Health Assessment Exam 3

Cardiovascular risk reduction and health promotion

Smoking cessation Control of BP, cholesterol level Weight, activity Healthy People 2020's overall goals for improving cardiovascular health include improved hypertension and cholesterol control, increased patient education regarding signs and symptoms of disease, and early treatment

When learning about peripheral vascular disease, the nursing student would learn that signs and symptoms of a DVT require immediate: A. Start of anticoagulants B. Preparation for surgery C. Transfer to the ICU as it is life-threatening D. Education of signs/symptoms of arterial occlusion

A. Start of anticoagulants Rationale: Complete arterial occlusion is limb-threatening situation. If a patient is experiencing symptoms of deep vein thrombosis (DVT), immediate intervention to start anticoagulants is necessary; pulmonary embolism is a life-threatening emergency.

The client with which conditions requires immediate nursing intervention? (Select all that apply.) A.Shortness of breath B.Sternal retractions C.Pulse oximetry reading of 95% D.Occasional expiratory wheeze E.Respiratory rate of 8 breaths/min F.Arterial blood gas showing a pH of 7.35g.Stridor

ANS: A, B, E, G The client with sternal retraction is experiencing serious respiratory difficulty, as is the client with stridor. The client who reports shortness of breath needs immediate assessment, as does the client with a respiratory rate of 8. A pulse oximetry of 95% is within normal limits, as is a pH of 7.35. The client with expiratory wheezes needs to be assessed, but not immediately.

Abdominal organs

GI organs Major organs: Stomach, SI, colon Accessory: liver, pancreas, gallbladdar GU organs Kidney, ureters, bladder Kidneys- control BP through renin, stimulate RBS through erythropoietin, filter/remove waste Males- spermatic cord Females- ovaries and uterus

Variations in heart sounds

Split Heart Sound. One normal variation in heart sounds is the split heart sound. When the valves close at the same time, one S2 is heard for both valves. Systolic Ejection Click. Systolic ejection clicks may occur early or in the middle of systole Pericardial Friction Rub. The pericardial friction rub is an important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating (sounds like Velcro) S3- Lub dub dub S4- Lub lub dub S3 and S4 are also called "gallops" or extra heart sounds Murmur- can have a systolic or diastolic murmur Snap- opening snap is an early diastolic sound (can be difficult to differentiate between an extra heart sound)

What labs might be completed to assess for cardiovascular issues?

Outcomes (partial list) §Demonstrates adequate circulation as evidenced by (AEB) strong peripheral pulses, BP within normal limits (WNL), adequate urinary output §Maintains fluid balance AEB clear lung sounds, stable body weight, I&O WNL, no edema Interventions (partial list) §Teach patient signs of cardiac ischemia and when to call 911. §Assess for CP, SOB, edema; document arrhythmias. §Weigh patient daily, monitor trends. Maintain accurate I&O data.

Collect subjective data related to the peripheral vascular symptoms, including pain, numbness or tingling, skin changes, edema, cramps, and decreased functional ability

Pain Arms/legs, where, describe, 1-10, better/worse, other symptoms Numbness or tingling Arms/legs/hands/feet, Better/worse Cramping Legs, sudden/gradual/walking/activity, duration Skin changes Hair loss, pallor, cool, thicker nails, color changes related to coldness Edema Does it go away when you put your legs up, worse at night or morning, redness/tenderness Decreased functional ability ADL

Common symptoms for male genitalia and rectal assessment

Pain Difficulties with urination Erectile dysfunction (ED) Penile lesions, discharge, rash Scrotal enlargement

Identify the locations of the peripheral pulses

Palpation arms Radial Brachial if you cant assess radial Palpation legs femoral Popliteal dorsal pedis or posterior tibial ABI (checks BP in arm vs calf)...advanced practice

Identify normal and abnormal findings related to the breast and axillae when performing inspection and palpation.

Urgent assessment (abnormal): New breast lump/swelling Existing lump with changes Axillary lump Skin irritation or dimpling Nipple discharge Nipple retraction Breast or nipple pain Common symptoms: Breast pain, rash, lumps/swelling, nipple discharge Need to obviously consider lifespan changes like pregnant women or adolescent girls because these things could either be normal or abnormal depending on period in life Pregnant women: Expression of colostrum Menarche (menstruation) Breasts can have inflammation and tenderness

ARTERIAL versus VENOUS

§Arterial ulcer: Deep, necrotic base §Occlusion: seven Ps §Venous ulcer: superficial, pale §Occlusion: DVT (pain, edema, erythema, warmth of affected extremity)

Peripheral Vascular and Lymphatic System Lifespan Considerations: Older Adults

§Arteriosclerosis: arterial calcification §Less arterial compliance à Increased systolic BP §Peripheral artery disease (PAD) §Dramatically á 7th/8th decade §Male = female §Cultural considerations §Arterial disease: common §Frequently underdiagnosed §ABI integration §Systolic hypertension often increases with age §Decreased activity à Increased venous stasis §DVT development §Decreased joint mobility

Initiate a plan of care based on findings from the respiratory assessment

Laboratory and diagnostic testing Lab data; radiography; pulmonary function tests Collaboration Diagnostic reasoning Nursing diagnoses; outcomes; interventions Outcomes (partial list) Maintain clear lung fields. Demonstrate effective coughing. Demonstrate improved ventilation and adequate oxygenation. Auscultate breath sounds every 2 hours. Position patient to optimize respiration. Teach and encourage incentive spirometry use every 2 hours.

Common laboratory and diagnostic testing for abdomen

Labs: CBC; BMP Esophagogastroduodenoscopy (EGD) Barium enema Colonoscopy Endoscopic retrograde cholangiopancreatography (ERCP) Computed tomography scan (CT) Magnetic resonance imaging (MRI)

Identify important topics for health promotion and risk reduction of the female genitalia and rectum.

Lifespan considerations Women who are pregnant Infants, children, and adolescents Older adults Menopause Vaginal infections; UTIs Dyspareunia; diminished libido Cultural considerations Risk reduction and health promotion Health goals Health promotion topics Menopausal changes Prevention: HPV and cancer; STIs HPV vaccine Breakthrough in cancer prevention In June, 2006, the Advisory Committee on Immunization Practices (ACIP) voted to recommend first vaccine developed to prevent cervical cancer CDC recommendation for girls or boys starting at age 11 or 12 years of age with a series of 3 injections within a 6 month period One of most important advances in women's health in recent years Vaccine targets HPV, responsible for most cases of cervical cancer It is recommended for girls and women before they become sexually active because it is not effective if individual is already infected with HPV Genital self-examination Female genital mutilation

What is cardiac output?

heart rate x stroke volume heart rate sympathetic (+), parasympathetic (-) stroke volume contractability (+), preload (+), afterload (-)

Identify normal and abnormal findings related to the female genitalia and rectum

mons pubis NORMAL Evenly covered with pubic hair ABNORMAL Absence of pubic hair in the adult client is abnormal. Lice or nits (eggs) at the base of the pubic hairs indicate infestation with pediculosis pubis. labia majora and perineum NORMAL The labia majora are equal in size and free of lesions, swelling, and excoriation. A healed tear or episiotomy scar may be visible on the perineum if the client has given birth. The perineum should be smooth. Keep in mind the woman's childbearing status during inspection. ABNORMAL Lesions may be from an infectious disease, such as herpes or syphilis. Excoriation and swelling may be from scratching or self-treatment of the lesions. labia minora, clitoris, urethral meatus, and vaginal opening NORMAL The labia minora appear symmetric, dark pink, and moist. The clitoris is a small mound of erectile tissue, sensitive to touch. The normal size of the clitoris varies. The urethral meatus is small and slit-like. The vaginal opening is positioned below the urethral meatus. Its size depends on sexual activity or vaginal delivery. A hymen may cover the vaginal opening partially or completely. ABNORMAL Asymmetric labia may indicate abscess. Lesions, swelling, bulging in the vaginal opening, and discharge are abnormal findings. Excoriation may result from the client scratching or self-treating a perineal irritation. Palpate Bartholin's glands ABNORMAL Swelling, pain, and discharge may result from infection and abscess. If you detect a discharge, obtain a specimen to send to the laboratory for culture. Palpate the urethra ABNORMAL Drainage from the urethra indicates possible urethritis. Any discharge should be cultured. Urethritis may occur with infection with Neisseria gonorrhoeae or Chlamydia trachomatis. The size of the vaginal opening and the angle of the vagina NORMAL The normal vaginal opening varies in size according to the client's age, sexual history, and whether she has given birth vaginally. The vagina is typically tilted posteriorly at a 45-degree angle and should feel moist. ABNORMAL A condition in which the vagina becomes thinner and dryer is vaginal atrophy. This occurs when the body lacks estrogen. Some causes may include: menopause, breast feeding, surgical removal of the ovaries, and cancer treatments. The risk increases if you smoke or with the absence of vaginal birth. vaginal musculature NORMAL 1 The client should be able to squeeze around the examiner's finger. Typically, the nulliparous woman can squeeze tighter than the multiparous woman. ABNORMAL 1 Absent or decreased ability to squeeze the examiner's finger indicates decreased muscle tone. Decreased tone may decrease sexual satisfaction. vaginal musculature NORMAL 2 No bulging and no urinary discharge. Inspect the vaginal musculature ABNORMAL 2 Bulging of the anterior wall may indicate a cystocele. Bulging of the posterior wall may indicate a rectocele. If the cervix or uterus protrudes down, the client may have uterine prolapse. If urine leaks out, the client may have stress incontinence. cervix NORMAL The surface of the cervix is normally smooth, pink, and even. Normally, it is midline in position and projects 1-3 cm into the vagina. In pregnant clients, the cervix appears blue (Chadwick's sign). ABNORMAL In a nonpregnant woman, a bluish cervix may indicate cyanosis; in a nonmenopausal woman, a pale cervix may indicate anemia. Redness may be from inflammation. observe the surface and the appearance of the os. discharge and lesions NORMAL The cervical os normally appears as a small, round opening in nulliparous women and appears slit-like in parous women. observe the surface and the appearance of the os. ABNORMAL Asymmetric, reddened areas, strawberry spots, and white patches are also abnormal. Cervical lesions may result from polyps, cancer, or infection. Cervical enlargement or projection into the vagina more than 3 cm may be from prolapse or tumor, and further evaluation is needed.

Five areas to listen to the heart

***listen with diagram all the way down, and then listen with the bell all the way back up ""All Patients Enjoy Taking Meds."

The nurse is assessing a client's breath sounds. Which assessment finding has been correctly linked to the nurse's primary intervention?A.Hollow sounds heard over trachea; increase oxygen flow rate. B.Crackles heard in bases; have the client cough forcefully. C.Wheezes heard in central areas; administer inhaled bronchodilator. D.Vesicular sounds heard over the periphery; have the client breathe deeply.

ANS: C Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no interventions.

Urgent Assessment for abdomen

Acute abdominal pain can indicate a ruptured appendix or diverticula, and the patient will need emergency surgery. A ruptured aortic aneurysm, ruptured fallopian tube, ruptured ovarian cyst, ectopic pregnancy, or penetrating trauma can cause bleeding into the abdominal cavity and result in hypovolemic shock and death. Massive amounts of blood can collect in the abdominal cavity quickly, and emergency surgery is indicated Potentially life-threatening symptoms that require prompt attention Severe dehydration: nausea, vomiting Fever Acute abdominal pain-(What could be the cause?)

Urgent assessment for male genitalia and rectal assessment

Acute scrotal conditions Testicular torsion: twisting/rotating of testicles Acute ischemia Trauma Infectious conditions UTI: indwelling catheters Inflammatory conditions Rectal bleeding

Blood vessels, peritoneum, and muscles in abdomen

Aorta and branching vessels Spleen- stores RBC and platelets, new RBC and macrophages, activates B and T lymphocytes Peritoneum- serous membrane that covers and holds organs in place Parietal- lines walls Visceral- covers organs

abnormal heart rhythm

Arrhythmias: abnormal heart rhythms with premature, delayed, or irregular beats Atrial fibrillation: irregularly irregular heart rhythm

§Common laboratory and diagnostic testing for Peripheral Vascular and Lymphatic System

Arterial: arteriogram Venous: serum d-dimer; venous ultrasonography; anticoagulation Labs §Serum evaluation: risk factors; CHO; triglycerides §Diabetics: blood glucose; hemoglobin A1C Ultrasonography §Doppler (continuous wave) MRI; CT Collaborating with the Interprofessional Team

Collect subjective data including nausea, vomiting, hematemesis, dysphagia, constipation, diarrhea, and urinary/renal symptoms

Assessment of risk factors Personal history General GI questions; chewing and swallowing Breathing; weight gain; GU issues; joint pain Neurological system; metabolism; skin Lymphatic, hematological systems Substance abuse; occupation; foreign travel Lifestyle Medications Family history Common symptoms in abdomen Indigestion Heartburn, gas, unpleasant fullness Anorexia How is your appetite Nausea, vomiting, hematemesis; abdominal pain Do you have N/V, with blood Dysphagia, odynophagia Difficulty swallowing, does it feel like food is stuck in your esophagus Change in bowel function Constipation; diarrhea Jaundice/icterus Color of skin, urine/stool Urinary/renal symptoms Incontinence; kidney/flank pain; ureteral colic

Collect subjective and objective data on the male genitalia, rectum, and prostate.

Assessment of risk factors Personal history Medical and surgical history Sexual history Medications Family history Frequency, urgency, hesitancy and nocturia Are you urinating more often than usual? Do you feel as if you cannot wait to urinate? Do you awaken during the night because you need to urinate? How often? Is this a recent change? Nocturia occurs with frequency and urgency in urinary tract disorders; other origins include cardiovascular, habitual, diuretic medication Dysuria Any pain or burning with urinating? Burning common with acute cystitis, prostatitis, and urethritis Sexual activity and contraceptive use Are you in a relationship involving sexual intercourse? Are aspects of sex satisfactory to you and your partner? Are you satisfied with the way you and your partner communicate about sex? Occasionally a man notices a change in ability to have an erection when aroused. Have you noticed any changes? Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about this method? Any sexual contact with a partner having an STI, such as gonorrhea, herpes, AIDS, chlamydia, venereal warts, or syphilis? When was this contact? Did you get the disease? How was it treated? Were there any complications? Do you use condoms to help prevent STIs? Do you have any questions or concerns about any of these diseases?

Peripheral Vascular and Lymphatic System inefficiencies

Atrial Insufficiency- red, cool, atrophied (shrunk down), ulcers Venous Insufficiency- brown, cool, edema, moist, (high risk of DVT because of pooling blood)

When the nurse assesses a 78-year-old patient with pneumonia, what is the priority assessment? A.Breath sounds B.Airway patency C.Respiratory rate D.Percussion sounds

B. Airway patency. Rationale: Consider the ABCs. Airway always assumes priority.

The nurse caring for a patient diagnosed with a 2nd rib fracture should know the location of the sternal angle is also called as what? A. Apex B. Angle of Louis C. Base D. 2nd ICS

B. Angle of Louis Rationale: From the suprasternal notch, walk your fingers down approximately 4 to 5 cm to the bony ridge that joins the manubrium to the sternum. This ridge, called the sternal angle (also known as the angle of Louis or sternomanubrial angle), varies in prominence and is usually easier to locate in thinner people. The sternal angle is continuous with the 2nd rib.

A student is learning to compute the cardiac output of his or her patients. What is the formula for computing cardiac output? A. Pulse pressure × stroke volume B. Heart rate × stroke volume C. Pulse pressure × heart rate D. Stroke volume × diastolic BP

B. Heart rate × stroke volume

Upon inspection, the nurse sees flesh-colored lesions surrounding the anal area. These lesions most likely indicate A.hemorrhoids. B.herpes simplex virus 2. C.AIDS. D.condyloma acuminatum infection.

D. Condyloma acuminatum infection. Rationale: Condyloma present as fleshy white to gray-appearing lesions. These lesions can be individual or may cluster in groups.

Identify teach opportunities for cardiovascular health promotion and risk reduction

Biographical information Past medical history Lifestyle/personal habits Medications Family history Goals

Collect subjective data including common symptoms of breast pain, rash, lumps, swelling, nipple discharge, or trauma.

Breast pain: location, intensity, duration, quality/description Severe pain = more likely resulting from trauma or infection but can be more common in certain times of a woman's life Noncycllic pain: sharp/burning Cyclic pain: heaviness Rash: dermatitis or eczema Lumps (benign breast conditions, fibroadenoma, cancer) Provide info on lumps found in axillae Single breast masses may indicate benign conditions Swelling. Any swelling in the breasts? In one spot or all over? Discharge. Any discharge from the nipple? Trauma. Any trauma or injury to the breasts?

The nurse assesses the neck vessels in the stable patient with heart failure to determine which of the following? A.The bilateral carotid pulse B.The presence of bruits C.The highest level of jugular venous pulsation D.The strength of the jugular veins

C. The highest level of jugular venous pulsation. Rationale: The nurse looks for fluid volume overload in the patient with congestive heart failure (CHF). An elevated jugular venous pulsation reflects fluid volume overload in the right heart. The bilateral carotid pulse is never palpated, because doing so may obstruct the circulation to the brain and cause the patient to faint. Bruits are auscultated in the carotids for the presence of narrowing that may lead to stroke; the carotids, not the jugular veins, are also palpated for arterial pulse strength.

Cardiac Lifespan Considerations: Older Adults

Cardiac changes §Left atrium enlarges, mitral valve closes more slowly §Decreased injection fraction à exercise intolerance §Decreased heart rate variability §Reduced maximum heart rates §Less able to respond to stressors Cultural considerations §Coronary heart disease (CHD) §Hypertension; obesity

Cultural considerations for female genitalia

Certain cultures only allow same-sex healthcare providers, and women may ask for their husbands or significant others to be present during the assessment. It is essential to respect all cultural considerations. There are some cultures, such as the Hispanic culture, in which it is believed to be inappropriate to touch the breasts. Please take a patient's culture into consideration and ask permission to examine or expose the breasts. Breast cancer in African-American women and in women of ethnic groups living in countries of low socioeconomic status, is virtually unknown; breast cancer incidence is rapidly increasing in underdeveloped countries. The human papillomavirus (HPV) is the most common cause of cervical cancer. The number of new cervical cancer cases has been declining steadily over the past decades. Incidence rates have declined over most of the past several decades in both Caucasian and African-American women. In 2013, Hispanic women had the highest rate of getting cervical cancer, followed by black, white, American Indian/Alaska Native, and Asian/Pacific Islander women. Black women were more likely to die of cervical cancer than any other group.For women in many countries in Africa, Asia, and Latin America, cervical cancer is often detected late, when there is little hope for successful treatment

Collect subjective data related to common cardiovascular symptoms including chest pain, dyspnea, diaphoresis, fatigue, edema, nocturnal, and palpitations

Chest pain (CP) Where, when, 1-10, describe, better/worse, other symptoms, goal Dyspnea; orthopnea and paroxysmal nocturnal dyspnea 1-10, when. How long, better/worse, other symptoms, better or worse than it was 6 mo ago Difficulty sleeping, how many pillows, wake short of breath Cough; diaphoresis How long, better/worse, other symptoms, medications, better or worse than it was 6 mo ago Excessive sweating, during what activities, other symptoms Fatigue How long, better/worse, other symptoms Edema Swelling, when did it start, better/worse Nocturia How often Palpitations When, better/worse, other symptoms

Common Respiratory Symptoms

Chest pain or discomfort Where, when, rate, pattern?, have you experienced this before, what makes it better/worse, what do you think is causing it, what is your goal Dyspnea Trouble breathing?, when, how long, what makes it better/worse, other symptoms?, gradual/sudden, limit ADL?, accompanying anxiety? Orthopnea or paroxysmal nocturnal dyspnea How many pillows?, trouble breathing when lying down Cough Do you have one, where is it coming from, what does it sound/feel like, how bad, how often, when, better/worse, other symptoms? Sputum or phlegm production from cough amount, appearance, color, odor, and viscosity mucoid- from bronchitis, clear or white purulent- yellow, green, creamy, foul odor= WBC/bacterial infection rust colored- TB and pneumococcal pneumonia sticky tenacious sputum may be from dehydration or CF heart failure- thin and frothy, slightly light pink ***sputum from the mouth= oral secretions, not sputum Wheezing or tightness in chest How severe compared to normal, when, better/worse Other symptoms Change in functional ability

Objective Data- advanced practice for female genitalia and rectum

Common and specialty/advanced techniques Equipment; preparation Comprehensive physical assessment External genitalia; internal genitalia Speculum examination Cervix, os Pap smear, cultures Vaginal wall Bimanual, retrovaginal examinations

Collect objective data related to the abdominal assessment using inspection, auscultation, percussion, and palpation

Comprehensive physical assessment Inspection; auscultation; percussion; palpation Eliciting abdominal reflex Assessing for ascites; peritoneal irritation Gallbladder inflammation Appendicitis Inspection Contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, and demeanor Abdomen flat and symmetric. No scars, striae, or varicosity. Skin even-toned. Umbilicus midline and inverted. No hernias noted. No distention, visible pulsations, or peristaltic wave noted. Respirations even, no use of accessory muscles. Auscultation Bowel Sounds This is done first because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. Use diaphragm because bowel sounds are relatively high pitched. Hold stethoscope against skin; pushing too hard may stimulate more bowel sounds. Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here. Note character and frequency of bowel sounds Bowel sounds originate from movement of air and fluid through small intestine Depending on time elapsed since eating, a wide range of normal sounds can occur Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute; do not bother to count them Judge if they are normal, hypoactive, or hyperactive Borborygmus is the sound of hyper peristalsis Perfectly "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding bowel sounds are completely absent Vascular sounds As you listen to abdomen, note presence of any vascular sounds or bruits. Using the bell and firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension. Usually no such sound is present. Percussion All four quadrants and borders of kidney, liver and spleen Light and deep Palpation Deep: Liver, spleen, kidney, abdominal aorta, Liver: Palpable liver edge against your right hand during inspiration. Spleen: A normal spleen is not palpable Kidney: It is common to be unable to palpate the kidneys except in slender patients (then you would be able to palpate the right kindey, the left one is usually unpalpable) Abdominal aorta: Pulsations of the aorta are palpable; the aorta should measure 2 cm (about ¾ in.). Bladder: The empty bladder is neither tender nor palpable Lymph nodes: Inguinal lymph nodes nontender and may be slightly palpable. With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses Making sense of what you are feeling is more difficult than it looks Helps to memorize anatomy and visualize what is under each quadrant as you palpate If you identify a mass, then note the following: Location Size/Shape Consistency: soft, firm, hard Surface: smooth, nodular Mobility, including movement with respirations Pulsatility Tenderness

Collect objective data related to the cardiac system utilizing accurate physical assessment techniques

Comprehensive physical assessment §Jugular vein Jugular venous pulses Jugular venous pressure §Carotid arteries Inspection Palpation; auscultation §Precordium Inspection; palpation Auscultation: most important CV technique Identify landmarks Specific auscultation sites: rationale Identify: rate/rhythm; S1, S2; extra sounds; murmurs Percussion: replaced by radiographs Inspection Inspect carotid artery for double stroke seen with S1 and S2 Inspect chest for lesions, masses or areas of tenderness Look for PMI at 4th-5th ICS Palpate Palpate carotid arteries ONE AT A TIME Avoid compress carotid sinus (causes parasympathetic simulations...reduced pule rate) Palpate chest for lesions, masses, or tender areas Feel for PMI if observed, if it is abnormal it is displaced left or downward PMI 5th left ICS at the MCL. The PMI may or may not be palpable in adults. No pulsations are palpated in other areas Auscultation Use bell to hear low pitched sounds such as a bruit on carotid arteries

Identify normal and abnormal findings including auscultation of crackles, wheezes, gurgles, and stridor

Crackles are discontinuous sounds that are caused by fluid in the airways or alveoli, or that result from the opening of collapsed airways and alveoli while they reinflate during deep breathing. They sound like hairs rubbing together near the ear or Velcro opening and are most often heard on inspiration, although they can occasionally be heard during expiration. Wheezes are continuous, high-pitched, musical sounds caused by air squeezing through narrowed airways, as occurs in asthma. Wheezes are generally heard during the expiratory phase in mild-to-moderate airway narrowing. In severe asthma attacks, however, they can be heard during both inspiration and expiration. It is important to document if you hear wheezes during inspiration, expiration, or both. Gurgling (Rhonchi) are continuous, low-pitched, snoring sounds resulting from secretions moving around in airways. Although they are often louder during the expiratory phase, they can be heard throughout the respiratory cycle. Rhonchi may clear with coughing and are heard most commonly in patients with chronic bronchitis. Stridor Loud, high pitched crowing or honking sound in the upper respiratory. Laryngeal or tracheal inflammation or aspiration of foreign object. Epiglotitis, croup or partially obstructed airway may need immediate attention. Diminished- heard in areas of emphysema, atelectasis, or pleural effusion Urgent assessment: Acute shortness of breath: emergent Immediate assessments Respiratory, pulse rates; BP; O2 saturation Lung auscultation; O2, inhaler administration Elevate head of bed. Continually assess patient anxiety level Encourage relaxation techniques. Once Patients are stable: Prioritize subjective data collected. Cluster care If a patient has acute shortness of breath, immediately assess airway respiratory and pulse rates, BP, and oxygen saturation. Auscultate the lungs to identify significant abnormalities, such as diminished or absent breath sounds, or evidence of fluid in the lungs. Administer oxygen or a bronchodilating inhaler as ordered. If the patient is in bed, elevate the head of the bed to reduce the effect of gravity on the effort of breathing.

A patient has dyspnea, edema, weight gain, and liquid intake greater than output. These symptoms are consistent with which nursing diagnosis? A.Ineffective cardiac tissue perfusion B.Decreased cardiac output C.Impaired gas exchange D.Excess fluid volume

D. Excess fluid volume. Rationale: Ineffective cardiac tissue perfusion describes the lack of blood being supplied to the myocardium and relates to cardiac ischemia and chest pain. Impaired gas exchange, a respiratory diagnosis, focuses on the exchange of oxygen and carbon dioxide at the alveolar level. Decreased cardiac output relates to CHF and reduced circulation. Dyspnea from fluid in the lungs and edema and weight gain from fluid accumulation in the body support the most accurate labeling of excess fluid volume.

After completing a history on a 45-year-old patient, the nurse suspects the patient may have uterine fibroids. What information might have led her to this conclusion? A.History of STIs B.History of multiple births C.Vaginal discharge D.Heavier than usual menstrual periods

D. Heavier than usual menstrual periods. Rationale: Fibroids are suspected when a patient presents with heavy menstrual flow, irregular bleeding, pelvic pressure, or all of these symptoms.

Control of heart rate

Dual Innervation Sympathetic Nervous System: Increases the heart rate Parasympathetic Nervous System: decreases the heart rate SNS §"Fight versus flight" reactions §Indirect function §Baroreceptors; chemoreceptors PNS §"Rest and digest" reaction

Identify important topics for health promotion and risk reduction related to male genitalia and rectal assessment

Health goals Prostate cancer; family planning; STIs Testicular self-examination Strategies; rationale Procedure Warning signs Cancer range- 15-35 Screening for prostate cancer Includes PSA and rectal exam Circumcision Testicular Self-Examination (TSE) Encourage self-care by teaching every male from 13 to 14 years old through adulthood how to examine his own testicles Overall incidence of testicular cancer is still rare, but testicular cancer most commonly occurs in young men age 15 to 35 Early detection of cancer enhanced if male is familiar with his normal consistency Points to include during health teaching are: T - timing, once a month S - shower, warm water relaxes scrotal sac E - examine, check for and report changes immediately Lifespan considerations Common issues Rectal reflex reduced slightly Urination changes Sexual function changes Cultural considerations

Identify important topics for health promotion and risk reduction related to breast disease and breast cancer.

Health goals: Increase proportion of mothers who breastfeed Reduce female breast cancer death rate by 10% Reduce late-stage female breast cancer Risk reduction: Screening tests Breast self-examination Right after menstrual period (breasts are smallest and least congested) If no menstruation, pick a familiar date to examine breasts each month Report any changes Some medications increase breast related problems May cause engorgement, mastalgia, galactorrhea, breast tenderness, and gynecomastia in men (androgens, antidepressants, antipsychotics)

Identify important topics for health promotion and risk related to the organ systems found within the abdomen.

Health promotion and goals Colorectal cancer screening Colonoscopy every 10 years; CT colonography (virtual colonoscopy) every 5 years; Flexible sigmoidoscopy every 5 years; Double-contrast barium enema every 5 years; Yearly fecal immunochemical test (FIT); Yearly guaiac-based fecal occult blood test (gFOBT); Stool DNA test (sDNA) every 3 years. Reduce new cases of ESRD Reduce cirrhosis deaths Risk reduction Colorectal cancer; food-borne illness Hepatitis: A, B, C Hepatitis A, B immunizations Hep A- resolves on its own, viral in nature... ORAL-FECAL Hep B and C- BLOOD AND BODILY FLUID Screening, patient teaching

Teach Breast Self-Examination (BSE)

Help each woman establish regular schedule of self-care. The best time to conduct BSE is right after menstrual period, when breasts are smallest and least congested. Advise pregnant or menopausal woman not having menstrual periods to select a familiar date to examine her breasts each month. Stress that self-examination will familiarize woman with her own breasts and their normal variation; emphasize absence of lumps (not the presence of them). Encourage her to report any unusual finding promptly. Avoid citing frightening mortality statistics about breast cancer and generating excessive fear and denial that actually obstructs a woman's self-care action. The simpler the plan, the more likely person is to comply. Describe correct technique and rationale and expected findings to note as woman inspects her own breasts. Teach woman to do this in front of a mirror while she is disrobed to waist. At home, she can start palpation in shower, where soap and water assist palpation. Then palpation should be performed while lying supine. Encourage woman to palpate her own breasts while you monitor her technique.

Urgent Assessment of Thorax

If a patient has acute shortness of breath, immediately assess airway respiratory and pulse rates, BP, and oxygen saturation. Auscultate the lungs to identify significant abnormalities, such as diminished or absent breath sounds, or evidence of fluid in the lungs. Administer oxygen or a bronchodilating inhaler as ordered. If the patient is in bed, elevate the head of the bed to reduce the effect of gravity on the effort of breathing.

Function of Abdomen

Ingestion, digestion of food Mechanical/chemical Nutrient absorption Small intenstine solid waste elimination

Consider the condition, age, gender, and culture of the patient to individualize the abdominal assessment.

Lifespan considerations: older adults Reduced: saliva production; stomach acid production Slowed: gastric motility; peristalsis Liver decreases in size and function (effects medication) processing Renal function declines (effects medication elimination) Diminished sensation of thirst Additional questions Risks for nutritional deficit Bowel function Daily medications Potential alterations Poor dentition Decreased muscle mass, tone Decreased motility, peristalsis bloating, distention, constipation Liver shrinkage decreased medication metabolism Decreased renal function decreased medication efficacy Cultural considerations African Americans are more likely to have chronic liver disease Higher rates of hep B Men are twice as likely to have liver and bowel cancer African Americans and Hispanics are x2 as likely to die from hep B and C X2 as likely to be diagnosed with diabetes and have complications Hispanics are 40% more likely than Caucasians to die from diabetes

When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved?

Liver. Rationale: The spleen is normally found in the 9th to 11th left intercostal space (ICS) in the left midaxillary line (MAL). The colon is in the lower quadrants of the abdomen. The kidney is located in the posterior flank, in the lower rib cage. It is percussed for tenderness and is not always palpable.

A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive?

Murphy sign. Rationale: The Murphy sign tests for gallbladder pain. The other signs test for peritoneal irritation in the lower quadrants.

Use subjective and objective data to analyze findings and plan interventions for the peripheral vascular and lymphatic systems

Nursing diagnoses; outcomes; interventions Outcomes (partial list) Peripheral pulses strong, symmetrical Capillary refill <3 seconds Decreased peripheral edema Interventions (partial list) Monitor peripheral pulses as ordered. Assess edema as ordered. Evaluate pain on 10-point scale.

Identify teaching opportunities for health promotion and risk reduction (peripheral vascular and lymphatic assessment)

Patients with PAD Risk factor modification Smoking; high-fat diet; limited activity level Hypertension; diabetes Daily assessment of the feet The risk factors most strongly associated with PAD are advancing age, smoking tobacco, and diabetes mellitus Patients with venous disease Education: methods of decreasing venous pressure Compression stockings Patients at risk for or with a history of DVT Chronic venous insufficiency (CVI) is a prevalent problem. The risk factors for CVI include older age, being female, having a family history of CVI, leg injuries, obesity, phlebitis, and pregnancy Advise these patients to avoid standing and sitting for long periods and to elevate the legs periodically to help combat the chronic edema that may accompany venous disease Patients with lymphatic disorders: extremity edema Avoid sitting, standing for long periods. Address chronic lymphedema early. As with venous disease, edema in the extremities is the primary symptom of lymphedema The most modifiable risk factors are smoking, a high-fat diet, and limited activity level. Of these, smoking has been found to be one of the most devastating risk factors. PAD is twice as likely to occur in people who smoke cigarettes; smoking is a very strong risk factor for AAAs as well Hypertension, diabetes, chronic kidney disease, and heredity are also risk factors for PAD Patients with venous disease should receive education on methods of decreasing venous pressure. Cardiovascular risk factors smoking hypercholesterolemia diet high is saturated fats sedentary lifestyle hypertension diabetes obesity genetics

Common symptoms for female genitalia and rectum

Pelvic pain Vaginal burning, discharge, itching Menstrual disorders Structural difficulties Sexual dysfunction Hemorrhoids

Cardiovascular health goals

Reduce coronary heart disease deaths Increase proportion of MI patients who receive timely defibrillation and thrombolytic therapy Increase proportion of adults with hypertension who control BP levels

Identify anatomical landmarks and reference lines of the abdomen

Right Upper Quadrant Right Lower Quadrant Left Upper Quadrant Left Lower Quadrant Right Hypochondriac Region Epigastric Region Left Hypochondriac Region Right Lumbar Region Umbilical Region Left Lumbar Region Right Inguinal Region Hypogastric (Suprapubic) Region Left Inguinal Region

Identify important topics for risk reduction for the respiratory system

Risk reduction Past history Health goals Lifestyle and personal habits Smoking cessation Occupational health Environmental exposure Prevention of asthma Medications Immunizations

Collect objective data about the peripheral vascular system, including color, temperature, pulses, capillary refill, and edema

Seven P's (Slideshow has 6; doesn't have perfusion) Pain Pallor: pale skin color Poikilothermia: inability to regulate core body temperature Paresthesias: numbness, tingling Pulselessness: lack of pulse via palpation, auscultation Paralysis: complete loss of muscle function Perfusion: capillary refill Comprehensive physical assessment Arms Legs Inspection Size, symmetry, atrophy/hypertrophy, edema, nail beds Palpation Temperature, turgor, grade femoral, popliteal, dorsalis pedis and posterior tibial pulses, palpate inguinal lymph nodes Auscultation doppler ABI Additional techniques Color change; manual compression test; Trendelenburg test

Urgent Assessment for female genitalia and rectum

Severe pain Acute infection Pelvic inflammatory disease (PID) Urinary tract infection (UTI) Gastrointestinal illness Appendicitis; pancreatitis; cholecystitis; strangulated hernia Musculoskeletal trauma Ruptured bladder, spleen, liver

Collect subjective data related to the female genitalia and rectum

Subjective data Assessment of risk factors Personal history Menstrual history Obstetrical history: gravida; para; term; preterm Menopause; gynecological history; immunizations Sexual history 5 Ps Partners, Practices, Prevention of Pregnancy, Protection from STDs, and Past History of STDs Sexual behavior Contraception; STIs Additional health risks Obesity Osteoporosis Hormonal contraceptive and tobacco use Medications, supplements Family history Subjective data questions Sexual activity and contraceptive use Are you in a relationship involving sexual intercourse? Are aspects of sex satisfactory to you and your partner? Are you satisfied with the way you and your partner communicate about sex? Occasionally a man notices a change in ability to have an erection when aroused. Have you noticed any changes? Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about this method? Any sexual contact with a partner having an STI, such as gonorrhea, herpes, AIDS, chlamydia, venereal warts, or syphilis? When was this contact? Did you get the disease? How was it treated? Were there any complications? Do you use condoms to help prevent STIs? Do you have any questions or concerns about any of these diseases?

Identify important topics for health promotion for the respiratory system

The following are health goals related to the respiratory system: 1. Increase the proportion of adults vaccinated against influenza and pneumococcal infections. 2. Reduce the number of missed workdays due to asthma exacerbations. 3. Reduce the proportion of adults whose activity level is limited by symptoms associated with chronic lung disease. 4. Reduce mortality from respiratory disorders. 5. Reduce the proportion of previous smokers and those who have never smoked but have been is exposed to secondhand tobacco smoke

Jugular pulsations description

The jugular pulse has five pulsations resulting from the backward effects of activity in the heart. The waves reflect atrial contraction and relaxation, ventricular contraction, and passive atrial and ventricular filling. -we put people at 30 degrees to look at it because when your standing you shouldn't have any and when you're supine everyone's should have it -she them turn their head to the left or to the right and you should see it

True or False. Analysis of assessment and laboratory data help clinicians identify the underlying cause of signs and symptoms.

True Rationale: Analysis of assessment and laboratory data help clinicians identify the underlying cause of signs and symptoms. Nurses use findings to identify the underlying functional problem, label it (sometimes in a nursing diagnosis format), and plan interventions based on patient outcomes.

Regions of the breast

Upper Inner, Lower Inner, Upper Outer, Lower Outer, Tail of Spence

A patient complains of a soft, irregular mass on the left side of the scrotum he noticed while walking. The nurse palpates a mass that feels like "a bag of worms." These findings are consistent with which condition?

Varicocele. Rationale: Varicocele is a condition caused by abnormal dilation and tortuosity of the veins along the spermatic cord, often on the left side. Upon palpation, the varicocele feels like a bag of worms.

Location of heart, great vessels

§Auscultation landmarks: anterior thoracic wall §Intercostal spaces (ICS); sternal lines §Midclavicular line (MCL) §Base: top of the heart; found at 2nd ICS §Apex: bottom of the heart; found at 5th ICS §Point of maximal impulse (PMI) §Arterial great vessels §Carotids (neck, also); aorta; pulmonary veins §Venous great vessels §Jugulars (neck, also); superior vena cava §Inferior vena cava; pulmonary arteries §Heart chambers §Atria; ventricles; septum §Atrioventricular (AV) valves: separate atria from ventricles §Tricuspid; mitral §Semilunar valves: separate ventricles from great vessels §Pulmonic; aortic §Heart wall: three layers §Endocardium: thin; lines interiors of chambers, valves §Myocardium: thick; muscular for pumping §Epicardium: thin; muscle, exterior layer §Pericardium: tough, fibrous; encloses/protects §Coronary arteries and veins The point of maximal impulse (PMI) is a term used to describe the area where the apical pulsation can be seen or palpated. In most adults, this impulse can commonly be found at the intersection of the 5th ICS mitral area and the left MCL in the mitral area

Urgent Assessment for Peripheral Vascular and Lymphatic System

§Complete arterial occlusion: limb-threatening situation §Symptoms: pain; numbness; coolness; extremity color change §Deep vein thrombosis (DVT): immediate anticoagulant therapy necessary §Symptoms: pain; edema; extremity warmth §Pulmonary embolism: life-threatening emergency §Signs: acute dyspnea; chest pain; tachycardia; diaphoresis; anxiety

Cardiac cycle in relation to ECG

§ECG records cardiac electrical changes as specific waves, intervals §P wave §PR interval §QRS complex §T wave §Pacemaker: SA node §Records cellular depolarization

Lobes of the Lungs

§Each lung: divided by oblique fissure §Left lung: two lobes §Right lung: three lobes §Minor fissure divides right upper lobe. §Horizontally §RML: auscultated anteriorly, under right breast §Lungs: divide into thirds §Upper, middle, and lower lung fields §Base: bottom §Apex: top §Auscultation §Anteriorly §Posteriorly

Collect objective data related to the respiratory system using accurate physical examination techniques

§Inspection §Thoracic cage, respirations, skin color, and condition §Person's facial expression, and LOC §Palpation §Confirm symmetric expansion §Detection of any lumps, masses, or tenderness §Percussion §Lung fields §Auscultation §Assess breath sounds, and note any abnormal/adventitious breath sounds.

Landmarks of the Thorax

§Landmarks (used to document accurately) §Vertical: ribs §Horizontal: Series of lines provide horizontal reference marks. §Anterior thoracic landmarks §Ribs: associated interspaces §Suprasternal (jugular) notch §Intercostal space (ICS) §Costal angle §Posterior thoracic landmarks §Ribs + vertebral spinal processes

Risk Reduction and Health Promotion for Respiratory

§Past history §Health goals §Lifestyle and personal habits §Smoking cessation §Occupational health §Environmental exposure §Prevention of asthma §Medications §Immunizations

Collect subjective data related to the respiratory system including chest pain, dyspnea, orthopnea, cough, sputum, wheezing, or fatigue

§Past medical history §Lifestyle and personal habits §Occupational history §Environmental exposures §Medications §Family history

Structure and Function Peripheral Vascular and Lymphatic System

§Peripheral vascular system §Arterial system §Arterial/arteriole walls: three layers §Tunica intima; tunica media; tunica externa §Elastic fibers §Smooth endothelial cell lining §Injury contributes: atherosclerosis pathogenesis §Capillaries: exchange nutrients, gases, metabolites between vessels, tissues §Venous system §Veins §Thin-walled, low-pressure system §Superficial system: greater, lesser saphenous §Deep system §Common femoral; femoral; §Popliteal; anterior/posterior/peroneal tibial vessels §Lymphatic system §Lymph nodes, lymphatic vessels, spleen, tonsils, and thymus §Maintains fluid, protein balance §Functions with immune system to fight infection §Lymph > lymphatic vessels à lymphedema

Mechanics of Respiration

§Primarily: automatic process §Main trigger for breathing: increased blood CO2 §Alteration causes §Medications (e.g., opiates, sedatives, overdose): hypoventilation §Anxiety, brain injury: hyperventilation §Inhalation §Diaphragm: contracts, flattens à pulling lungs down §Thorax, lungs: elongate, á vertical diameter §External intercostals: open ribs, á diameter §Increased thoracic diameter à thorax pressure < atmospheric pressure §Approximately 500 to 800 mL of air enters lungs. §Expiration: passive process §Diaphragm, internal intercostal, abdominals relax §Lung pressure > atmospheric pressure §Air pushed from lungs: chest, abdomen relax §Conditions à altered respirations

Structure and Function of Thorax

§Respiratory portions §Upper: warms, moisturizes, transports air to lower §Lower: oxygenation, ventilation occur §Thorax: One of the body's most dynamic regions §Constantly in motion §Bony thoracic cage (12 pairs of ribs) §Thoracic cavity: three main compartments §Thoracic nerves: T1-T12; dermatomes §Phrenic nerve §Intercostal nerves §Thoracic muscles §Arterial blood supply §Numerous veins §Lungs: pulmonary arteries (2), pulmonary veins (2)

Identify the cardiac cycle

§Systole; diastole §First heart sound (S1): beginning of ventricular systole; "lub" §Second heart sound (S2): end of systole, beginning of diastole; "dub"

Lower Respiratory Tract

§Trachea bifurcates §Right main bronchus: shorter, wider, more vertical §Branches: bronchi; bronchioles; alveoli §Larger airway sounds > smaller airway sounds §Pleurae: continuous membranes within thorax §Visceral: lines outer lung surface §Parietal: lines thoracic wall, mediastinum; diaphragm §Pleural space

Reference Lines of the Thorax

§Vertical §Anterior (parallel to sternum) §Midsternal: medial sternum §Midclavicular: bilateral, medial clavicles §Anterior axillary lines: bilateral, axillary folds § Posterior (parallel to vertebral line) §Vertebral line: medial vertebral spinal processes §Midscapular line: medial of scapulae §Posterior axillary line: superior axilla to inferior thoracic §Midaxillary line: medial axilla

Objective Data for male genitalia and rectal assessment

•Common and specialty or advanced techniques Equipment; preparation •Comprehensive physical assessment Groin Penis Glans; shaft; external meatus Scrotum Inguinal region, femoral areas •Special circumstances, advanced techniques Testicles Transillumination of scrotum Hernias Perianal and rectal examination Anus; prostate; stool It is normal for a male to feel apprehensive about having his genitalia examined, especially by a female examiner Younger adolescents usually have more anxiety than older clients But any male may have difficulty dissociating a necessary, matter-of-fact step in physical examination from feeling this is an invasion of his privacy Concerns are similar to those experienced by female during examination of genitalia Modesty, fear of pain, cold hands, negative judgment, or memory of previously uncomfortable examinations Additionally, he may fear comparison to others, or fear having an erection during examination that would be misinterpreted by examiner Apprehension becomes manifested in different behaviors Many act resigned or embarrassed and may avoid eye contact Occasional man will laugh and make jokes to cover embarrassment; also man may refuse examination by female and may insist on male examiner Take time to consider these feelings, as well as to explore your own You may feel embarrassed and apprehensive too You may worry about your age, lack of clinical experience, causing pain, or even that your movements might "cause" an erection Some examiners feel guilty when this occurs; you need to accept these feelings and work through them so that you can examine the male in a professional way Your demeanor is important; your unresolved discomfort magnifies any discomfort the man may have Your demeanor should be confident and relaxed Do not discuss genitourinary history or sexual practices while you are performing examination as it may be perceived as judgmental Use a firm deliberate touch, not soft, stroking one If erection does occur, do not stop the examination or leave the room; this only focuses more attention on the erection and increases embarrassment Reassure the male that this is only a normal physiologic response to touch Proceed with the rest of examination

Collect objective data related to the breasts and axillae such as dimpling of skin, lumps, and nipple discharge.

•Common and specialty/advanced techniques •Clinical breast examination (CBE) •Equipment; preparation •Comprehensive physical assessment •Inspection •Palpation •Vertical pattern; consistency •Tenderness; nodules; nipple palpation •Bimanual technique •Male breasts •Teaching BSE •Lifespan considerations •Pregnant and lactating women; newborns, infants •Children, adolescents; older adults •Cultural considerations •Collaboration with Interprofessional Team

Summary Checklist: Abdomen Examination

•Inspection Contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, and demeanor •Auscultation Bowel sounds; note any vascular sounds •Percussion All four quadrants and borders of liver and spleen •Palpation Light and deep palpation in all four quadrants, and palpate for liver and spleen