Assessment Test 1

The patient with a myocardial infarction feels

Heaviness in the chest region. The pain associated with myocardial infarction does not radiate to the trapezius muscle. Nausea, vomiting, dizziness, palpitations, and dyspnea are the symptoms of myocardial infarction.

Cardiac input increases with

Heavy exercise to meet body demand for increased metabolism. If the heart pumps more blood into the container (i.e., the blood vessels), the pressure on the container walls increases. *Increased BP

Volume is decreased during

Hemorrhage *Decreased BP

Stridor

High-pitched, monophonic, inspiratory, crowing sound; louder in neck than over chest wall *Originating in larynx or trachea, upper airway obstruction from swollen, inflamed tissues or lodged foreign body *Croup and acute epiglottitis in children and foreign inhalation; obstructed airway may be life-threatening

Wheeze—High-pitched (sibilant)

High-pitched, musical squeaking sounds that sound polyphonic (multiple notes as in a musical chord); predominate in expiration but may occur in both expiration and inspiration *Air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors; the passageway walls oscillate in apposition between the closed and barely open positions; the resulting sound is similar to that of a vibrating reed *Diffuse airway obstruction from acute asthma or chronic emphysema

Wheezes are

High-pitched, musical squeaking sounds that sound polyphonic and predominate in expiration, but may occur in both expiration and inspiration.

Mood or Affect: Abnormal

Hostile, distrustful, suspicious, crying.

The normal stimulus to breathe for most of us is an increase of carbon dioxide in the blood, or _______.

Hypercapnia

Stationary hand during percussion.

Hyperextend the middle finger (the pleximeter) and place its distal joint and tip firmly against the person's skin. Avoid the person's ribs and scapulae. Percussing over a bone yields no data because it always sounds "dull." Lift the rest of the stationary hand up off the person's skin (Fig. 8-1). Otherwise the resting hand will dampen off the produced vibrations, just as a drummer uses the hand to halt a drum roll.

Physiologic Changes from Poorly Controlled Pain: Pulmonary

Hypoventilation Hypoxia Decreased cough Atelectasis

A decrease of oxygen in the blood _______ also increases respirations but is less effective than hypercapnia.

Hypoxemia

A decrease in oxygen in the blood is referred to as

Hypoxemia. Hypoxemia also increases the respiration, but it is less effective than hypercapnia.

The skills requisite for the physical examination are:

IPPA - they are performed one at a time in this order: - Inspection - Palpation - Percussion - Auscultation

Why must you keep the examination room warm when using a stethescope?

If the person starts shivering, the involuntary muscle contractions could drown out other sounds. *Clean the stethoscope endpiece with an alcohol wipe. Then warm it by rubbing it in your palm. This avoids the "chandelier sign" elicited when placing a cold endpiece on a warm chest!

Facial features: Abnormal

Immobile, masklike, asymmetric, drooping

Physiologic Changes from Poorly Controlled Pain: Immune

Impaired cellular immunity Impaired wound healing

Pulse: Rate

In the adult at physical and mental rest, recent clinical evidence shows the normal resting heart range of 95% of healthy persons at 50 to 95 beats/min.24 Traditional resting heart rate limits established in the 1950s are 60 to100 beats/min. This range is still used; however, no research evidence supports it.

What is hyperventilation?

Increase in both rate and depth. Normally occurs with extreme exertion, fear, or anxiety. Also occurs with diabetic ketoacidosis (Kussmaul respirations), hepatic coma, salicylate overdose (producing a respiratory alkalosis to compensate for the metabolic acidosis), lesions of the midbrain, and alteration in blood gas concentration (either an increase in CO2 or a decrease in oxygen). Hyperventilation blows off CO2, causing a decreased level in the blood (alkalosis).

Consolidation of lung tissues may cause _______ fremitus.

Increased

Physiologic Changes from Poorly Controlled Pain: Endocrine

Increased adrenergic activity

What does the term hypercapnia indicate about a patient's respiratory status?

Increased carbon dioxide in the blood *Respiration helps maintain the pH of the blood by supplying oxygen to the blood and eliminating excess carbon dioxide. Hypercapnia is the term used to describe an increase in the carbon dioxide levels in the blood, and this is the normal stimulus for breathing.

Pneumonia is an

Infection in either one or both the lungs and is caused by microbes. Pneumonia causes inflammation in the air sacs of the lungs.

Checking for normal range of findings: Muscles and Skin

Inspect the skin and tissues for color, swelling, and any masses or deformity. *To assess for changes in sensation, ask the person to close his or her eyes. Test the person's ability to perceive sensation by breaking a tongue blade in two lengthwise. Lightly press the sharp and blunted ends on the skin in a random fashion and ask to identify it as sharp or dull (see Fig. 23-23). This test will help you identify location and extent of altered sensation.

What is the thoracic cage?

Is a bony structure with a conical shape, which is narrower at the top. It is defined by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae. Its "floor" is the diaphragm.

Incident pain

Is an acute type that happens predictably when certain movements take place. Examples include pain in the lower back on standing or whenever turning a hospitalized patient from side to side.

Cutaneous pain

Is derived from skin surface and subcutaneous tissues. Cutaneous pain is superficial, sharp, or burning.

Chronic (persistent) pain

Is diagnosed when the pain continues for 6 months or longer. It can last 5, 15, or 20 years and beyond. Chronic pain can be divided into malignant (cancer-related) and nonmalignant. *Chronic pain does not stop when the injury heals. It persists after the predicted trajectory. It outlasts its protective purpose, and the level of pain intensity does not correspond with the physical findings. Chronic pain originates from abnormal processing of pain fibers from peripheral or central sites.

Peripheral neuropathy (PN)

Is symmetric damage to peripheral nerves (feet or hands) resulting in pain without stimulation of the nerves. This is a common neuropathic pain characterized by numbness and tingling, with interspersed shooting or lancinating pain that is not attributed to a specific nociceptive source. Diabetic neuropathy is a common complication of diabetes and may relate to demyelination of the larger peripheral nerves, with an increase in smaller myelinated nerves. Other etiologies may include ischemic damage to nerves or hyperglycemia, causing changes in nerve microenvironment. Patients experience burning pain in feet bilaterally, which is often worse at night.

Standard precautions: Respiratory hygiene/cough etiquette

Is targeted at patients and accompanying persons with undiagnosed transmissible respiratory infections. Elements include: (1) education of staff, patients, and visitors; (2) posted signs in language(s) appropriate to the population; (3) source control measures (e.g., covering the mouth/nose with a tissue when coughing and promptly disposing of used tissues, using surgical masks on the coughing person); (4) hand hygiene after contact with respiratory secretions; and (5) spatial separation of >3 feet from people with respiratory infections in common waiting areas.

8 Characterisitics: Associated Factors

Is this primary symptom associated with any others (e.g., urinary frequency and burning associated with fever and chills)? Review the body system related to this symptom now rather than waiting for the Review of Systems section later. Many clinicians review the person's medication regimen now (including alcohol and tobacco use) because the presenting symptom may be a side effect or toxic effect of a chemical.

What is Hypothermia

Is usually caused by accidental, prolonged exposure to cold. It also may be purposefully induced to lower the body's oxygen requirements during heart or peripheral vascular surgery or neurosurgery, amputation, postcardiac arrest, or gastrointestinal (GI) hemorrhage.

What is an otoscope used for?

It funnels light into the ear canal and onto the tympanic membrane. Five specula, each a different size, are available to attach to the head. Choose the largest one that will fit comfortably into the person's ear canal.

What is an opthalmoscope?

It illuminates the internal eye structures. Its system of lenses and mirrors enables you to look through the pupil at the fundus (background) of the eye, much like looking through a keyhole at a room beyond. *The ophthalmoscope can compensate for myopia (nearsightedness) or hyperopia (farsightedness) but does not correct for astigmatism.

What is an obesogenic environment?

It is an interaction of biologic and social factors, but notably a U.S. environment with few opportunities for physical activity and an overabundance of inexpensive high-calorie food.

What is inspection?

It is close, careful scrutiny, first of the individual as a whole and then of each body system. Inspection begins the moment you first meet the person and develop a "general survey." As you proceed through the examination, start the assessment of each body system with inspection. *Learn to use each person as his or her own control and compare the right and left sides of the body. The two sides are nearly symmetric. Inspection requires good lighting, adequate exposure, and occasional use of certain instruments (otoscope, ophthalmoscope, penlight, nasal and vaginal specula) to enlarge your view.

The nurse is assessing the lungs of the patient on the anterior side of the chest. Where would the nurse find the highest point of the lung?

It is found up to 3 to 4 cm above the clavicle. *In the anterior chest, the apex or highest point of the lung tissue is 3 to 4 cm above the clavicles. The clavicle, commonly known as the collarbone, is located between the sternum and the scapula. Posteriorly, the location of the seventh cervical vertebra marks the apex of the lung tissue. **The base, or the lower border of the lung, rests on the diaphragm at about the sixth rib in the midclavicular line. Deep inspiration expands the lungs, and the lower border of the lungs drops up to the twelfth thoracic vertebra.

What is a normal feature of the right lung that the nurse should be aware of? - It is shorter than the left lung. - It has an upper and lower lobe. - It is narrower than the left lung. - Its lobes sit as horizontal bands.

It is shorter than the left lung. *The lungs are paired, but asymmetrical, structures. The right lung is shorter than the left lung because of the presence of the liver, which sits just under the right lung. The right lung has three, not two, lobes: an upper, middle, and lower lobe. The left lung only has two lobes: an upper lobe and a lower lobe. The left lung is narrower than the right lung because the heart bulges to the left. The lobes of neither lung are set as horizontal bands: instead, they are stacked in diagonal sloping segments and are separated by fissures that run obliquely through the chest.

The nurse starts to count the ribs of the patient from the angle of Louis. Which statement precisely describes the "angle of Louis"? - It is continuous with the first rib. - It marks the top edge of the sternum. - It is also known as the suprasternal notch. - It is the articulation of the manubrium and the body of the sternum.

It is the articulation of the manubrium and the body of the sternum. *The angle of Louis is the articulation of the manubrium and the body of the sternum. It is a useful place to start counting the ribs. The angle of Louis helps the nurse localize a respiratory finding horizontally. It is a palpable ridge between the manubrium and the body of the sternum, and it does not mark the top edge of the sternum. The angle of Louis is also called the sternal angle, not the suprasternal notch. It is continuous with the second rib.

How is the temporal artery thermometer (TAT) used?

It is used by sliding the probe across the forehead and behind the ear. The thermometer works by taking multiple readings and providing an average.

How does the tympanic membrane thermometer (TMT) work?

It senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus (the internal carotid artery); thus it is an accurate measurement of core temperature.

The diaphragm of the stethoscope is most often used because

Its flat edge is best for high-pitched sounds—breath, bowel, and normal heart sounds. Hold the diaphragm firmly against the person's skin, firm enough to leave a slight ring afterward.

Abnormal posture finding in aging adult

Kyphosis is the humpback appearance common in the very old and with osteoporosis.

The nurse is caring for a patient who has an incompetent tricuspid valve. Where should the nurse observe the palpable thrill in this patient?

Left lower sternal border *Tricuspid regurgitation occurs in the patient with incompetent tricuspid valve. The tricuspid valve is present near the left lower sternal border. Therefore, the nurse can feel a palpable thrill in the left lower sternal border of the patient with tricuspid regurgitation

What is tangential lighting and what is its purpose?

Light directed at an angle. It highlights pulsations and body contours better than perpendicular lighting

Range of motion: Abnormal

Limited joint range of motion. Paralysis—Absent movement. Jerky, uncoordinated movement.

Crackles - Coarse (coarse rales)

Loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but reappear shortly—sounds like opening a VELCRO FASTNER *Inhaled air collides with secretions in the trachea and large bronchi *Pulmonary edema, pneumonia, pulmonary fibrosis, and the terminally ill who have a depressed cough reflex

Basic principle: A structure with relatively more air (e.g. the lungs) produces a

Louder, deeper, and longer sound because it vibrates freely; *Whereas a denser, more solid structure (e.g. the liver) gives a softer, higher, shorter sound because it does not vibrate as easily

Wheeze—Low-pitched (sonorous rhonchi)

Low-pitched; monophonic, single note, musical snoring, moaning sounds; they are heard throughout the cycle, although they are more prominent on expiration; may clear somewhat by coughing7a *Airflow obstruction as described earlier by the vibrating reed mechanism; the pitch of the wheeze cannot be correlated to the size of the passageway that generates it *Bronchitis, single bronchus obstruction from airway tumor

The most remarkable point about the posterior chest is that it is almost all ______ _______.

Lower lobe *The upper lobes occupy a smaller band of tissue from their apices at T1 down to T3 or T4. At this level the lower lobes begin, and their inferior border reaches down to the level of T10 on expiration and T12 on inspiration. **Note that the right middle lobe does not project onto the posterior chest at all.

The systolic pressure is the

Maximum pressure felt on the artery during left ventricular contraction, or systole

The ophthalmoscope enlarges your view of the eye so you can inspect the

Media (anterior chamber, lens, vitreous) and the ocular fundus (the internal surface of the retina).

An accentuated S 1 occurs with

Mitral stenosis

The nurse feels a palpable thrill in the fifth interspace around the left midclavicular line of a patient with

Mitral stenosis

A sharp pain that does not radiate, dyspnea on exertion, and diaphoresis may occur in the patient with

Mitral valve prolapse

What are atelectatic crackles?

NOT pathologic. They are short, popping, crackling sounds that last only a few breaths. When sections of alveoli are not fully aerated (as in sleepers or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

The left lung is _______ than the right lung because the _______ bulges to the left.

Narrower; heart

Physiologic Changes from Poorly Controlled Pain: Gastrointestinal

Nausea Vomiting Ileus

Can you ever auscultate over a gown?

Never listen through a gown. Even though you see this on television, listening through clothing creates artifactual sound and muffles any diagnostically valuable sound from the heart or lungs. Therefore reach under a gown to listen, and take care that no clothing rubs on the stethoscope.

Overall appearance: Normal

No signs of acute distress are present.

Pathologic pain develops by two main processes:

Nociceptive and/or neuropathic processing.

A patient presents with Biot's respiration. Which finding will the nurse expect? - Breathing rate of less than 10 per minute - Gradual wax-and-wane pattern of respiration - Normal breathing interrupted by apnea - Normal inspiration followed by prolonged expiration

Normal breathing interrupted by apnea *The breathing pattern in Biot's respiration is irregular. A series of three to four normal respirations is followed by a period of apnea. The length of the cycle is variable and lasts for 10 seconds to 1 minute. It is generally seen in patients with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis. In chronic obstructive lung disease, the patient undertakes normal inspiration and prolonged expiration to overcome the increased airway resistance. Gradual wax-and-wane pattern of respiration is seen in the Cheyne-Stokes respiration. A breathing rate of less than 10 per minute occurs in patients who have bradypnea.

What is Chronic obstructive breathing?

Normal inspiration and prolonged expiration to overcome increased airway resistance. In a person with chronic obstructive lung disease, any situation calling for increased heart rate (exercise) may lead to dyspneic episode (air trapping) because the person does not have enough time for full expiration.

Respirations

Normally a person's breathing is relaxed, regular, automatic, and silent. *Report additional objective data (e.g., labored, shallow, or deep breathing; retractions in infants and children; and accessory muscle use in adults). **Normal adult respiration rate is between 10-20 a minute

Obvious Physical Deformities

Note any congenital or acquired defects: Missing extremities or digits; webbed digits; shortened limb.

Range of motion: Normal

Note full mobility for each joint and that movement is deliberate, accurate, smooth, and coordinated.

Normal range of findings: Joints

Note the size and contour of the joint. Measure the circumference of the involved joint for comparison with baseline. Check active or passive range of motion. Joint motion normally causes no tenderness, pain, or crepitation. *Observe posture; normally it is erect and relaxed.

On the anterior chest the fissure ________ crosses the _____ rib in the midaxillary line and terminates at the ____ rib in the midclavicular line.

Oblique (the major or diagonal); 5th; 6th *The right lung also contains the horizontal (minor) fissure, which divides the right upper and middle lobes. This fissure extends from the 5th rib in the right midaxillary line to the 3rd intercostal space or 4th rib at the right sternal border.

Checking for normal range of finding: Abdomen

Observe for contour and symmetry. Palpate for muscle guarding and organ size Note any areas of referred pain.

Decreased fremitus occurs with

Obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema. Any barrier that comes between the sound and your palpating hand decreases fremitus. *Occurs when anything obstructs transmission of vibrations (e.g., an obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema). Any barrier that gets in the way of the sound and your palpating hand decreases fremitus.

What is a sigh?

Occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli. Frequent sighs may indicate emotional dysfunction and also may lead to hyperventilation and dizziness.

Chemotherapy-induced PN (CIPN)

Occurs after chemotherapy treatment for cancer. The risk increases with the number of agents used in the course of treatment, higher cumulative doses of neurotoxic agents, preexisting neuropathy from diabetes or other causes, and older age. A symptom is numbness or burning, shooting pain in a glove-and-stocking distribution. NOTE: With any cancer survivor, you must address new onset of pain promptly to rule out pathologic recurrence of the cancer because this is what survivors most fear.

Sternal Angle

Often called the angle of Louis, this is the articulation of the manubrium and body of the sternum, and it is continuous with the second rib. The angle of Louis is a useful place to start counting ribs *The angle of Louis also marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

Malignant pain

Often parallels the pathology created by the tumor cells. The pain is induced by tissue necrosis or stretching of an organ by the growing tumor. It fluctuates within the course of the disease. Chronic nonmalignant pain is often associated with musculoskeletal conditions such as arthritis, low back pain, or fibromyalgia.

Physiologic Changes from Poorly Controlled Pain: Renal

Oliguria Urinary retention

8 Characteristics: Timing

Onset, Duration and Frequency *"The pain started yesterday" will not mean much when you return to read the record in the future. The report must include answers to questions such as, "How long did the symptom last (duration)? Was it steady (constant) or did it come and go during that time (intermittent)? Did it resolve completely and reappear days or weeks later (cycle of remission and exacerbation)?"

What is the most convenient and accurate site to get temperature?

Oral temperature - The sublingual pocket has a rich blood supply from the carotid arteries that quickly responds to changes in inner core temperature.

Somatic pain

Originates from musculoskeletal tissues or the body surface. Whether somatic pain is sharp or dull, it is usually well localized and easy to pinpoint. Somatic pain, like visceral pain, can be accompanied by nausea, sweating, tachycardia, and hypertension caused by the ANS response.

Visceral pain

Originates from the larger internal organs (i.e., stomach, intestine, gallbladder, pancreas). It often is described as dull, deep, squeezing, or cramping. The pain impulse is transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system (ANS). That is why visceral pain often presents along with autonomic responses such as vomiting, nausea, pallor, and diaphoresis.

The pulmonary vein carries

Oxygenated blood from the lungs to the heart.

Record the normal response to all these maneuvers as

PERRLA = Pupils Equal, Round, React to Light, and Accommodation. *PERRL - can be done on conscious/unconscious patients **A (Accommodation) - can only be done on conscious patients because they need to be able to understand and follow directions

The patient with pulmonary hypertension experiences

Pain in the chest region, and may have dyspnea, lower-extremity edema, and fatigue.

Cholecystitis is a gastrointestinal disorder that is associated with

Pain in the right upper abdomen, nausea and vomiting, and anorexia.

Neuropathic pain is

Pain that does not adhere to the typical and rather predictable phases in nociceptive pain. It is "pain caused by a lesion or disease of the somatosensory nervous system." Neuropathic pain implies an abnormal processing of the pain message from an injury to the nerve fibers. This type of pain is the most difficult to assess and treat. Pain is often perceived long after the site of injury heals, and it evolves into a chronic condition. Neuropathic pain is described as burning, shooting, and tingling. *Conditions that may cause neuropathic pain include diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and chemotherapy. Further examples include CNS lesions such as stroke, multiple sclerosis, and tumor.

Taking BP with failure to palpate radial artery while inflating: inflating cuff too high results in

Pain.

Skin color: Abnormal

Pallor, cyanosis, jaundice, erythema, any lesions

Twelfth Rib

Palpate midway between the spine and the person's side to identify its free tip

What is palpation?

Palpation follows and often confirms points that you noted during inspection. Palpation applies your sense of touch to assess these factors: texture; temperature; moisture; organ location and size; and any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain. Different parts of the hands are best suited for assessing different factors:

There are five components of jugular venous pressure—V wave occurs with

Passive atrial filling due to increase in pressure and volume in the right atria. *The V wave occurs with passive atrial filling because of the increasing volume in the right atria and increased pressure.

Why are past health events important?

Past health events are important because they may have residual effects on the current health state. The previous experience with illness may also give clues about how the person responds to illness and the significance of illness for him or her. *Past health events include: Childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, last examination date, allergies, and current medications

While assessing a patient with pulmonic stenosis, the nurse hears medium pitched murmurs in the left second intercostal space. Which finding does the nurse observe in the patient?

Pathologic S 4 *Murmurs can be heard in the left intercostal space in the patient with pulmonic stenosis. Calcification of the pulmonic valve in the patient with pulmonic stenosis may result in the enlargement of the right ventricle. The fourth heart sound, S 4, occurs after the diastole due to resistance of the ventricles to fill with blood. It commonly occurs in the presence of an enlarged right ventricle.

What is percussion?

Percussion is tapping the person's skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.

The depth of penetration of percussion has limits.

Percussion sets into motion only the outer 5 to 7 cm of tissue. It does not penetrate to reveal any change in density deeper than that. In addition, an abnormal finding must be 2 to 3 cm wide to yield an abnormal percussion note. Lesions smaller than that are not detectable by percussion.

The patient reports having a sudden stabbing pain below the sternum, in the upper back, and in the neck. During the assessment, the nurse also finds that the patient has a fever, joint pains, and a dry cough. What condition is most consistent with these findings?

Pericarditis *Sudden pain in the substernal region that radiates to the trapezius muscle and is present in the upper back is a sign of pericarditis. Pericarditis refers to the inflammation of the pericardium. Fever, dry cough, and joint pains are subjective symptoms of pericarditis.

Normal Range of Finding in the aging adult:

Physical Appearance: By the eighth and ninth decades, body contour is sharper with more angular facial features, and body proportions are redistributed. Gait—Older adults often use a wider base to compensate for diminished balance, arms may be held out to help balance, and steps may be shorter or uneven. Posture—A general flexion occurs by the eighth or ninth decade.

Bronchial (tracheal) breath sounds:

Pitch: High Amplitude: Loud Duration: Inspiration < expiration Quality: Harsh, hollow tubular Normal location: Trachea and larynx

Vesicular breath sounds:

Pitch: Low Amplitude: Soft Duration: Inspiration > expiration Quality: Rustling, like the sound of the winds in the trees Normal location: Over peripheral lung fields where air flows through smaller bronchioles and alveoli

Brochovesicular breath sounds:

Pitch: Moderate Amplitude: Moderate Duration: Inspiration = expiration Quality: Mixed Normal location: Over major bronchi where fewer alveoli are located: posterior between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces

Confirm symmetric chest expansion by

Placing your warmed hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10. Slide your hands medially to pinch up a small fold of skin between your thumbs. Ask the person to take a deep breath. Your hands serve as mechanical amplifiers; as the person inhales deeply, your thumbs should move apart symmetrically. Note any lag in expansion. *ABNORMAL: Unequal chest expansion occurs with marked atelectasis, lobar pneumonia, pleural effusion, thoracic trauma such as fractured ribs, or pneumothorax. Pain accompanies deep breathing when the pleurae are inflamed.

Inflammation of the pleura may cause ______ _______ fremitus.

Pleural friction

The nurse is likely to find a palpable grating sensation with breathing in a patient who has

Pleural friction fremitus.

A college student comes to the emergency room with complaints of a sudden, sharp pain on the right side, and shortness of breath. The right side of the chest is not moving with inspiration. The patient's trachea is deviated toward the left; there is no tactile fremitus on the right. The nurse hears hyperresonant percussion sounds on the right and resonant sounds on the left. There are no breath sounds heard on the right. Which disorder does the nurse suspect?

Pneumothorax *Pneumothorax is a condition in which free air in the pleural space causes partial or complete lung collapse. In pneumothorax, unequal chest expansion is seen with decreased tactile fremitus. The trachea shifts to the unaffected side. Breath sounds are decreased or absent, and percussion reveals hyperresonance.

While assessing the cardiac health of a middle-aged patient, which finding would the nurse consider abnormal? - Presence of apical impulse - Presence of a venous hum - Presence of jugular venous pulse - Presence of a third heart sound

Presence of a third heart sound *In middle-aged adults, the third heart sound (S3) or ventricular gallop is usually abnormal. The S3 indicates decreased compliance of the ventricles, and it may be the earliest sign of heart failure.

Which sign would be present in a patient with atherosclerosis?

Presence of bruit sound *Atherosclerotic disease causes turbulence in the blood flow and results in a bruit sound.

The patient with angina pectoris feels

Pressure such as discomfort behind the sternum or in the retrosternal region. Nausea, vomiting, dyspnea, and diaphoresis are the subjective symptoms of angina pectoris.

Body, build, contour: Normal

Proportions are: 1. Arm span (fingertip to fingertip) equals height. 2. Body length from crown to pubis roughly equal to length from pubis to sole.

The nurse is assessing a patient who coughed up pink, frothy sputum several times during the day. What is the probable cause for this finding? Tuberculosis Viral infection Bacterial infection Pulmonary edema

Pulmonary edema *Pulmonary edema is likely to cause pink, frothy sputum production. Some sympathomimetic medications also have a side effect of pink-tinged mucus.

Pink, frothy sputum is associated with:

Pulmonary edema, some sympathomimetic medications have a side effect of pink-tinged mucus.

Impalpable apical impulse is the sign of

Pulmonary emphysema

The nurse can feel a palpable thrill in the second left interspace in the patient with

Pulmonic stenosis

What should the nurse assess first in the patient while doing a regional cardiovascular assessment?

Pulse and blood pressure

Cardiac input decreases with

Pump failure (weak pumping action after myocardial infarction, or in shock) *Decreased BP

Complex Regional Pain Syndrome (CRPS) or Reflexive Sympathetic Dystrophy (RSD)

RSD/CRPS is a chronic progressive nerve condition, characterized by burning pain, swelling, stiffness, and discoloration of the affected extremity. It affects both men and women, usually around 40 to 60 years old, and occurs weeks to months after a nerve injury (e.g., carpal tunnel syndrome, broken leg, cerebral lesions). A key feature is that a typically innocuous stimulus (e.g., a light brush of a cotton ball or clothing) can create a severe, intense painful response. Objective data include swelling, disappearance of skin wrinkles, cool skin temperature, discoloration, brittle nails, and finally atrophic changes (pale, dry, shiny skin and muscle atrophy). Treatment includes high doses of drugs (e.g., prednisone, amitriptyline, pregabalin, clonidine) to decrease symptoms and physical therapy to regain limb function.

What is hyperventilation?

Rapid, deep breathing - causes carbon dioxide to be blown off.

Hyperventilation is the presence of

Rapid, deep breathing in an individual that causes the carbon dioxide to be blown off.

What is tachypnea?

Rapid, shallow breathing. Increased rate, >24 per minute. This is a normal response to fever, fear, or exercise. Rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.

Which type of temperature provides the closest approximation to core temperature?

Rectal temperature, but it is much more invasive, so you need to weight the pros and cons *In children the temporal artery route misses fever in as many as 30% of children 6 to 36 months old14; therefore it may be advantageous to use rectal temperature in children with a suspected fever or infection.

Nocturia

Recumbency at night promotes fluid resorption and excretion; this occurs with heart failure in the person who is ambulatory during the day.

Pain that is felt at a particular site but originates from another location is known as

Referred pain. For example, an inflamed appendix in the right lower quadrant of the abdomen may have referred pain in the periumbilical area, or the pain from acute coronary syndrome may be felt in the left arm or neck.

What can cause a wide split in the second heart sound?

Right bundle branch block

Posture: Abnormal

Rigid spine and neck; moves as one unit (e.g., arthritis). Stiff and tense, ready to spring from chair, fidgety movements. Shoulders slumped; looks deflated (e.g., depression).

Elasticity of arterial walls may result in increased BP with

Rigidity, hardening as in arteriosclerosis (heart pumping against greater resistance). When the container walls are stiff and rigid, the pressure needed to push the contents increases.

Chronic dyspnea is

SOB lasting for more than 1 month. It may have neurogenic, respiratory, or cardiac origin.

__________ is a condition that involves the rotation of the vertebrae.

Scoliosis * The patient with scoliosis has a lateral S-shaped curvature of the thoracic and lumbar spine. Scoliosis causes unequal shoulder and scapular height and unequal hip levels.

Which heart sound occurs due to the closure of the semilunar valves? First heart sound (S 1) Second heart sound (S 2) Third heart sound (S 3) Fourth heart sound (S 4)

Second heart sound (S 2) *The second heart sound (S2) occurs with the closure of the semilunar valves, and it indicates the end of systole.

The bronchi are lined with goblet cells and cilia, what is the purpose of these cells and cilia?

Secrete mucus that entraps the particles, and cilia, which sweep particles upward where they can be swallowed or expelled.

The _______ valves are set between the ventricles and the arteries.

Semilunar (SL) *They open during pumping, or systole, to allow blood to be ejected from the heart.

Which statement best describes the semilunar valves? - Semilunar valves are intra-arterial valves. - Semilunar valves are closed during the ventricular systole. - Semilunar valves lie between the ventricles and the great vessels. - Semilunar valves are also called the tricuspid and the mitral valves.

Semilunar valves lie between the ventricles and the great vessels.

Sex: Normal

Sexual development is appropriate for sex and age. If the individual is transgender, note the stage of transformation.

A patient reports pain and discomfort in the chest. After assessing the patient, the nurse determines that the pain is of pulmonary origin. Which characteristics in the patient enabled the nurse to make this conclusion? Squeezing burning pain, dyspnea on exertion, and an intolerance to exercise Sharp pain that does not radiate, dyspnea on exertion, along with diaphoresis Sharp stabbing pain that worsens with deep breathing and a cough with hemoptysis Sharp pleuritic pain that worsens with deep breathing along with tightness in the chest

Sharp stabbing pain that worsens with deep breathing and a cough with hemoptysis *When caring for a patient with chest pain, the first intervention of the nurse is to differentiate whether the chest pain is of cardiac, pulmonary, gastrointestinal, or musculoskeletal origin. A sharp stabbing pain in the chest worsens with deep breathing due to blockage in the pulmonary artery. Hemoptysis refers to the coughing of blood from the respiratory tract. These are the characteristics of a pulmonary embolism.

Acute pain

Short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Examples of acute pain include surgery, trauma, and kidney stones. Acute pain has a self-protective purpose; it warns the individual of actual or threatened tissue damage.

The right lung is ________ than the left lung because of the underlying ________.

Shorter; liver

What is dyspnea?

Shortness of breath (SOB) *In hospitalized patients dyspnea is a common symptom and a predictor of adverse outcomes. **Determine how much activity precipitates the shortness of breath (SOB)—state specific number of blocks walked, number of stairs.

What is Biot respiration?

Similar to Cheyne-Stokes respiration, except that the pattern is irregular. A series of normal respirations (three to four) is followed by a period of apnea. The cycle length is variable, lasting anywhere from 10 seconds to 1 minute. Seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis.

Which term can be used to describe the pacemaker of the heart?

Sinoatrial node *The automaticity of the heart enables it to contract by itself, independent of any signals or stimulation from the body. The heart contracts in response to an electrical current conveyed by a conduction system. Specialized cells in the sinoatrial node near the superior vena cava initiate an electrical impulse. The sinoatrial node triggers electrical impulses at regular intervals to cause the heart muscles to beat in an orderly sequence; hence, it is the pacemaker.

What is bradypnea?

Slow breathing. A decreased but regular rate (<10 per minute), as in drug-induced depression of the respiratory center in the medulla, increased intracranial pressure, and diabetic coma.

What is Hypoventilation?

Slow, shallow breathing - causes carbon dioxide to build up in the blood,

Shine a light from the side across the cornea and check for

Smoothness and clarity. This oblique view highlights any abnormal irregularities in the corneal surface. There should be no opacities (cloudiness) in the cornea, the anterior chamber, or the lens behind the pupil. Do not confuse an arcus senilis with opacity. The arcus senilis is a normal finding in aging persons *ABNORMAL: A corneal abrasion causes irregular ridges in reflected light, producing a shattered look to light rays

Physiologic Changes from Poorly Controlled Pain: Musculoskeletal

Spasm Joint stiffness

Nociceptors

Specialized nerve endings called nociceptors are designed to detect painful sensations from the periphery and transmit them to the CNS. Nociceptors are located primarily within the skin; joints; connective tissue; muscle; and thoracic, abdominal, and pelvic viscera. These nociceptors can be stimulated directly by mechanical or thermal trauma or secondarily by chemical mediators that are released from the site of tissue damage. *Nociceptors carry the pain signal to the CNS by two primary sensory (or afferent) fibers: Aδ and C fibers

While assessing a patient who has fever, cough, and myalgia, the nurse confirms that the patient has pneumonia. Which other symptom would the nurse expect to find in the patient? - Pressure-like pain felt in the chest during morning hours - Sudden severe pain in the chest with a change in location - Stabbing pain located in the chest with a cough on one side - Burning sensation within the chest after having large meals

Stabbing pain located in the chest with a cough on one side *Pneumonia is an inflammatory condition which may occur due to bacterial infection. The patient feels stabbing pain with a cough on one side of the chest due to inflammation of the pleura.

Pectus carinatum, or pigeon breast, is a condition in which the

Sternum protrudes forward. The ribs slope back at either side and the vertical depressions are present along the costochondral junctions.

Esophageal spasm is associated with crushing pain in the

Substernal region and dysphagia.

Which blood vessel drains the blood from the head and upper extremities?

Superior vena cava

What is diaphoresis?

Sweating, especially to an unusual degree as a symptom of disease or a side effect of a drug.sweating, especially to an unusual degree as a symptom of disease or a side effect of a drug.

Abnormal range of findings: Abdomen

Swelling, bulging, herniation, inflammation, organ enlargement

Abnormal range of findings: Joints

Swelling, inflammation, injury, deformity, diminished range of motion, increased pain on palpation (crepitation is an audible and palpable crunching that accompanies movement) *Slumped posture or abdominal guarding with pain.

Rust colored sputum is associated with:

TB, pneumococcal pneumonia

Physiologic Changes from Poorly Controlled Pain: Cardiac

Tachycardia Elevated blood pressure Increased myocardial oxygen demand Increased cardiac output

Orthostatic (or Postural) Vital Signs

Take serial measurements of pulse and BP when (1) you suspect volume depletion; (2) when the person is known to have hypertension or is taking antihypertensive medications; or (3) when the person reports fainting or syncope. *Have the person rest supine for 2 or 3 minutes, take baseline readings of pulse and BP, and repeat the measurements with the person sitting and then standing. For the person who is too weak or dizzy to stand, assess supine and then sitting with legs dangling. When the position is changed from supine to standing, normally a slight decrease (less than 10 mm Hg) in systolic pressure may occur.

The absence of bilateral breath sounds indicates

That the patient may have a pulmonary disorder and is not a normal finding.

A diminished S 2 heart sound indicates

That the patient may have aortic stenosis.

Sternum

The "breastbone" has three parts: the manubrium, the body, and the xiphoid process. Walk your fingers down the manubrium a few centimeters until you feel a distinct bony ridge, the sternal angle.

Viscosity may be increased when

The "thickness" of blood is determined by its formed elements, the blood cells. When the contents are thicker, the pressure increases. Increased hematocrit in polycythemia *Increased BP

What is residual volume?

The amount of air remaining in the lungs even after the most forceful expiration.

BP in the aging adult

The aorta and major arteries tend to harden with age. As the heart pumps against a stiffer aorta, the systolic pressure increases, leading to a widened pulse pressure. With many older people, both the systolic and diastolic pressures increase, making it difficult to distinguish expected aging values from abnormal hypertension.

What is the precordium?

The area on the anterior chest directly overlying the heart and great vessels

Pathologic S 3 occurs due to

The backward flow of blood into the left atrium in the patient with mitral regurgitation.

BMI: Abnormal

The cause of weight gain is usually excess caloric intake; occasionally it is endocrine disorders, drug therapy (e.g., corticosteroids), or depression.

What is Hemoptysis?

The coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.

What is pulse pressure?

The difference between the systolic and diastolic pressures and reflects the stroke volume

Pulse: Force

The force of the pulse shows the strength of the heart's stroke volume. A "full, bounding" pulse denotes an increased stroke volume (e.g., as with anxiety, exercise, and some abnormal conditions). The pulse force is recorded using a three-point scale: 3+—Full, bounding 2+—Normal, expected 1+—Weak, thready (reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock) 0—Absent

Auscultating through a hairy chest.

The friction on the endpiece from a man's hairy chest causes a crackling sound that mimics an abnormal breath sound called crackles. To minimize this problem, wet the hair before auscultating the area.

The internal jugular vein drains blood from

The head, but not from the upper extremities.

Stature: Normal

The height appears within normal range for age, genetic heritage

Left ventricle dilation and hypertrophy is caused by

The increased stroke volume of the left ventricle.

What is resonance?

The low-pitched, clear, hollow sound that predominates in healthy lung tissue in the adult. The resonant note may be duller in the athlete with a heavily muscular chest wall and in the heavily obese adult in whom subcutaneous fat produces scattered dullness. *ABNORMAL: Asymmetry is important: one side with prominent dullness or marked hyperresonance indicates underlying disease.

What is vital capacity?

The maximum amount of air that a person can expel from the lungs after first filling the lungs to maximum.

What is the mediastinum?

The middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels.

What is the myocardium?

The muscular wall of the heart; it does the pumping.

Pulse in the aging adult

The normal range of heart rate is 50 to 95 beats/min, but the rhythm may be slightly irregular. The radial artery may feel stiff, rigid, and tortuous in an older person, although this condition does not necessarily imply vascular disease in the heart or brain. The increasingly rigid arterial wall needs a faster upstroke of blood, so the pulse is actually easier to palpate.

What is forced expiratory time?

The number of seconds it takes for the person to exhale from total lung capacity to residual volume. It is a screening measure of airflow obstruction. *A forced expiration of 6 seconds or more occurs with obstructive lung disease.

A patient complains of sudden pain in the shoulder and the lateral region of the chest. The nurse finds that the patient has acute dyspnea and a cough. What conclusion could the nurse draw from these findings?

The patient has a pneumothorax. *It is caused due to accumulation of air in the pleural space.

What finding does the nurse identify as normal when assessing the chest of an elderly patient? - The patient has an outward curvature noted in the thoracic spine. - The respirations are deeper, with 40% increase in the tidal volume. - The costal angle is about 50% wider than seen in the younger adult. - The anteroposterior diameter is less than the transverse diameter.

The patient has an outward curvature noted in the thoracic spine. *Kyphosis, or an outward curvature of the thoracic spine, is a normal finding in elderly patients. The person compensates by holding their head extended and tilted back. It is normal to find that the respirations are deeper with a 40% increase in the tidal volume in the pregnant patient, but not in the elderly patient. The thoracic cage appears wider and the costal angle widens by about 50% in the pregnant patient, but not in the elderly patient. The aging adult has a barrel-shaped chest, with the anteroposterior diameter equal to the transverse diameter.

The nurse is caring for a patient who has pain in the substernal region. The patients states, "I feel like some object is blocking my throat." After doing an assessment, the nurse finds that the pain may be caused by gastrointestinal complications. What condition may be causing the patient's symptoms? The patient may have cholecystitis. The patient may have pancreatitis. The patient may have esophageal spasms. The patient may have gastroesophageal reflux.

The patient may have esophageal spasms. *The squeezing of the muscles of the esophagus may prevent food from reaching the stomach, leaving it stuck in the esophagus. This may lead to the feeling in the patient that some object is obstructing the throat or esophagus. This causes pain in the substernal region. These characteristics indicate that the patient has esophageal spasms. **Cholecystitis is the inflammation of the gallbladder leading to the blockage of the cystic duct. Therefore, it causes pain in the epigastric region. ***Inflammation of the pancreas and upper abdominal pain is an early sign of pancreatitis. ****The pain associated with gastroesophageal reflux disease occurs in the retrosternal region, but not the substernal region.

Which assessment finding will the nurse document for a patient with chronic respiratory disease? - The patient has cutaneous angiomas. - The patient's distal phalanx is clubbed. - The patient appears to be very drowsy. - The patient appears restless and anxious.

The patient's distal phalanx is clubbed. *Clubbing of the distal phalanx occurs with chronic respiratory disease following the growth of vascular connective tissue. Cutaneous angiomas, or spider nevi, are noted in the patient with liver disease. Cerebral hypoxia may cause excessive drowsiness. It may also cause the patient to be restless, anxious, and irritable.

Personal hygiene: Normal

The person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group. (Note that a wide variation of dress and hygiene is "normal." Many cultures do not include use of deodorant or women shaving legs.). Hair is groomed, brushed. Makeup is appropriate for age and culture.

Age: Normal

The person appears his or her stated age

Level of consciousness: Normal

The person is alert and oriented to person, place, time, and situation. Attends to and responds appropriately to your questions.

Mood or Affect: Normal

The person is comfortable and cooperative with the examiner and interacts pleasantly.

Facial expression: Normal

The person maintains eye contact (if culturally appropriate); expressions are appropriate to the situation (e.g., thoughtful, serious, or smiling). (Note expressions both while the face is at rest and while the person is talking.)

Position: Normal

The person sits comfortably with arms relaxed at sides and head turned to examiner.

Posture: Normal

The person stands comfortably erect as appropriate for age. Note the normal "plumb line" through anterior ear, shoulder, hip, patella, ankle. Exceptions are the standing toddler, who has a normally protuberant abdomen ("toddler lordosis"), and the aging person, who may be stooped with kyphosis.

What is Respiration?

The physical act of breathing; air rushes into the lungs as the chest size increases (inspiration) and is expelled from the lungs as the chest recoils (expiration).

What is mean arterial pressure (MAP)?

The pressure forcing blood into the tissues averaged over the cardiac cycle. This is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer. Rather it is a value closer to diastolic pressure plus one third the pulse pressure.

Pulse: Rhythm

The pulse normally has a regular, even tempo. An abnormality of this would be something like a sinus arrhythmia *If any other irregularities are felt, auscultate heart sounds for a more complete assessment

Anterior chest shape and configuration of the chest wall.

The ribs are sloping downward with symmetric interspaces. The costal angle is within 90 degrees. Development of abdominal muscles is as expected for the person's age, weight, and athletic condition. *ABNORMAL: - Barrel chest has horizontal ribs and costal angle >90 degrees. - Hypertrophy of abdominal muscles occurs in chronic emphysema.

Costal angle

The right and left costal margins form an angle where they meet at the xiphoid process. Usually 90 degrees or less, this angle increases when the rib cage is chronically overinflated, as in emphysema.

What part of the thoracic cavity contains the lungs?

The right and left pleural cavities, on either side of the mediastinum.

Inferior Border of the Scapula

The scapulae are located symmetrically in each hemithorax. The lower tip is usually at the seventh or eighth rib.

What is the characteristic feature of the third heart sound, S 3?

The sound occurs at the left lower sternal border. *S 3 is a ventricular filling sound and it occurs due to the backward flow of blood into the left atrium. The third heart sound occurs in the apex or left lower sternal border, and the sound does not change with respiration.

Speech pattern: Normal

The stream of talking is fluent, with an even pace. The person conveys ideas clearly. Word choice is appropriate for culture and education. Communicates in prevailing language easily by himself or herself or with an interpreter.

What is the endocardium?

The thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.

What is the forced vital capacity (FVC)?

The total volume of air exhaled.

The nurse is caring for a patient with small amounts of tissue consolidation in the lungs. What will the nurse hear through the stethoscope when the patient whispers a phrase? - The voice is transmitted clearly into the stethoscope. - The voice will be muffled, faint, and almost inaudible. - The voice can be heard similar to a whisper in the ears. - The "eee" sound changes to long bleating "aaa" sound.

The voice can be heard similar to a whisper in the ears *When the patient with small amounts of tissue consolidation in the lungs whispers a phrase, the voice is heard like a whisper in the ears. The condition is said to be whispered pectoriloquy. **When the patient has bronchophony, the voice is transmitted very clearly into the stethoscope. This is due to the increased lung density. In a normal lung, the response is faint, muffled, and almost inaudible. If an "eee" sound changes to the long bleating "aaa" sound through the stethoscope, the patient is said to have egophony, or the voice of a goat.

What is the forced expiratory volume in 1 second (FEV1)?

The volume exhaled in the first measured second. A normal outcome is a FEV1/FVC ratio of 75% or greater, meaning that no significant obstruction of airflow is present. *Mild obstruction of airflow is an FEV1/FCV ratio of 60% to 70%; moderate obstruction is a measure of 50% to 60%; severe obstruction is a ratio of less than 50%.

Nutrition: Normal

The weight appears within normal range for height and body build; body fat distribution is even.

The nurse is caring for an elderly patient. Which finding does the nurse associate with Cheyne-Stokes respiration? - The respiration cycle length is variable. - The breathing period lasts for 10 seconds. - Three to four respirations are followed by apnea. - There are periods of apnea in between normal breaths.

There are periods of apnea in between normal breaths. *Cheyne-Stokes respirations include periods of apnea in between normal breaths. The breathing periods last from 30 to 45 seconds, with periods of apnea lasting for about 20 seconds.

During an assessment, the nurse palpates rhonchal fremitus in a patient. Which condition may need to be further investigated?

Thick bronchial secretions *Fremitus is a palpable vibration. When the patient is asked to say something, the sounds generated from the larynx are transmitted through the patent bronchi and the lung parenchyma to the chest wall, and can be felt as vibrations. Rhonchal fremitus is found when bronchial secretions are thick.

8 Characteristics: Character or Quality

This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike. Use similes: Does blood in the stool look like sticky tar? Does blood is vomit look like coffee grounds?

Diaphragmatic excursion

This diaphragmatic excursion should be equal bilaterally and measure about 3 to 5 cm in adults, although it may be up to 7 to 8 cm in well-conditioned people *ABNORMAL: Note an abnormally high level of dullness and absence of excursion. These occur with pleural effusion (fluid in the space between the visceral and parietal pleura) or atelectasis of the lower lobes.

Marfan Syndrome

This inherited connective tissue disorder is characterized by tall, thin stature (≥95th percentile), arachnodactyly (long, thin fingers), hyperextensible joints, arm span greater than height, pubis-to-sole measurement exceeding crown-to-pubis measurement, sternal deformity (note pectus excavatum), high-arched narrow palate, narrow face, and pes planus (flat feet). Early morbidity and mortality occur as a result of cardiovascular complications such as mitral regurgitation and aortic dissection.

Anorexia Nervosa

This serious mental health disorder is characterized by severe and life-threatening weight loss in an otherwise healthy person. Behavior is characterized by fanatic concern about weight, aversion to food, distorted body image (perceives self as fat despite skeletal appearance), starvation diets, frenetic exercise patterns, and striving for perfection. Results in amenorrhea in females.

What is a bladder scanner used for?

To assess urine retention

What is a doppler sonometer used for?

To augment pulse or blood pressure measurement.

What is the function of the goblet cells of the lungs?

To entrap small particulate matter *The bronchial tree protects alveoli from small particulate matter that comes with inhaled air. The bronchi are lined with goblet cells, whose primary function is to secrete mucus that entraps particulate matter.

What is the purpose of valves?

To prevent backflow of blood. They open and close passively in response to pressure gradients in the moving blood.

What is a monofilament used for?

To test sensation in the foot.

What do the trachea and bronchi do?

Transport gases between the environment and the lung parenchyma. *They constitute the dead space, or space that is filled with air but is not available for gaseous exchange. **This is about 150 mL in the adult.

While assessing a patient, the nurse finds that the liver and the jugular vein have become enlarged. The nurse could best hear the soft and pansystolic heart murmur at the lower right and left sternal borders. Which disorder does the nurse suspect?

Tricuspid regurgitation *In tricuspid regurgitation, backflow of the blood occurs through the incompetent tricuspid valve into the right atrium. This results in engorged pulsating jugular veins and an enlarged liver. A soft, blowing, pansystolic heart murmur can be best heard at the right and the left lower sternal border. The murmur increases with inspiration.

Calcification of the tricuspid valve impedes the forward flow of the blood into the right ventricle during diastole, in ....

Tricuspid stenosis

People with COPD often sit in a

Tripod position, leaning forward with arms braced against their knees, chair, or bed. This gives them leverage so the abdominal, intercostal, and neck muscles all can aid in expiration.

Position: Abnormal

Tripod—Leaning forward with arms braced on chair arms; occurs with chronic pulmonary disease. Sits straight up and resists lying down (e.g., heart failure). Curled up in fetal position (e.g., acute abdominal pain).

Rust-colored sputum is associated with

Tuberculosis and pneumococcal pneumonia.

Symmetry: Abnormal

Unilateral atrophy or hypertrophy. Asymmetric location of a body part.

Weight: Normal

Use a standardized balance or electronic standing scale (Fig. 9-2). Instruct the person to remove his or her shoes and heavy outer clothing before standing on the scale. When a sequence of repeated weights is necessary, aim for approximately the same time of day and the same type of clothing worn each time. Record the weight in kilograms and in pounds.

To assess tactile (or vocal) fremitus ....

Use either the palmar base (the ball) of the fingers or the ulnar edge of one hand and touch the person's chest while he or she repeats the words "ninety-nine" or "blue moon." These are resonant phrases that generate strong vibrations. Start over the lung apices and palpate from one side to another. Symmetry is most important; the vibrations should feel the same in the corresponding area on each side. Avoid palpating over the scapulae because bone damps out sound transmission. ABNORMAL: Asymmetric findings suggest dysfunction that you can assess further with the stethoscope.

8 Characteristics: Quantity or Severity

Use pain scale. Quantify the symptom of pain. Attempt to quantify the sign or symptom such as "profuse menstrual flow soaking five pads per hour." Quantify the symptom of pain using the scale shown on the right. With pain, avoid adjectives, and ask how it affects daily activities. Then record if the person says, "I was so sick I was doubled up and couldn't move" or "I was able to go to work, but then I came home and went to bed."

Striking hand during percussion

Use the middle finger of your dominant hand as the striking finger (the plexor) (Fig. 8-2). Hold your forearm close to the skin surface, with your upper arm and shoulder steady. Scan your muscles to make sure that they are steady but not rigid. The action is all in the wrist, and it must be relaxed. Spread your fingers, swish your wrist, and bounce your middle finger off the stationary one. Aim for just behind the nail bed or at the distal interphalangeal joint; the goal is to hit the portion of the finger that is pushing the hardest into the skin surface. Flex the striking finger so its tip, not the finger pad, makes contact. It hits directly at right angles to the stationary finger. *Percuss 2 times in this location using even, staccato blows. Lift the striking finger off quickly; a resting finger dampens vibrations. Then move to a new body location and repeat, keeping your technique even. The force of the blow determines the loudness of the note. You do not need a very loud sound; use just enough force to achieve a clear note. The thickness of the person's body wall will be a factor. You need a stronger percussion stroke for people with obese or very muscular body walls.

Pressure-like discomfort in the chest during the morning hours may occur in the patient with

Variant angina.

What is the characteristic of the first heart sound in the patient who has a complete heart block?

Varied intensity

Vascular resistance is increased during

Vasoconstriction. Peripheral vascular resistance is the opposition to blood flow through the arteries. When the container becomes smaller (e.g., with constricted vessels), the pressure needed to push the contents becomes greater. *Increased BP

Vascular resistance is decreased during

Vasodilation. Conversely, if the container becomes larger (e.g., vasodilation), less pressure is needed. *Decreased BP

Volume is increased with

Volume of circulating blood refers to how tightly the blood is packed into the arteries. Increasing the contents in the container increases the pressure. Increased sodium and water retention, intravenous fluid overload *Increased BP

What is the single most important step to decrease risk of microorganism transmission?

Wash your hand promptly and thoroughly: 1. Before and after every physical patient encounter 2. After contact with blood, body fluids, secretions, and excretions 3. After contact with any equipment contaminated with body fluids 4. after removing gloves *Using alcohol-based hand rubs takes less time than soap-and-water handwashing; it also kills more organisms more quickly and is less damaging to the skin because of emollients added to the product. Alcohol is highly effective against both gram-positive and gram-negative bacteria ***Rub all hand surfaces with 3 to 5 mL of alcohol for 20 to 30 seconds. Use the mechanical action of soap-and-water handwashing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., Clostridium difficile and noroviruses).8 Rub all hand surfaces for 40 to 60 seconds

8 Characteristics: Aggravating or Relieving Factors

What makes the pain worse? Is it aggravated by weather, activity, food, medication, standing bent over, fatigue, time of day, or season? What relieves it (e.g., rest, medication, or ice pack)? What is the effect of any treatment? Ask, "What have you tried?" or "What seems to help?"

What is a split S2?

When the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separately.

When would the nurse perform the abdominojugular test?

When the nurse suspects heart failure *If the venous pressure is elevated or if the nurse suspects heart failure, then the abdominojugular test should be performed. This test was formerly known as hepatojugular reflux. When performing the abdominojugular test, sustained venous distention is suggestive of right-sided heart failure.

When should you wear gloves?

When the potential exists for contact with any body fluids (e.g., blood, mucous membranes, body fluids, drainage, open skin lesions). *However, wearing gloves is not a protective substitute for washing hands because gloves may have undetectable holes or become torn during use, or hands may become contaminated as gloves are removed. Wear a gown, mask, and protective eyewear when the potential exists for any blood or body fluid spattering (e.g., suctioning, arterial puncture).

8 Characteristics: Setting

Where was the person or what was the person doing when the symptom started? What brings it on? For example, "Did you notice the chest pain after shoveling snow, or did the pain start by itself?"

Viral infections, colds, and bronchitis are likely to cause _______ or _______ mucoid sputum.

White; Clear

Pulse

With every beat the heart pumps an amount of blood—the stroke volume—into the aorta. This is about 70 mL in the adult. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse. Palpating the peripheral pulse gives the rate and rhythm of the heartbeat and local data on the condition of the artery. *Assess the pulse, including (1) rate, (2) rhythm, and (3) force.

Kyphosis is associated with aging and is common among

Women, much before menopause. Kyphosis is also known as the dowager's hump of postmenopausal women and is related to physical fitness. Women who exercise regularly are less likely to develop kyphosis.

Which component of the jugular venous pulse corresponds to the opening of the tricuspid valve?

Y descent *There are five components of jugular venous pressure—A wave, C wave, X descent, V wave, and Y descent. Y descent indicates passive ventricular filling and opening of the tricuspid valve.

_______ or _______-colored sputum is associated with bacterial infections.

Yellow; Green

In forced expiration the _________ _________ contract powerfully to push the abdominal viscera forcefully in and up against the diaphragm, making it dome upward and squeeze against the lungs.

abdominal muscles

What is hypertension?

abnormally high BP

Accessory muscles are used in ______ ______ ______ and ______ ______.

acute airway obstruction; massive atelectasis

Angina

an important cardiac symptom, occurs when the heart's own blood supply cannot keep up with metabolic demand. Chest pain also may have pulmonary, musculoskeletal, or gastrointestinal (GI) origin; it is important to differentiate. *A squeezing "clenched fist" sign is characteristic of angina, but the symptoms below may be anginal equivalents in the absence of chest pain

Retraction suggests obstruction of respiratory tract or that increased inspiratory effort is needed, as with _________.

atelectasis

A lag in expansion occurs with

atelectasis, pneumonia, and postoperative guarding.

The two __________ valves separate the atria and the ventricles.

atrioventricular (AV)

Croup is associated with what type of cough?

barking

The "top" of the heart is the broader ______, and the "bottom" is the ______

base; apex

The left AV valve is the ________ or ________ valve

bicuspid; mitral

The AV valves are anchored by

chordae tenineae

Lungs are hyperinflated with _______ _______, which results in hyperresonance where you would expect cardiac dullness.

chronic emphysema

Those in Southwest and Mexico have risk for _________

coccidioidomycosis

Colds, bronchitis, pneumonia are associated with what type of cough?

congested

The pleurae extend approximately 3 cm below the level of the lungs, forming the __________ __________.

costodiaphragmatic recess *This is a potential space; when it abnormally fills with air or fluid, it compromises lung expansion.

General symptoms that may signal breathing problems:

cough, SOB *Some gases produce specific symptoms: - Carbon monoxide: dizziness, headache, fatigue; - Sulfur dioxide: cough, congestion.

In ________ the ventricles relax and fill with blood.

diastole

Clubbing of ________ ________ occurs with ________ because of growth of vascular connective tissue.

distal phalynx; COPD

Early heart failure is associated with what type of cough

dry

Abnormally wide costal angle with little inspiratory variation occurs with _________.

emphysema

Bulging indicates trapped air as in the forced expiration associated with ________ or ________.

emphysema; asthma

When sitting, the patient's feet should be flat on the floor because BP has a ________ measurement when legs are crossed versus uncrossed.

false-high

Posturally induced crackles (PICs) are

fine crackles that appear with a change from sitting to the supine position or with a change from supine to supine with legs elevated

Mycoplasma pneumonia is associated with what type of cough?

hacking

Paroxysmal nocturnal dyspnea (PND) occurs with

heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Typically the person awakens after 2 hours of sleep with the perception of needing fresh air.

People in rural Midwest have risk for _______ exposure

histoplasmosis

Neck muscles are _______ in COPD from aiding in forced respirations across the obstructed airways.

hypertrophied

Rhonchal fremitus

is palpable with thick bronchial secretions. *Vibration felt when inhaled air passes through thick secretions in the larger bronchi. This may decrease somewhat by coughing.

Normal voice transmission

is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said. Pathology that increases lung density enhances transmission of voice sounds. *Consolidation or compression of lung tissue will enhance the voice sounds, making the words more distinct. **Voice sounds are not elicited routinely. Rather these are supplemental maneuvers performed if you suspect lung pathology on the basis of earlier data. When they are performed, you are testing for the possible presence of bronchophony, egophony, and whispered pectoriloquy

Because volume and pressure increase when the right side of the heart fails to pump efficiently, the _______ veins expose this.

jugular

The anteroposterior (AP) diameter should be

less than the transverse diameter. The ratio of AP to transverse diameter is about 0.70 to 0.75 in adults, and it increases with age. *ABNORMAL: AP = transverse diameter, or "barrel chest." Ribs are horizontal, chest appears as if held in continuous inspiration. This occurs in COPD from hyperinflation of the lungs

Cutaneous angiomas (spider nevi) associated with _______ _______ or ______ ______ may be evident on the chest.

liver disease; portal hypertension

Dullness behind the right breast occurs with right ________ ________ _______.

middle lobe pneumonia

Hemoptysis may occur with

mitral stenosis

Chest pain of thoracic origin occurs with _______ _______ from coughing or from inflammation of pleura overlying pneumonia.

muscle soreness

Early inspiratory crackles occur with

obstructive disease: chronic bronchitis, asthma, and emphysema

Pleural friction fremitus is

palpable with inflammation of the pleura *Produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. The opposing surfaces make a coarse grating sound when rubbed together during breathing. This sound is best detected by auscultation, but it may be palpable and feels like two pieces of leather grating together. It is synchronous with respiratory excursion. Also called a palpable friction rub.

The visceral pleura is is continuous with the ________ ________ lining the inside of the chest wall and diaphragm.

parietal pleura

The thin, slippery _______ are serous membranes that form an envelope between the lungs and the chest wall

pleurae

Pleural friction rub is caused when

pleurae become inflamed and lose their normal lubricating fluid; their opposing roughened pleural surfaces rub together during respiration; heard best in anterolateral wall where greatest lung mobility exists

The inside of the envelope, the ________ ________, is a potential space filled only with a few milliliters of lubricating fluid.

pleural cavity *It normally has a vacuum, or negative pressure, which holds the lungs tightly against the chest wall. The lungs slide smoothly and noiselessly up and down during respiration, lubricated by a few milliliters of fluid.

A palpable grating sensation with breathing indicates

pleural friction fremitus

Coal miners have risk for _________

pneumoconiosis

Unequal chest expansion occurs when part of the lung is obstructed ________ or collapsed or when guarding to avoid postoperative or _________ _________.

pneumonia; pleurisy pain

You can hear S1 over all the _________, but usually it is loudest at the _________.

precordium; apex

Although it is heard over all the ________, S2 is loudest at the _______

precordium; base

Gaseous exchange occurs across the ________ ________ in the alveolar duct and in the millions of ________.

respiratory membrane; alveoli *Note how the alveoli are clustered like grapes around each alveolar duct. This bunched arrangement creates a surface area for gas exchange that is as large as a tennis court.

Late inspiratory crackles occur with

restrictive disease: pneumonia, heart failure, and interstitial fibrosis

Noisy breathing occurs with ______ ______ or _______ _______.

sever asthma; chronic bronchitis

The right main bronchus is ________, ________, and more ________ than the left main bronchus.

shorter; wider; vertical

Stone cutters, miners, and potters have risk for ________

silicosis

Heart contraction is _______.

systole *During systole blood is pumped from the ventricles and fills the pulmonary and systemic arteries. This is one third of the cardiac cycle.

Superior vena cava drains venous blood from

the head and upper extremities

What is a sinus arrhythmia?

the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. Inspiration momentarily causes a decreased stroke volume from the left side of the heart; to compensate the heart rate increases.

With aging there is an increase in systolic BP caused by

thickening and stiffening of the large arteries, which in turn are caused by collagen and calcium deposits in vessel walls and loss of elastic fibers. This stiffening (arteriosclerosis) creates an increase in pulse wave velocity because the less compliant arteries cannot store the volume ejected.

The right lung has ______ lobes, and the left lung has ______ lobes.

three; two *Lobes stack in diagonal sloping segments and are separated by fissures that run obliquely through the chest.

The ______ lies ______ to the esophagus and is 10 to 11 cm long in the adult.

trachea; anterior *It begins at the level of the cricoid cartilage in the neck and bifurcates just below the sternal angle into the right and left main bronchi **Posteriorly tracheal bifurcation is at the level of T4 or T5.

Long-term exposure to ____________ ________ __________ increases risk for allergic disease in children, as shown from global evidence in China and India.

traffic-related air pollution

The right AV valve is the _______ valve

tricuspid

The carotid artery is a central artery whose timing closely coincides with

ventricular systole.

The _______ _______ lines the outside of the lungs, dipping down into the fissures.

visceral pleura

The following factors affect the intensity of tactile fremitus:

• Fremitus is most prominent between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall. It normally decreases as you progress down because more and more tissue impedes sound transmission. • Fremitus feels greater over a thin chest wall than over an obese or heavily muscular one where thick tissue damps the vibration. • A loud, low-pitched voice generates more fremitus than a soft, high-pitched one. *Conditions that increase the density of lung tissue make a better conducting medium for sound vibrations and increase tactile fremitus.

Percussion has the following uses:

• Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors •Signaling the density (air, fluid, or solid) of a structure by a characteristic note • Detecting an abnormal mass if it is fairly superficial; the percussion vibrations penetrate about 5 cm deep—a deeper mass would give no change in percussion • Eliciting a deep tendon reflex using the percussion hammer

BMI Adult: Extreme Obesity

≥ 40

Which statement describes the structure of the lungs? - "The lungs contain approximately 300 alveoli." - "The right lung is shorter and wider than the left lung." - "The trachea bifurcates at the level of T10 posteriorly." - "The right lung has two lobes, and the left lung has three lobes."

"The right lung is shorter and wider than the left lung."

Pain is defined as an

"Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is always subjective." *The subjective report is the most reliable indicator of pain. Because pain occurs on a neurochemical level, the diagnosis of pain cannot be made exclusively on physical examination findings, although these findings can lend support. Self-report is the "gold standard" of pain assessment.

Standard precautions: Hand hygiene

(1) Avoid unnecessary touching of surfaces in close proximity to the patient. (2) When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash them with soap and water. (3) If not visibly soiled, decontaminate hands with an alcohol-based hand rub. Perform hand hygiene: (a) before having direct contact with patients; (b) after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; (c) after contact with a patient's intact skin (e.g., taking a pulse or blood pressure or lifting a patient); (d) after contact with medical equipment in the immediate vicinity of the patient; (e) after removing gloves.

Standard precautions: Use of gloves, gown, mask, eye protection or face shield

(1) Wear gloves when you anticipate that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., patient incontinent of stool or urine) could occur. (2) Wear a gown to protect skin and clothing when you anticipate contact with blood, body fluids, secretions, or excretions. (3) Use mouth, nose, and eye protection to protect the mucous membranes during procedures that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.

Conditions with characteristic timing of cough:

(1) continuous throughout day—acute illness (e.g., respiratory infection) (2) afternoon/evening—may be exposure to irritants at work (3) night—postnasal drip, sinusitis (4) early morning—chronic bronchial inflammation of smokers.

What are the four major functions of the respiratory system?

(1) supplying oxygen to the body for energy production (2) removing carbon dioxide as a waste product of energy reactions (3) maintaining homeostasis (acid-base balance) of arterial blood (4) maintaining heat exchange (less important in humans). *By supplying oxygen to the blood and eliminating excess carbon dioxide, respiration maintains the pH or the acid-base balance of the blood. Although a number of compensatory mechanisms regulate the pH, the lungs help maintain the balance by adjusting the level of carbon dioxide through respiration.

The mechanical expansion and contraction of the chest cavity alters the size of the thoracic container in what two dimensions?

(1) the vertical diameter lengthens or shortens, which is accomplished by downward or upward movement of the diaphragm (2) the anteroposterior (AP) diameter increases or decreases, which is accomplished by elevation or depression of the ribs

The closure of the AV valves contributes to the first heart sound _______ and signals the beginning of _______.

(S1); sytole

When pressure falls below pressure in the aorta, some blood flows backward toward the ventricle, causing the aortic valve to swing shut. This closure of the semilunar valves causes the second heart sound ________ and signals the end of ________.

(S2); systole

The normal temperature is influenced by:

- A diurnal cycle of 1° to 1.5° F, with the trough occurring in the early morning hours and the peak occurring in late afternoon to early evening. - The menstruation cycle in women. Progesterone secretion, occurring with ovulation at midcycle, causes a 0.5° to 1° F rise in temperature that continues until menses. - Exercise. Moderate-to-hard exercise increases body temperature. - Age. Wider normal variations occur in the infant and young child because of less effective heat control mechanisms. In older adults temperature is usually lower than in other age-groups, with a mean of 36.2° C (97.2° F) via the oral route. Rectal temperatures remain 0.5° C higher than oral temperatures in older adults.22

After conducting a cardiac examination, the nurse concludes that the patient has normal cardiopulmonary functioning. Which findings enabled the nurse to reach this conclusion? - Absence of cardiac murmur - S 2 is louder at the base of the heart - Presence of accentuated first heart sound (S 1) - Presence of diminished second heart sound (S 2) - Absence of equal and bilateral breath sounds

- Absence of cardiac murmur - S 2 is louder at the base of the heart *While conducting a cardiac examination, the nurse should evaluate the heart sounds; this helps to determine the cardiac functioning. Cardiac murmur is caused by abnormal blood flow. Therefore, the absence of cardiac murmur indicates that the patient has intact cardiac valves. The first heart sound (S 1) and second heart sound (S 2) are heart sounds that are produced by the opening or closing of the heart valves; it is normal for S 2 to be louder when auscultating at the base of the heart.

The average BP in the young adult varies with many factors such as:

- Age. Normally a gradual rise occurs through childhood and into the adult years. • Sex. Before puberty no difference exists between males and females. After puberty females usually show a lower BP reading than do male counterparts. After menopause BP in females is higher than in male counterparts. • Race. In the United States an African-American adult's BP is often higher than that of a White person of the same age. The incidence of hypertension is twice as high in African Americans as in Whites. The reasons for this difference are not understood fully, but we do know that genetic profile and environmental factors are involved. • Diurnal rhythm. A daily cycle of a peak and a trough occurs: the BP climbs to a high in late afternoon or early evening and then declines to an early-morning low. • Weight. BP is higher in obese people than in people of normal weight of the same age (including adolescents). • Exercise. Increasing activity yields a proportionate increase in BP. Within 5 minutes of terminating the exercise, the BP normally returns to baseline. • Emotions. The BP momentarily rises with fear, anger, and pain as a result of stimulation of the sympathetic nervous system. • Stress. The BP is elevated in people feeling continual tension because of lifestyle, occupational stress, or life problems.

Which conditions may cause a pathologic S 3, or a ventricular gallop? - Anemia - Pregnancy - Hyperthyroidism - Cardiomyopathy - Pulmonary stenosis

- Anemia - Pregnancy - Hyperthyroidism *A ventricular gallop occurs due to an increase in fluid volume. Anemia, pregnancy, and hyperthyroidism may increase cardiac output in the patient. Therefore, the nurse can hear ventricular gallop in the pregnant patient or in the patient with anemia or hyperthyroidism. **An atrial gallop, or pathologic S 4, is present in the patient with cardiomyopathy or pulmonary stenosis.

Acute Bronchitis: IPPA

- Condition An acute infection of the trachea and larger bronchi characterized by cough, lasting up to 3 weeks. Most cases are viral and do not require antibiotics. Epithelium of bronchi are inflamed and damaged, releasing proinflammatory mediators. Large airways are narrowed from capillary dilation, increased mucus production, loss of cilia function, and swelling of epithelium. More cases occur with smokers, aging adults, children, and in winter months. - Inspection Cough is productive or nonproductive. Also sore throat, low-grade fever, postnasal drip, fatigue, substernal aching. - Palpation No pain, no increased fremitus. - Percussion Resonance predominates. - Auscultation May be clear and equal bilaterally. No egophony. - Adventitious sounds No crackles (distinguishes the consolidation of pneumonia, no wheeze).

Acute Respiratory Distress Syndrome (ARDS): IPPA

- Condition An acute pulmonary insult (trauma, gastric acid aspiration, shock, sepsis) damages alveolar capillary membrane, leading to increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema. Gross examination (autopsy) would show dark red, firm, airless tissue, with some alveoli collapsed and hyaline membranes lining the distended alveoli. - Subjective Acute onset of dyspnea, apprehension. - Inspection Restlessness; disorientation; rapid, shallow breathing; productive cough; thin, frothy sputum; retractions of intercostal spaces and sternum. Decreased PaO2, blood gases show respiratory alkalosis, x-ray films show diffuse pulmonary infiltrates; a late sign is cyanosis. - Palpation Hypotension. - Auscultation Tachycardia. - Adventitious Sounds Crackles, rhonchi.

Asthma (Reactive Airway Disease): IPPA

- Condition An allergic hypersensitivity to certain inhaled allergens (pollen), irritants (tobacco, ozone), microbes, stress, or exercise that produces a complex response characterized by bronchospasm and inflammation, edema in walls of bronchioles, and secretion of highly viscous mucus into airways. These factors greatly increase airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea, and chest tightness. - Inspection During severe attack: increased respiratory rate, SOB with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostal spaces. Expiration labored, prolonged. When chronic, may have barrel chest. - Palpation Tactile fremitus decreased, tachycardia. - Percussion Resonant. May be hyperresonant if chronic. - Auscultation Diminished air movement. Breath sounds decreased, with prolonged expiration. Voice sounds decreased. - Adventitious Sounds Bilateral wheezing on expiration, sometimes inspiratory and expiratory wheezing.

Emphysema: IPPA

- Condition Caused by destruction of pulmonary connective tissue (elastin, collagen); characterized by permanent enlargement of air sacs distal to terminal bronchioles and rupture of interalveolar walls. This increases airway resistance, especially on expiration, producing a hyperinflated lung and an increase in lung volume. Cigarette smoking accounts for 80% to 90% of cases of emphysema. - Inspection Increased AP diameter. Barrel chest. Accessory muscles used to aid respiration. Tripod position. SOB, especially on exertion. Respiratory distress. Tachypnea. - Palpation Decreased tactile fremitus and chest expansion. - Percussion Hyperresonant. Decreased diaphragmatic excursion. - Auscultation Decreased breath sounds. May have prolonged expiration. Muffled heart sounds resulting from overdistention of lungs. - Adventitious Sounds Usually none; occasionally, wheeze.

Pleural Effusion (Fluid) or Thickening: IPPA

- Condition Collection of excess fluid in the intrapleural space, with compression of overlying lung tissue. Effusion may contain watery capillary fluid (transudative), protein (exudative), purulent matter (empyemic), blood (hemothorax), or milky lymphatic fluid (chylothorax). Gravity settles fluid in dependent areas of thorax. Presence of fluid subdues all lung sounds. - Inspection Increased respirations, dyspnea; may have dry cough, tachycardia, cyanosis, asymmetric expansion, abdominal distention. - Palpation Tactile fremitus decreased or absent. Tracheal shift away from affected side. Chest expansion decreased on affected side. - Percussion Dull percussion. No diaphragmatic excursion on affected side. - Auscultation Breath sounds decreased or absent. Voice sounds decreased or absent. When remainder of lung is compressed near the effusion, may have bronchial breath sounds over the compression along with bronchophony, egophony, whispered pectoriloquy. - Adventitious Sounds Crackles, pleural rub.

Pneumothorax: IPPA

- Condition Free air in pleural space causes partial or complete lung collapse. Air in pleural space neutralizes the usual negative pressure present; thus lung collapses. Usually unilateral. Pneumothorax can be (1) spontaneous (air enters pleural space through rupture in lung wall, (2) traumatic (air enters through opening or injury in chest wall), or (3) tension (trapped air in pleural space increases, compressing lung and shifting mediastinum to the unaffected side). - Inspection Unequal chest expansion. If large, tachypnea, cyanosis, apprehension, bulging in interspaces. - Palpation Tactile fremitus decreased or absent. Tracheal shift to opposite side (unaffected side). Chest expansion decreased on affected side. Tachycardia, decreased BP. - Percussion Hyperresonant. Decreased diaphragmatic excursion. - Auscultation Breath sounds decreased or absent. Voice sounds decreased or absent. - Adventitious Sounds None.

Lobar Pneumonia: IPPA

- Condition Infection in lung parenchyma leaves alveolar membrane edematous and porous; thus red blood cells (RBCs) and white blood cells (WBCs) pass from blood to alveoli. Alveoli progressively fill up (become consolidated) with bacteria, solid cellular debris, fluid, and blood cells, which replace alveolar air. This decreases surface area of the respiratory membrane, causing hypoxemia. - History Fever, cough with pleuritic chest pain, blood-tinged sputum, chills, SOB, fatigue. - Inspection Increased respirations >24/min. Guarding and lag on expansion on affected side. - Palpation Chest expansion decreased on affected side. Tactile fremitus increased if bronchus patent, decreased if bronchus obstructed. - Percussion Dull over lobar pneumonia. - Auscultation Tachycardia. Loud bronchial breathing with patent bronchus. Voice sounds have increased clarity; bronchophony, egophony, whispered pectoriloquy present. - Adventitious Sounds Crackles, fine to medium.

Tuberculosis: IPPA

- Condition Inhalation of tubercle bacilli into the alveolar wall starts: (1) Initial complex is acute inflammatory response—macrophages engulf bacilli but do not kill them. Tubercle forms around bacilli. (2) Scar tissue forms, lesion calcifies and shows on x-ray. (3) Reactivation of previously healed lesion. Dormant bacilli now multiply, producing necrosis, cavitation, and caseous lung tissue (cheeselike). (4) Extensive destruction as lesion erodes into bronchus, forming air-filled cavity. Apex usually has the most damage. - Subjective Initially asymptomatic, showing as positive skin test or on x-ray study. Progressive TB involves weight loss, anorexia, easy fatigability, low-grade afternoon fevers, night sweats. May have pleural effusion, recurrent lower respiratory infections. - Inspection Cough initially nonproductive, later productive of purulent, yellow-green sputum; may be blood tinged. Dyspnea, orthopnea, fatigue, weakness. - Palpation Skin moist at night from night sweats. - Percussion Resonant initially. Dull over any effusion. - Auscultation Normal or decreased vesicular breath sounds. - Adventitious Sounds Crackles over upper lobes common, persist following full expiration and cough.

Chronic Bronchitis: IPPA

- Condition Proliferation of mucus glands in the passageways, resulting in excessive mucus secretion. Inflammation of bronchi with partial obstruction of bronchi by secretions or constrictions. Sections of lung distal to obstruction may be deflated. Bronchitis may be acute or chronic with recurrent productive cough. Chronic bronchitis is usually caused by cigarette smoking. - Inspection Hacking, rasping cough productive of thick mucoid sputum. Chronic—Dyspnea, fatigue, cyanosis, possible clubbing of fingers. - Palpation Tactile fremitus normal. - Percussion Resonant. - Auscultation Normal vesicular. Voice sounds normal. Chronic—Prolonged expiration. - Adventitious Sounds Crackles over deflated areas. May have wheeze.

Heart Failure: IPPA

- Condition Pump failure with increasing pressure of cardiac overload causes pulmonary congestion or an increased amount of blood present in pulmonary capillaries. Dependent air sacs deflated. Pulmonary capillaries engorged. Bronchial mucosa may be swollen. - Inspection Increased respiratory rate, SOB on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, pallor in light-skinned people. - Palpation Skin moist, clammy. Tactile fremitus normal. - Percussion Resonant. - Auscultation Normal vesicular. Heart sounds include S3 gallop. - Adventitious Sounds Crackles at lung bases.

Lung Cancer: IPPA

- Condition This is the most fatal of malignancies, claiming as many lives per year as breast, colorectal, and prostate cancers combined. The major cause is tobacco smoking (85%), followed by exposure to secondhand smoke and asbestos exposure. Four types: squamous cell usually starts in central bronchi near the hilus; adenocarcinoma usually starts in periphery and escapes early detection; large cell also starts in periphery with tumors arranged as clusters; small cell (oat cell) compresses and narrows central bronchi.15 - Subjective Fatigue, nausea and vomiting, change in taste perception, anorexia. Persistent cough may also be productive; dyspnea; dull poorly localized chest pain. 10%-25% are asymptomatic. - Inspection Weight loss, clubbing, hoarseness, anemia, hemoptysis - Auscultation May have wheezing, atelectasis, pleural effusion, pneumonia distal to obstruction.

Pneumocystis jiroveci (P. carinni) Pneumonia : IPPA

- Condition This virulent form of pneumonia is a protozoal infection associated with AIDS. The parasite P. jiroveci (P. carinii) is common in the United States and harmless to most people, except to the immunocompromised, in whom a diffuse interstitial pneumonitis ensues. Cysts containing the organism and macrophages form in alveolar spaces, alveolar walls thicken, and the disease spreads to bilateral interstitial infiltrates of foamy, protein-rich fluid. - Inspection Anxiety, SOB, dyspnea on exertion, malaise are common; also tachypnea; fever; a dry, nonproductive cough; ; cyanosis. - Palpation Decreased chest expansion. - Percussion Dull over areas of diffuse infiltrate. - Auscultation Breath sounds may be diminished. - Adventitious Sounds Crackles may be present but often are absent.

Pulmonary Embolism: IPPA

- Condition Undissolved materials (e.g., thrombus or air bubbles, fat globules) originating in legs or pelvis detach and travel through venous system, returning blood to right heart, and lodge to occlude pulmonary vessels. Over 95% arise from deep vein thrombi in lower legs as a result of stasis of blood, vessel injury, or hypercoagulability. Pulmonary occlusion results in ischemia of downstream lung tissue, increased pulmonary artery pressure, decreased cardiac output, and hypoxia. Rarely, a saddle embolus in bifurcation of pulmonary arteries leads to sudden death from hypoxia. More often small-to-medium pulmonary branches occlude, leading to dyspnea. These may resolve by fibrolytic activity. - Subjective Chest pain, worse on deep inspiration, dyspnea. - Inspection Apprehensive, restless, anxiety, mental status changes, cyanosis, tachypnea, cough, hemoptysis, PaO2 <80% on pulse oximetry. Arterial blood gases show respiratory alkalosis. - Palpation Diaphoresis, hypotension. - Auscultation Tachycardia, accentuated pulmonic component of S2 heart sound. - Adventitious Sounds Crackles, wheezes.

Atelectasis (Collapse): IPPA

- Condition: Collapsed shrunken section of alveoli or an entire lung as a result of (1) airway obstruction (e.g., the bronchus is completely blocked by thick exudate, aspirated foreign body, or tumor); the alveolar air beyond the obstruction is gradually absorbed by the pulmonary capillaries, and the alveolar walls cave in); (2) compression on the lung; and (3) lack of surfactant (hyaline membrane disease). - Inspection Cough. Lag on expansion on affected side. Increased respiratory rate and pulse. Possible cyanosis. - Palpation Chest expansion decreased on affected side. Tactile fremitus decreased or absent over area. With large collapse, tracheal shift toward affected side. - Percussion Dull over area (remainder of thorax sometimes may have hyperresonant note). - Auscultation Breath sounds decreased vesicular or absent over area. Voice sounds variable, usually decreased or absent over affected area. - Adventitious Sounds None if bronchus is obstructed. Occasional fine crackles if bronchus is patent.

There are no valves between the vena cava and the right atrium or between the pulmonary veins and the left atrium.

- For this reason abnormally high pressure in the left side of the heart gives a person symptoms of pulmonary congestion - Abnormally high pressure in the right side of the heart shows in the distended neck veins and abdomen.

What are some histologic thorax and lung changes in the aging adult?

- Gradual loss of intra-alveolar septa and a decreased number of alveoli: therefore less surface area is available for gas exchange. - In addition, the lung bases become less ventilated as a result of closing off of a number of airways: this increases the older person's risk for dyspnea with exertion beyond his or her usual workload. *The histologic changes also increase the older person's risk for postoperative pulmonary complications. He or she has a greater risk for postoperative atelectasis and infection from a decreased ability to cough, a loss of protective airway reflexes, and increased secretions.

The nurse is preparing a patient for cardiac assessment. Which interventions should the nurse follow while assessing? - Compress on the carotid artery during the assessment. - Have the patient sit during the carotid artery assessment. - Put the patient in a supine position to assess the precordium. - Maintain a warm room temperature during cardiac assessment. - Assess the neck vessels first during the cardiovascular assessment.

- Have the patient sit during the carotid artery assessment. - Put the patient in a supine position to assess the precordium. - Maintain a warm room temperature during cardiac assessment. *The nurse should ask the patient to sit during the carotid artery assessment because the seated position allows proper exposure of the neck. The nurse places the patient in the supine position while auscultating the precordium to obtain accurate jugular venous pressure. The nurse needs to maintain a warm room temperature during the cardiac assessment because a cold room may make the patient uncomfortable, and shivering interferes with auscultating heart sounds. **The nurse should not compress the carotid artery during the assessment, because it can cause vagal stimulation and the patient may develop bradycardia. The nurse should start observations from the periphery and move in toward the heart. Hence, the nurse should assess the pulse and blood pressure, not the neck, first.

Which structures will the nurse assess when looking at the mediastinum? - Lungs - Heart - Trachea - Esophagus - Pleural cavities

- Heart - Trachea - Esophagus *The mediastinum is in the middle section of the thoracic cavity. The nurse, while assessing the mediastinum, will actually be assessing the heart, trachea, and the esophagus along with the great vessels. The lungs are contained in the right and left pleural cavities on either side of the mediastinum and are not examined with the mediastinum.

What is bradycardia?

- Heart rate less than 50 beats/min. *NOTE: Heart rates in the 50s/min occur normally in the well-trained athlete whose heart muscle develops along with the skeletal muscles. The stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable cardiac output.

What happens to the thoracic cavity during inspiration?

- In inspiration increasing the size of the thoracic container creates a slightly negative pressure in relation to the atmosphere; therefore air rushes in to fill the partial vacuum. - The major muscle responsible for this increase is the diaphragm. - During inspiration contraction of the bell-shaped diaphragm causes it to descend and flatten. This lengthens the vertical diameter. - Intercostal muscles lift the sternum and elevate the ribs, making them more horizontal. This increases the AP diameter.

Note the borders of cardiac dullness normally found on the anterior chest, and do not confuse these with suspected lung pathology

- In the right hemithorax, the upper border of liver dullness is located in the 5th intercostal space in the right midclavicular line. - On the left, tympany is evident over the gastric space.

Normal Lung: IPPA

- Inspection AP < transverse diameter, relaxed posture, normal musculature; rate 10 to 18 breaths/min, regular; no cyanosis or pallor. - Palpation Symmetric chest expansion. Tactile fremitus present and equal bilaterally, diminishing toward periphery. No lumps, masses, or tenderness. - Percussion Resonant. Diaphragmatic excursion 3 to 5 cm and equal bilaterally. - Auscultation Vesicular over peripheral fields. Bronchovesicular parasternally (anterior) and between scapulae (posterior). - Adventitious Sounds None.

After reviewing the medical history of a female patient, the nurse suspects that the patient is at risk for developing cardiovascular complications. Which findings led the nurse to this conclusion? - LDL level of 150 mg/dL - Body mass index of 30 kg/m 2 - Total cholesterol of 240 mg/dL - Blood pressure of 120/80 mm Hg - Fasting blood glucose level of 90 mg/dL

- LDL level of 150 mg/dL - Body mass index of 30 kg/m 2 - Total cholesterol of 240 mg/dL *High levels of low-density lipoprotein (LDL or "bad" cholesterol) slowly block arteries, which can result in myocardial infarction and stroke. LDL levels above 130 are considered high. A body mass index of greater than 25 kg/m 2 indicates obesity in the patient. The obese patient is at high risk for developing heart disease. Total blood cholesterol is a measure of LDL cholesterol, HDL cholesterol, and other lipid components. It should be less than 200 mg/dL. Therefore, total cholesterol levels of 240 mg/dL indicate high risk for developing cardiovascular complications. A blood pressure of 120/80 mm Hg is a normal finding. The blood glucose level of 90 mg/dL is also a normal finding.

Hemodynamic Changes with Aging

- Left ventricular wall thickness increases: an adaptive mechanism to accommodate the vascular stiffening that creates an increased workload on the heart. - No change in resting heart rate occurs with aging. - Cardiac output at rest is not changed with aging.

Examining an adolescent:

- Normally head to toe - Sitting on examination table - Try to keep clothes on and work around it as much as possible - They have big emotions, they want feedback that his/her body is healthy and developing normally - Great time for teaching and giving them a positive attitude about promoting wellness - Examine genitalia last and do it quickly

As you proceed through the health history, the measurements, and the vital signs, consider and make note of these four areas:

- Physical appearance - Body structure - Mobility - Behavior.

Which actions should the nurse take when doing a 6-minute walk test (6 MWT) with a patient? - Put a pulse oximeter on the patient's finger. - Ask the person to walk as fast as possible. - Remind the patient not to stop for a rest. - Conduct the test in a flat-surfaced corridor. - Stop if oxygen saturation is less than 85%.

- Put a pulse oximeter on the patient's finger. - Conduct the test in a flat-surfaced corridor. - Stop if oxygen saturation is less than 85%. *The 6 MWT is a safe, simple, inexpensive, clinical measure of functional status in aging adults. The nurse uses a pulse oximeter on the patient's finger to monitor the oxygen saturation. The nurse should do the test on a flat-surfaced corridor with controlled environment. The test must be stopped if the patient's oxygen saturation drops below 85% or if extreme breathlessness occurs. The nurse must ask the patient to set his or her own pace to cover as much ground in 6 minutes. The patient can be assured that it is fine to slow down or stop for rest at any time.

Normal adult respiratory patterns:

- Rate—10 to 20 breaths/min - Depth—500 to 800 mL - Pattern—Even - The ratio of pulse to respirations is fairly constant, about 4 : 1. Both values increase as a normal response to exercise, fear, or fever. - Depth—Air moving in and out with each respiration.

Which clinical findings does the nurse observe in the patient with mitral regurgitation? - S 1 is diminished. - S 2 is accentuated. - Arterial pulse is diminished. - Apical impulse is heard lower. - Palpable thrill is heard during systole.

- S 1 is diminished. - S 2 is accentuated. - Apical impulse is heard lower. *Mitral regurgitation is the condition in which the mitral valve does not close properly. Due to improper closure of mitral valve, the patient may have diminished S 1 and accentuated S 2. Apical impulse displaces down due to volume overload. **Volume overload may not occur in the patient with mitral regurgitation. ***Diminished arterial pulse is a sign of tricuspid stenosis. ****A palpable thrill heard during systole is a sign of pulmonic stenosis.

Which additional muscles are involved in increasing the size of the thoracic cage during forced inspiration after heavy exercise? - Scaleni - Trapezii - Diaphragm - Sternomastoids - Intercostal muscles

- Scaleni - Trapezii - Sternomastoids

Increased breath sounds mean that

- Sounds are louder than they should be (e.g., bronchial sounds are abnormal when they are heard over an abnormal location, the peripheral lung fields). - They have a high-pitched, tubular quality, with a prolonged expiratory phase and a distinct pause between inspiration and expiration. - They sound very close to your stethoscope, as if they were right in the tubing close to your ear. - They occur when consolidation (e.g., pneumonia) or compression (e.g., fluid in the intrapleural space) yields a dense lung area that enhances the transmission of sound from the bronchi. - When the inspired air reaches the alveoli, it hits solid lung tissue that conducts sound more efficiently to the surface.

Which assessment findings should the nurse identify with a barrel chest? - The thorax is symmetrical in the elliptical shape. - The chest appears as if held in continuous inspiration. - The ribs appear to be horizontal in relation to the spine. - The scapulae are placed symmetrically in each hemithorax. - The anteroposterior diameter is equal to the transverse diameter.

- The chest appears as if held in continuous inspiration. - The ribs appear to be horizontal in relation to the spine. - The anteroposterior diameter is equal to the transverse diameter. *The barrel chest appears as if it is held in continuous inspiration. In this position, the ribs are horizontal in relation to the spine. On the other hand, the ribs in a normal chest slope downwards at an angle of 45 degrees in relation to the spine. In the barrel chest, the anteroposterior diameter and the transverse diameter are equal. Normally, the anteroposterior diameter is less than the transverse diameter. The thorax is usually symmetrical in the elliptical shape and is not specific to the barrel chest. The scapulae are normally placed symmetrically in each hemithorax. These findings are not specific with barrel chest.

Which changes take place during the process of inspiration? - The diaphragm descends. - The elastic recoil property acts. - The intercostal muscles contract. - The intrathoracic pressure decreases. - The anteroposterior diameter decreases.

- The diaphragm descends. - The intercostal muscles contract. - The intrathoracic pressure decreases.

Examining Aging Adult

- The older adult should be sitting on the examination table; a frail older adult may need to be supine. - Arrange the sequence to allow as few position changes as possible. - Allow rest periods when needed. - Head to toe approach - Adjust examination pace to meet the possible slowed pace of the aging person. It is better to break the complete examination into a few visits than to rush through the examination and turn off the person. - Use physical touch (unless there is a cultural contraindication). This is especially important with the aging person because other senses such as vision and hearing may be diminished. - Do not mistake diminished vision or hearing for confusion. Confusion of sudden onset may signify a disease state. It is noted by short-term memory loss, diminished thought process, diminished attention span, and labile emotions. - Be aware that aging years contain more life stress. How the person adapts to these losses significantly affects health assessment.

The nurse is assessing the anterior chest of a patient. Which assessment findings need further investigation? - The patient breathes through pursed lips. - The costal angle is greater than 90 degrees. - The facial expression is benign and relaxed. - The abdominal muscles indicate hypertrophy. - The ribs are sloping downwards symmetrically.

- The patient breathes through pursed lips. - The costal angle is greater than 90 degrees. - The abdominal muscles indicate hypertrophy. *The patient breathes through pursed lips to exhale slowly. This allows the pressure in the bronchial tree to remain positive and fewer airways collapse. It is an indication of chronic obstruction pulmonary disease (COPD) and needs further investigation. If the costal angle is greater than 90 degrees, the patient has a barrel chest. A barrel chest is the result of equal anteroposterior-to-transverse diameter and ribs that are horizontal. This condition must be investigated further, because it often occurs with chronic emphysema and asthma as a result of the hyperinflation of lungs. Hypertrophy of the abdominal muscles occurs in chronic emphysema and needs further investigation. A patient without breathing difficulty will have a benign and relaxed facial expression. In the normal chest, the ribs slope downward with symmetric interspaces and a costal angle less than 90 degrees.

The nurse is caring for a patient with pectus excavatum. What are the characteristics of this condition? - The patient has a markedly sunken sternum. - The condition is congenital, not symptomatic. - The ribs slope back on either side of the sternum. - The depression is more noticeable on inspiration. - The depressions are at the costochondral junction.

- The patient has a markedly sunken sternum. - The condition is congenital, not symptomatic. - The depression is more noticeable on inspiration. *The patient with pectus excavatum has a markedly sunken sternum and adjacent cartilages. This condition is also known as funnel breast. It is congenital, but not a symptomatic condition. Surgery may be indicated if the sternal depression is severe. Depression begins at the second intercostal space, becoming depressed mostly at the junction of the xiphoid with the body of the sternum. It is more noticeable on inspiration.

A nursing instructor is describing the pleurae to a class of nursing students. Which statements should the nursing instructor include? - The pleurae are thin, slippery, serous membranes. - The parietal pleura lines the outside of the lungs. - The pleural cavity normally has negative pressure. - The pleura lies between the lungs and the chest wall. - The visceral pleura lines the inside of the chest wall.

- The pleurae are thin, slippery, serous membranes. - The pleural cavity normally has negative pressure. - The pleura lies between the lungs and the chest wall. *The pleurae are thin, slippery, serous membranes that form an envelope between the lungs and the chest wall. The pleural cavity is a space which may be filled only with a few milliliters of lubricating fluid that allow the lungs to slide smoothly and noiselessly up and down during normal respiration. The pleural cavity normally has a negative pressure, or vacuum, which holds the lungs tightly against the chest wall. In abnormal conditions, it may be filled with air or fluids that compromise lung expansion. The parietal pleura lines the inside of the chest wall and the diaphragm, whereas the visceral pleura lines the outside of the lungs.

Shape and configuration of the chest wall:

- The spinous processes should appear in a straight line. - The thorax is symmetric, in an elliptical shape, with downward sloping ribs, about 45 degrees relative to the spine. - The scapulae are placed symmetrically in each hemithorax *ABNORMAL: Skeletal deformities may limit thoracic cage excursion: scoliosis, kyphosis

Which findings should the nurse observe in a patient with left ventricular hypertrophy? - Visible apical heave - Change in heart location - Impalpable apical impulse - Diameter of the heart 3.5 cm - Higher jugular venous pressure

- Visible apical heave - Diameter of the heart 3.5 cm *Left ventricular hypertrophy is the thickening of the myocardium of the left ventricle. Apical heave occurs due to pressure loading in the left ventricular hypertrophy. Left ventricular hypertrophy will not increase the diameter of the heart, so a diameter of 3.5 cm is normal. Left ventricular hypertrophy does not cause dilation of the heart.

The thorax has an elliptical shape with an anteroposterior-to-transverse diameter documented as

1 : 2 or 0.70 ABNORMAL: Barrel Chest - Note equal AP-to-transverse diameter and that ribs are horizontal instead of the normal downward slope. This is associated with normal aging and also with chronic emphysema and asthma as a result of hyperinflation of lungs.

The General Survey: Physical Appearance

1. Age 2. Sex 3. Level of consciousness 4. Skin color 5. Facial features 6. Overall appearance

Percussing over a body structure causes vibrations that produce characteristic waves and are heard as "notes", which are differentiated by the following components:

1. Amplitude (intensity) - loud or soft 2. Pitch (frequency) 3. Quality (timbre) 4. Duration

The level of BP is determined by five factors

1. Cardiac output. 2. Peripheral Vascular Resistance 3. Volume of circulating blood 4. Viscosity 5. Elasticity of vessel walls

Inspecting the anterior chest includes:

1. Checking shape and configuration of the chest wall 2. Assessing the level of consciousness 3. Note skin color and condition 4. Assessing the quality of respirations

Subjective Data: Heart and Neck Vessels

1. Chest pain 2. Dyspnea 3. Orthopnea 4. Cough 5. Fatigue 6. Cyanosis or pallor 7. Edema 8. Nocturia 9. Past cardiac history 10. Family cardiac history 11. Patient-centered care (cardiac risk factors)

Palpating the posterior chest should include:

1. Confirmation of symmetric chest expansion 2. Assessing tactile fremitus 3. Palpating the entire chest wall

Lung and Thorax: Subjective Data

1. Cough 2. Shortness of breath 3. Chest pain with breathing 4. History of respiratory infections 5. Smoking history 6. Environmental exposure 7. Patient-centered care

Adventitious Lung Sounds: Discontinuous Sounds

1. Crackles - Fine 2. Crackles - Coarse 3. Atelectatic Crackles 4. Pleural Friction Rub

Percussing the posterior chest includes:

1. Determining the predominant note over the lung fields. 2. Checking for resonance 3. Determining diaphragmatic excursion

Auscultating the posterior chest includes:

1. Evaluating the presence and quality of normal breath sounds. 2. Checking for adventitious sounds 3. Checking for voice sounds

General Survey: Behavior

1. Facial Expression 2. Mood and affect 3. Speech 4. Speech pattern 5. Dress 6. Personal Hygiene

General Survey: Mobility

1. Gait 2. Range of motion 3. No involuntary movements (i.e. tics, tremors, seizures)

Components of standard precautions are:

1. Hand Hygiene 2. Use of gloves, gown, mask, eye protection, or face shield 3. Respiratory hygiene/cough etiquette

Abnormalities in body height and proportion:

1. Hypopituitary Dwarfism 2. Gigantism 3. Acromegaly (Hyperpituitarism) 4. Achondroplastic Dwarfism 5. Anorexia Nervosa 6. Endogenous Obesity-Cushing Syndrome 7. Marfan Syndrome

What 8 critical characteristics should your final summary of any symptom the person has include?

1. Location 2. Character or Quality 3. Quantity or Severity 4. Timing 5. Setting 6. Aggravating or Relieving Factors 7. Associated Factors 8. Patient's Perception

Palpating the anterior chest includes:

1. Palpating symmetric chest expansion 2. Assessing tactile (vocal) fremitus - 99 3. Palpating the anterior chest wall

Inspection of the posterior chest includes:

1. Shape and configuration 2. Position person takes to breath 3. Assess skin color and condition

General Survery: Body Structure

1. Stature 2. Nutrition 3. Symmetry 4. Posture 6. Position 5. Body, build, contour 6. Obvious physical deformities

Anterior thoracic landmarks

1. Suprasternal notch 2. Sternum 3. Sternal angle 4. Costal angle

Vital Signs

1. Temperature 2. Pulse 3. Respirations 4. Blood Pressure

Posterior thoracic landmarks

1. Vertebra prominens 2. Spinous processes 3. Inferior border of the scapula 4. Twelfth rib

General Survey: Measurements

1. Weight 2. Height 3. BMI

Adventitious Lung Sounds: Continuous Sounds

1. Wheeze - High-pitched (sibilant) 2. Wheeze - Low-pitched (sonorous rhonchi) 3. Stridor

Decreased or absent breath sounds occur:

1. When the bronchial tree is obstructed at some point by secretions, mucus plug, or a foreign body 2. In emphysema as a result of loss of elasticity in the lung fibers and decreased force of inspired air; the lungs also are already hyperinflated, so the inhaled air does not make as much noise 3. When anything obstructs transmission of sound between the lung and your stethoscope such as pleurisy or pleural thickening or air (pneumothorax) or fluid (pleural effusion) in the pleural space *A silent chest means that no air is moving in or out; an ominous sign.

How many thoracic vertebrae are present in the human body?

12 *There are 7 cervical, 5 lumbar, and 6 sacrococcygeal vertebrae.

BMI Adult: Normal weight

18.5 to 24.9 kg/m2

BMI Adult: Overweight

25 to 29.9 kg/m2

The heart extends from the ______ to the ______ intercostal space and from the right border of the sternum to the left midclavicular line.

2nd; 5th

In the anterior chest the apex, or highest point, of lung tissue is ...

3 to 4 cm above the inner third of the clavicles.

How much movement of the chest should normally occur during deep inspiration in an average adult?

3 to 5 cm *This movement may be up to 7 to 8 cm in well-conditioned people.

BMI Adult: Obesity 1

30 to 34.9 kg/m2

BMI Adult: Obesity Class 2

35 to 39.9 kg/m2

What is the normal ratio of pulse rate to respiratory rate

4:1

How deep can a percussion of the chest penetrate?

5 to 7 cm *The nurse percusses the lung fields to determine the predominant notes. The depth of the penetration of percussion has limits. Percussion sets into motion only the outer 5 to 7 cm of tissue. It does not penetrate to reveal any change in the density deeper than that.

BMI Adult: Underweight

< 18.5 kg/m2

Chronic dyspnea is SOB lasting

>1 month and may have neurogenic, respiratory, or cardiac origin. It also occurs with anemia, anxiety, and deconditioning

What is Cyanosis?

A bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

Reason for seeking care is

A brief, spontaneous statement in the person's own words that describes the reason for the visit. *Not a diagnostic statement, so avoid translating it into terms of a medical diagnosis.

What is Crepitus?

A coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

What is Cheye-Stokes respiration?

A cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds) alternating the cycle. The most common cause is severe heart failure; other causes are renal failure, meningitis, drug overdose, and increased intracranial pressure. Occurs normally in infants and aging persons during sleep.

Orthostatic hypotension

A drop in systolic pressure of ≥20 mm Hg or increase in pulse of ≥20 beats/min occurs with a quick change to a standing position. These changes are caused by abrupt peripheral vasodilation without a compensatory increase in cardiac output. Orthostatic changes occur with prolonged bed rest, older age, hypovolemia, and some medications.

What is Pectus Carinatum?

A forward protrusion of the sternum, with ribs sloping back at either side and vertical depressions along costochondral junctions (pigeon breast). Less common than pectus excavatum, this minor deformity requires no treatment. If severe, surgery may be indicated.

What is an acinus?

A functional respiratory unit that consists of the bronchioles, alveolar ducts, alveolar sacs, and the alveoli.

Achondroplastic Dwarfism

A genetic disorder in converting cartilage to bone results in normal trunk size, short arms and legs, and short stature. It is characterized by a relatively large head with frontal bossing; midplace hypoplasia; and often thoracic kyphosis, prominent lumbar lordosis, and abdominal protrusion. The mean adult height in men is about 131.5 cm (4 ft 4 in) and in women about 125 cm (4 ft 1 in).

What assessment finding will the nurse document in a patient with pneumonia? - A smooth chest expansion - A lag in the chest expansion - A palpable grating sensation - A slight inspiratory variation

A lag in the chest expansion *The nurse should note a lag in the chest expansion in a patient with pneumonia. Normally, the chest expansion should be smooth, with the thumbs moving apart symmetrically.

What is Scoliosis?

A lateral S-shaped curvature of the thoracic and lumbar spine, usually with involved vertebrae rotation. Note unequal shoulder and scapular height and unequal hip levels, rib interspaces flared on convex side. More prevalent in adolescent age-groups, especially girls. Mild deformities are asymptomatic. If severe (>45 degrees) deviation is present, scoliosis may reduce lung volume, and person is at risk for impaired cardiopulmonary function. Primary impairment is cosmetic deformity, negatively affecting self-image. Refer early for treatment, possible surgery.

What is hyperresonance?

A lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax.

What is Pectus Excavatum?

A markedly sunken sternum and adjacent cartilages (also called funnel breast). Depression begins at second intercostal space, becoming depressed most at junction of xiphoid with body of sternum. More noticeable on inspiration. Congenital, usually not symptomatic. When severe, sternal depression may cause embarrassment and a negative self-concept. Surgery may be indicated.

What is Tachycardia

A more rapid heart rate, variably defined as over 95 beats/min or over 100 beats/min *Tachycardia occurs with fever and also with sepsis, pneumonia, myocardial infarction, and pancreatitis. This evidence predicts complications and worse survival rates in the latter conditions.

What is the diaphragm?

A musculotendinous septum that separates the thoracic cavity from the abdomen.

What is a pulse oximeter?

A noninvasive method to assess arterial oxygen saturation (SpO2). A healthy person with no lung disease normally has an SpO2 of 97% to 99%, but a value of >95% is clinically acceptable in the presence of a normal hemoglobin.

What is fremitus?

A palpable vibration.

The presence of a loud or accentuated S 1 heart sound indicates

A prolapsed mitral valve.

Anisocoria

A small number of people (5%) normally have pupils of two different sizes

What is a symptom?

A subjective sensation that the person feels from the disorder.

Pericarditis is a cardiovascular disorder that is associated with

A sudden, stabbing pain in the substernal region that radiates to the trapezius muscle, dry cough, and muscle and joint pain.

Which statement describes a thrill? - A thrill is a palpation of the chest. - A thrill is seen over the apical impulse. - A thrill is associated with a venous hum. - A thrill is a sustained thrust of the ventricle of the heart.

A thrill is a palpation of the chest. *A thrill is a vibration felt by the nurse on palpation of the chest. It is likened to the throat of a purring cat. The thrill signifies turbulent blood flow and directs the nurse to locate the origin of loud murmurs.

What is the pericardium?

A tough, fibrous, double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid. This ensures smooth, friction-free movement of the heart muscle. It is anchored to the diaphragm.

Breakthrough pain

A transient spike in pain level, moderate to severe in intensity, in an otherwise controlled pain syndrome. It can result from end-of-dose medication failure. This occurs when a patient taking a long-acting opioid has a recurrence of pain before the next scheduled dose. Treatment of end-of-dose failure includes shortening the interval between doses or increasing the dose of medication. Breakthrough pain can also be the result of incident or episodic pain. This is a predictable breakthrough pain that may be triggered by a physical stimulus such as a return to activity after a surgery or from a psychosocial event.

What is Hyperthermia?

AKA fever, is caused by pyrogens secreted by toxic bacteria during infections or from tissue breakdown such as that following myocardial infarction, trauma, surgery, or malignancy. Neurologic disorders (e.g., a stroke, cerebral edema, brain trauma, tumor, or surgery) also can reset the thermostat of the brain at a higher level, resulting in heat production and conservation.

Standard precautions apply to ....

ALL patients

A dull note (soft, muffled thud) signals

Abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

What is hypotension?

Abnormally low BP

Forced inspiration such as that after heavy exercise or occurring pathologically with respiratory distress commands the use of the

Accessory neck muscles to heave up the sternum and rib cage. *These neck muscles are the sternomastoids, the scaleni, and the trapezii.

Acute cough vs chronic cough duration

Acute cough lasts less than 2 or 3 weeks; chronic cough lasts over 2 months.

Which group of patients is likely to be affected by scoliosis? - Adolescents - Menopausal women - Postmenopausal women - Women who exercise regularly

Adolescents *Scoliosis is prevalent in the adolescent group, especially in girls. Mild deformities are asymptomatic, but any deviation greater than 45 degrees increases the risk for impaired cardiopulmonary function.

Respirations in the aging adult

Aging causes a decrease in vital capacity and a decreased inspiratory reserve volume. You may note a shallower inspiratory phase and an increased respiratory rate.

Asthma is an

Allergic hypersensitivity characterized by bronchospasms and inflammation, edema in the walls of the bronchioles, and secretion of highly viscous mucus into the airways.

Pain in the aging adult:

Although pain is a common experience among individuals 65 years of age and older, it is not a normal process of aging. Pain indicates pathology or injury. It should never be considered something to tolerate or accept in one's later years.

Characteristics of Percussion Notes: Tympany

Amplitude: Loud Pitch: High Quality: Musical and drumlike Duration: Sustained longest Sample Location: Over air-filled viscus (e.g., the stomach, the intestine)

Characteristics of Percussion Notes: Hyperresonant

Amplitude: Louder Pitch: Lower Quality: Booming Duration: Longer Sample Location: Normal over child's lung. ***ABNORMAL: in the adult, over lungs with increased amount of air as in emphysema

Characteristics of Percussion Notes: Resonant

Amplitude: Medium-loud Pitch: Low Quality: Clear, hollow Duration: Moderate Sample Location: Over normal lung tissue

Characteristics of Percussion Notes: Dull

Amplitude: Soft Pitch: High Quality: Muffled thud Duration: Short Sample Location: Relatively dense organ as liver or spleen

Characteristics of Percussion Notes: Flat

Amplitude: Very soft Pitch: High Quality: A dead stop of sound, absolute dullness Duration: Very short Sample Location: When no air is present, over thigh muscles or bone or over tumor

What abnormality would the nurse expect in a patient with kyphosis? - A condition that involves the rotation of the vertebrae - An exaggerated posterior curvature of the thoracic spine - A lateral S-shaped curvature of the thoracic and lumbar spine - An unequal shoulder and scapular height and unequal hip levels

An exaggerated posterior curvature of the thoracic spine *The patient with kyphosis has a humpback or an exaggerated posterior curvature of the thoracic spine. The patient may hyperextend the neck to maintain a level of vision.

Kyphosis

An exaggerated posterior curvature of the thoracic spine (humpback) that causes significant back pain and limited mobility. Severe deformities impair cardiopulmonary function. If the neck muscles are strong, compensation occurs by hyperextension of head to maintain level of vision. Kyphosis has been associated with aging, especially the familiar "dowager's hump" of postmenopausal osteoporotic women. However, it is common well before menopause. It is related to physical fitness; women with adequate exercise habits are less likely to have kyphosis.

In the aging adult the chest cage commonly shows

An increased AP diameter, giving a round barrel shape and kyphosis or an outward curvature of the thoracic spine. The person compensates by holding the head extended and tilted back.

What is hypoventilation?

An irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain.

What is a sign?

An objective abnormality that you as the examiner could detect on physical examination or in laboratory reports.

Weight: Abnormal

An unexplained weight loss may be a sign of a short-term illness (e.g., fever, infection, disease of the mouth or throat) or a chronic illness (e.g., endocrine disease, malignancy, depression, anorexia nervosa, bulimia). Unexplained weight gain may indicate fluid retention (e.g., heart failure).

Unilateral distention of the external jugular veins is the characteristic sign of

Aneurysm. The patient with an aneurysm will not have a pulse deficit and an enlarged heart.

Sudden severe pain with a change in location occurs in the patient with

Aortic dissection.

A stream of blood regurgitates back through the incompetent aortic valve into the left ventricle during diastole in .....

Aortic regurgitation

The second right interspace is the area of the aortic valve. Therefore, the palpable thrill occurs in this area in the patient with

Aortic stenosis

Calcification of the cusps of the aortic valve occurs in

Aortic stenosis. It restricts the forward flow of the blood during systole.

Laterally lung tissue extends from the

Apex of the axilla down to the 7th or 8th rib.

Age: Abnormal

Appears older than stated age, as with chronic illness or chronic alcoholism

What are standard precautions based on?

Are based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. Precautions apply to all patients, regardless of suspected or confirmed infection status, and in any setting in which health care is delivered.

Aδ fibers

Are myelinated and larger in diameter; thus they transmit the pain signal rapidly to the CNS. The sensation is very localized, short term, and sharp in nature because of the Aδ fiber stimulation.

C fibers

Are unmyelinated and smaller, and they transmit the signal more slowly. The "secondary" sensations are diffuse and aching, and they last longer after the initial injury.

BP with coarctation of the aorta:

Arm pressures are high. Thigh pressure is lower because the blood supply to the thigh is below the constriction.

A reproducible BP difference in the two arms of more than 10 to 15 mm Hg may indicate

Arterial obstruction on the side with the lower reading. This warrants referral.

Speech: Normal

Articulation (the ability to form words) is clear and understandable.

Bronchophony

Ask the person to repeat "ninety-nine" while you listen with the stethoscope over the chest wall; listen especially if you suspect pathology. Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said ABNORMAL: Pathology that increases lung density enhances transmission of voice sounds; you auscultate a clear "ninety-nine" The words are more distinct than normal and sound close to your ear

Whispered Pectoriloquy

Ask the person to whisper a phrase such as "one-two-three" as you auscultate. The normal response is faint, muffled, and almost inaudible ABNORMAL: With only small amounts of consolidation, the whispered voice is transmitted very clearly and distinctly, although still somewhat faint; it sounds as if the person is whispering right into your stethoscope, "one-two-three"

Test for accommodation by

Asking the person to focus on a distant object (Fig. 14-18). This process dilates the pupils. Then have the person shift the gaze to a near object such as your finger held about 7 to 8 cm (3 inches) from the person's nose. A normal response includes (1) pupillary constriction, and (2) convergence of the axes of the eyes. *ABNORMAL: Absence of constriction or convergence. Asymmetric response.

A young adult patient comes to the emergency department complaining of difficulty breathing. The person appears cyanotic and uses accessory neck muscles. The nurse hears audible wheezing. There is decreased tactile fremitus with hyperresonant sounds on percussion. Normal breath sounds are distant and hard to hear because of wheezing. Which disorder does the nurse suspect?

Asthma

_______ is the most common chronic disease in childhood

Asthma

There are five components of jugular venous pressure—A wave reflects

Atrial contraction due to the backward flow of blood to the vena cava. *During this phase, some blood flows backward to the vena cava during the right atrial contraction.

There are five components of jugular venous pressure— X descent indicates

Atrial relaxation. *X wave shows atrial relaxation when the right ventricle contracts during the systole and pulls the bottom of the atria downward.

A fixed split S 2 occurs in the patient with

Atrial septal defect due to the earlier closure of the aortic valves than the pulmonic valves.

The first heart sound (S 1) occurs with the closure of the ....

Atrioventricular valves, and indicates the beginning of systole.

The atrioventricular node is present in the

Auricular septum; it helps in the conduction of the cardiac impulse.

Egophony

Auscultate the chest while the person phonates a long "ee-ee-ee-ee" sound. Normally you should hear "eeeeeeee" through your stethoscope ABNORMAL: Over area of consolidation or compression the spoken "eeee" sound changes to a bleating long "aaaaa" sound

What is auscultation?

Auscultation is listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen.

Normal relaxed breathing is

Automatic and effortless, regular and even, and produces no noise. The chest expands symmetrically with each inspiration.

A patient with paroxysmal nocturnal dyspnea may

Awaken from sleep with SOB. This patient may need to be upright in order to achieve comfort.

What is paroxysmal nocturnal dyspnea?

Awakening from sleep with SOB and needing to be upright to achieve comfort.

Yellow or green sputum is associated with:

Bacterial infections

8 Characteristics: Location

Be specific, ask the person to point to the location. Is the pain localized to this site or radiating? Is the pain superficial or deep?

Acute Pain Behaviors

Because acute pain involves autonomic responses and has a protective purpose, individuals experiencing moderate-to-intense levels of pain may exhibit the following behaviors: guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vital signs.

In terms of palpation, the dorsa (backs) of hands and fingers are best for

Best for determining temperature because the skin here is thinner than on the palms

In terms of palpation the fingertips are best for

Best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps

In terms of palpation, the base of fingers (metacarpophalangeal joints) or ulnar surface of the hand is best for

Best for vibration

Blood pressure

Blood pressure (BP) is the force of the blood pushing against the side of its container, the vessel wall. The strength of the push changes with the event in the cardiac cycle.

Personal Hygiene: Abnormal

Body odor, scent of alcohol. Unkempt appearance in an individual who previously had good hygiene may indicate depression, malaise, or illness.

Symmetry: Normal

Body parts look equal bilaterally and are in relative proportion to each other.

This involuntary control of respirations is mediated by the respiratory center in the _________.

Brainstem (pons and medulla) *The major feedback loop is humoral regulation, or the change in carbon dioxide and oxygen levels in the blood and, less important, the hydrogen ion level.

Abnormal range of findings: Muscles and Skin

Bruising, lesions, open wounds, tissue damage, atrophy, bulging, change in hair distribution *Absent pain sensation (analgesia); increased pain sensation (hyperalgesia); or if a severe pain sensation is evoked with a stimulus that does not normally induce pain (e.g., the blunt end of the tongue blade, cotton ball, clothing) (allodynia)

How does the nurse assess for tactile fremitus in a patient?

By placing the palmar base of one hand to touch the patient's chest

How are the intercostal spaces of the thorax numbered?

By the ribs present above the spaces

The nurse is assessing the jugular pulse of a patient. Which jugular pulse component reflects ventricular contraction?

C wave *The jugular pulse, a waveform that moves backward, is caused by events upstream. The jugular pulse has five components. The C wave occurs due to ventricular contraction. It is the backflow from the bulging upward of the tricuspid valve when it closes at the beginning of the ventricular systole.

Posteriorly the location of ______ marks the apex of lung tissue, and ______ usually corresponds to the base.

C7; T10 *Deep inspiration expands the lungs, and their lower border drops to the level of T12.

Rectus abdominis and internal intercostal muscles are used to force expiration in _______.

COPD

Tense, strained, tired facies and purse-lipped breathing (the lips in a whistling position) accompany

COPD *By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse.

Nutrition: Abnormal

Cachectic, emaciated. Simple obesity, with even fat distribution. Centripetal (truncal) obesity—Fat concentrated in face, neck, trunk, with thin extremities, as in Cushing syndrome

In the aging adult, the costal cartilages become _________; thus the thorax is less _________.

Calcified; mobile - Respiratory muscle strength declines after age 50 years and continues to decrease into the 70s. - A more significant change is the decrease in elastic properties within the lungs, making them less distensible and lessening their tendency to collapse and recoil. - In all, the aging lung is a more rigid structure that is harder to inflate. *These changes result in an increase in small airway closure, which yields a decreased vital capacity and an increased residual volume

Hypoventilation causes

Carbon dioxide to build up in the blood.

Overall appearance: Abnormal

Cardiac or respiratory signs— Diaphoresis, clutching the chest, shortness of breath, wheezing. Pain, indicated by facial grimace, holding body part.

A squeezing pain occurs due to the obstruction of coronary arteries and is a symptom

Cardiac problems

When pain is poorly controlled over an extended period of time

Cells within the dorsal horn become altered in size and function, and this damage ultimately turns future pain signals into more exaggerated or hypersensitive processing.

Temperature

Cellular metabolism requires a stable core, or "deep body," temperature of a mean of 37.2° C (99° F). The body maintains a steady temperature through a thermostat, or feedback mechanism, regulated in the hypothalamus of the brain. The thermostat balances heat production (from metabolism, exercise, food digestion, external factors) with heat loss (through radiation, evaporation of sweat, convection, conduction). *The various routes of temperature measurement reflect the core temperature of the body. The normal oral temperature in a resting person is 37° C (98.6° F), with a range of 35.8° to 37.3° C (96.4° to 99.1° F). The rectal temperature measures 0.4° to 0.5° C (0.7° to 1° F) higher. **The thermostatic function of the hypothalamus may become scrambled during illness or central nervous system (CNS) disorders.

Report temperature in:

Celsius unless your agency uses the Fahrenheit scale. *104=40; 98.6=37; 95=35 **Along with your results, make sure to note the route used to obtain the temperature reading.

The nurse is examining the most prominent spinous process in the vertebral column of a patient who may have spondylosis. Which posterior vertebral landmark is the nurse examining?

Cervical 7 *The seventh cervical vertebra is the most prominent bony spur protruding at the base of the neck. Sometimes, two bumps are found to be equally prominent. In such a case, the upper one is the seventh cervical vertebra, and the lower one is the first thoracic vertebra.

Temperature in the aging adult

Changes in the body's temperature regulatory mechanism leave the aging person less likely to have fever but at a greater risk for hypothermia. Thus the temperature is a less reliable index of the older person's true health state. Sweat gland activity is also diminished.

Biot's respiration is similar to

Cheyne-Stokes respiration, but the breathing pattern is irregular, with variable respiration cycle length. A series of three to four normal respirations is followed by a period of apnea. The length of the respiration cycle lasts from 10 seconds to 1 minute.

______ ______ has a history of productive cough for 3 months of the year for 2 years in a row.

Chronic bronchitis

Cardiomyopathy is a

Chronic disease. The nurse would not find a pulse deficit in the patient with cardiomyopathy.

Persistent (Chronic) Pain Behaviors

Chronic pain behaviors have even more variability than acute pain behaviors. People with chronic pain typically try to give little indication that they are in pain and therefore are at higher risk for underdetection. Behaviors that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and change in appetite. *Chronic pain behaviors such as spending time with other people, movement, exercise, prayer, sleeping, or inactivity underscore the more subtle, less anticipated ways in which people behave when they are experiencing chronic pain (e.g., they use sleeping to self-distract). Unfortunately clinical staff may inadvertently interpret this behavior as "comfort" and fail to follow up with an appropriate pharmacologic intervention.

Dress: Normal

Clothing is appropriate to the climate, looks clean and fits the body, and is appropriate to the person's culture and age-group (e.g., normally Amish women wear clothing from the 19th century; Indian women may wear saris). Culturally determined dress should not be labeled as inappropriate by Western standards or adult expectations.

Dress: Abnormal

Clothing too large and held up by belt suggests weight loss, as does the addition of new holes in belt. Clothing too tight may indicate obesity or ascites. Consistent wear of certain clothing may provide clues: long sleeves may conceal needle marks of drug abuse or thin arms of anorexia; Velcro fasteners instead of buttons may indicate chronic motor dysfunction.

The nurse is giving a lecture about adventitious sounds to nursing students. Which sound should the nurse compare to the opening of a Velcro fastener?

Coarse crackles

White or clear mucoid is associated with:

Colds, bronchitis, viral infections

Atelectasis is defined as the

Collapse or closure of the lung resulting in reduced or absent gas exchange.

Skin color: Normal

Color tone is even, pigmentation varying with genetic background; skin is intact with no obvious lesions. Make note of tattoos and piercings and stage of healing.

Deep somatic pain

Comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Pain may result from pressure, trauma, or ischemia. Deep somatic pain often is described as aching or throbbing.

Increased fremitus occurs with

Compression or consolidation of lung tissue (e.g., lobar pneumonia). This is present only when the bronchus is patent and the consolidation extends to the lung surface. Note that only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect it. *Occurs with conditions that increase the density of lung tissue, thereby making a better conducting medium for vibrations (e.g., compression or consolidation [pneumonia]). There must be a patent bronchus, and consolidation must extend to lung surface for increased fremitus to be apparent.

Level of consciousness: Abnormal

Confused, drowsy, lethargic

What are wheezes?

Continuous musical sounds heard mainly over expiration.

Sharp pleuritic pain that worsens with deep breathing, chest tightness, and warmth at the site are the characteristics of

Costochondritis, which is a musculoskeletal complication.

What should the nurse expect to assess when auscultating the lung sounds of a patient with heart failure? - Occasional wheezing - Crackles in the lung bases - Crackles over upper lobes - Bilateral expiratory wheezing

Crackles in the lung bases *The nurse is likely to hear crackles at the lung bases. Occasional wheezing may be identified while auscultating the patient with emphysema. Crackles over the upper lobes are heard in the patient with tuberculosis. Bilateral wheezing may heard in the patient with asthma.

What should the nurse expect to feel while palpating a patient's chest wall after undergoing thoracic surgery? - Crepitus - Rhonchal fremitus - Decreased fremitus - Pleural friction fremitus

Crepitus *The nurse is likely to feel crepitus, which is a coarse, crackling sensation palpable over the skin surface. Crepitus occurs when air escapes from the lung and enters the subcutaneous tissue after open thoracic surgery. Rhonchal fremitus is palpable with thick bronchial secretions. Decreased fremitus occurs with obstructed bronchus, pleural effusion, or thickening. Pleural friction fremitus is palpable with the inflammation of the pleura.

A barking cough may be caused by

Croup

Testing the pupillary light reflex:

Darken the room and ask the person to gaze into the distance. (This dilates the pupils.) Advance a light in from the side* and note the response. Normally you will see (1) constriction of the same-sided pupil (a direct light reflex), and (2) simultaneous constriction of the other pupil (a consensual light reflex). ABNORMAL: Dilated pupils. Dilated and fixed pupils. Constricted pupils. Unequal or no response to light

A pneumothorax may result in ________ fremitus.

Decreased

What is indicated in a patient with pathologic S3?

Decreased compliance of the ventricles *S3 is the third heart sound. It is also known as a ventricular gallop or an S3 gallop. In adults, S3 is usually abnormal. The pathologic S3 indicates decreased compliance of the ventricles; it may be the earliest sign of heart failure.

While assessing the tactile fremitus of the patient, the nurse learns that the fremitus is decreased. Which disorder may be diagnosed in the patient? - Bronchitis - Pleural effusion - Lobar pneumonia - Pulmonary infarction

Decreased fremitus occurs when the bronchus of the patient is obstructed. Any barrier that comes between the sound and the palpating hand of the nurse will decrease the fremitus. When there is air outside the lung in the chest cavity, it prevents lung expansion and decreases the tactile fremitus. Pleural effusion, thickening pneumothorax, or emphysema may be responsible for this.

Hypopituitary Dwarfism

Deficiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency. The 9-year-old girl at left appears much younger than her chronologic age, with infantile facial features and chubbiness. The age-matched girl at right shows increased height, more mature facial features, and loss of infantile fat.

Sex: Abnormal

Delayed or precocious puberty.

The inferior vena cava carries

Deoxygenated blood from the lower extremities to the right side of the heart.

Physiologic Changes from Poorly Controlled Pain: Poorly controlled chronic pain

Depression Isolation Limited mobility and function Confusion Family distress Diminished quality of life

In terms of palpation, a grasping action of the fingers and thumb is best for

Detecting the position, shape, and consistency of an organ or mass

The nurse is assessing a patient for shortness of breath (SOB). What term should the nurse use to document excessive sweating associated with shortness of breath?

Diaphoresis

Which structure separates a patient's thoracic cavity from the abdomen?

Diaphragm

In the anterior chest the base, or lower border of the lungs, rests on the

Diaphragm at about the 6th rib in the midclavicular line.

Which murmurs are caused by an obstruction of the flow of blood into the ventricles?

Diastolic rumbles

What is orthopnea?

Difficulty breathing when supine. State number of pillows needed to achieve comfort (e.g., "two-pillow orthopnea").

Orthopnea refers to

Difficulty in breathing when a person is lying in the supine position. If the patient requires two pillows to breathe comfortably while lying down, the nurse notes the condition as two-pillow orthopnea.

What are Crackles?

Discontinuous popping sounds heard over inspiration

Crackles - Fine (formerly known as rales)

Discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing; you can simulate this sound by rolling a strand of hair between your fingers near your ear or by moistening your thumb and index finger and separating them near your ear *Inspiratory crackles: inhaled air collides with previously deflated airways; airways suddenly pop open, creating explosive crackling sound *Expiratory crackles: sudden airway closing

Crackles are

Discontinuous, high-pitched, short popping sounds heard during inspiration that are not cleared by coughing.

When do the AV valves open?

During the heart's filling phase, or diastole, to allow the ventricles to fill with blood. *During the pumping phase, or systole, the AV valves close to prevent regurgitation of blood back up into the atria.

Speech: Abnormal

Dysarthria and dysphagia. Speech defect, monotone, garbled speech.

The patient with gastroesophageal reflux disease may have a burning sensation in the chest after

Eating large meals

Endogenous Obesity—Cushing Syndrome

Either administration of adrenocorticotropin (ACTH) or excessive production of ACTH by the pituitary stimulates the adrenal cortex to secrete excess cortisol. This causes Cushing syndrome, characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round, plethoric face (moon face). Excessive catabolism causes muscle wasting; weakness; thin arms and legs; reduced height; and thin, fragile skin with purple abdominal striae, bruising, and acne. Note that the obesity here is markedly different from exogenous obesity caused by excessive caloric intake, in which body fat is evenly distributed and muscle strength is intact.

The diastolic pressure is the

Elastic recoil, or resting, pressure that the blood exerts constantly between each contraction.

Body, build, contour: Abnormal

Elongated arm span (e.g., Marfan syndrome, hypogonadism)

A middle-aged patient comes to the clinic and states, "I can't get my breath when I walk." The nurse notes that the patient has a barrel chest and is using the accessory muscles to breathe. The patient's respiratory rate is 28. On palpation, there is a limited expansion and decreased tactile fremitus. Percussion yields hyperresonant sounds. On auscultation, prolonged expiration, scattered wheezes, and rhonchi are present. Which disorder does the nurse suspect?

Emphysema

The patient with _________ is likely to have an abnormally wide costal angle with slight inspiratory variation.

Emphysema

What is the thin layer of endothelial tissue that lines the inner surface of the heart and the valves called?

Endocardium

The trachea lies anterior to the

Esophagus. It begins at the level of the cricoid cartilage in the neck and bifurcates just below the sternal angle into the right and the left main bronchi.

Type of pain summary: Nociceptive (somatic or visceral)

Etiology: Activity of nociceptors in cutaneous and deep musculoskeletal tissue in response to tissue-damaging stimuli. Inflammation Pain Descriptors: Somatic: Dull; Aching; Well-localized; Nocturnal Visceral: Deep, squeezing pressure; Local tenderness and referred; Poorly localized Associated Descriptors: Somatic: Postoperative pain; Bone metastases; Arthritis Sports injury; Mechanical back pain Visceral: Liver metastases; Pancreatic cancer Treatment Options: Treat the underlying cause; Nonsteroidal anti-inflammatory drug (NSAID); Opioid; Muscle relaxant; Corticosteroid; Bisphosphonate

Cancer pain

Etiology: Infiltration of lesion Nerve injury from periphery or central nervous system Pain Descriptors: Dependent on underlying pathology Associated Descriptors: Bone metastases neuropathy Treatment Options: Symptom control—any of the above

Type of pain summary: Neuropathic

Etiology: Primary lesion (neuroma) or dysfunction in nervous system causing ectopic charges within the nervous system Pain Descriptors: Constant dull ache; Burning; Stabbing; Vicelike; Electric shocklike; Numbness; Tingling; Allodynia; Hyperalgesia; Hyperpathia Associated Descriptors: Distal polyneuropathy (diabetes, HIV); Central poststroke pain; Herpes zoster; Trigeminal neuralgia; Neuropathic back pain; Complex regional pain syndrome Treatment Options: Tricyclic antidepressant (TCA); Anticonvulsant; Antidepressant; Antineuroleptic; Local anesthetic; Bisphosphonate; Corticosteroid; Opioid; Interventional techniques

Gait: Abnormal

Exceptionally wide base. Staggering, stumbling. Shuffling, dragging, nonfunctional leg. Limping with injury. Propulsion—Difficulty stopping

Waist Circumference

Excess abdominal fat is an important independent risk factor for disease, over and above that of BMI. If most of the weight is carried around the waist instead of around the hips, the person is at higher risk for heart disease and type 2 diabetes. *With the person standing, locate the hip bone—the very top is the iliac crest. Place a measuring tape around the waist, parallel to the floor, at the level of the iliac crest. The tape should be snug but not pinch in the skin. Note the measurement at the end of a normal expiration

Level of consciousness: Cerebral hypoxia may be reflected by

Excessive drowsiness or anxiety, restlessness, and irritability.

Gigantism

Excessive secretion of growth hormone by the anterior pituitary results in overgrowth of the entire body. When this occurs during childhood before closure of bone epiphyses in puberty, it causes increased height (here 2.09 m, or 6 ft 9 in) and weight and delayed sexual development.

Acromegaly (Hyperpituitarism)

Excessive secretion of growth hormone in adulthood after normal completion of body growth causes overgrowth of bone in face, head, hands, and feet but no change in height. Internal organs also enlarge (e.g., cardiomegaly); and metabolic disorders (e.g., diabetes mellitus) may be present.

Stature: Abnormal

Excessively short or tall

What happens to the thoracic cavity during expiration?

Expiration is primarily passive. As the diaphragm relaxes, elastic forces within the lung, chest cage, and abdomen cause it to dome up. All this squeezing creates a relatively positive pressure within the alveoli, and the air flows out.

Speech pattern: Abnormal

Extremes of few words or constant talking.

Facial features: Normal

Facial features are symmetric with movement.

Using a cuff that is too narrow yields a

Falsely high BP because it takes extra pressure to compress the artery.

Taking BP with a cuff too narrow for extremity may result in

Falsely high BP because it uses excessive pressure to occlude brachial artery

Taking BP with cuff wrap too loose or uneven, or bladder balloons out of wrap results in

Falsely high BP because it uses excessive pressure to occlude brachial artery

Taking BP when arm position is below level of heart may result in

Falsely high BP reading because additional force of gravity added to brachial arty pressure

Taking blood pressure reading when person is anxious or angry or has just been active can result in

Falsely high BP reading due to sympathetic nervous system stimulation

While taking BP, failure to wait 1-2 min before repeating entire reading results in

Falsely high diastolic because of venous congestion in forearm

While taking BP, halting during descent and reinflating cuff to recheck systolic results in

Falsely high diastolic because of venous congestion in forearm

When taking BP, deflating the cuff too slowly results in

Falsely high diastolic because venous congestion in forearm makes sounds less audible

Taking BP when person is supporting their own arm may result in

Falsely high diastolic pressure because sustained isometric muscular contraction

Taking BP with faulty leg position (e.g., person's legs are crossed) may result in

Falsely high systolic and diastolic because translocation of blood volume from dependent legs to thoracic area

Taking BP when arm position is above level of heart may result in

Falsely low BP reading because it eliminates effect of hydrostatic pressure

When taking BP, pushing stethoscope too hard on brachial artery results in

Falsely low diastolic. Excessive pressure distorts artery, and sounds continue

When taking BP, deflating the cuff too quickly results in

Falsely low systolic or falsely high diastolic caused by insufficient time to hear tapping

Taking BP with failure to palpate radial artery while inflating: inflating cuff not high enough results in

Falsely low systolic. Misses initial systolic tapping or may tune in during auscultatory gap (tapping sounds disappear for 10 to 40 mm Hg and then return; common with hypertension)

Physiologic Changes from Poorly Controlled Pain: CNS

Fear Anxiety Fatigue

Suprasternal Notch

Feel this hollow U-shaped depression just above the sternum, between the clavicles.

Gait: Normal

Feet approximately shoulder width apart; foot placement is accurate; walk is smooth and even, and person can maintain balance without assistance. Associated movements such as symmetric arm swing are present.

8 Characteristics: Patient's Perception

Find out the meaning of the symptom by asking how it affects daily activities (Fig. 4-3). "How has this affected you? Is there anything you can't do now that you could do before?" Also ask directly, "What do you think it means?" This is crucial because it alerts you to potential anxiety if the person thinks the symptom may be ominous.

Facial expression: Abnormal

Flat, depressed, angry, sad, anxious. However, note that anxiety is common in ill people. Also, some people smile when they are anxious.

The iris normally appears

Flat, with a round regular shape and even coloration. Note the size, shape, and equality of the pupils. Normally the pupils appear round, regular, and of equal size in both eyes. In the adult resting size is from 3 to 5 mm. *ABNORMAL: rregular shape. Although they may be normal, all unequal-size pupils call for a consideration of central nervous system injury.

Vertebra prominens

Flex your head and feel for the most prominent bony spur protruding at the base of the neck. This is the spinous process of C7. If two bumps seem equally prominent, the upper one is C7, and the lower one is T1.

Examination of an ill person

For the person in some distress, alter the position during the examination. For example, a person with shortness of breath or ear pain may want to sit up, whereas a person with faintness or overwhelming fatigue may want to be supine. Initially it may be necessary just to examine the body areas appropriate to the problem, collecting a mini-database. You may return to finish a complete assessment after the initial distress is resolved.

The slope of the earpiece of a stethoscope should point

Forward toward your nose. *This matches the natural slope of your ear canal and efficiently blocks out environmental sound.

While assessing a patient, the nurse hears a cracking or grating sound on auscultation. What abnormality is suspected in the patient?

Friction rub *Palpable friction rub is produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. Then, the opposing surfaces make a coarse grating sound when rubbed together during breathing.

Nociceptive pain develops when

Functioning and intact nerve fibers in the periphery and the CNS are stimulated. It is triggered by events outside the nervous system from actual or potential tissue damage. Nociception can be divided into four phases: (1) transduction (2) transmission (3) perception (4) modulation Other examples of nociceptive pain include a skinned knee, kidney stones, menstrual cramps, muscle strain, venipuncture, or arthritic joint pain. Nociceptive pain is typically predictable and time limited based on the extent of the injury. Nociceptive pain originating from visceral sites is described as aching if localized and cramping if poorly localized; from somatic sites, it is described as throbbing/aching.

Gender differences in pain:

Gender differences are influenced by societal expectations, hormones, and genetic makeup. Traditionally men have been raised to be more stoic about pain, and more affective or emotional displays of pain are accepted for women. Hormonal changes have strong influences on pain sensitivity for women. Regarding migraine, the prevalence is equal in prepubertal girls and boys, but after puberty it increases to 18% for women and 6% for men. Women may have more postoperative and procedural pain than men and are more likely to have chronic fibromyalgia.

What is used to measure joint range of motion?

Goniometer

How would the nurse describe an innocent murmur?

Grade 2, midsystolic, musical *A murmur is a blowing, swooshing sound that occurs with a turbulent blood flow in the heart or the great vessels. The innocent murmur is generally soft, midsystolic, short, and has a vibratory or musical quality. It is Grade 2.

While assessing a patient with cyanosis, the nurse hears a loud murmur that lasts throughout systole. A thrill is also palpable. Which classification best describes the murmur?

Grade 4 holosystolic *The intensity of the loudness of the heart murmur is described in terms of six grades: Grade 1 is the lowest and Grade 6 is the highest. If the murmur is heard throughout the systole or diastole, then it is called holosystolic and holodiastolic, respectively. A systolic murmur may also occur with a normal heart, but a diastolic murmur always indicates heart disease. In this instance, the murmur lasts throughout the systole, is loud and is associated with a thrill. It is therefore classified as Grade 4 and holosystolic. When the loudness of the murmur gradually increases, it is called crescendo; in case of decrescendo, the murmur gradually decreases. The murmur is neither increasing nor decreasing gradually; hence, it is not a crescendo or a decrescendo murmur. Since the murmur is not heard during the diastolic phase of the heart, it is not a holodiastolic murmur.

Which assessment finding would the nurse associate with mycoplasma pneumonia? - Dry cough - Barking cough - Hacking cough - Congested cough

Hacking cough

The bell of the diaphragm

Has a deep, hollow, cuplike shape. It is best for soft, low-pitched sounds such as extra heart sounds or murmurs. Hold it lightly against the person's skin, just enough that it forms a perfect seal. Holding it any harder causes the person's skin to act as a diaphragm, obliterating the low-pitched sounds.

A dry cough may be an early indication of

Heart failure

While assessing a patient, the nurse finds elevated jugular venous pressure, ventricular gallop, and a pulse deficit. The diagnostic results of the patient indicate that the diameter of heart is 5 cm. Which complication does the nurse suspect in the patient?

Heart failure *An elevated jugular venous pressure, pulse deficit, and a heart diameter of greater than 4 cm indicate the patient has heart failure. A pathologic S 3 (ventricular gallop) occurs due to decreased compliance of the ventricles in the patient with heart failure.