflation) and from loss of lung elasticity. Pigeon chest results from a displaced sternum. Flail chest results when the ribs are fractured. Funnel chest occurs when there is a depression in the lower portion of the sternum; it is associated with Marfan's syndrome or rickets.

The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of? A. Crackles B. A friction rub C. Sonorous wheeze D. Sibilant wheeze

A Rationale: Crackles are described as bubbling- or popping-type sounds that are usually audible during inspiration. Wheezes are typically musical in tone and continuous. A friction rub is a continuous, grating-type sound.

When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following? A. Crackles B. Vesicular C. Wheezes D. Rales

A Rationale: Crackles are soft, high pitched discontinuous sounds.

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds? A. Each lub-dub is one beat. B. Each lub-dub is two beats. C. Heart sounds are caused by the opening of heart valves. D. The lub-dub sounds occur within 2 seconds of each other.

A Rationale: Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate.

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene? A. Palpation of both carotid arteries at the same time B. Warming of a stethoscope before assessing a client's breath sounds C. Placing a tongue blade at the side of the tongue while the client pushes it to the left and right D. Occlusion of one of the client's nostrils while the client breathes through the nose

A Rationale: Palpation of both carotid arteries at once can obstruct blood flow to the brain, potentially causing dizziness or loss of consciousness. The other assessments are correct as described.

A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. What would be the nurse's response to this finding? A. Document and report the finding of abnormal rhonchi breath sounds B. Document the finding of normal bronchovesicular breath sounds C. Document and report the finding of abnormal stridor breath sounds D. Document the finding of normal bronchial sounds

A Rationale: Rhonchi breath sounds are abnormal low-pitched, continuous sounds auscultated during inspiration and expiration that signify air passing through or around secretions. Bronchovesicular breath sounds are normal sounds heard on inspiration and expiration. Stridor are harsh, loud, high-pitched sounds auscultated on inspiration that signal narrowing of the upper airway or presence of a foreign body in the airway. Bronchial sounds are normal blowing, hollow sounds, auscultated over the larynx and trachea.

The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response? A. Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." B. Client describes shortness of breath and increased sputum production. C. Client reports breathlessness and productive cough. D. Client reports respiratory distress and frequent spitting.

A Rationale: The client's reason for seeking care should always be stated in the client's own words which should be document in quotations. This subjective data is important for all health care providers to review.

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? A. Wheezes B. Fine crackles C. Pleural friction rub D. Stertorous breathing

A Rationale: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations.

Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? A. Wheezes B. Fine crackles C. Pleural friction rub D. Stertorous breathing

A Rationale: Wheezes are continuous sounds that originate in small air passages that are narrowed by secretions, swelling, or tumors and the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations.

Turbulent whoosh between S1 and S2

A cardiac murmur

Barrel chest

A condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

Undoing

A defense mechanism whereby a person cancels out an unacceptable desire or act by performing another act; "I'm sorry I hit you. I bought you roses".

Compensation

A defense mechanism whereby something is done to make up for something that is lacking; "I might be too short for baskeball, but I'm great in music."

Intermittent pulse

A pulse in which beats occasionally are skipped

Cheyne-Stokes

Abnormal breathing pattern; ranges from very shallow breathing pattern with periods of apnea May indicate end-of-life

Dysrhythmia

Abnormal heart rhythm

Murmurs

Abnormal heart sounds; blowing, wooshing sounds

Adventitious lung sounds

Abnormal lung sounds; result from air moving through. moisture, mucus, or narrowed airways. Also a result from sudden opening of collapsed alveoli.

Tachycardia

Abnormally rapid heartbeat

Bradypnea

Abnormally slow breathing

Bradycardia

Abnormally slow heartbeat

Apnea

Absence of breathing

"I recently lost my spouse; I go to the gym for two hours every morning because it helps me cope."

Adaption

Capillary refill

After blanching nail bed, color should return to normal within <3 secs

How is a pulse graded?

Amplitude & Quality (Graded on a Scale) -0 Absent -+1 Weak/Thready -+2 Strong -+3 Strong -+4 Bounding

Stressor

Anything causing a person to experience stress; change in the balanced state

What are the 5 areas for listening to the heart? (All People Enjoy Time Magazine)

Aortic area - Right 2nd intercostal space Pulmonic - Left 2nd intercostal space Erb's Point - Left 3rd intercostal space Tricuspid - Left 4th intercostal space (sternal border) Mitral - Left 5th intercostal space (medial to midclavicular line)

Where is the S1 ("lub") sound the loudest?

Apex of the heart

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these? A. Bronchial B. Bronchovesicular C. Vesicular D. Adventitious

B Rationale: Bronchial breath sounds are high pitched, with expiration longer than inspiration. Bronchovesicular sounds are moderate "blowing" sounds with equal inspiration and expiration. Vesicular sounds are soft and low-pitched, with longer inspiration than expiration. Adventitious sounds are not normally heard in the lungs.

During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Apical heart rate E. Murmur

B & D Rationale: To auscultate the closure of the mitral valve, place the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space.

Where is the S2 ("dub") sound heard the loudest?

Base of the heart

A nurse assesses patient breath sounds for patients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? (Select all that apply.) A. Musical or squeaking sounds or highpitched continuous sounds auscultated during inspiration and expiration B. Sonorous or coarse sounds with a snoring quality auscultated during inspiration and expiration C. Soft, low-pitched, whispering sounds heard over most of the lung fields D. Medium-pitched, medium-intensity, blowing sounds; auscultated over the first and second interspaces anteriorly and the scapula posteriorly E. Blowing, hollow sounds; auscultated over the larynx and trachea F. Bubbling, crackling, or popping sounds auscultated during inspiration and expiration

C, D, E Vesicular breath sounds are soft, low-pitched, whispering sounds, heard over most of the lung fields, with sound on inspiration being longer than expiration. Bronchovesicular sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Bronchial sounds heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Musical or squeaking sounds describes a sibilant wheeze, sonorous or coarse sounds with a snoring quality describes a sonorous wheeze, and bubbling, crackling, or popping sounds describes crackles.

Abnormal thorax/respiratory findings during palpation:

Cool or excessively dry or moist skin Muscle asymmetry Tenderness Masses

What should sputum be assessed for?

Color, consistency, and amount

Where might I palpate a precordial thrill? A. Carotid arteries B. Over the sternum C. Brachial or radial pulse locations D. In the 2nd intercostal space (on the right or left side)

D

Anasarca

Generalized edema throughout the body

Projection

Defense mechanism by which people disguise their own threatening impulses by attributing them to others; "I am overweight because you make me so nervous I have to eat."

Denial

Defense mechanism by which people refuse to accept reality; "I can quit drinking any time I want to."

Dyspnea

Difficulty breathing

Psychosocial stressors

Factors in our daily routines and in our social and physical environments that cause us to experience stress

True or false: When palpating a patient's pulse, you should palpate the pulse on one side and afterwards palpate the other.

False Rationale: Pulses should be assessed bilaterally and simultaneously to assess that they are equal. The only pulse that should be palpated one at a time is the carotid pulse.

Crackles or rales

Fine to coarse bubbling, crackling, or popping sounds sounds (not cleared with coughing) Low to high pitched, discontinuous sounds Auscultated during inspiration and expiration Opening of deflated small airways and alveoli; air passing through fluid in the airways

S1

First heart sound ("lub") Heard when tricuspid and mitral valves close Beginning of systole

Mild anxiety

First level of anxiety; increased alertness and perceptional field. Motivates learning and growth.

Non-pitting edema

Fluid accumulation that is "harder" and not compressible when pressure is applied. This type of edema is observed in the later stages of lymphedema

Stridor

Harsh, loud, high-pitched Auscultated on inspiration Narrowing of upper airway (larynx or trachea); presence of foreign body in the airway

Abnormal thorax/respiratory findings during inspection:

Increased A/P diameter (barrel chest) Abnormal breathing pattern or respirations with use of accessory muscles Unequal chest expansion

Pitting edema

Indentation left after pushing down on the skin Generally more organ related (cardiac, renal)

Repression

Keeping distressing thoughts and feelings buried in the unconscious; an adult woman can't remember her child abuse.

Bronchovesicular breath sounds

Medium-pitched, blowing sounds and intensity with equal inspiration and expiration times over the larger airways; expected finding

Where would I assess a bruit?

Over the carotid arteries (with the bell of a stethoscope)

The 6 Ps of peripheral vascular assessment

Pain: especially with passive motion Pallor (perfusion): compare bilaterally for pallor, cyanosis, or coolness of skin Peripheral Pulses: compare bilaterally for pulse presence, rate, quality. Parasthesia (sensation): may be 1st symptoms of change. N/T, "pins and needles" Paralysis: result of prolonged nerve compression or irreversible muscle damage Pressure: Puffiness, skin may become taut, shiny. Patient may report tightness or pressure.

Fremitus

Palpable vibration of the chest wall produced by vocalization.

Thrills

Palpable vibration that can accompany murmurs or cardiac malformation

Edema

Puffy swelling of tissue from the accumulation of fluid

Tachypnea

Rapid breathing

"I failed the course because I always had to work the night before an exam."

Rationalization

Regression

Return to an earlier or less advanced condition; a toilet trained toddler returns to wetting his pants after his new sister is born.

S2

Second heart sound ("dub") Heard when aortic and pulmonic valves close End of systole/beginning of diastole

Moderate anxiety

Second level of anxiety; narrows a person's perceptional field. They can only focus on immediate concerns. Tremors, increased heart rate & respirations, "butterflies"

Vesicular breath sounds

Soft, low-pitched, breezy sounds, inspiration three times longer than expiration over most of the peripheral areas of the lungs; vesicular breath sounds are an expected finding

Rhonchi (sonorous wheeze)

Sonorous or coarse; snoring quality Low-pitched continuous sounds Auscultated during inspiration and expiration Coughing may clear the sound somehat Air passing through or around secretions

Physiological stressors

Stressors that affect body structure or function (chemical agent, physical agent, infectious agents)

Severe anxiety

Third level of anxiety; very narrow focus. Anxiety is no longer conducive to functioning. This leads to maladaptive behaviors (threatening to self and/or others).

True or false: During a cardiovascular assessment, the nurse should inspect and palpate bilaterally and simultaneously.

True

S4

Unexpected finding Precedes the S1 heart sound ("dee-lub-dub")

S3

Unexpected finding Third heart sound, heard quickly after S2 ("lub-dub-dee")

Bounding pulse

Unusually strong pulse

Anxiety

Vague sense of impending doom or apprehension precipitated by new and unknown experiences

Abnormal findings during the inspection phase of a cardiovascular assessment:

Visible pulsations other than apical pulse Neck vein distention