Health Assessment Exam 3

The lungs has how many lobes?

3 right, 2 left(has to have room for heart)

Erb's point

3rd intercostal space, left sternal border

Transmitted Voice Sounds: Bronchophony

Ask patient to repeat "99". Bronchophony is negative when spoken voice heard through stethoscope sounds muffled. If "99" is heard clearly and louder over dense areas, it indicates pneumonia.

Transmitted Voice Sounds: whisper pectoriloquy

Ask the Pt to whisper "1,2,3" (healthy lung areas should not be able to make this out) Frequencies more able to be transmitted in abnormal lungs

vesicular breath sounds

Normal breath sounds made by air moving in and out of the alveoli.

Best fats

Nuts, fish, avacados

OLDCART

O- onset L- location D- duration C- characteristics A- aggravating factors R- relieving factors T- treatment

Rhonchi

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways. "Snore"

Systole

Contraction of the heart (s1)

Check cholesterol every 5 years if

Low risk

Traumatic Flail Chest

Multiple rib fractures, caves inward on inspiration, moves outward on expiration

wheezes

continuous high-pitched musical sounds produced during breathing

Full respiratory cycle

inspiration and expiration

bronchovesicular breath sounds

medium-pitched and quieter sounds normally heard over the mainstem bronchi

eupnea

normal breathing

sternal border

outer edge of the sternum

Cheynes-Stokes

periods of labored respirations followed by apnea

Apical pulse (PMI)

point of maximum impact, palpable at the 5th intercostal space, left midclavicular line

crackles (rales)

popping sounds heard on auscultation of the lung when air enters diseased airways and alveoli; occurs in disorders such as bronchiectasis or atelectasis (Indicate fluid or mucous, fine is high pitch, coarse is low pitch)

Grade 2 murmur

quiet but clearly audible

Tachypnea

rapid breathing

bradypnea

slow breathing

Intercostal spaces

spaces between the ribs (under each rib)

stridor

strained, high-pitched sound heard on inspiration caused by obstruction in the trachea

midclavicular line

the line through the center of each clavicle

T wave

ventricular repolarization and relaxation

Grade 1 murmur

very faint

cardiac output

volume of blood pumped by each ventricle in one minute

Stroke volume

The volume of blood ejected with each heart beat

S2 sound (dub)

closure of aortic and pulmonic valves- loudest at base

a murmur sounds like a

-blowing or swishing sound -best heard with bell of steth

Midscapular line

imaginary line on the back that runs vertically through the center of the scapula

QRS wave

impulse thru bundle of his to purkinje fibers causing ventricles to contract

Palpate vibrations on posterior thorax

"on back"

Vetebral line

A line running vertically down through the spinous processes of the spine

Which of the following are the main functions of the cardiovascular system? (Choose all that apply.)

A. Deliver oxygen to the tissues B. Remove waste products from the tissues C. Maintains perfusion to the body tissues

Dyspnea is a general symptom of several different disease processes. Some factors that may aggravate it are: (Choose all that apply.) A. Exertion B. Lying down C. Inhaled irritants D. Sitting up

A. Exertion B. Lying down C. Inhaled irritants

Resonance

Air filled

midaxillary line

An imaginary vertical line that starts at the middle of the axilla (armpit) and extends down the side of the chest.

Sternal Angle (Angle of Louis)

Anterior Thoracic Landmark . Continuous with 2nd rib - Useful place to start counting ribs . Also site of tracheal bifurcation into L and R bronchus . Corresponds with the upper border with of the atria of the heart . Lies above the 4th thoracic vertebrae (T4) on the back

Turning to left side helps palpate the

Apical pulse

One of the more serious and concerning symptoms is:

Chest pain

COPD

Chronic Obstructive Pulmonary Disease, lung Dz commonly seen in smokers

Perfusion

Circulation of blood within an organ or tissue in adequate amounts to meet current needs of the cells.

S1 sound (lub)

Closing of mitral and tricuspid valves- loudest at apex

Of the three tvpes of stethoscopes, which one is most unsuitable to conduct a full cardiac examination?

Diaphragm only

coarse crackles

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds?

Starting at the age of 20, the recommended screening frequency for a fasting lipoprotein profile if low risk for adults is:

Every 5 years

Smoking is a habit that only affects the individual who smokes.

False

carotid artery

Feeds blood to brain

When auscultating the anterior chest on a large-breasted woman, the nurse should:

Gently move the breast tissue to the side

Pitting edema and Nocturia could be

Heart failure

Check cholesterol every 2 years if

High risk

Pwave

Impulse from SA node and causes atrial contraction

Hyperresonance

Increase in space like barrel chested COPD patients

Diastole

Relaxation of the heart (s2)

electrical conduction of the heart

SA node, AV node, bundle of His, right and left bundle branches, Purkinje fibers

Blood flow through the heart

SVC --> Rt atria --> Tricuspid --> Rt ventricle --> Pulmonic valve --> Lungs --> Lt atria --> Mitral valve --> Lt ventricle --> aortic valve --> aorta --> Body

Pleural friction rub is indicated by

Sandpaper or gravel sounds (most common lower lateral outside of lungs)

Afterload

The force or resistance against which the heart pumps.

Palmar base

The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?

Fifth intercostal space, left midclavicular line

The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?

Tripod, barrel, clubbed, crackles

The nurse working in a hospital assesses the respiratory status of a 64-year-old male client with a history of chronic obstructive pulmonary disease (COPD). Upon inspection, the client is in the ________________ position, has a _______________chest and the nails are____________ and ____________________ are heard on auscultation.

Preload

The precontraction pressure in the heart as the volume of blood builds up.

Grade 6 murmur

Very loud, with thrill. May be heard with stethoscope entirely off the chest

pleural friction rub

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

accentuated

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?

bronchitis

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?

sternal notch

a medial notch at the superior end of the sternum

tactile fremitus

a tremulous vibration of the chest wall during speaking that is palpable on physical examination

murmur is caused by

a valve that isnt working well. either the valve isnt opening all the way due to stenosis, or not closing all of the way causing regurg

apnea

absence of breathing

APE To Man stands for

aortic, pulmonic, erb's point, tricuspid, mitral

Bottom of the heart is called

apex

Top of the heart is called

base

blood pressure (BP)

cardiac output x peripheral resistance

Kussmal's breathing pattern

deep, regular, and rapid (acidosis)

The __________ is the primary muscle(s) of the respiratory system?

diaphragm

Orthopnea is:

difficulty breathing when lying down

jugular vein

drains blood from the head

tympany percussion

drumlike sound, loud intensity, high pitch, medium duration, located in stomach

Solid Organ Sound in percussion

dullness

pitting edema

edema that retains an imprint when touched

Transmitted Voice Sounds: Egophony

eee, aaa

xphoid process

end of sternum

Three layers of the heart

epicardium, myocardium, endocardium

nocturia

excessive urination at night