Health Assessment Exam 3
The lungs has how many lobes?
3 right, 2 left(has to have room for heart)
Erb's point
3rd intercostal space, left sternal border
Transmitted Voice Sounds: Bronchophony
Ask patient to repeat "99". Bronchophony is negative when spoken voice heard through stethoscope sounds muffled. If "99" is heard clearly and louder over dense areas, it indicates pneumonia.
Transmitted Voice Sounds: whisper pectoriloquy
Ask the Pt to whisper "1,2,3" (healthy lung areas should not be able to make this out) Frequencies more able to be transmitted in abnormal lungs
vesicular breath sounds
Normal breath sounds made by air moving in and out of the alveoli.
Best fats
Nuts, fish, avacados
OLDCART
O- onset L- location D- duration C- characteristics A- aggravating factors R- relieving factors T- treatment
Rhonchi
Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways. "Snore"
Systole
Contraction of the heart (s1)
Check cholesterol every 5 years if
Low risk
Traumatic Flail Chest
Multiple rib fractures, caves inward on inspiration, moves outward on expiration
wheezes
continuous high-pitched musical sounds produced during breathing
Full respiratory cycle
inspiration and expiration
bronchovesicular breath sounds
medium-pitched and quieter sounds normally heard over the mainstem bronchi
eupnea
normal breathing
sternal border
outer edge of the sternum
Cheynes-Stokes
periods of labored respirations followed by apnea
Apical pulse (PMI)
point of maximum impact, palpable at the 5th intercostal space, left midclavicular line
crackles (rales)
popping sounds heard on auscultation of the lung when air enters diseased airways and alveoli; occurs in disorders such as bronchiectasis or atelectasis (Indicate fluid or mucous, fine is high pitch, coarse is low pitch)
Grade 2 murmur
quiet but clearly audible
Tachypnea
rapid breathing
bradypnea
slow breathing
Intercostal spaces
spaces between the ribs (under each rib)
stridor
strained, high-pitched sound heard on inspiration caused by obstruction in the trachea
midclavicular line
the line through the center of each clavicle
T wave
ventricular repolarization and relaxation
Grade 1 murmur
very faint
cardiac output
volume of blood pumped by each ventricle in one minute
Stroke volume
The volume of blood ejected with each heart beat
S2 sound (dub)
closure of aortic and pulmonic valves- loudest at base
a murmur sounds like a
-blowing or swishing sound -best heard with bell of steth
Midscapular line
imaginary line on the back that runs vertically through the center of the scapula
QRS wave
impulse thru bundle of his to purkinje fibers causing ventricles to contract
Palpate vibrations on posterior thorax
"on back"
Vetebral line
A line running vertically down through the spinous processes of the spine
Which of the following are the main functions of the cardiovascular system? (Choose all that apply.)
A. Deliver oxygen to the tissues B. Remove waste products from the tissues C. Maintains perfusion to the body tissues
Dyspnea is a general symptom of several different disease processes. Some factors that may aggravate it are: (Choose all that apply.) A. Exertion B. Lying down C. Inhaled irritants D. Sitting up
A. Exertion B. Lying down C. Inhaled irritants
Resonance
Air filled
midaxillary line
An imaginary vertical line that starts at the middle of the axilla (armpit) and extends down the side of the chest.
Sternal Angle (Angle of Louis)
Anterior Thoracic Landmark . Continuous with 2nd rib - Useful place to start counting ribs . Also site of tracheal bifurcation into L and R bronchus . Corresponds with the upper border with of the atria of the heart . Lies above the 4th thoracic vertebrae (T4) on the back
Turning to left side helps palpate the
Apical pulse
One of the more serious and concerning symptoms is:
Chest pain
COPD
Chronic Obstructive Pulmonary Disease, lung Dz commonly seen in smokers
Perfusion
Circulation of blood within an organ or tissue in adequate amounts to meet current needs of the cells.
S1 sound (lub)
Closing of mitral and tricuspid valves- loudest at apex
Of the three tvpes of stethoscopes, which one is most unsuitable to conduct a full cardiac examination?
Diaphragm only
coarse crackles
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds?
Starting at the age of 20, the recommended screening frequency for a fasting lipoprotein profile if low risk for adults is:
Every 5 years
Smoking is a habit that only affects the individual who smokes.
False
carotid artery
Feeds blood to brain
When auscultating the anterior chest on a large-breasted woman, the nurse should:
Gently move the breast tissue to the side
Pitting edema and Nocturia could be
Heart failure
Check cholesterol every 2 years if
High risk
Pwave
Impulse from SA node and causes atrial contraction
Hyperresonance
Increase in space like barrel chested COPD patients
Diastole
Relaxation of the heart (s2)
electrical conduction of the heart
SA node, AV node, bundle of His, right and left bundle branches, Purkinje fibers
Blood flow through the heart
SVC --> Rt atria --> Tricuspid --> Rt ventricle --> Pulmonic valve --> Lungs --> Lt atria --> Mitral valve --> Lt ventricle --> aortic valve --> aorta --> Body
Pleural friction rub is indicated by
Sandpaper or gravel sounds (most common lower lateral outside of lungs)
Afterload
The force or resistance against which the heart pumps.
Palmar base
The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?
Fifth intercostal space, left midclavicular line
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?
Tripod, barrel, clubbed, crackles
The nurse working in a hospital assesses the respiratory status of a 64-year-old male client with a history of chronic obstructive pulmonary disease (COPD). Upon inspection, the client is in the ________________ position, has a _______________chest and the nails are____________ and ____________________ are heard on auscultation.
Preload
The precontraction pressure in the heart as the volume of blood builds up.
Grade 6 murmur
Very loud, with thrill. May be heard with stethoscope entirely off the chest
pleural friction rub
What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?
accentuated
When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?
bronchitis
When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?
sternal notch
a medial notch at the superior end of the sternum
tactile fremitus
a tremulous vibration of the chest wall during speaking that is palpable on physical examination
murmur is caused by
a valve that isnt working well. either the valve isnt opening all the way due to stenosis, or not closing all of the way causing regurg
apnea
absence of breathing
APE To Man stands for
aortic, pulmonic, erb's point, tricuspid, mitral
Bottom of the heart is called
apex
Top of the heart is called
base
blood pressure (BP)
cardiac output x peripheral resistance
Kussmal's breathing pattern
deep, regular, and rapid (acidosis)
The __________ is the primary muscle(s) of the respiratory system?
diaphragm
Orthopnea is:
difficulty breathing when lying down
jugular vein
drains blood from the head
tympany percussion
drumlike sound, loud intensity, high pitch, medium duration, located in stomach
Solid Organ Sound in percussion
dullness
pitting edema
edema that retains an imprint when touched
Transmitted Voice Sounds: Egophony
eee, aaa
xphoid process
end of sternum
Three layers of the heart
epicardium, myocardium, endocardium
nocturia
excessive urination at night