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NURS 3100 Health Assessment Exam 2 Study Guide: *Remember, the end result of REALLY learning material is that you will be an expert & confident practitioner. You will identify problems early, minimize complications, provide comfort, & even Save Lives!55 Multiple Choice Questions. This list covers the most important topics, but may not cover every possible test item.Using power points, lecture notes, and text book, familiarize yourself with the following concepts:Respiratory System:Signs of respiratory distress (flaring, use of accessory muscles, retractions, cyanosis)Flaring= labored respiratory; hypoxiaUse of accessory muscles= facilitate inspiration in chronic airway obstruction or atelectasisRetractions= when the area between neck and ribs sinks due to not getting enough air and struggling to breatheCyanosis= cold or hypoxiaObserve chest wall for deformities (AP vs Transverse dimensions & significance of). Know how to assess for equal expansion, trachea midline, equal scapulaeNormal chest= AP< lateral (1:2 ratio)Barrel Chest= AP> lateral (1:1 ratio)Pectus excavatum = funnel chestPectus carinatum = pigeon chestTactile fremitus: findings, possible interpretations (when this would be decreased or increased)Fremitus- vibrations of air in bronchial tubesUse hand to palpate as client repeats “99”Should be symmetrical and easily felt in upper lobesNormal to diminish toward base of lungsPercussion findings: (when might hear hyper-resonance, dullness over lungs?)Resonance- low-pitched, normal over lungsTympany- drum-like, normal over abdomenDullness- fluid or solid, normal over heart and liverConsolidation, pleural effusion, tumor if heard over lungsHyper resonance- trapped airCOPD, emphysema, pneumothorax if heard over lungsKnow lung sounds: Where you expect to hear, pitch, significance/what to do for abnormals: Vesicular- low pitched, normally over peripheral lung fieldsBronchial (tracheal)- over trachea, loud, harshBroncho-vesicular- by sternum & between scapulaeFine Crackles- (Fine Rales); high pitched, (rubbing hair by ear, fire)Coarse Crackles- (Coarse Rales): loud, low pitched, bubbling; may clear with coughing. Inhaled air collides with secretions in trachea & large bronchiWheezes- high, musical whistling; air passing thru constricted airway (asthma)Stridor- inspiratory wheeze associated with obstruction of airwayIf you hear abnormal breath sounds, ask the client to cough as this can clear the airways. Then listen again and note any change.Respiratory signs such as clubbing, cyanosis, barrel chest, pursed-lip breathing, tri-pod positioningAuscultation of lungs- location/# of lobes, use diaphragm, pattern, compare side to side for symmetry. Know steps of respiratory assessment. Right lung: 3 lobesLeft lung: 2 lobesPalpate, percuss, auscultateMove in a ladder pattern How to assess chest expansion, including normal findings & significancePlace hands on back with thumbs pointing in toward spinePatient breathes in and your hands should move apartHow to perform voice transmission tests-normal findings & significanceListen while patient says 99 and E As you move toward base of lungs sound should diminishShould be hard to understand what they are sayingIf you can hear what they are saying, something is abnormalDiscuss signs of pleural effusion, pneumothorax, pneumonia, asthma, COPDPleural EffusionCollection of excess fluid in intrapleural space with compression of lungfluid settles in bottom of thoracic cavityfluid subdues lung soundstachypnea, dyspnea, tachycardia, cyanosis, tactile fremituspercussion- dull; no diaphragmatic excursion on affected sideauscultation- breath sounds decreased or absent, cracklesPneumothoraxAir in the pleural cavity resulting in partially or completely collapsed lungUsually unilateralCaused by trauma to chest wall or spontaneous ruptureCauses unequal chest expansionTachypnea, cyanosis, apprehension, anxietyBreath sounds decreased or absentTactile fremitus absent or decreasedHemothorax- same symptoms but its blood instead of airPneumoniaInfection in lung causing alveolar membranes to fill with fluid/pus which replaces space for air exchangeTactile fremitus- INCREASEDPercussion- dull over affected lobeAuscultation- loud bronchial breathing, diminished lung sounds in some casesCough, fever, tachycardia, dyspnea, pleural pain, respiratory distressAsthmaRetractive Airway DiseaseTriggers activate inflammatory response- bronchospasm, edema in bronchioles, secretion of highly viscous mucus, increase in airway resistanceSymptoms: Increased respiratory rate, sob, wheezing, accessory muscles used, retractions, labored and prolonged expirationPalpation- tactile fremitus decreasedPercussion- resonanceAuscultation- diminished air movement, breath sounds decreased, wheezingCOPDChronic Airflow LimitationEmphysema and chronic bronchitisSymptomsEasily fatigued, frequent respiratory infections, use of accessory muscles to breathe, thin, fingernail clubbing, chronic cough, pursed lip breathing, wheezing, barrel chestKnow risks of lung cancer & education to provide to patient on decreasing riskLEADING CAUSE OF DEATH IN THE US & EUROPERisk Factors:Cigarette smoking (self or 2nd hand)Genetic predispositionExposure to toxins (asbestos, radon, environmental factors)Workplace pollutantsPoor dietDecrease Risk:Stop smoking! Avoid 2nd hand smoke!Check for occupational or home exposure to asbestos or radonSeek care for prolonged cough or pain in chest areaAffects more men than womenBlack men have more incidence and mortality ratesAffects mainly elderly patients (over 60)Respiratory assessment landmarks (sternal angle, costal angle, sternal notch, C7 (vertebral prominens)Sternal angle- bony ridge a few centimeters below the suprasternal notch; also called angle of LouisCostal angle- angle between ribsSternal notch- u shaped indention on top of sternumC7- sticks out on back of neckCardiac, Neck Vessels, Peripheral Vascular:-Know basic landmarks (expected location of heart, midclavicular lines, apex, base, aortic, pulmonic, erb’s point, tricuspid, mitral) “All People Enjoy Time Magazine”Heart is between left 2nd and 5th intercostal spaceApex is bottom of heartBase is top of heartAortic valve = 2nd right intercostal spacePulmonic valve = 2nd left intercostal spaceErb’s point = 3rd ICS at left sternal borderTricuspid valve = 4th or 5th ICS at left sternal borderMitral valve = 5th ICS at left midclavicular line-Know which intercostal spaces the valves are heard best overSee above-Know which heart sounds correspond with which valve closuresS1 – “LUB”; Tricuspid and Mitral valves (R&L AV valves)S2- “DUB”; Aortic and Pulmonic valves (R&L SL valves)-Heart sounds (Normal vs. Abnormal): S1, S2- what makes sound? Where heard loudest? What is S3, S4, Murmurs (what are they, how to grade; Technique/sequence to auscultate). Is S3 ever normal and/if in who?S1 and S2 are normalMakes lub dub soundS1 loudest at apexS2 loudest at baseS3 Ventricular GallopVibrations from resistance to ventricular filling heard over the chestOccurs immediately after S2Can be a normal finding in young athletesOtherwise it is abnormalS4 Atrial GallopAt the end of diastole, just before S1Occurs in a non-compliant ventricle: CAD, hypertension, cardiomyopathyAbnormalMurmursSwishing or blowing sound caused by turbulent backflow of bloodCan be caused byIncreased blood velocity (exercise, thyrotoxicosis)Narrow or incompetent valveDecreased blood viscosity (thickness, as in anemia)Abnormal chamber openingsGrading MurmursI – difficult to hear; experienced examiner and quiet environment are neededII – can be heard upon laying stethoscope on chest, but it is very quiet; examiner must listen closelyIII – requires no effort to hear; is readily heard when stethoscope is placed on chestIV – loud with a thrillV – very loud; easily palpated thrillVI – audible with stethoscope only near chest-Capillary refill- purpose, how & where to check, what does it indicateIf the refill takes longer than 1-2 seconds it indicates poor circulationPress nail bed, blanch, let go, color should return within 1-2 seconds-Sequence of Cardiovascular exam: inspect, palpate, percuss, auscultateInspectAuscultatePalpatePercuss -Define bruit & thrill; Where do you assess for these & how; indicates what?Bruit- a blowing, swishing sound indicating blood flow turbulenceAuscultation over carotid arteryIndicates plaque build-up in arteryThrill- purr-like vibration feeling indicating turbulent blood flowPalpate over apex, left sternal border, and base of heart-Know signs/how to identify MI, heart failure, Allen’s test, Homan’s SignMyocardial Infarction (MI)Coronary Artery OcclusionCrushing chest pain that does not subsideHeart FailureCough- pink, frothy sputumJVDPitting edemaFalling O2 saturationCrackles or wheezesDyspneaOrthopneaStress/AnxietyAllen’s testOcclude radial and ulnar pulses and have patient pump handLet go of ulnar pulseColor should return to pinky side of hand within 2-5 secondsThis shows whether or not the patient has good circulation in that arteryHoman’s signUsed to test for deep vein thrombosis (DVT)Dorsiflexion of foot will cause pain in the back of kneeBe careful with this as it can let loose a blood clot-Pulses- Be able to locate/name all. Assess for rate, regularity, and amplitude. INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET -Cautions for examining carotidsOnly feel one at a timeNever take pulse bilaterally; could cut off blood flow to brainPalpate GENTLYPulse amplitude and strength should be the same bilaterally-How to locate & assess apical pulse, how to locate & palpate apical impulsePosition client supine or on left lateral sideUse 1-2 finger pads to palpate in the mitral areaFeels like a gentle tap5th left ICS and midclavicular line-Be able to trace/list the proper sequence of blood flow through the heartSup VC Right Atrium Tricuspid (R AV) valve Right Ventricle Pulmonic (R SL) valve Pulmonary artery Lungs Pulmonary veins Left Atrium Bicuspid/Mitral (L AV) valve Left Ventricle Aortic (L SL) Valve Aorta Body-Know what defines Jugular Venous DistentionBulging jugular veinSign of increased central venous pressure in vena cava-What occurs during diastole? Systole?Diastole- ventricles relax, AV valves open, SL valves shut, fill with blood2/3 of cardiac cycleSystole- ventricles contract, AV valves snap shut, SL valves open, pump blood out1/3 of cardiac cycle-Characteristics of Arterial versus Venous systemsArteriesCarry OXYGENATED, nutrient-rich blood from the heart to the capillariesHigh pressureMaintain BP by constricting or dilating in response to the parasympathetic nervous systemVeinsCarry DEOXYGENATED, nutrient-depleted blood from tissues back to heartMuch lower pressureAct as a reservoir for extra blood-Define pulse deficit and lymphedemaLymphedema- high protein swelling of limbLymph builds up in interstitial spaces after a surgical removal of lymph nodesPulse deficit- difference in palpable pulse and heart rateUsually seen in atrial fibrillation-Know how Ankle Brachial Index is calculated and what normal results includeSystolic blood pressure taken using a doppler ultrasound and cuff from arm and ankle on both sidesHighest number for each is keptAnkle divided by arm .9-1.9 is normal and means circulation is goodTests for PAD- a condition where arteries in arms and legs are narrowed or blocked by plaque-Characteristics & risks of venous versus arterial ulcers/skin appearanceVenous Insufficiency/ PVDInadequate return of venous blood from legs to heartTired/heavy legsCramping/aching in legsPain worsens with standingPain improves with elevationVenous (stasis) UlcerShallow ulcer with irregular borderBleedingSeen on legsThin and blue surrounding skinDarkening of legsArterial Insufficiency/ PADNarrowing of arteries commonly the pelvis and legsCrampingWorsens with exerciseSubsides with restArterial (ischemic) UlcerHave a punched out appearanceTendons, bones, underlying joints exposedCovered with minimal granular tissuePallor, dry skin, loss of hair, fissuring of nailsUsually on toes and anklesCan be on legs-Risk factors for cardiovascular disease (modifiable versus non-modifiable)Modifiable- things you can control/change; modify (smoking, weight, cholesterol, nutrition, exercise, alcohol, drugs, etc.)Non-modifiable- things you cannot change (age, race, gender, etc.)Breast Exam:Breast exam-method of assessment and palpation techniques, including what to do if a lump is found. All lumps should be further assessed and referredInspectionPalpationPatient lays supinePalpate for texture and elasticity: look for thickening from tumorTenderness and temperatureMasses: location, size in cm, shape, mobility, consistency, tendernessNipples: wear gloves, compress nipple gentlyMastectomy or lumpectomy siteUse a sensitive but matter of fact approachWedge technique, circular or vertical stripHave client lay supine with arm overhead. Place small pillow under breast being palpated. Use flat pads of 3 fingers to palpate breasts in one of 3 patterns. Palpate every square inch in each level of pressure (light, medium, firm)! Use bimanual technique if there are large breasts. Know what abnormal lymph node findings can be associated with breast cancer.LumpsSwellingRednessWarmthDimplingPainProminent or asymmetric patternRetractionBe familiar with Tail of Spence and how to document locations on breast (quadrants)Know the site of most breast tumorsUPPER OUTER QUADRANTKnow signs of breast cancer (dimpling, bloody nipple discharge, retraction, lump, etc)Retraction- when nipple starts out as raised but begins to pull inwardDimpling- dimpling of breast tissueDischargeKnow signs of Paget’s, Peau D’orangePaget’s DiseaseRedness and flaking of nippleLate signs are tingling, itching, sensitivity, burning, discharge, and painUnderlying invasive ductal carcinomaPeau D’orangeInflammatory cancerAccumulation of excess lymph fluid inside breast tissue cause pores to enlarge due to edemaHEENT Exam:Cervical lymph nodes: Normal vs. worrisome (How to assess, Lymphadenopathy, characteristics to check)Swelling and tenderness are abnormalAssess by feeling, palpating Lymphadenopathy: Thyroid: Know the steps on how to assess (how to palpate, how/when to auscultate)Usually nonpalpable, nontenderReach from behind the client to palpateAuscultate for bruits if enlargedAuscultate only if enlargement is seenHeadaches: Cluster vs. Tension vs. Migraine vs. SinusCluster Headache: Stabbing, sudden onset at same time of daymay have reddened eye/drooping, in orbit of eye more common in young malesTension Headache:Dull/tight/diffuse patternOccur with stress and anxietyAchingMore common in womenMigraine:Severe throbbing, may have N/VSensitive to light; aura (visual changes associated with migraines)One spot where the pain is More common in womenCan last for daysSinus:Pressure, tenderness on faceMay have nasal drainage/bad breathWorse when bending overTumor related:May worsen with cough/sneezeMay have neurologic symptomsCommonly occurs in the morningCharacteristics of Pharyngitis (Strep vs viral sore throat)Strep is caused by bacteria; can see white patches on throat and tonsilsViral is caused by virusPERRLA: Know what each letter stands for & how to assess each testPERRLA = Pupils Equal, Round, Reactive to Light, AccommodationCorneal light reflex test- have patient look at a penlight. The light reflex should fall within the pupils bilaterally equalEsotropia- light reflex is in the interior of a pupilExotropia- light reflex is toward outer edge of pupilKnow how to check of mydriasis, anisocoria, miosis-what do these indicate?Mydriasis- dilated pupilsAnisocoria- unequal pupilsMiosis- pinpoint pupils; seen with narcotic usageHow to check Visual acuity testing (Snellen) & what documentation means (Ex: 20/20 vs 20/80)Person stands 20 feet away from the chart20/40 or worse = need corrective lenses20/80 means that a person can read at 20 ft what a person with normal eyesight could read at 80 ft awayTerms- Ptosis, chalazion, hordeolum, conjunctivitis, ectropion, cataracts (what will red flex look like if cataracts are present?)Ptosis- droopy eyelid, can be born with it or can be caused by tumorEctropion- eyelid is pulling away from eye so you can see the inside of eyelid; no treatment unless patient is uncomfortableHordeolum- (aka sty) infected external eyelid glandChalazion- similar to hordeolum; occurs UNDER eyelid, inflamed sebaceous (Meibomian) glandConjunctivitis- (AKA Pink Eye) inflammation of the conjunctiva; can be due to allergies or bacteriaCataract- leading cause of blindness worldwide, Black spots or spokes against the background of the red light reflex is indicative of cataracts.Define Consensual reaction, Presbyopia, Corneal light reflexPresbyopia- age related change in the eyes in which the lens can’t accommodate for near visionCorneal light reflex- use pen light to observe parallel alignment of light reflection in corneasConsensual reaction- when light is shined in the right eye, the left eye pupil should also react and vise versaOtoscopic exam: (such as positioning & what you are expected to visualize): normal and abnormal findings of tympanic membrane, outer ear, how to hold otoscopeInspectionInspect the external auditory canal for discharge, color, consistency of cerumen, canal walls, and nodulesInspect the tympanic membrane for shape, consistency, and landmarksTympanic membrane should be a pearly gray color if normalTerms: pinna, tragus, otitis media, otitis externa, presbycusis, types of hearing loss & signs of eachPinna- auricle, basically the outer earOtitis media- infection of middle earOtitis externa- infection of outer earPresbycusis- hearing loss associated with aging, hard to heat high pitched soundsConductive hearing loss- something blocks or impairs the passage of vibrations from getting to the inner earMay result in bone conduction being better than air conduction in the affected ear and the Weber would lateralize to that side)Sensorineural (perceptive) hearing loss- damage is located in the inner earDue to a disease processAC>BC and Weber lateralized to non-affected sideCan be congenital or acquiredKnow how to conduct Rinne & Weber tests (expected findings related to air and bone conduction)Weber TestStrike the tuning forkUse tuning fork placed on the center of the head or foreheadAsk whether the client hears the sounds better in one ear or the same in bothRinne TestUse the tuning fork and place at the base of clients mastoid processWhen the client can no longer hear the sound, note the time interval and move the tuning fork in front of the external earNote how long they can hear the soundExpected to hear the sound longer in front of ear than when tuning fork was on bone bc air conduction is better than boneKnow how to conduct Romberg test; what it means & what a positive test isHave client stand with feet together and arms at side, close eyes for 20 secondsCheck for swayingTests equilibriumIf the patient loses their balance or sways, it is a positive testSinuses-how to assess in steps; know signs of sinus infection Palpate for tenderness and crepitationPercussion and transillumination for air vs. fluid or pusMouth: Signs of Abnormal findings (fungal infection like yeast; leukoplakia) vs. normal findings (soft, spongy palate)AbnormalCheilosis- sides of mouth cracking and soreCarcinoma of lip or tongue- cancerLeukoplakia- thick white patches in your mouth from smokingFungal infection- black hairy tongueGingivitisSmooth, red, shiny tongue- vitamin B12 deficiencyNormalSoft, spongy palatePinkNo receding gumsHas all teethKnow how to grade tonsils1+, 2+, 3+, 4+ INCLUDEPICTURE "" \* MERGEFORMATINET Know signs & risks of oral cancerRisksTobacco products!!!Heavy alcohol useHPV infectionPoor oral hygienePoor diet/nutritionWeak immune systemAge 55+Use of mouthwash with alcohol contentSignsSores that do not healLumpRed or white patch on inside of mouth or tongueUlcersBad breathPain Know how to locate and name lymph nodes in head and neckPreauricular nodes- in front of earsPostauricular nodes- behind earsOccipital nodes- posterior base of skullTonsillar nodes- angle of mandible, on the anterior edge of the sternocleidomastoid muscleSubmandibular nodes- medial border of the mandible Submental nodes- a few centimeters behind the tip of the mandibleSuperficial cervical nodes- superficial to the sternomastoid musclePosterior cervical nodes- posterior to the sternocleidomastoid muscle and anterior to the trapezius in the posterior triangleSupraclavicular nodes- hook fingers over clavicles and feel deeply between the clavicles and sternomastoid muscle INCLUDEPICTURE "" \* MERGEFORMATINET Know where and how to assess the TMJShould be nontender without crepitation or swellingMouth should open/close fully and jaw move smoothly laterallyShould not hear any popping or clickingFingers in front of ears, instruct patient to open and close jawKnow facial abnormalities (signs of Parkinson’s, Acromegaly, CVA)Acromegaly- enlargement of facial bones; can be seen in feet and hands tooParkinson’s- mask-like facial appearance, shuffling gate and diminished reflexesCVA (cerebrovascular accident)- stroke; can be caused by a clot or by bleeding on the brain (hemorrhage); paralysis or droopiness on one side of face ................
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