Health Assessment Notes Exam 2

Consensual reflex of the pupil

- Light is shown into one pupil and both constrict

Questions to ask for lungs and thorax assessment

- Presenting problem: cough, dyspnea, chest pain and cough - Personal health history (asthma?) - family history Lifestyle (smoking? - Health practices

Eye assessment: cardinal fields of vision

- Tests CN III (oculomotor), CN IV (trochlear) and CN VI (abducens) - nstruct the client to focus on an object you are holding (approximately 12 in from the client's face). Move the object through the six cardinal positions of gaze in a clockwise direction, and observe the client's eye movements - Failure of eyes to follow movement symmetrically indicates a weakness in one or more extraocular muscles or dysfunction of the CN that innervates that muscle

sinus assessment

1. Frontal - press up under bony brow, note tenderness. Tap (percuss) sinus 2. Maxillary - press up on maxillary sinus, note tenderness, percuss. -translumination -crepitus upon palpation is present w/ a viral upper respiratory infection - Tenderness to palpation in clients w/ allergies or acute bacterial rhinosinusitis - On percussion air would produce more resonance, fluid would be more dull - transillumination - normal=light shines through giving a reddish glow; When inflamed and blocked with secretions and mucus the light fails to shine through and the sinus appears opaque

Heart valves

Atrioventricular valves close w/ ventricular contraction and open with ventricular relaxation - Tricupsid valve - 3 flaps, between R atrium/ventricle - Bicuspid (mitral) valve - 2 flaps, between L atrium/ventricle Semilunar valves - open during ventricular contraction, closed during ventricular relaxation - Pulmonic valve - at beginning of pulmonic artery - Aortic valve - beginning of ascengind aorta

•When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for chronic arterial insufficiency? •A. Sedentary lifestyle •B. A family history of arterial insufficiency •C. Intake of 1 to 2 alcoholic drinks per day •D. 14-year history of smoking a pack a day

D - 14-year history of smoking a pack a day

myocardial infarction (MI)

heart attack; death of myocardial tissue (infarction) caused by ischemia (loss of blood flow) as a result of an occlusion (plugging) of a coronary artery; usually caused by atherosclerosis; symptoms include pain in the chest or upper body (shoulders, neck, and jaw), shortness of breath, sweating, pallor, thready pulse, diaphoresis, and nausea

Important terms for Heart and PVS

o Ischemia: decrease blood flow to tissue, may be reversible, and not cause tissue death o Infarction: no blood flow to tissue causing tissue death o Vasodilation: blood vessels dilate, dropping BP o Vasoconstriction: blood vessels constrict, increasing BP o Hypervolemia: high blood volume, can cause HTN/elevated BP/Pulmonary failure o Hypovolemia: Low blood volume, dehydration o Dependent Position: leg or arm down or below level of heart o Trendelenburg Position: Head down and legs up o Nocturia: excessive voiding at night, associated with left sided heart failure or obstructive sleep apnea (OSA). o Arteriosclerosis: thickening or hardening of the arteries

Hyperthyroidism signs and symptoms

Symptoms - Nervousness - Fatigue - Weakness - Palpitations - Heat intolerance - Excessive sweating - Dyspnea - Diarrhea - Insomnia - Poor concentration - Oligomenorrhea Signs - Weight loss - Hair loss - Tachycardia - Proximal myopathy - Warm, moist skin - Hyperkinesis - Stare, lid lag, lid retraction, and exophthalmos (with Graves disease) - Emotional liability - Hyperactive reflexes - Thyroid enlargement (in most cases)

Physical assessment: General, anterior thorax and posterior thorax

- Nasal flaring - indicates low O2 - Pursed lips - trying to keep alveoliopen longer to get air "air hungry" - Color of skin, lips and chest - ruddy, purple = cyanosis - Color of fingernails = pale or cyanotic - Shape of nails - clubbing, greater than 180 angle - patient position - relaxed vs tripod (laboring) Anterior thorax - Shape and configuration - anterior posterior diameter less than transverse diameter, 1:2 - Position of trachea - midline - Position of sternum - midline, straight, no retractions - Slope of ribs - ribs slope down, symmetric spaces, costal angle within 90 degrees - Intercostal spaces - retractions present (abnormal) = need more air; bulging = trapped air - Accessory muscle use? - sternomastoid, scalene, and/or trapezius, used to make breathing more effective Palpation: - Palpate for tenderness (may indicate muscle strain) - sensation - localized warmth may indicate infection - Surface - masses or lesions - Crepitus (subcutaneous emphysema) - abnormal, occurs w/ injuries or chest tube placement - Fremitus - not typical assessment, involves feeling the chest wall as pt states "ninety nine" - Chest expansions - can look or feel - hands along costal margins bilaterally as patient takes deep breath Posterior thorax - Configuration - position and shape of scapula and chest wall - Spinous processes: straight? Uneven? - Ribs at 45 degree angle from spine - barrel chest=increased angle - Accessory muscle use? trapezius and/ or shoulder muscles Palpation: -Tenderness (muscles) and Sensation (warmth) - top to bottom, left to right, bilateral - Crepitus aka Subcutaneous emphysema - abnormal, occurs with injuries or chest tube placement - Surface Characteristics - lesions, masses - Fremitus "ninety-nine." o Chest Expansion - unequal expansion may indicate lung collapse or incomplete expansion due to trauma or illness - Could have a mucus plug

Breathing patterns

- Normal - 12 to 20 breaths/min, regular - Tachypnea - over 24 breaths/min, shallow - Bradypnea - less than 10 breaths/min, shallow - Hyperventilation - high RR and deper - Hypoventilation - decreased RR, shallow and possibly irregular - Kussmaul - rapid, deep, shallow (Daibetic Ketoacidosis) - Cheyne-stokes respiration - regular, periods of apnea followed by periods of deep, rapid breathing - increased intracranial pressure/drug over dose - Biot's respiration - irregular, variable depth and rate followed by periods of apnea, brain damage/infection - Ataxic - varying rate and depth (worse than Biot's) - Apnea - periods of no breathing - Air trapping - Difficulty exhaling air (COPD) - Orthopnea - difficultry breathing when lying down flat, associated with heart issues - COPD, emphysema and chronic bronchitis - Dyspnea - difficulty breathing

Thoracic deformites and configurations

- Normal - 1:2 anteroposterior diameter compared to transverse diameter, straight spine - Barrel chest (associated w/ emphysema) - Pectus excavatum (funnel chest) - sunken sternum - Pectus carinatum (pigeon chest) - forward protrusion of the chest - Scoliosis - 's' or 'c' shape curve of the spine to the left or right, idiopathic for the most part - Kyphosis - forward curve of spine common in elderly - Lordosis - exaggerated inward curvature of the lumbar area, might be seen in pregnant patients

PVS Assessment: arms

- Observe arm size - symmetry - measure arm circumference if needed - if asymmetrical may mean lymphedema from blocked lyphatic circulation (from breast surgery) - usually affects one extremity causing induration and nonpitting edema - prominent venous patterning w/ edema may indicate venous obstruction - Observe arm/hand color - should be the same bilaterally - Raynaud disorder - vasoconstriction or vasospasm of fingers or toes characterized by rapid changes of color (occurs bilaterally) - Palpate fingers, hands, and arms - should be warm to the touch bilaterally from fingertips to upper arms - cool extremity may be a sign of arterial insufficiency - Capillary refill - should be 2-3 seconds or less - if greater could be due to vasoconstriction, low CO, shock, arterial occlusion and hypothermia - Palpate radial and ulnar pulses -increased radial pulse volume indicates hyperkinetic state - diminished or absent pulse suggest partial or complete arterial occlusion - ulnar pulse may not be detected - Palpate brachial pulse - place three fingertips of each hand at the clients right and left medial antecubital creases, Alternatively, palpate the brachial pulse in the groove between the biceps and triceps - Palpate epitrochlear lymph nodes - Take the client's left hand in your right hand as if you were shaking hands. Flex the client's elbow about 90 degrees. Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles (Fig. 22-12). If nodes are detected, evaluate for size, tenderness, and consistency

PVS assessment: Legs

- Observe skin color of legs - pallor when up and rubor (redness) when down = arterial insufficiency; Cyanosis when dependent suggests venous insufficiency. A rusty, ruddy, or brownish pigmentation (rubor) around the ankles indicates venous insufficiency - Inspection hair distribution - should be even & symmetrical; loss of hair or shiny skin = arterial insufficiency - Inspect legs for ulcers or lesions - Ulcers with smooth, even margins that occur at pressure areas, such as the toes and lateral ankle, result from arterial insufficiency. Ulcers with irregular edges, bleeding, and possible bacterial infection that occur on the medial ankle result from venous insufficiency - Inspect for edema - Bilateral edema may be detected by the absence of visible veins, tendons, or bony prominences. Bilateral edema usually indicates a systemic problem, such as heart failure, or a local problem, such as lymphedema, but lymphedema is always unilateral unless elephantiasis is diagnosed - Unilateral edema is characterized by a 1-cm difference in measurement at the ankles or a 2-cm difference at the calf, and a swollen extremity. It is usually caused by venous stasis due to insufficiency or an obstruction. It may also be caused by lymphedema - Palpate temp. of legs/feet - coolness may indicate arterial insufficiency - localized warmth = thrombophlebitis - Palpate inguinal lymph nodes - Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy) may be from a local infection or generalized lymphadenopathy. Fixed nodes may indicate malignancy - Palpate and auscultate femoral arteries - should be stron and equal bilaterally - Weak or absent femoral pulses indicate partial or complete arterial occlusion - bruit = partial obstruction of artery - Palpate popliteal pulse - Ask the client to raise (flex) the knee partially. Place your thumbs on the knee while positioning your fingers deep in the bend of the knee. Apply pressure to locate the pulse (may be nonpalpable but an absent pulse may indicate occluded artery) - Palpate dorsalis pedis pulses & posterior tibial - should be present, use doppler if in doubt - A weak or absent pulse may indicate impaired arterial circulation (pulse is congenitally absent in 5-10% of population)

Heart failure

- Occurs when either ventricles fail to pump blood efficiently into aorta or pulmonary arteries - Left-sided: restlessness, confusion, orthopnea, tachycardia, fatigue, cyanosis, cough, crackles, wheezes, blood tinged sputum - elevated pulmonary capillary wedge pressure - Right-sided: fatigue, increased peripheral venous pressure, enlarged liver and spleen, may be secondary to chronic pulmonary problems, distended jugular veins, anorexia & complaints of GI distress, weight gain, dependent edema

Normal Heart sounds

- Produced by valve closure - S1 - "LUB" - head best at apex L MCL, 5th ICS - mitral and tricuspid valve closure - S2 - "DUB" - heard best at base of heart - beginning of diastole aortic and pulmonic valve closure

Religion vs. spirituality

- Religion is defined as the rituals, practices, and experiences shared within a group that involve a search for the sacred. - Spirituality is defined as a search for meaning and purpose in life; it seeks to understand life's ultimate questions in relation to the sacred.

Venous insufficiency

- S/S: aching/cramping pain, edema, thick/tough skin, skin reddish-blue in color; ulcers: irregular, painful, superficial, edema, red to yellow base, medial malleolus/anterior tibial area - frequently associated w/ dermatitis - Edema associated - caused by obstruction or insufficiency of deep veins over time

Arterial insufficiency

- S/S: intermittent pain (worse w/ activity), pulses diminished to absent; redness of skin in dependent position and pallor with leg up (worses pain); dry shiny cool skin; loss of hair over toes and dorsum of foot; nails thickened and ridged; ulcers: tips of toes, in between toes & heels; painful, deep, circular, pale black to dry and gangrene

Extra heart sounds

- S3 and S4 - diastolic filling sounds both can be heard over apical area - S3 - heard agter S2 caused by ventricular vibration due to ventricular resistance (stiffness) during atrial contraction - "ventricular gallop" (ischemic heart disease, anemia) - S4 - just before S1 (late diastole) - "atrial gallop" (coronary artery disease, aortic stenosis, etc)

Visual acuity tests

- Snellen chart or E chart - near (14/14 is normal - presbyopia = impaired near vision) or far (20/20 is normal - can distinguish from 20 feet away - myopia = impaired far vision) - a client is legally blind when vision in the better ye w/ corrective lenses is 20/200

Visual problems

- Spots or floaters - common among clients with myopia or older than 40 - Blind spots - may be from glaucoma; intermittent - associated with vascular spasms or pressure on optic nerve; consistent may be due to retinal detachment - require immediate attention - Halos/rings around lights - associated with narrow-angle glaucoma - Trouble seeing at night - associated with optic atrophy, glaucoma and vitamin A deficiency - Diplopia - may indicate increased intracranial pressure due to injury or a tumor - Loss of central vision - macular degeneration (11 million people in US have some form of age-related macular degeneration)

Assessing hearing

- Whisper test - asking the client to gently occlude the ear not being tested and rub the tragus with a finger in a circular motion. Start with testing the better hearing ear and then the poorer one. With your head 2 ft behind the client (so that the client cannot see your lips move), whisper a two-syllable word such as "popcorn" or "football." Ask the client to repeat it back to you. If the response is incorrect the first time, whisper the word one more time. Identifying three out of six whispered words is considered passing the test - Weber test - helps to evaluate the conduction of sound waves through bone to help distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear). Strike a tuning fork softly with the back of your hand and place it at the center of the client's head or forehead - vibrations should be heard equally in both ears - w/ conductive hearing loss client reports 'hearing; in the poor ear - w/sensorinerual hearing loss client reports lateralization of sound in good ear - Rinne test - compares air and bone conduction sounds. Strike a tuning fork and place the base of the fork on the client's mastoid process - Ask the client to tell you when the sound is no longer heard - Move the prongs of the tuning fork to the front of the external auditory canal. Ask the client to tell you if the sound is audible after the fork is moved (AC> BC) - BC>AC in conductive hearing loss - Romberg test - This tests the client's equilibrium. Ask the client to stand with feet together, arms at sides, and eyes open, then with the eyes closed - client falls it would indicate a vestibular disorder

varicose veins

- abnormally swollen, twisted veins with defective valves; most often seen in the legs - Cause: incompetent valves of the veins, weak walls or obstruction - Reasons: pregnancy, obesity, prolonged sitting or standing - veins appear distended & bulging

Allen test

- evaluates patency of the radial or ulnar arteries - essential before arterial sampling (arterial blood gas) or arterial line insertion/placement. It is implemented when patency is questionable or before such procedures as a radial artery puncture. The test begins by assessing ulnar patency. Have the client rest the hand palm side up on the examination table and make a fist. Then use your thumbs to occlude the radial and ulnar arteries - Pink coloration returns to the palms within 3-5 seconds if the ulnar artery is patent. - Pink coloration returns within 3-5 seconds if the radial artery is patent. - With arterial insufficiency or occlusion of the ulnar artery, pallor persists. With arterial insufficiency or occlusion of the radial artery, pallor persists.

cardiac output

- heart rate x stroke volume - typically 5-6 L/min - Stroke volume - amount of blood contracted from heart with each contraction - Preload - degree of stretch, meaning the greater the preload the greater the SV (stretched too much can affect the contractility of the heart) - Afterload - degree of pressure the heart has to push/pump against, increased afterload = decreased SV (Think - PVS disease) - Contractility: increased contractility = increased SV

Heart

- located within mediastinum - between the lungs - Vertical extension from left 2nd (base) to left 5th ICS (apex) - Horizontally extended from right edge of sternum to left MCL - Anterior portion - precordium - Right side of heart - pumps blood to lungs for O2 and CO2 exchange - Left side - pumps blood into systemic circulation

Nasal assessment

- not often but with suspicion of injury or poor breathing - Check patency of nostrils - client breath through each nostril w/ other occluded - External nose structure - color should be same as rest of the face with no tenderness (tenderness on palpation accompanies a local infection) - Inspect internal nose - use an otoscope w/ a short wide-tip attachment or you can also use a nasal speculum and penlight - Use your nondominant hand to stabilize and gently tilt the client's head back. Insert the short wide tip of the otoscope into the client's nostril without touching the sensitive nasal septum. Slowly direct the otoscope back and up to view the nasal mucosa, nasal septum, the inferior and middle turbinates, and the nasal passage (the narrow space between the septum and the turbinates)

PERRLA

- pupils equal, round, reactive to light and accommodation - Reactive to Light (constrict) - Direct and Consensual Response to Light - Accommodation - pupils constrict & Eyes Converge - Pupils Dilate when focused on distant objects - Pupils constrict when focusing on close objects

Corneal Light Reflex (Hirschberg Test)

- test assesses parallel alignment of the eyes. Hold a penlight approximately 12 in from the client's face. Shine the light toward the bridge of the nose while the client stares straight ahead. Note the light reflected on the corneas - reflection of light on the corneas should be in the exact same spot on each eye

Sternum (breastbone)

-Manubrium - connects to clavicles and first 2 pairs of ribs - superior portion: suprasternal notch - sternal angle or angle of louis: where second pair of ribs connect - Body - Xiphoid process

•An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. What would the nurse suspect? •A. Arterial insufficiency •B. Musculoskeletal weakness •C. Venous insufficiency •D. Diabetic neuropathy

A - arterial sufficiency - Arterial insufficiencyExplanation:Cool, pale skin, delayed capillary refill, and absence of pulses are associated with arterial insufficiency. Pain, muscle cramping, and weakness with activity may indicate arterial disease. Musculoskeletal weakness would be associated with complaints of fatigue or a decrease in strength. With venous insufficiency, edema would most likely be noted. Neurologic impairment would include possible complaints of numbness, tingling, or changes in sensation.

•While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. How would the nurse document the findings? •A. Pericardial friction rub •B. Midsystolic click •C. Summation gallop •D. Aortic ejection click

A - pericardial friction rub

•The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral? •A. Venous insufficiency •B. Stasis ulceration •C. Arterial occlusion •D. Dependent edema

A - venous insufficiency

What is the verbal and behavioral system of culture, when it is transmitted from one generation to the other? A. Culture is learned B. Culture is shared C. Culture is adapted D. Culture is universal

A. Culture is learned. Culture is learned when it is transmitted from one generation to the other. Culture is shared when norms for behaviors, values, and beliefs are shared by the cultural group. Culture is associated with adaptation to the environment. Culture is universal as it may vary but humans cannot exist without culture.

•A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessment should focus on the signs and symptoms of what health problem? •A. Myocardial infarction •B. Heart failure •C. Atherosclerosis •D. Heart block

B - heart failure

The clinic nurse is reviewing the medication history of a 39-year-old female client. Which medication would the nurse identify as a potential risk factor for thrombophlebitis? •A. A beta-adrenergic blocker •B. A selective serotonin reuptake inhibitor (SSRI) •C. An oral contraceptive •D. An antilipid agent

C - an oral contraceptive

National Standards for Culturally and Linguistically Appropriate Services in Health Care

- Standard 1: Ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. - Standard 2: Implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. - Standard 3: Ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. - Standard 4: Offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. - Standard 5: Provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. - Standard 6: Assure the competence of language assistance provided to limited English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). - Standard 7: Make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. - Standard 8: Develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. - Standard 9: Conduct initial and ongoing organizational self-assessments of CLAS-related activities and integrate cultural and linguistic competence-related measures into internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. - Standard 10: Ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated. - Standard 11: Maintain a current demographic, cultural, and epidemiologic profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. - Standard 12: Develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities. - Standard 13: Ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. - Standard 14: Regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and provide public notice in their communities about the availability of this information.

Great vessels

- Superior & inferior vena cava - return blood to the heart - Pulmonary artery (bifurcates) - exits right ventricle and feeds blood to the lungs - Pulmonary veins (2 from each lung) - brings O2 to left atrium - Aorta - transports O2 concentrated blood from the ventricle to the systemic circulation

Thrombophlebitis/thromboses

- Swelling and inflammation due to infection or superfiical clot - S/S: localized redness, thickening and tenderness - May have pain when walking

nasal discharge

- Thick or purulent green-yellow, malodorous discharge = bacterial infection - A foul smelling discharge = a foreign body or chronic sinusitis - Purulent nasal discharge is seen with acute bacterial rhinosinusitis - Bloody discharge = neoplasm, trauma, forceful sneezing, or an opportunistic infection as a fungal disease - Epistaxis (nosebleeds) = secondary to trauma, chronic sinusitis, malignancy, bleeding disorder, cocaine abuse, pregnancy, mono

Heart murmurs

- Turbulent blood flow with a swooshing or blowing sound upon auscultation - Causes: increased amount of blood velocity (anemia, pregnancy, fever), heart defects (congenital), faulty valve, abnormal heart chambers or septal defects (injury, surgery, congenital) - Characteristics: Timing: systole or diastole (systolic murmur can be present in a healthy heart whereas a diastolic murmur always indicates heart disease), intensity: grade 1-6; Pitch: high, medium or low; quality : blowing, rushing, roaring, rumbling, harsh or musical; shape or pattern; Location: over what valve; transmission (felt in other areas from origin - If you determine where the murmur transmits, you can determine the direction of blood flow and the intensity of the murmur); ventilation & position (Determine if the murmur is affected by inspiration, expiration, or a change in body position)

Mouth assessment

- Wear gloves, have a penlight and tongue depressor available - Inspect the lips (pallor=anemia; bluish=cold/hypoxia; red=ketoacidosis, COPD) - Inspect teeth and gums - Inspect buccal (cheek) mucosa - leukoplakia - pre cancerous lesions (chalky white raised patches) are see in chronic irritation, heavy smoking and alcohol use - koplik spots (tiny whitish spots that lie over reddened mucosa - early sign of measles) - Inspect and palpate tongue - should be pink, moist, a moderate size with papillae present - Palpate any lesions present for induration (hardness) - increases the likelihood of cancer - Use a square gauze pad to hold the client's tongue to each side - Inspect hard and soft palate - The hard palate is pale or whitish with firm, transverse rugae (wrinkle-like folds) - Palatine tissues are intact; the soft palate should be pinkish, movable, spongy, and smooth - Inspect uvula - Apply a tongue depressor to the tongue (halfway between the tip and back of the tongue) and shine a penlight into the client's wide-open mouth ("ahhhh") - No redness of or exudate from uvula or soft palate. Midline elevation of uvula and symmetric elevation of the soft palate. - Inspect tonsils and posterior pharyngeal wall - Tonsils may be present or absent. They are normally pink and symmetric and may be enlarged to 1+ in healthy clients - Throat is normally pink, without exudate or lesions (bright red throat w/white/yellow exudate indicates pharyngitis

Culture

"the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making."

Cardiac cycle

- - Systole - heart muscle contracts and pumps blood from the chambers into the arteries (S1 - lub) - 1/3 of cycle - high pressure from filling causes AV valves to close (S1 - start of systole) - then aortic and pulmonic valves open (high pressure) - · Rapid ventricular emptying/ejection - pressure falls causing valves to close (S2 - end of systole/ start of diastole) - Diastole - heart muscle relaxes and allows the chambers to fill with blood (S2 - dub) - 2/3 of cycle - AV valves open, ventricles relax - near the end the atria contract to finish emptying the atrial chambers which raises the ventricle pressure (atrial kick)

Spirituality

- A search for meaning and purpose in life - seeks to understand life's ultimate questions in relation to the sacred - Informal, non-organized, self-reflection, subjective, as in difficult to consistently measure

Accomodation/Convergence

- Accommodation occurs when the client moves his or her focus of vision from a distant point to a near object, causing the pupils to constrict. Hold your finger or a pencil about 12-15 in from the client. Ask the client to focus on your finger or pencil and to remain focused on it as you move it closer in toward the eyes - normal pupillary response is constriction of the pupils and convergence of the eyes when focusing on a near object

Valvular heart disease

- Acquired or congenital - Stenotic valve - does not open completely - Incompetent valve - does not close completely - Causes: rheumatic fever, endocarditis

Reference lines (thoracic assessment)

- Anterior (midsternal, left and right mid-clavicular) - Posterior (vertebral, left and right scapular) - Lateral (posterior axillary line, midaxillary line and anterior axillary line)

Areas of auscultation

- Aortic area: Second ICS at the right sternal border—the base of the heart - Pulmonic area: Second or third ICS at the left sternal border—the base of the heart - Erb point: Third ICS at the left sternal border - Mitral (apical): Fifth ICS near the left MCL—the apex of the heart - Tricuspid area: Fourth or fifth ICS at the left lower sternal border

Peripheral vascular system

- Arteries - carry oxygenated blood, high pressure/pulse, major arteries: aorta, carotid, temporal; of the arm: brachial, radial, ulnar; of the legs: femoral, popliteal, dorsalis pedis, posterior tibial - Veins - carry deoxygenated blood and waste back to heart, contains 70% of blood, thinner and can expand more easily, major veins: internal/external jugular veins; veins of legs: femoral and popliteal (deep) and great and small saphenous veins (superficial); Mechanism of Action: One-way valves, muscular. contraction, & pressure gradient through act of breathing - Capillaries & fluid exchange - maintain balance between vascular/tissue spaces; oxygen, nutrient & fluid exchange occurs at this level through hydrostatic force and osmotic pressure; important for the balance of lymphatic/tissue fluid and preventing swelling/edema - Lymphatic system - made up of lymphatic capillaries, vessels and nodes; function: remove extra fluid and plasma proteins from tissue - return the excess to the veins (subclavian veins) - defend the body against microorganisms, and absorb lipids from small intestine; lymph nodes (small, nonpalpable 1-2 cm), epitrochlear nodes (3 cm above elbow), superficial inguinal nodes (inner groin area and drain legs/external genitalia/lower abdomen/buttocks

Normal lung sounds

- Bronchial - over trachea, high pitch, cannot be heard posteriorly - Bronchovesicular - over major bronchi, moderate pitch - Vesicular - peripheral lung field, low pitch

Voice sounds

- Bronchophony - ask patient to say 'ninety-nine' while listening to chest - phrase should be hard to hear but if area is more consolidate it becomes easier to hear the phrase - Egophony - have patient stat 'E' while listening to chest - should be distinguishable and soft - areas of Consolidation - E sounds louder and like A - Whispered pectoriloquy - have patient whisper 'one, two, three' while listening to chest - should sound faint and muffled - if area is consolidated the sounds may be more distinct and easier to hear

Neck vessels

- Carotid artery pulse - R and L common carotid arteries from brachiocephalic trunk/aortic arch between trachea and R/L sternocleidomastodid muscles - centrally located arterial pulse (close to heart) oxygenates the brain - Jugular venous pulse and pressure - internal and external veins (IJV and EJV) - central liens are placed in IJV - directs blood back to heart through superior vena cava - JV pressure tells us about right side heart function (w/ right-sided heart failure - raises pressure/volume and blood backflows)

Pneumothorax

- Cause: air in pleural cavity - Minor: slightly short of breath, anxious, and chest pain - Major: dyspnea, tachypnea, cyanosis - Decrease in chest/air movement on affected side - Tracheal movement toward unaffected side

Pneumonia

- Cause: infected bronchioles/alveoli - Viral: clear sputum and/or non-productive cough - Bacterial: productive cough with white, tan, yellow or green sputum - S/S: fever, tachypnea and dyspnea - Crackles and/or wheezes

Acute bronchitis

- Cause: inflammation of the bronchi - infection - rhonchi & crackles with wheezing after coughing - Cough - may be productive - Substernal chest pain - worse with cough - fever - Malaise - Elevated RR

Emphysema

- Cause: overinflated/damaged alveoli over time - loss of elasticity and sponginess - underweight with barrel chest - work hard to breath so spend more energy - Dyspnea with exertion - Diminished breathing and voice sounds - Wheezing or crackles - Decreased diaphragmatic excursion - Damaged alveoli/overinflated / less compliant

angina pectoris

- Chest pain due to ischemia of heart tissue - Caused by arteriosclerosis of coronary arteries - Can occur due to increased demand of the heart - stress/activity - S/S: squeezing pain, shouldn't last more than 30 minutes

Sputum

- Clear - viralallergies - White or mucoid - viral colds - Yellow or green - bacterial - Blood - trauma, infection - Rust-like - TB or pneumonia - Pink and frothy - fluid overload in the lungs known as pulmonary edema usually associated with some level of heart failure - can be due to some acute or chronic. problem/illness - sounds like wet crackles

Modifications to be Considered for a Culturally Competent Interview

- Communication o Time o Space o Eye contact and face positioning o Body language and hand gestures o Silence o Touch

Adventitious (abnormal) lung sounds

- Crackles (fine) - high -pitched popping sound during inspiration from inhaled air opening small deflated air passages covered w/ exudate (not cleared w/ coughing - continuous) - Crackles (coarse) - low-pitched/bubbling/moist sounds from inspiration to early expiration (like velcro/discontinuous) - inhaled air in contact w/ secretions in bronchi & trachea associated with atelectasis - Wheezes - air passing through thickened or constricted airway (usually inflammation) - sibilant: high-pitched, musical, mainly during expiration, asthma - sonorous: low-pitched snoring, may clear w/ coughing, heard mainly during expiration - bronchitis - Pleural friction rub - rubbing or inflamed pleural layers - grating sound/more superficial - Rhonchi - sounds like rumbling or a snore (coarse) - may clear w/ coughing or suctioning - continuous (obsturction/ secretion - common in COPD, pneumonia, cystic fibrosis) - Stridor - harsh, honking wheeze heard if listening over trachea area - occurs during inspiration and expiration - narrowing of the area between the vocal cords due to swelling because of trauma, intubation or allergic reaction - trachea is potentially closed off (allergic reaction)

Phases of EKG or ECG

- Depolarization: electrical impulse stimulates the ions to cross the cell membrane and triggers the action potential which leads to muscular contraction/activity - Repolarization: · return of ions to previous state, state of rest, no electrical activity - P-wave: atrial depolarization, impulse conducted through atria, causing atrial contraction - PR interval: Beginning of atrial depolarization to the beginning of ventricular depolarization - QRS complex: Ventricular depolarization (conduction of ventricular impulse) causing ventricular contraction - ST segment: Period between ventricular depolarization & beginning of ventricular repolarization - T-wave: Ventricular repolarization, ventricles rest - This is the electrical pattern for one heart beat

Where to auscultate lung sounds?

- Do not listen over clothes obviously - Use diaphragm of stethoscope - be careful not to make the patient hyperventilate - tell them when to breathe through their mouth - Anterior thorax - listen slightly above clovicle down to about the 6th ribe bilaterally - Posterior thorax - start at C7 (apex of lung) and move down to T10 from side to side

Eye asssessment: external structures

- Eyebrows - symmetrical - Eyelids and eyelashes - symmetrical, turnings (should be no inward or outward turning of eyelid), color, swelling (allergies, or bacterial/viral infection), lesions or discharge (bacterial/viral infection) - can eyelids close (if not client at risk of corneal damage) - drooping of upper lid may be attributed to oculomotor nerve damage, weakened muscle or tissue or a congenital disorder - Eyeballs should be symmetrically aligned in sockets without protruding or sinking - protruding eyeballs / retracted eyelid margins (exophthalamos) is characteristic of graces disease (type of hyperthyroidism) - sunken eyes= dehydration or chronic wasting illnesses - Bulbar conjunctiva/sclera - color/lesions (clear moist and smooth - redness suggest conjunctivitis; yellow sclera = jaundice; dryness = allergies or trauma) - lower and upper palpebral conjunctiva should be clear and free of swelling or lesions - Inspect/ palpate lacrimal apparatus - No swelling or redness should appear The puncta is visible without swelling or redness and is turned slightly toward the eye - no drainage on palpation - Inspect cornea and lens - cornea is transparent, moist and smooth - both w/o opacities (w/ lens associated w/ cataracts) - Inspect iris & pupil -iris is round, flat and evenly color - pupils are equal in size, round w/ regular border - Visual acuity

12 ribs

- First 7 pairs connect to the sternum - 7 through 10 connect to cartilage - 11-12 are floating ribs connected to posterior vertebrae - free and palpable - 12 thoracic vertebrae (C7 is typically where you start auscultating the lungs) - Muscles = intercostal muscles - Crtilage - Scapula

Common eye problems

- Glaucoma - increased intraocular pressure results in damage to the retina and optic nerve with loss of vision - Cataracts - clouding of the lens - Macular degeneration - Loss of central vision - damage to macula of retina

Questions to ask: heart and peripheral vascular system

- Heart - chest pain, tachycardia, palpitations, fatigue, dizziness, cough, dyspnea, nocturia, edema, heartburn - PVS - skin changes, ulcers, temperature changes, pain, swelling/edema - Personal health history (heart or BP meds, baseline HR and BP) - Family history (family members that smoke, history of heart or PVS disease) - Lifestyle (smoking? diet?) - Health practices (stress at home/work)

Hormonal regulation

- Hypercapnia - high carbon dioxide levels -Hypoxemia or hypoxia - decrease in O2

Pericarditis

- Inflammation of the pericardium - S/S: pericardial friction rub and chest pain/sharp pain - Causes: MI, infection, trauma, surgery

Ear Assessment: inspection/palpation

- Inspect and palpate external ear first (should be equal in size bilaterally (normally 4-10 cm) - Otoscopic exam (internal ear) - § Position the otoscopic. Speculum not more than 0.5 inches into the ear § Examine the ear for pain first § Make sure the speculum is an appropriate size § For the adult, the pinna is pulled up and back to straighten the ear canal § Eardrum should be pearly grey, intact · Otitis media (middle ear infection) - looks red, bulging, with puss (concern is for the eardrum to burst) · Otitis externa - infection of the ear canal (lots of puss typically)

Heart assessment

- Inspect for pulsations: Patient in supine position with HOB 30-45 degrees up, apical pulse may not be visible (would be at L MCL/5th ICS) - heaves or lifts, other than the apical pulsation are considered abnormal and should be evaluated. A heave or lift may occur as the result of an enlarged ventricle from an overload of work Thrills (vibrations) - palpated over 2-3 ICS indicates aortic/pulmonic stenosis or systemic hypertension - Palpate apical - patient in supine position (may need to turn to left size) - palpate at L MCL/ 5th ICS and it should be size of a nickel (1-2 cm) - larger indicates cardiac enlargement - Palpate for abnormal pulsations at apex, left sternal border and base (using palmar surfaces to palpate) - findings may indicate murmur (grade 4 or higher) - Auscultation of the heart - HR should be 60-100 (bradycardia, normal, tachycardia), rhythm (regular or irregular - w/ a pulse deficit indicates atrial fibrillation, atrial flutter, varying degrees of heart block) - S1 loudest at apex, carotid pulse correlates with S1 - S2 loudest at base - listen for murmurs (use diaphragm and bell across heart and put client in different positions because murmurs occur or subside according to client position) Listen over pulmonic, aortic, mitral (apical), erb's point and tricupsid valves

Head assessment

- Inspect head - symmetric, round, erect, midline; note lesions, movement - Palpate - hard and smooth; note tenderness - Inspect face - symmetric (smile/stick tongue out), shape, movement - Palpate TMJ and temporal artery - Cranium: houses and protects brain and sensory organs: 8 bones (frontal, parietal -2, temporal-2, occipital, ethmoid, sphenoid) - Facial bones: give shape to the face: 14 bones all immovable except for mandible at TMJ (maxilla-2, zygomatic-2, inferior conchae-2, nasal-2, lacrimal-2, palatine-2, vomer, mandible) - TMJ - temporomandibular joint · place your index finger over the front of each ear as you ask the client to open the mouth · Move side to side · Document swelling, tenderness, warmth, or crepitus with palpation · Grind teeth? Mouthguard? - Temporal artery: amplitude/regularity - Hair/scalp

Assessment of neck blood vessels

- Inspect jugular venous pulse - supine w/ HOB at 30-45 degrees, should not be visible when patient is sitting up, have patient turn head to left and inspect suprastenal notch w/ penlight - if seen it could indicate ventricular failure, pulmonary HTN pulmonary emboli or cardiac tamponade Evaluate jugular venous pressure - assess at various positions - supine, 30, 45, 60 and 90 - normal to see in supine position - should not be distended, bulging or protruding at 45 degrees or greater - may indicated right-sided heart failure - Auscultate and palpate carotid arteries - listen with bell/ have patient hold breath when listening - if there is bruit, blowing or swishing this may indicate arterial occlusion (occlusive arterial disease), palpate one side at a time - should be regular, equal and 2+ strength - weak = hypovolemia, shock, low CO - strong= hypervolemia or high CO - o Upon palpation, carotid arteries should be elastic and no thrills should be felt (narrowing)

Pupil constriction

- Miosis - pinpoint - typically from narcotic drugs (codeine, fentanyl, oxycodone) or brain damage - Mydriasis - dilated and fixed pupils, typically result from CNS injury, circulatory collapse or deep anesthesia - Anisocoria - pupils on unequal size - can be normal vs. abnormal

Ethnocentrism

Perception that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others.

Thoracic cavity

Trachea (flexible hyaline cartilage, no gas exchange, contains cilia) -> Bronchi (no gas exchange, contains cilia, right is shorter and more vertical) -> Bronchioles (end at alveolar duct) -> alveolar duct connects to alveolar sac that contains alveoli ( where gas exchange occurs, collapse results in atelectasis) -> lungs (apex slightly above clavicle, right = 3 lobes, left=2 lobes) -> pleural membranes (thin double layered serous membranes, pleural space contains serous fluid with inflammation comes a lot of pain which can cause guarding which causes atelectasis, infection, etc.) - diaphragm (respiratory muscle, allows for vertical expansion of lungs

cover/uncover test

o Cover one of patient's eyes o Have patient focus on distant object o Uncover patient's eye o Observe uncovered eye for movement o If uncovered eye moves to focus = WEAKNESS o Repeat with other eye § Esotropia (eye moves inward) § Exotropia (eye is moved outward) § Hypertrophia (eye moved upward)

Neck assessment

o Inspect neck - symmetric, head centered, no masses - swelling or enlarged masses/nodules may indicate enlarged thyroid gland, inflammation of lymph nodes or a tumor o Inspect movement of neck - swallow o Inspect cervical vertebrae - flex chin forward - prominence other than C7 is abnormal o Inspect range motion - flexion, extension, abduction, rotation - muscle spasms, inflammation or cervical arthritis may cause stiffness, rigidity, and limited mobility of the neck, which may affect daily functioning o Palpate trachea - midline - place fingers on sternal notch - feel each side of the notch and palpate the tracheal rings(the first upper ring above the smooth tracheal rings is the cricoid cartilage- deviated to one side (we would think cancer) o Palpate thyroid - hyoid bone (arch shaped bone that does not articulate directly with any other bone located high in anterior neck) - thyroid cartilage (under hyoid bone - area that widens at the top of the trachea - adams apple) - Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right. This will relax the client's neck muscles. Then place your thumbs on the nape of the client's neck with your other fingers on either side of the trachea below the cricoid cartilage. Use your left fingers to push the trachea to the right. Then use your right fingers to feel deeply in front of the sternomastoid muscle o Muscles - § sternomastoid: rotates & flexes head § trapezius: extends head/moves shoulders § 11th cranial nerve: spinal accessory - turning against resistance, shrugging shoulders o Cervical vertebrae § 7 cervical vertebrae, support head § C7: boney prominence when neck flexed § "3, 4, 5 keeps the diaphragm alive § Less than (C1 - 2) = quadriplegia - Observe jugular veins and carotid arteries -

visual field test

position yourself approximately 2 ft away from the client at eye level. Have the client cover the left eye while you cover your right eye (Fig. 16-10). Look directly at each other with your uncovered eyes. Next, fully extend your left arm at midline and slowly move one finger (or a pencil) upward from below until the client sees your finger (or pencil). Test the remaining three visual fields of the client's right eye (i.e., superior, temporal, and nasal). Repeat the test for the opposite eye.

Pleural effusions

§ Buildup of fluid in pleural - might require bed side tap § Due to fluid overload or inflammation § S/S: chest pain, pain with breathing, trouble breathing, cough

Hemothorax

§ Cause: Blood in pleural space (trauma, injury, or a procedure) § Muffled breath sounds § Dullness on percussion (tissue full of blood) § S/S similar to pneumothorax

Atelectasis

§ Collapsed Alveoli § Cause: Hypoventilation (shallow breathing/Post-op patients) § Affected lobe - diminished or absent lung sounds § Decreased O2 levels depending on the level of collapse

Terms for thoracic assessment

§ Consolidation - area of lung that is filled with liquid making it swollen or less soft § Derecruitment of lungs - collapse of alveoli § Recruitment of lungs - expansion of alveoli § Aeration - movement of air in the lungs § Adventitious sounds - abnormal breath sounds § Exudate - excreted substance

Asthma

§ LS: Crackles & Wheezing (Audible) § Decrease LS or breath sounds § Bronchoconstriction § Elevated RR, HR § Prolonged expiration § Dyspnea § Anxious § Cough

Lung cancer

§ S/S: Weight loss, congestion, wheezing, hemoptysis, labored breathing, dyspnea § LS: Normal to diminished over affected area § LS with partial obstruction due to tumor: Wheezes

Electrical pathway of the heart

§ Sinoatrial Node - SA node or sinus node or pacemaker of heart · Located posterior wall of right atrium - near superior/inferior vena cava junction · Inherent Rhythm Generation: 60-100 beats/min · Conduct impulses over right and left atrium at the same time to cause them to contract at the same time · Impulse conducted to AV node. § Atrioventricular Node (AV) - · Located: Interaterial Septum · Relays impulses to AV bundle or bundle of His (upper interventricular septum) · Next, the impulse travels down the RIGHT & LEFT purkinje fibers in the myocardium of the L and R ventricles - both should contract at the same time · Inherent Rhythm of 40-60 beats per minute (if SA node not working)

Aneurysm

· Localized Dilation of artery caused by weakness in arterial wall · Can occur anywhere along aorta and iliac vessels