health assessment exam #2

thrill

*abnormal* rhythmic vibration felt when palpating an artery

legs: *(auscultation)*

*auscultate the femoral pulses* -no sounds auscultated over the femoral arteries

cardiac tamponade

*becks triad* -hypotension -JVD -muffled heart sounds

which races have little to no body odor and which have a lot?

*none* -Asian and Native American *a lot* -whites and African Americans

S4, S1, S2, S3

*normal* S1 "lub" S2 "dubb" *extra heart sounds* S4, S3

dimpling

Suggests malignancy

pustule

a pus-filled sac example: acne

what do we listen to the heart using?

diaphragm then bell

oculomotor (III)

eye movement

what makes the human heart different?

four chambers

tinea capitis

pustules

EKG

what the heart is doing electrically 12 lead records depolarization and depolarization

clinical tip: respiratory patterns

when assessing respiratory patterns, it is more objective to describe the breathing pattern, rather than just labeling the pattern

pallor

(loss of color) is seen in arterial insufficiency, decreased blood supply, and anemia vary from pale to ashen without underlying pink

milk cysts

(sacs filled with milk) and infections (mastitis), may turn into an abscess and occur if breastfeeding or recently given birth.

pulmonary veins

(two from each lung) return oxygenated blood to the left atrium

interpretation of ABI values

*0.00-0.40* -severe peripheral arterial disease (PAD), sufficient to cause resting pain or gangrene *0.41-0.90* -PAD sufficient to cause claudication *0.91-1.30* -normal vessels *>1.30* -noncompressible, severely calcified vesel patients with an ABI less than 0.90 have a higher risk for coronary artery disease, stroke, and death and therefore should be referred to a credentialed vascular laboratory for further testing

PUSH scoring

*4, necrotic tissue (eschar):* black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin *3, slough:* yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous *2, granulation tissue:* pink or beefy red tissue with a shiny, moist, granular appearance *1, epithelial tissue:* for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface *0, closed/resurfaced:* the wound is completely covered with epithelium (new skin)

skin cancer: ABCDE

*A:* asymmetry *B:* borders *C:* color *D:* diameter *E:* elevated

main differences between arterial and venous insufficiency

*ATERIAL:* cool, loss of hair, circular in shape, shiny *VENOUS:* red/blue, irregular shape ulcers, superficial

what valves are open allowing blood to flow from the atria into the ventricles?

*AV valves* -triscuspid and mitral valves (occurs during ventricular diastole, the ventricles are being filled)

5 A's Intervention for Smoking Cessation

*Ask* -about current smoking status *Advise* -to quit and provide information on how beneficial quitting is *Assess* -willingness to quit *Assist* -with finding resources and making a plan to quit *Arrange* -for follow ups to help the patient follow through and quit

deep vein thrombosis (DVT) vs. peripheral artery disease (PAD)

*DVT* -warm, aren't getting ENOUGH blood flow *PAD* -coldness, aren't getting ANY blood

when palpating the carotid artery, do you palpate both sides at the same time?

*NO,* your patient's BP will drop and they will in turn pass out

if you hear an abnormal heart sound what do you do?

*REFER*

what do you do if you identify any sign of heart disease?

*REFER*

traditional 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 valve* -fourth or fifth ICS at the left lower sternal border

heart (precordium), anterior chest *auscultation*

*auscultate HR and rhythm* -rates should be 60-100 BPM with regular rhythm. a regularly irregular rhythm, such as sinus arrhythmia when the HR increases with inspiration and decreases with expiration, may be normal in young adults -resting pulse rate (RPR) varies by age, gender, and ethnic/racial factors. adult females RPRs are a few beats faster than male RPRs *if you detect an irregular rhythm, auscultate for a pulse rate deficit* -the radial and apical pulse rates should be identical *auscultate to identify S1 and S2* -S1 ("lub") -S2 ("dubb") -S1 corresponds with each carotid pulsation and is loudest at the apex of the heart. S2 immediately follows after S1 and is loudest at the base of the heart *listen to S1* -use diaphragm of stethoscope -a distinct sound is heard in each area but the loudest at the apex. may becomes softer with inspiration. a split S1 may be heard normally in young adults at the left lateral sternal border *listen to S2* -distinct sound is heard in each area but is loudest at the base. a split S2 (into two distinct sounds of it components- A2 and P2) is normal and termed *physiologic splitting.* it is usually heard late in inspiration at the second or third left interspaces *auscultate for extra heart sounds* -use diaphragm first then the bell -normally no sounds are heard. a physiologic S3 heart sound is a benign finding commonly heard at the beginning of the diastolic pause in children, adolescents, and young adults. it is rare after age 40. the physiologic S3 usually subsides upon standing or sitting up. a physiologic S4 heart sound may be heard near the end of diastole in well-conditioned athletes and in adults older than age 40 or 50 with no evidence of heart disease, especially after exercise *auscultate for murmurs* -normally no murmurs are heard. however, innocent and physiologic midsystolic murmurs may be present in a healthy heart *auscultate with the client assuming other positions* -left lateral position -use bell of stethoscope -S1/2 heart sounds are normally present -sit up, lean forward, and exhale -S1/2 heart sounds are normally present

posterior & anterior thorax: *auscultation*

*auscultate for breath sounds* -three types of normal breath sounds may be auscultated: bronchial, bronchovesicular, and vesicular -posterior chest wall at the apex of the lung at C7 -sometimes breath sounds may be hard to hear with obese or heavily muscled clients due to increased distance to underlying lung tissue *auscultate for adventitious sounds* -adventitious sounds: sounds added or superimposed over normal breath sounds -no adventitious sounds, such as crackles (discrete and discontinuous sounds) or wheezes (musical and continuous) are auscultated

neck vessels: *auscultation and palpation*

*auscultate the carotid arteries* -use bell of stethoscope and has client hold breath for a moment -no blowing or swishing or other sounds are heard *palpate the carotid arteries* -arteries are elastic and no thrills are noted -pulses are equally strong; a 2+ or normal with no variation in strength from beat to beat. contour is normally smooth and rapid on the upstroke and slower and less abrupt on the downstroke. the strength of the pulse is evaluated on a scale from 0-3 as follows: *Pulse Amplitude Scale* 0: absent 1+: weak, diminished (easy to obliterate) 2+: normal (obliterate with moderate pressure) 3+: bounding (unable to obliterate or requires firm pressure)

nail changing colors and what they show

*bacterial* -green/black/brown *fungal* -yellow/thick/crumbling *yeast infection* -white and separation

posterior & anterior thorax: *auscultate voice sounds*

*bronchophony* -ask the client to repeat the phrase "ninety-nine" while you auscultate the chest wall -voice transmission is soft, muffled, and indistinct. the sound of the voice may be heard but the actual phrase cannot be distinguished *egophony* -ask the client to repeat the letter "E" while you listen over the chest wall -voice transmission will be soft and muffled but the letter "E" should be distinguishable *whispered pectoriloquy* -ask the client to whisper the phrase "one-two-three" while you auscultate the chest wall -transmission of sound is very faint and muffled. it may be inaudible

legs: *(special tests for arterial or venous insufficiency)*: ankle-brachial index

*determine ankle-brachial index (ABI)* -this test is used to compare upper and lower-limb systolic blood pressure. the ABI is the ratio of the ankle systolic BP to the arm (brachial) systolic BP. the ABI is considered an accurate objective assessment for determining the degree of PAD. -generally, the ankle pressure in a healthy person is the same or slightly higher than the brachial pressure, resulting in an ABI of approximately 1, or no arterial insufficiency

grades of heart murmurs (pg. 459)

*grade 1* -very faint, heard only after the listener has "tuned in"; may not be heard in all positions *grade 2* -quiet, but heard immediately on placing the stethoscope on the chest *grade 3* -moderately loud *grade 4* -loud *grade 5* -very loud, may be heard with a stethoscope partly off the chest *grade 6* -may be heard with the stethoscope entirely off the chest

dermis

*inner layer of skin* well-vascularized, connective tissue layer containing collagen, elastic fibers, nerve endings, an lymph vessels. origin of sebaceous glands, sweat glands, and hair follicles

the axillae: *inspection and palpation*

*inspect and palpate the axillae* -no rash or infection noted -no palpable nodes or one to two small (less than 1 cm), discrete, contender, moveable nodes in the central area

the male breasts: *inspection and palpation*

*inspect and palpate the breasts, areolas, nipples, and axillae* -no swelling, nodules, or ulceration should be detected

posterior thorax: *inspection:*

*inspect configuration of the scapulae & chest wall* -scapulae are symmetric and nonprotruding. shoulders and scapulae are at equal horizontal positions. -the ratio of anteroposterior to transverse diameter is 1:2 -spinous process appears straight, and thorax appears symmetric, with ribs sloping downward at approximately a 45-degree angle in relation to the spine *observe the use of accessory muscles* -the client does not use accessory (trapezius/shoukder) muscles to assist breathing. the diaphragm is the major muscle at work. this is evidenced by expansion of the lower chest during expansion *inspect the client's positioning* -client should be sitting up and relaxed, breathing easily with arms at sides or in lap

heart (precordium), anterior chest *inspection*

*inspect for any pulsations on anterior chest over heart* -the apical pulse may or may not be visible. if apparent, it would be in the mitral area (left MCL, fourth or fifth ICS). the apical impulse is a result of the left ventricle moving outward during systole

general inspection

*inspect for nasal flaring and pursed lip breathing* -nasal flaring is not observed. normally the diaphragm and the external intercostal muscles do most of the work of breathing. this is evidenced by outward expansion of the abdomen and lower ribs on inspiration as well as return to resting position on expiration *observe color of face, lips, and chest* -the client has evenly colored skin tone, without unusual or prominent discoloration *inspect color and shape of nails* -pink tones should be seen in the nail beds. there is normally a 160-degree angle between the nail base and the skin

anterior thorax: *inspection*

*inspect for shape and configuration* -the anteroposterior diameter is less than transverse diameter. the ratio of anteroposterior diameter to the transverse diameter is 1:2 *inspect position of the sternum* -sternum is positioned at midline and straight *watch for sternal retractions* -retractions are not observed *inspect slope of the ribs* -ribs slope downward with symmetric intercostal spaces. costal angle is within 90 degrees *observe quality and pattern of respiration* -respirations are relaxed, effortless, and quit. they are regular rhythm and normal depth at a rate of 12-20 per minute in adults. tachypnea and bradypnea may be normal in some clients *inspect intercostal spaces* -no retractions or bulging of the intercostal spaces are noted *observe for use of accessory muscles* -use of accessory muscles (sternomastoid and rectus abdnominis) is not seen with normal respiratory effort. after strenuous exercise or activity, clients with normal respiratory status may use neck muscles for a short time to enhance breathing

skin assessment

*inspect general skin coloration* -inspection reveals evenly colored skin tones without unusual or prominent discolorations *odors emanating from the skin* -slight or no odor of perspiration, depending on activity *inspect for color variations* -common variations include suntanned areas, freckles, or white patches known as vitiligo -generalized loss of pigmentation is seen in *albinism* -dark-skinned clients have lighter colored palms, soles, nail ned, and lips *assess skin integrity* -skin is intact, and there are no reddened areas *inspect for lesions* -skin is smooth, without lesions. stretch marks, scars, freckles, moles, or birthmarks are common findings -freckles or moles may be scattered over the skin in no particular pattern *use the Braden scale to predict pressure sore risk*

inspection of nails

*inspect nail grooming and cleanliness* -nails are clean and manicured *inspect nail color and markings* -pink tones should be seen. some longitudinal ridging is normal -dark-skinned clients may have freckles or pigmented streaks in their nails *inspect shape of nails* -there is normally a 160-degree angle between the nail base and the skin

female breasts: *inspection*

*inspect size and symmetry* -breasts can be a variety of sizes and are somewhat round and pendulous. one breast may normally be larger than the other *inspect color and texture* -color varies depending on the client's skin tone. texture is smooth with no edema -linear stretch marks may be seen during and after pregnancy or with significant weight gain or loss *inspect superficial venous pattern* -veins radiate either horizontally and toward the axilla (transverse) or vertically with a lateral flare (longitudinal). veins are more prominent during pregnancy *inspect the areolas* -areolas vary from dark pink to dark brown, depending on the client's skin tones. they are round and may vary in size. small montgomery tubercles are present *inspect the nipples* -nipples are nearly equal bilaterally in size and are in the same location on each breast. nipples are usually everted, but they may be inverted or flat -no discharge should be present *inspect for retraction and dimpling* -the client first raises arms overhead, then lowers them and presses them against the hips, and finally presses the hands together with the fingers of one hand pointing opposite to the fingers of the other hand -the client's breasts should rise symmetrically, with no sign of dimpling or retraction *ask client to lean forward from the waist* -breasts should hang freely and symmetrically

inspection and palpation: skin and hair

*inspect the scalp and hair for general color and condition* -natural hair color, as opposed to chemically colored hair, varies among clients from pale to blonde to black to grey to white. the color is determined by the amount of melanin present *at 1-inch intervals, separate the hair from the scalp and inspect and palpate the hair and scalp for cleanliness, dryness or oiliness, parasites, and lesions* -scalp is clean and dry. sparse dandruff may be visible. hair is smooth and firm, somewhat elastic. *inspect amount and distribution of scalp, body, axillae, and pubic hair* -varying amounts of terminal hair cover the scalp, axillae, body, and pubic areas according to normal gender distribution. fine vellus hair covers the entire body except for the soles, palms, lips, and nipples. normal male pattern balding is symmetric -individuals may shave or chemically remove axillary and general hair. some individuals, both male and female may also remove all body hair

jugular veins (anatomy)

*internal* -deep and medial to the sternocleidomastoid muscle *external* -more superficial; they lie lateral to the sternocleidomastoid muscle and above the clavicle

common nail disorders

*longitudinal ridging* -parallel ridges running lengthwise. may be seen in the elderly and some young people with no known etiology *half-and-half nails* -nails that are half white on the upper proximal half and pink on the distal half. may be seen in chronic renal disease *pitting* -seen with psoriasis *clubbing* -spoon-shaped nails that may be seen with trauma to cuticles or nail folds or in iron deficiency anemia, endocrine or cardiac disease -chronic- think respiratory *yellow nail syndrome* -yellow nails grow slow and are curved. may be seen in AIDS and respiratory syndromes *paronychia* -local infection

arms: *(inspection)*

*observe arm size and venous pattern; also look for edema* -arms are bilaterally symmetric with minimal variation in size and shape. no edema or prominent venous patterning *observe coloration of the hands and arms* -color varies depending on the client's skin tone, although color should be the same bilaterally

legs: *(inspection)*

*observe skin color while inspecting both legs from the toes to the groin* -pink color for lighter-skinned clients and pink or red tones visible under darker pigmented skin. there should be non changes in pigmentation *inspect distribution of hair on legs* -hair covers the skin on the legs and appears on the dorsal surface of the toes *inspect for lesions or ulcers* -legs are free of lesions or ulcerations *inspect for edema* -identical size and shape bilaterally; no swelling or atrophy *inspect for varicosities and thrombophlebitis* -ask the client to stand and inspect for superficial vein thrombophlebitis, lightly palpate for tenderness -veins are flat and barely seen under the surface of the skin

neck vessels: *inspection*

*observe the jugular venous pulse* -client should be in supine position with the torso elevated 30-45 degrees -the jugular venous pulse is not normally visible with the client sitting upright. this position fully distends the vein, and pulsations may or may not be discernible *evaluate jugular venous pressure* -the jugular vein should not be distended, bulging, or protruding at 45 degrees or greater

epidermis

*outer layer of skin* the outermost layer consists of dead, keratinized cells that render the skin waterproof composed of four distinct layers: stratum corneum, stratum lucidum, stratum granulosum, stratum germinativum replaced every 3-4 weeks (ex. hair, nails, dental enamel, horny tissues)

venous insufficiency

*pain* -aching, cramping *pulses* -present but may be difficult to palpate through edema *skin characteristics* -pigmentation in gaiter area (area of medial and lateral malleolus) -skin thickened and tough -may be reddish-blue in color -frequently associated with dermatitis *ulcer characteristics* -location: medial malleolus or anterior tibial area -pain: if superficial, minimal pain; but may be very painful -depth of ulcer: superficial -shape: irregular border -ulcer base: granulation tissue- beefy red to yellow fibrinous in chronic long-term ulcer -leg edema: moderate to severe

arterial insufficiency

*pain* -intermittent claudication to sharp, unrelenting, constant *pulses* -diminished or absent *skin characteristics* -dependent rubor -elevation pallor of foot -dry, shiny skin -cool-to-cold temperature -loss of hair over toes and dorsum of foot -nails thickened and ridged *ulcer characteristics* -location: tips of toes, toe webs, heel or other pressure areas if confined to bed -pain: very painful -depth of ulcer: deep, often involving joint space -shape: circular -ulcer base: pale black to dry and gangrene -leg edema: minimal unless extremity kept in dependent position constantly to relieve pain

legs: *(palpate)*

*palpate edema* -if edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting -no edema (pitting or nonpitting) present in the legs *palpate bilaterally for temperature of the feet and legs* -use backs of fingers -toes, feet, and legs are equally warm bilaterally *palpate the superficial inguinal lymph nodes* -nontender, moveable lymph nodes up to 1 or even 2 cm are commonly palpated *palpate the femoral pulses* -femoral pulses strong and equal bilaterally *palpate the popliteal pulses* -it is not unusual for the popliteal pulse to be difficult or impossible to detect, and yet for circulation to be normal *palpate the dorsalis pedis pulses* -dorsalis pedis pulses are bilaterally strong. this pulse is congenitally absent in 5-10% of the population *palpate the posterior tibial pulses* -the posterior tibial pulses should be strong bilaterally. however, in about 15% if healthy clients, the posterior tibial pulses are absent

posterior thorax: *palpation:*

*palpate for tenderness and sensation* -client reports no tenderness, pain, or unusual sensations. temperature should be equal bilaterally *palpate for crepitus* -also called subcutaneous emphysema: crackling sensation (like bones or hairs rubbing against each other) that occurs when air passes through fluid or exudate. -the examiner finds no palpable crepitus *palpate surface characteristics* -skin and subcutaneous tissue are free of lesions and masses *palpate for fremitus* fremitus: vibrations of air in the bronchial tubes transmitted to the chest wall -ask client to say ninety-nine -fremitus is symmetrical and easily identified in the upper regions of the lungs. if fremitus is not palpable on either side, the client may need to speak louder. a decrease in the intensity if fremitus is normal as the examiner moves toward the base of the lungs. however, fremitus should remain symmetric for bilateral positions *assess chest expansion* -hands on chest wall with your thumbs at the level T9/10 -when the client takes a deep breath, the examiner's thumbs should move 5 to 10 cm apart symmetrically

anterior thorax: *palpation*

*palpate for tenderness, sensation, and surface masses* -no tenderness or pain is palpated over the lung area with respirations *palpate for tenderness at costochondral junctions of ribs* -palpation does not elicit tenderness *palpate for crepitus as you would on the posterior thorax* -ne crepitus is palpated *palpate for any surface masses or lesions* -no unusual surface masses or lesions are palpated *palpate for fremitus* -fremitus is symmetric and easily identified in the upper regions of the lungs. a decreased intensity of fremitus is expected toward the base of the lungs. however, fremitus should be symmetric bilaterally *palpate anterior chest expansion* -thumbs move outward in a symmetric fashion from the midline

palpation of nails

*palpate nail to assess texture* -nails are hard and basically immobile *palpate to assess texture and consistency, noting whether nail plate is attached to nail bed* -nails are smooth and firm; nail plate should be firmly attached to nail bed *test capillary refill in nail beds by pressing the nail tip briefly and watching for color change* -pink tone returns immediately to blanched nail beds when pressure is released

palpation skin assessment

*palpate skin to assess texture* -skin is smooth and even *palpate to assess thickness* -skin is normally thin but can calluses are common on areas of the body that are exposed to constant pressure (ex. the heels) *palpate to assess moisture* -skin surfaces vary from moist to dry depending on the area assessed. recent activity or a warm environment may cause increased moisture *palpate to asses temperature* -skin is normally a warm temperature *palpate to assess mobility and turgor* -normally, the skin is mobile, with elasticity and returns to original shape quickly. recoil is usually immediate *palpate to detect edema* -skin rebounds and does not remain indented when pressure is released*

female breasts: *palpation*

*palpate texture and elasticity* -palpation reveals smooth, firm, elastic tissue *palpate for tenderness and temperature* -a generalized increase in nodularity and tenderness may be a normal finding associated with the menstrual cycle or hormonal medications. breasts should be a normal body temperature *palpate for masses* -no masses should be palpated. however, a firm inframammary transverse ridge may normally be palpated at the lower base of the breasts -if you detect any lump, *refer the client for further evaluation* *palpate the nipples* -the nipple may become erect and the areola may pucker in response to stimulation. a milky discharge is usually normal only during pregnancy and lactation. however, some women may normally have a clear discharge *palpate mastectomy or lumpectomy* -scar is whitish with no redness or swelling. no lesions, lumps, or tenderness noted

heart (precordium), anterior chest *palpation*

*palpate the apical impulse* -the apical impulse is palpated in the mitral area and may be the size of a nickel (1-2 cm). amplitude is usually small- like a gentle tap. the duration is brief, lasting through the first two-thirds of systole and often less. in obese clients or clients with large breasts, the apical impulse may not be palpable *palpate for abnormal pulsations* -no pulsations or vibrations are palpated in the areas of the apex, left sternal border, or base

arms: *(palpation)*

*palpate the client's fingers, hands, and arms, and note the temperature* -skin is warm to the touch bilaterally from fingertips to upper arms *palpate to assess capillary refill time* -capillary beds refill (and, therefore, color returns) in 2 seconds or less *palpate the radial pulse* -radial pulses are bilaterally strong (2+). artery walls have a resilient quality (bounce) *palpate the ulnar pulses* -the ulnar pulses may not be detectable *palpate the brachial pulse if you suspect arterial insufficiency* -brachial pulses have equal strength bilaterally *palpate the epitrochlear lymph nodes* -palpate behind the elbow in the grove between the biceps and triceps muscles -normally, epitrochlear lymph nodes are not palpable *perform the Allen test* -evaluates potency of the radial or ulnar arteries. essential before material sampling (ABGs or material line placement. -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

posterior thorax: *percussion:*

*percuss for tone* -*resonance* is the percussion tone elicited over normal lung tissue. percussion elicits flat tones over the scapula -*hyperresonance* is elicited in cases of trapped air such as in emphysema or pneumothorax *percuss for diaphragmatic excursion* -ask the client to exhale forcefully and hold the breath -excursion should be equal bilaterally and measure 3-5 cm in adults -ask the client to inhale deeply and hold it -the level of diaphragm may be higher on the right because of the position of the liver -in well-conditioned clients, excursion can measure up to 7 or 8 cm

anterior thorax: *percussion*

*percuss for tone* -resonance is the percussion tone elicited over normal lung tissue -percussion elicits dullness over breast tissue, the heart, and the liver. tympany is detected over the stomach, and flatness is detected over the muscles and bones

legs: *(special tests for arterial or venous insufficiency)*: position change test

*perform position change test for arterial insufficiency* -the client should be in a supine position. place one forearm under both of the client's ankles and the other forearm underneath the knees. raise the legs about 12 in. above the level of the heart. as you support the client's legs, ask the client to pump the feet up and down for about a minute to drain the legs if venous blood, leaving only arterial blood to color the legs -normal findings: feet pink to slightly pale in color in the light-skinned client with elevation. inspect the soles in the dark-skinned client, although it is more difficult to see subtle color changes in darker skin. when the client sits up and dangles the legs, a pinkish color returns to the tips of the toes in 10 seconds or less. the superficial veins on top of the feet fill in 15 seconds or less -normal responses with absent pulses suggest than an adequate collateral circulation has developed around an arterial occlusion

stages of Lymphedema

*stage 0* -no obvious signs or symptoms. impaired lymph drainage is subclinical. lymphedema (LE) may be present for months to years before progressing to later stages. edema is not evident. *stage I (spontaneously reversible)* -swelling is present. affected area pits with pressure. elevation relieves swelling. skin texture is smooth. *stage II (spontaneously irreversible)* -skin tissue is firmer. skin may look tight, shiny, and tissue may have a spongy feel. pitting may or may not be present as tissue fibrosis (hardening) begins to develop. elevation does not completely alleviate the swelling. hair loss or nail changes may be experienced in affected extremity. assistance will be needed to reduce edema. *stage III (irreversible)* -LE has progressed to the lymphostatic elephantiasis stage, at which the limb is very large. affected area is nonpitting, often with permanent eczema. skin is firm and thick, with hair (fibrotic) underlying tissue having an unresponsive feel. skin folds develop. at increased risk for recurrent cellulitis, infections (lymphangitis), or ulcerations. affected limb may ooze fluid. elevation will not alleviate symptoms

pressure ulcer staging

*stage I* -intact skin, nonblanching, over a bony prominence *stage II* -partial-thickness, shallow open ulcer, red-pink wound bed, without slough *stage III* -full-thickness, subcutaneous fat may be visible, slough may be present *stage IV* -full-thickness tissue loss with exposed bone, tendon, or muscle -slough or eschar may be present on some parts of the wound bed *unstageable* -full-thickness tissue loss in which the case of the ulcer is covered by slough and/or eschar

what are the different positions for listening to the heart?

*supine position* -during auscultation and palpation of the neck vessels and during inspection, palpation, and auscultation of the precordium *left lateral position* -palpation of the apical impulse *left lateral and sitting-up/leaning-forward position* -auscultate for the presence of any abnormal sound not detected with the client in the supine position

client leans forward and uses arms to support weight and lift chest to increase breathing capacity is known as what?

*tripod position* often seen in COPD

Measuring ankle-brachial index (ABI)

*use the following steps to measure ABI* -have the client rest in a supine position for at least 5 minutes -apply the BP cuff to first one arm and then the other to determine the brachial pressure using the Doppler. first palpate the pulse and use the Doppler to hear the pulse. the "whooshing" sound indicates the brachial pulse. pressures in both arms are assessed because asymptomatic stenosis in the subclavian artery can produce an abnormally low reading and should not be used in the calculations. record the *higher reading.* -apply the BP cuff to the right ankle, then palpate the posterior tibial pulse at the medial aspect of the ankle and the dorsalis pedis pulse on the dorsal aspect of the foot. using the same Doppler technique as in the arms, determine and record *both* systolic pressures. repeat this procedure on the left ankle.

lateral vertical reference lines

-*midaxillary line* -*anterior axillary line* -*posterior axillary line*

anterior vertical reference lines

-*midsternal line* -*right midclavicular line* -*left midclavicular line*

posterior vertical reference lines

-*vertebral line* -*right scapular line* -*left scapular line*

U wave

-May or may not be present -If present, it follows the T wave and represents the final phase of ventricular repolarization

what are the most commonly detected skin cancers?

-basal cell carcinoma -squamous cell carcinoma -melanoma

edema associated with lymphedema

-caused by abnormal or blocked lymph vessels -nonpitting -usually bilateral; may be unilateral -no skin ulceration or pigmentation

edema associated with chronic venous insufficiency

-caused by obstruction or insufficiency of deep veins -pitting, documented as: 1+ = slight pitting 2+ = deeper than 1+ 3+ = noticeably deep pit; extremity looks larger 4+ = very deep pit; gross edema in extremity -usually unilateral; may be bilateral -skin ulceration and pigmentation may be present

pleural effusion

-decreased fremitus -dull percussion -decreased breath sounds

pneuomothorax

-decreased fremitus -unequal chest expansion -hyperresonance percussion -decreased breath sounds

legs: *(special tests for arterial or venous insufficiency)*: Trendelenburg Test

-determining the competence if the saphenous vein valves and the retrograde (backward) filling go the superficial veins. the client should lie supine. elevate the client's leg 90 degrees for about 15 seconds or until the veins empty. with the leg elevated, apply a tourniquet to the upper thigh. -assist the client to a standing position and observe for venous filling. remove the tourniquet after 30 seconds, and watch for sudden filling of the varicose veins from above/

tumor

-dull percussion -increased bronchophony

secondary skin lesions

-erosion -ulcer -scar (cicatrix) -fissure

self-assessment: how to examine your own skin

-examine head and face -use a blow dryer to inspect scalp -check hands, including nails -examine elbows, arms and underarms -focus on neck, chest, and torso -women: check under breasts -inspect back of neck, shoulders, upper arms, back, buttocks, and legs -check legs and feet, including soles, heels, and nails -examine genitals

common skin variations

-freckles -vitiligo -striae (stretch marks) -seborrheic keratosis (warty or crusty pigmented lesion) -scar -mole -cutaneous tag -cutaneous horn -cherry angiomas (small raised spots)

emphysema

-increase costal angle above 90 degrees -pursed lip breathing -45 degree spinal column or more -hyperresonance percussion -diaphragmatic descent health sound -bulging of intercostal spaces -discontinous crackles -wheeze (sibilant)

conditions that cause heart murmurs

-increased blood velocity -structural valve defects -valve malfunction -abnormal chamber openings

consolidation

-increased fremitus -increased breath sounds -egophony = "A" -decreased/dullness percussion -creptius -increased bronchophony

hyperthyroidism

-increased moisture and diaphoresis -warm skin

when examining the skin, hair, and nails remember these key points:

-inspect skin color, temperature, moisture, texture -check skin integrity -be alert for skin lesions -evaluate hair condition: loss or unusual growth -note nail bed condition and capillary refill

chronic bronchitis

-labored/noisy breathing -discontinuous crackles -wheeze (sonorous)

primary skin lesions

-macule and patch -papule and plaque -nodule and tumor -vesicle and bulla -wheal -pustule -cyst

clinical tip: ABI

-make sure to use a correctly sized BP cuff. the bladder of the cuff should be 20% wider than the diameter of the client's limbs. -document BP cuff sizes used on the nursing plan of care (ex. "12-cm BP cuff used for brachial pressure: 10-cm BP cuff used for ankle pressure"). this minimizes the risk of shift-to-shift discrepancies in ABIs. -inflate the BP cuff enough to ensure complete closure of the artery. inflation should be 20-30 mmHg beyond the point at which the last arterial sign was detected. -avoid deflating the BP cuff too rapidly. instead, try to maintain a deflation rate of 2-4mmHg/sec for clients with arrhythmias. deflating the cuff more rapidly than that may cause you to miss the client's highest pressure and record an erroneous (low) BP measurement.

hypoxia

-nasal breathing -cyanosis -fingernail clubbing

Trendelenburg test: normal findings

-no pulsation is palpated if the client has competent valves -saphenous vein fills from below in 30 seconds. if valves are competent, there will be no rapid filling of the varicose veins from above (retrograde filling) after removal of tourniquet

anemia

-pallor -pale or cyanotic nails -spoon nails

SLE

-patchy hair loss -butterfly rash -9:1 female to male ratio

CHF

-pursed lip breathing -ruddy/purple

asthma

-pursed lip breathing -labored/noisy breathing -bulging of intercostal spaces -discontinuous crackles -wheeze (sibilant)

hypothyroidism

-rough, flaky dry skin -dry hair

COPD

-ruddy/purple -tripod position -muscle soreness -decreased chest excursion at base of lungs -abdominal muscles & internal muscles are used in expiration

atelectasis

-trapezius, shoulders or muscles used for inspiration -unequal chest expansion -diaphragmatic descent -retraction of intercostal spaces -increased bronchophony -neck muscles used in inspiration

acute or chronic airway obstruction

-trapezius, shoulders, muscle for inspiration -retraction of intercostal spaces -neck muscles used in inspiration

pneuomonia

-unequal chest expansion -dull percussion -increased bronchophony -crackles (coarse)

fungal infections

-yellow nails (psoriasis) -blue-green fluroresence (Wood's light)

clinical tip: 5 major types of tattoos

1) *traumatic*, caused by debris embedded in skin, as after a motorcycle accident 2) *amateur*, placed by nonprofessionals using India ink with a pin 3) *professional*, applied by a professional or skilled tattoo artist 4) *medical*, used to delineate a landmark for radiation 5) *cosmetic*, used for permanent eyeliner, lipstick, hair, blush, or eyebrows

ECG phases

1) P wave 2) PR interval 3) QRS complex 4) ST segment 5) T wave 6) QT interval 7) U wave

how is pitting edema graded?

1+ to 4+ scale with 4+ being the most severe

normal respiration rate

12-20 breaths/min

how many sets of jugular veins are there?

2 internal and external

how many positions do we put the patient in to listen to the heart?

3

low risk women should begin getting yearly mammograms at what age?

40

benign breast disease

Also called fibrocystic breast disease, benign breast disease is marked by round, elastic, defined, tender, and mobile cysts. The condition is most common from age 30 to menopause, after which it decreases.

complete cardiovascular assessment

BP, skin, nails, head, thorax and lungs, and peripheral pulses, along with cardiac assessment (heart and neck vessels)

cardiac output

HR X SV normal: 5 to 6L/min

ST segment

Period between ventricular depolarization and the beginning of ventricular repolarization blood is going from your ventricles out

pacemaker of the heart?

SA node

macule and patch

Small, flat, non-palpable skin color change less than 1 cm with a circumscribed border examples: freckles, flat moles, vitiligo

retracted breast tissue

Suggests malignancy

cancerous tumors

These are irregular, firm, hard, not defined masses that may be fixed or mobile. They are not usually tender and usually occur after age 50.

fibroadenomas

These lesions are lobular, ovoid, or round. They are firm, well defined, seldom tender, and usually singular and mobile. They occur more commonly between puberty and menopause.

a local or systemic infection

What do enlarged lymph nodes indicate?

heart

a hollow, muscular, four-chambered (left and right atria, left and right ventricles) organ located in the middle of the thoracic cavity between the lungs in the space called the *mediastinum*

what is peripheral cyanosis a result of?

a local problem resulting from vasoconstriction

subcutaneous tissue

a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles *beneath the dermis* stores fat as an energy reserve, provides insulation to conserve internal body heat, serves as a cushion to protect bones and internal organs, vascular pathways for the supply of nutrients and removal of waste products to and from the skin

concept mastery alert: lymphedema

a patient with lymphedema usually presents with nonpittting edema of only one extremity, which causes induration, not ulceration, of the skin and shows no pigment changes

Intraductal papilloma

a small growth inside a milk duct of the breast, often near the areola. It is harmless and occurs in women ages 35-50

pericardium

a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart

if we hear any heart sound besides "lubdubb" what does this mean?

abnormal

paresthesia

abnormal sensation of numbness and tingling without objective cause

diabetes

acanthosis nigricans

pericardial effusion

accumulation of fluid in the pericardial cavity, can lead to the heart to collapse

clinical tip: auscultation

again, do not attempt to listen through clothing or other materials. however, if the client has a large amount of hair on the chest and/or back, listening thought a thin T-shirt can decrease extraneous sounds that may be misinterpreted as crackles

crepitus

also called subcutaneous emphysema crackling sensation (like bones or hairs rubbing against each other) that occurs when air passes through fluid or exudate

clinical tip: breast cancer in males

although rare, men can have breast cancer, which may not be caught until the late stages, because many in society are unaware of its occurrence in men

clinical tip: carotid arteries

always auscultate the carotid arteries before palpating because palpation may increase or slow the HR, changing the strength of the carotid impulse heard

clinical tip: anterior thorax palpation

anterior and anterolateral thoracic palpation is best for assessing the right lung's middle lobe

clinical tip: Trendelenburg test

arterial blood flow is not occluded if there are arterial pulses distal to the tourniquet

older adult consideration: hair

as people age, hair feels coarser and dryer. the hair is also thinner with slower growth

vascular skin lesions

associated with bleeding, aging, circulatory conditions, diabetes, pregnancy, and hepatic disease, among other problems -petechia -ecchymosis -hematoma -cherry angioma -spider angioma -telangiectasis

cancerous lesions

asymmetry, irregular borders, color variations, diameter greater than 1/4 inch or 6 mm and evolving or changing over time

P wave

atrial depolarization blood flow is coming into the atrium

pathologic S4

atrial gallop coronary artery disease, hypertensive heart disease, cardiomyopathy, and aortic stenosis

sebaceous glands

attached to hair follicles and, therefore are present over most of the body, *excluding the soles and palms* they secrete an oily substance called *sebum* that waterproofs the hair and skin

clinical tip: pulsations of the neck vessels

be careful not to confuse pulsations of the carotid arteries with pulsations of the internal jugular veins

older adult consideration: palpating neck vessels

be cautious with older clients because atherosclerosis may have caused obstruction and compression may easily block circulation

older adult consideration: thoracic expansion

because of calcification of the costal cartilages and loss of the accessory musculature, the older client's thoracic expansion may be decreased, although it should still be symmetric

what do you listen to the carotid artery with?

bell

clinical tip: bilateral coolness

bilateral coolness of the feet and legs suggests one of the following: the room is too cool, the client may have recently smoked a cigarette, the client is anemic, or the client is anxious. all of these factors cause vasoconstriction, resulting in cool skin

veins

blood vessels that carry deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart

arteries

blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries

the "B" in the ABCDE rule for skin cancer stands for what?

border

major arteries of the arm

brachial, radial, ulnar

sternum

breastbone divided into three parts: the manubrium, the body, and the xiphoid process

clinical tip: breath sounds

breath sounds are considered normal only in the area specified. heard elsewhere, jeu are considered abnormal sounds. for example, bronchial breath sounds are abnormal if heard over the peripheral lung fields

what are the three types of normal breath sounds?

bronchial, bronchovesicular, and vesicular

where do you check cyanosis for African Americans?

buccal mucosa and nail beds

what is central cyanosis a result of?

cardiopulmonary problem

what is the number one cause of death in the US?

cardiovascular disease

what causes yellow cast in skin tones

carotene

vagus (X)

carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera promotes swallowing, talking, and production of digestive juices

trigeminal (V)

carries sensory impulses of pain, touch, and temperature from the face to the brain

jaundice

characterized by yellow skin tones, ranging from pale to pumpkin, particularly of the sclera, oral mucosa, palms, and soles

older adult consideration: chest pain

chest pain related to pleuritis may be absent in older adult clients because of age-related alterations in pain perception

valves are pulled open and closed by what?

chordae tendineae

vesicle and bulla

circumscribed, elevated, palpable mass containing serous fluid examples: herpes simplex/zoster. varicella

hypotension

clammy skin

shock

clammy skin

first heart sound

closing of AV (mitral and tricuspid) valves (S1) signals the beginning of systole

clinical tip: auscultating heart sounds

closing your eyes reduces visual stimuli and distractions, and may enhance your ability to concentrate on auditory stimuli

second heart sound

closure of semilunar valves (S2) signals the end of systole

lipomas

collection of fatty tissue that may also appear as a lump

hair

consists of layers of keratinized cells develops in a *hair follicle* two general types: *vellus hair (peach fuzz)* -provides thermoregulation *terminal hair (longer & coarser)* -protects the scalp, provides insulation, self-expression

thoracic cage

constructed of the sternum, 12 pairs of ribs, thoracic vertebrae, muscles, and cartilage provides support and protection for many important organs, including those of the lower respiratory system

trochlear (IV)

contracts one eye muscle to control inferomedial eye movement

abducens (VI)

controls lateral eye movement

older adult consideration: proper hygiene practices

decreased flexibility and mobility may impair the ability of some elderly clients to maintain proper hygiene practices, such as nail cutting, bathing, and hair care

bronchial obstruction

decreased fremitus

hypoventilation

decreased rate, decreased depth, irregular pattern

dehydration

decreased turgor

older adult consideration: deep breathing

deep breathing may be especially difficult for the older client, who may fatigue easily. thus, offer rest as needed

three types of veins

deep veins, superficial veins, perforator (or communicator) veins

assessing a patient's skin turgor is done to assess which clinical finding?

dehydration

PR interval

delay of AV node to allow filling of ventricles

who is at risk for DVT?

diabetes, hypertension, high cholesterol, smoking, 65 or older

obstruction of tracheobronchial tree

diminished fremitus

cancer

dimpling with fixation in the breast can be caused from what?

clinical tip: auscultating S1/2 sounds

do not ask the client to hold his or her breath. breath holding will cause any normal or abnormal split to subside

when is the PQ interval occurring?

during diastole

clinical tip: edema in the ankles

edema in the ankles may make it difficult or impossible to palpate a posterior tibial pulse. in this case, Doppler ultrasound may be used to assess the pulse

papule and plaque

elevated, palpable solid mass less than 0.5 cm and circumscribed border examples: warts, psoriasis

nodule and tumor

elevated, solid, palpable mass that extends deeper into dermis than papule 0.5-2 cm and circumscribed examples: keloid, squamous cell carcinoma

what is the skin composed of?

epidermal, dermal, and subcutaneous tissue

clinical tip: skin integrity- dark-skinned clients

erythema in the dark-skinned client may be difficult to see. however, the affected skin feels swollen and warmer than the surrounding skin

while educating a patient on prevention of skin cancer, the nurse discusses all of the following except what?

examining the skin surface every week for changes

dermatitis

excessive scaliness

hyperhidrosis

excessive sweating

patient education on preventing coronary artery disease

exercise, quit smoking, eat right, omega 3 (fish or fish pills), control waist size (pear vs. apple)

pulmonary artery

exits the right ventricle, bifurcates, and carries blood to the lungs

a macule is an elevated, palpable, solid mass with circumscribed border (T/F)

false

a pigskin-like or orange-peel appearance results from edema, which is seen in pregnancy (T/F)

false

pressure areas in stage I involve epidermis, dermis, and subcutaneous tissue (T/F)

false

the left lung is made up of three lobes; the right lung contains only two lobes (T/F)

false

tripod position is a characteristic feature in lung atelectasis (T/F)

false

deep veins

femoral vein and popliteal vein in the leg

major arteries of the leg

femoral, popliteal, dorsalis pedis, posterior tibial

linear crack in the skin that may extend to the dermis and may be painful is called what?

fissure

clinical tip: difficult pulses to palpate

for difficult-to-palpate pulses, use a Doppler ultrasound device

carotid arterial pulse

good for assessing amplitude and contour of the pulse wave pulse should normally have a smooth, rapid upstroke that occurs in early systole and a more gradual downstroke

older adult consideration: hair loss

hair loss on lower extremities occurs with again and is, therefore, not an absolute sign of arterial insufficiency in the older client

what does the integumentary consist of?

hair, skin, and nails

nails

hard, transparent plates of keratinized epidermal cells that grow from the *cuticle* *nail body:* extends over the nail bed and has a pink tinge as a result of blood vessels underneath *lunula:* crescent-shaped area located at the base of the nail

vestibulocochlear (VIII)

hearing and balance

adventitious breath sounds: (continuous) *wheeze (sibilant)*

high-pitched, musical sounds heard primarily during expiration but may also be heard on inspiration associated with: acute asthma or chronic emphysema

adventitious breath sounds: (discontinuous) *crackles (fine)*

high-pitched, short, popping sounds heard during inspiration and not cleared with coughing associated with: obstructive disorders: asthma, bronchitis, emphysema

cardiovascular system

highly complex, consisting of the heart and a closed system of blood vessels

manual compression test

if a client has varicose veins, perform manual compression to assess the competence of the vein's valves. ask the client to stand. firmly compress the lower portion of the varicose vein with one hand. place your other hand 6-8 in. above your first hand. feel for pulsation to your fingers in the upper hand. repeat this test in the other leg if varicosities are present.

clinical tip: apical pulsation

if the apical pulsation cannot be palpated, have the client assume a left lateral position. this displaces the heart toward the left chest wall and relocates the apical impulse farther to the left

clinical tip: breast implants

if the client has breast implants, she should check her breasts regularly, paying extra attention to how breasts look and feel. the implants have a different texture the original breast tissue. in 90% of breast cancer cases, the women finds the breast lump herself and learning to recognize changes with the implants is one of the best ways to detect cancer if it develops

clinical tip: differentiating S1/2

if you are experiencing difficulty differentiating S1 from S2, palpate the carotid pulse: the harsh sound that you hear from the carotid pulse is S1

clinical tip: popliteal pulse

if you cannot detect a pulse, try palpating with the client in a prone position. partially raise the leg, and place your fingers deep in the bend of the knee. repeat palpation in opposite leg, and note amplitude bilaterally. use a Doppler ultrasound to assess popliteal pulse if concerned!

clinical tip: abnormal sounds

if you hear an abnormal sound during auscultation, always have the client cough, then listen again and note any change. coughing may clear the lungs

jugular venous pulse

important for determining the hemodynamics of the right side of the heart

clinical tip: skin inspection in an obese client

in an obese client, carefully inspect skin on the limbs, under breasts, and in the groin area where problems are frequent due to perspiration and friction

older adult consideration: apical impulse

in older clients, the apical impulse may be difficult to palpate because of increased anteroposterior chest diameter

most breast cancers are located where?

in the upper, outer quadrant of the breast

clinical tip: auscultating heart sounds in women

in women with large breasts, it may be helpful to ask the client to pull her breast upward and to her side when you are auscultating for heart sounds

clinical tip: palpating the arms

inaccurate findings may result if the room is cool, if the client has edema, has anemia, or if the client recently smoked a cigarette

hyperventilation

increased rate and increased depth

air trapping

increasing difficulty in getting breath out

accessory (XI)

innervates neck muscles (sternocleidomastoid and trapezius)

what is the first symptom of peripheral artery disease (PAD)?

intermittent claudication characterized by weakness, cramping, aching, fatigue, frank pain with activity; located in the calves, thighs, or buttocks but rarely in the feet

biot respiration

irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea

what causes the aortic and pulmonic valve to open?

isometric contraction (all four valves are closed) there is now high pressure inside the ventricles, causing the two valves to open and blood being rapidly ejected

what is the skins purpose?

it is a physical barrier that *protects the underlying tissues and organs* from microorganisms, physical trauma, UV radiation, and dehydration. vital role in *temperature maintenance*, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. it also provides individual identity to a person's appearance

right-sided heart failure raises pressure and volume, thus raising ________________.

jugular venous pressure

clinical tip: jugular venous pressure

jugular venous pressure is often omitted and replace by a medical order for pulmonary artery catheter placement. however, when performed correctly, this assessment is low cost and effective.

older adult considerations: kyphosis

kyphosis (an increased curve of the thoracic spine) is common in older clients. it results from a loss of lung resiliency and a loss of skeletal muscle. it may be a normal finding

great vessels

large veins and arteries leading directly to and away from the heart

where do you hear the apical pulse?

left fifth intercostal space

bradypnea

less than 10 breaths/min, regular

fissure

linear crack in the skin that may extend ti the dermis and may be painful examples: chapped lips or hands, athletes foot

if you hear an abnormal heart sound what do you do *before* referring the patient?

listen for a full minute

vesicular *(breath sounds)*

long in inspiration, short in expiration

terminal hair

long, coarse, pigmented hair found on the scalp, legs, arms, and bodies of males and females

erosion

loss of superficial epidermis that does not extend to the dermis examples: scratch mark, canker sore

adventitious breath sounds: (continuous) *wheeze (sonorous)*

low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle. these may clear with coughing associated with: bronchitis or single obstructions and snoring before of sleep apnea

adventitious breath sounds: (discontinuous) *crackles (course)*

low-pitched, bubbling, moist sounds that may persist from early inspiration to early expiration: softly separating velcro associated with: pneumonia, pulmonary edema, pulmonary fibrosis

adventitious breath sounds: (continuous) *pleural friction rub*

low-pitched, dry, grating sound; much like crackles only more superficial and occurs during both inspiration & expiration associated with: pleuritis

clinical tip: inspection of the arms

mark locations on arms with a permanent marker to ensure the exact same locations are used with each reassessment

cyanosis

may cause white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival areas

palpitations

may occur with an abnormality of the heart's conduction system (arrhythmias) or during the heart's attempt to increase CO by increasing the HR. these may cause the client to feel anxious

PUSH Tool

measure pressure ulcer healing assesses: *length X width* -measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. multiply these two measurements (length X width) to obtain an estimate of surface area in square centimeters (cm2). caveat: do not guess! always use a centimeter ruler and always use the same method each time the ulcer is measure *exudate amount* -estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. estimate the exudate (drainage) as none, light, moderate, or heavy *tissue type* -this refers to the types of tissues that are present in the wound (ulcer) bed. use PUSH to score

what is the major determinant in skin color?

melanin

tachypnea

more than 24 breaths/min, shallow

clinical tip: fibrocystic breast changes

more than half of women have fibrocystic breast changes at some time. the term "fibrocystic breast disease" is no longer used and is referred to as "fibrocystic breasts" or "fibrocystic breast changes"

clinical tip: normal variations

normal variations in S1 are heard at the base and the apex of the heart. S1 is softer at the base and louder at the apex of the heart. An S1 may be split along the lower left sternal border, where the tricuspid component of the sound, usually too faint to be heard, can be auscultated. A split S1 heard over the apex may be an S4.

older adult consideration: dyspnea

older adults may experience dyspnea with certain activities due to age-related changes of the lungs (loss of elasticity, fewer functional capillaries, and loss of lung resiliency)

older adult consideration: amount of hair

older clients have thinner hair because of a decrease in hair follicles. pubic, axillary, and body hair also decrease with aging. alopecia is seen, especially in men. hair loss occurs from the periphery of the scalp and moves to the center. older women may have terminal hair growth on the chin growing due to hormonal changes.

older adult consideration: skin lesions

older clients may have skin lesions associated with aging, including seborrheic or senile keratoses, senile lentigines, cherry angiomas, purpora, and cutaneous tags and horn

older adult consideration: arterial disease

older clients with arterial disease may not have the classic symptoms of intermittent claudication, but may experience coldness, color change, numbness, and abnormal sensations

older adult consideration: nails

older clients' nails may appear thickened, yellow, and brittle because of decreased circulation in the extremities

how often do you reassess skin?

once every 8-12 hours

clinical tip: Allen Test

opening the hand into exaggerated extension may cause persistent pallor (false-positive Allen Test)

where is the base of the heart?

opposite to the apex top not bottom

Peau d'orange

orange peel appearance of breast due to edema

what suggests arterial insufficiency?

pallor when elevated and rumor when dependent loss of hair ulcers

vellus hair

peach fuzz covers most of the body and provides thermoregulation

all of the following are used when evaluating the skin, except?

percussion

older adult consideration: perspiration

perspiration decreases with aging because sweat gland activity decreases

where is the ulnar pulse?

pinky

how to auscultate heart sounds

position yourself on the client's right side. the client should be supine, with the upper trunk elevated 30 degrees. use the diaphragm of the stethoscope to auscultate all areas of the pericardium for high-pitched sounds. use the bell of the stethoscope to detect (differentiate) low-pitched sounds or gallops. concentrate on each heart sound individually.

Braden Scale

predicting pressure sore risk assesses: (all scaled 1-4: 1 being the worst, 4 being the best) *sensory perception* -ability to respond meaningfully to pressure-related discomfort *moisture* -degree to which skin is exposed to moisture *activity* -degree of physical activity *mobility* -ability to change and control body position *nutrition* -usual food and intake pattern *friction and shear*

when is the QRS- wave occurring?

presystole and systole

wheal

raised red skin lesion due to interstitial fluid examples: urticaria (hives) and insect bites

kissmaul respirations

rapid, deep, labored

mastitis

reddened, painful area on breast warm to palpation

paget disease

redness and flaking of the nipple tingling, itching, increased sensitivity, burning, discharge, and pain in the nipple

dehydration

reduce volume of pleural fluid

mobility

refers to how easily the skin can be pinched

cardiac cycle

refers to the filling and emptying of the heart's chambers *diastole:*relaxation of the ventricles, known as filling *systole:*contraction of the ventricles, known as emptying

turgor

refers to the skin's elasticity and how quickly the skin returns to its original shape after being pinched

cheyne-stokes respiration

regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea

clinical tip: lungs

remember that most lung tissue in the upper lobes of both lungs is located on the anterior surface of the chest wall. similarly, the lower lobes of both lungs are primarily located toward the posterior surface of the chest wall. in addition, the right middle lobe of the lung does not extend to the posterior side of the thoracic wall, thus must be assessed from the anterior and anterolateral surfaces alone.

what do the jugular veins do?

return blood to the heart from the head and neck by way of the superior vena cava

superior and inferior vena cava

return blood to the right atrium from the upper and lower torso

what does having fully distended jugular veins, bulging, or protrusion likely indicate?

right ventricular failure pulmonary hypertension, pulmonary emboli, cardiac tamponade, obstructive pulmonary disease

cyst

sac containing fluid

bronchovesicular *(breath sounds)*

same during inspiration and expiration location: over the major bronchi-posterior between the scapulae; anterior: around the upper sternum in the first and second intercostal spaces

superficial veins

saphenous veins

clinical tip: scars

scarifications may be used by some individuals who want to have a scar or keloid. these scars involve cutting or burning of the skin to leave permanent scars

pruitus

severe itching

bronchial *(normal breath sounds)*

short during inspiration, long in expiration location: trachea and thorax

ataxic

significant disorganization with irregular and varying depths of respiration

what is the largest organ in the body?

skin

ulcer

skin loss extending past epidermis, with necrotic tissue loss examples include: states ulcer, pressure ulcer

scar (cicatrix)

skin mark left after healing of a wound or lesion that represents replacement of connective tissue of the injured tissue examples: healed surgical incision

capillaries

small blood vessels that form the connection between the arterioles and venues and allow the circulatory system to maintain the vital equilibrium between the vascular and intercostal spaces

olfactory (I)

smell

risk factor for coronary artery disease?

smoking

what greatly increases the risk of heart disease?

smoking

clinical tip: posterior thorax

some clinicians prefer to inspect the entire thorax first, followed by palpation of the anterior and posterior thorax, then percussion and auscultation of the anterior and posterior thorax

clinical tip: assessing moisture

some nurses believe that using the dorsal surfaces of the hands to assess moisture leads to a more accurate result

adventitious sounds

sounds added or superimposed over normal breath sounds and heard during auscultation

murmurs

sounds created by abnormal, turbulent flow of blood in the heart conditions that contribute to turbulent blood flow include: 1) increased blood velocity 2) structural valve defects 3) valve malfunction 4) abnormal chamber openings (ex. septal defect)

what contains varying amounts of fat and connects the skin to underlying structures?

subcutaneous tissue

retracted nipple

suggests malignancy

S3 and S4 pathologic sounds together create a quadruple rhythm,, which is called a _______.

summation gallop

mastectomy

surgical removal of a breast

when is the ST segment occurring?

systole when the blood is being pumped out

clinical tip: measurement in centimeters

taking a measurement in centimeters from the patella to the location to be measured can aid in getting the exact location on both legs. if additional readings are necessary, use a felt-tipped pen to ensure exact placement of the measuring tape

facial (VII)

taste, facial expression, tears, salvation

glossopharyngeal (IX)

taste, gag reflex

older adult consideration: cotochondral tenderness

tenderness or pain at the costochondral junction of the ribs is seen with fractures, especially in older clients with osteoporosis

ribs

the 12 pairs constitute the main structure of the thoracic cage *rib 1:* curves up immediately under the clavicles so that only a small portion of these ribs and the first interspaces are palpable *ribs 2-6:* easy to count anteriorly because of their articulation with the sternal body *ribs 7-10:* connect to the cartilages of the pair lying superior to them rather than the sternum *ribs 11-12:* "floating" ribs because they do not connect to either the sternum or another pair of ribs anteriorly. they are posteriorly attached to the vertebra

older adult consideration: coughing

the ability to cough effectively may be decreased in the older client because of weaker muscles and increased rigidity of the thoracic wall

stroke volume (SV)

the amount of blood pumped from the heart with each contraction

clinical tip: apical impulse

the apical impulse was originally called the point of maximal impulse (PMI). however, this term is no longer used because a maximal impulse may occur in other areas of the precordium as a result if abnormal conditions

clinical tip: fremitus

the ball of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation

what part of the stethoscope do you use when listening to heart murmurs?

the bell

what happens when the aortic and pulmonic valve open?

the blood flows from the ventricles to the body (ventricles are being emptied)

what constitutes the *lower respiratory system*?

the lungs, distal portion of the trachea, and the bronchi

orthopnea

the need to sit more upright to breath easily due to fluid accumulation in the lungs

lymphatic system

the network of vessels through which lymph drains from the tissues into the blood

older adult consideration: nipples

the older client may have smaller, flatter nipples that are less erectable on stimulation

older adult consideration: breast size

the older client may notice a decrease in the size and firmness of the breasts as she ages because of a decrease in estrogen levels. glandular tissue decrease whereas fatty tissue increases. a well-fitting supportive bra can reduce breast discomfort related to sagging breasts

older adult consideration: breasts

the older client often has more pendulous, less firm, and saggy breasts

older adult consideration: palpation of breasts

the older client's breasts may feel more granular, and the inframammary ridge may be more easily palpated as it thickens

older adult consideration: skin

the older client's skin becomes pale due to decreased melanin production and decreased dermal vascularity

older adult consideration: skin turgor

the older client's skin loses its turgor because of a decrease in elasticity and collagen fibers. sagging or wrinkled skin appears in the facial, breast, and scrotal areas

older adult consideration: skin moisture

the older client's skin may feel dryer than a younger client's skin because sebum production decreased with age

how do we prepare the patient to check their jugular venous pressure?

the patient should be in a supine position with the torso elevated 30-45 degrees. make sure the head and torso are on the same plane. ask the client to turn head slightly to the left. inspect pulsations on the neck with a tangential light. watch for distention of the jugular veins.

thorax

the portion of the body extending from the base of the neck superiorly to the level of the diaphragm inferiorly

heart pumping

the right side of the heart pumps blood to the lungs for gas exchange (pulmonary circulation) the left side of the heart pumps blood to all other parts of the body (systemic circulation)

clinical tip: sternum and ribs

the sternum and ribs may be more prominent in the older client because of loss of subcutaneous fat

where are malignant masses or tumors normally found in the breast?

the upper outer quadrant

clinical tip: position change test

this assessment maneuver will not be accurate if the client has PVD of the veins with incompetent valves

outer structure of the thorax

thoracic cage

where is the radial pulse?

thumb

clinical tip: how to differentiate between central and peripheral cyanosis?

to differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa

what is the purpose of respiration?

to maintain an adequate oxygen level in the blood to support cellular life

hypoglossal (XII)

tongue movement

QT interval

total time for ventricular depolarization and repolarization

aorta

transports oxygenated blood from the left ventricle to the body

a dimpling or retraction of the nippled or fibrous tissue may indicate breast cancer (T/F)

true

bronchial, bronchovesicular, and vesicular sounds are normal breath sounds (T/F)

true

carotene is responsible for yellow color of the skin (T/F)

true

spoon nails are a characteristic feature of iron deficiency anemia (T/F)

true

studies have shown that up to 75% of clients with asthma have or are more susceptible to gastroesophageal reflux disease (GERD) (T/F)

true

the bronchi and trachea represent dead space in the respiratory system (T/F)

true

lungs

two cone-shaped, elastic structures suspended within the thoracic cavity right lung: three lobes left lung: two lobes *divided into lobes by fissures*

sweat glands

two types: *eccrine glands* -located over the entire skin -primary function is secretion of sweat and thermoregulation, which is accomplished by evaporation of sweat from the skin surface *apocrine glands* -associated wth hair follicles in the axillae, perineum, and areolae of the breasts. -small and nonfunctional until puberty, at which time they are activated and secrete a milky sweat

chest trauma

unequal chest expansion

Fibroadenomas

usually 1-5 cm, round or oval, mobile, firm, solid, elastic, nontender, single or multiple benign masses found in one or both breasts

how are heart sounds produced?

valve closure

older adult consideration: varicosities

varicosities are common in the older client

acanthosis nigricans

velvety darkening of the skin in body folds and creases, especially in the neck, groin, and axilla (seen in diabetes)

QRS complex

ventricular depolarization and atrial repolarization contractions

pathologic S3

ventricular gallop may be heard with ischemic heart disease, hyperkinetic states (anemia), or restrictive myocardial disease

T wave

ventricular repolarization

fremitus

vibrations of air in the bronchial tubes transmitted to the chest wall ask the client to say ninety-nine should be symmetrical and easily identified

optic (II)

vision

clinical tip: counting the spinous process

when counting the spinous process, it is helpful to know when they align with their corresponding ribs only to the fourth thoracic vertebra (T4). after this, the spinous processes angle downward from their own vertebral body and can be palpated over the vertebral body and rib below.

clinical tip: total body assessment

when performing a total body system examination, it is often convenient to assess the heart and neck vessels immediately after assessment of the thorax and lungs

clinical tip: assessing for fremitus on female client

when you assess for fremitus on the female client, avoid palpating the breast. breast tissue dampens the vibrations

lymph nodes

where microorganisms, foreign materials, dead blood cells, and abnormal cells are trapped and destroyed

fluid accumulation in the lungs from heart failure can cause one to cough up what?

white- or pink-tinged sputum

older adult consideration: lymph nodes

with aging, lymphatic tissue is lost, resulting in smaller and fewer lymph nodes

skin cancer

with the exception of malignant melanoma, most skin cancers are easily seen and easily cured, or at least controlled. malignant melanoma can be deadly if not discovered and treated early, which is one reason why professional health assessment and skin self-assessment can be life-saving procedures

when must a head to toe skin assessment be completed by?

within 6 hours of admission

__________ lesions are configured in a linear fashion and clustered along a nerve line

zosteriform