HA Blueprint Exam 2 - Exam 2 study guide PDF

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NU303 Exam 2 Blueprint Fall 2020 Respiratory Breath sounds/thorax – look at the chart that differentiates them – where are they heard in each age group and what do they sound like?  Bronchial – heard on anterior side over the trachea and larynx o Pitch – high o Amplitude – loud o On inspiration they are harsh and hollow and on expiration they are tubular o Expiration is longer than inspiration  Vesicular – heard over peripheral lung fields where air flows through smaller bronchioles and alveoli o Pitch – low o Amplitude – soft o Inspiration longer than expiration o Rustling like the sound of wind in the trees  Bronchovesicular – heard over major bronchi where fewer alveoli are located – posteriorly heard between scapulae (esp. on right) – anteriorly heard around upper sternum in 1st and 2nd intercostal spaces o Pitch – moderate o Amplitude – moderate o Quality of sound is mixed o Expiration and inspiration are equal Expected changes in sounds and assessment of:  Infants and Children o Inspection  Rounded thorax with equal A-T chest diameter – by 6 reaches 1:2 ratio  Newborn’s chest circumference = 30-36 cm (2 cm than head until 2)  Apgar scoring system – newborns first respiratory assessment to measure successful transition to extrauterine life  Obligate nose breather until 3 months  Count respiratory rate for 1 full minute (30-40 BPM, up to 60)  Respiratory pattern may be irregular when extremes in room temp. occur or with feeding or sleeping  Brief periods of apnea less than 10-15 seconds are common  More common in premature infants o Palpation  Palpate symmetric chest expansion by encircling infant’s thorax with both hands  Further palpation should yield no lumps, masses or crepitus – may feel costochondral junctions in some normal infants

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o Auscultation  Normally yields bronchovesicular breath sounds in peripheral lung fields of infant and child up to 5/6 years  Try using smaller pediatric diaphragm end piece or place bell over infant’s interspaces, not over ribs  Use pediatric diaphragm on older infant or toddler Adults Aging adult

Expected changes with aging with thorax:  Infant o Rounded thorax with an equal anteroposterior-to-transverse chest diameter  Pregnancy o Thoracic cage may appear wider o Deeper respirations and an increase in tidal volume by 40%  Aging adult o Increasing AP diameter, kyphosis (outward curvature of thoracic spine) o Chest expansion may be somewhat decreased, although still symmetric o Tend to tire easily during auscultation when deep mouth breathing is required o Costal cartilages become calcified – less mobile thorax Adventitious Sounds  Added sounds that are not normally heard in lungs  Sources differ as to the classification and name of these sounds o Crackles (rales) – discontinuous popping sounds heard over inspiration  Late inspiratory crackles occur with restrictive disease  Pneumonia, heart failure, and interstitial fibrosis  Early inspiratory crackles occur with obstructive disease  Chronic bronchitis, asthma, emphysema o Wheeze (rhonchi) – continuous musical sounds heard mainly over expiration  Atelectatic crackles o Not pathologic o Short, popping, cracking sounds that sound like fine crackles but do not last beyond a few breaths o Heard only in the periphery Atelectasis – partial collapse of an alveoli – part of lung loses ability to relax and recoil  When people don’t take deep breaths, after surgery, happens in elderly when sleeping  Neonates always have atelectasis Newborn Assessment  Let the parent hold an infant supported against chest or shoulder (ignore usual sequence of physical examination)  Seize opportunity with sleeping infant to inspect and listen to lung sounds next  Crying infant may not be a problem because it can enhance palpitation of tactile fremitus and auscultation of breath sounds

Percussion of sounds in the lungs:  Tumor – dull (soft, muffled thud) – abnormal density in the lungs  Fluid – dull percussion over affected area  Air – hyperresonance (lower-pitched booming sound) Pneumothorax – free air in pleural space causes partial or complete lung collapse – this air neutralizes the usual pressure present – usually unilateral – NO BREATH SOUNDS – trachea moves to other side  Can be: o Spontaneous – air enters pleural space through rupture in lung wall o Traumatic – air enters through opening or injury in chest wall o 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 (unaffected side) – chest expansion decreased on affected side – tachycardia, decreased BP  Percussion – hyperresonant  Auscultation – breath sounds decreased or absent – voice sounds decreased or absent  Adventitious sounds – none Bronchitis (acute)  Inspection – cough is productive/nonproductive; sore throat, low-grade fever postnasal drip, fatigue, substernal aching  Palpation – no pain, no increased fremitus  Percussion – resonant  Auscultation – may be clear and equal bilaterally – no egophony  Adventitious sounds – no crackles Bronchitis (chronic)  Inspection – hacking, rasping cough productive of thick mucoid sputum; 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 Pleural friction – “when I take a deep breath it hurts”  Palpable grating sensation Asthma  Inspection – during severe attack = increased respiratory rate, SOB with audible wheeze, use of accessory muscles, cyanosis, apprehension, retraction of intercostal spaces; expiration is labored and prolonged – 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 Pneumonia  Inspection – inspection respirations > 24/min – guarding and lag on expansion on affected side (children = sternal retraction; nasal flaring)  Palpation – pulse > 100 BPM, chest expansion decreased on affected side – tactile fremitus if bronchus patent, decreased if obstructed  Percussion – dull over lobar pneumonia  Auscultation – tachycardia; loud bronchial breathing; voice sounds have increased clarity; bronchophony, egophony, whispered pectoriloquy present (children = diminished breath sounds)  Adventitious sounds – crackles (fine to medium) 

Crepitus – grating sound/sensation produced by friction between bone and cartilage or fractured bone – can be heard over the clavicle if a fracture has occurred How do we assess the lungs/thorax?  Inspection o Thoracic cage, respirations, skin color and condition o A person’s facial expression, and LOC  Palpation o Confirm symmetric expansion and tactile fremitus o Detection of any lumps, masses, or tenderness  Percussion o Lung fields and estimate diaphragmatic excursion  Auscultation o Assess breath sounds, and note any abnormal/adventitious breath sounds o Perform bronchophony, whispered pectoriloquy, or egophony as needed 

Bronchophony – ask the person to repeat “ninety-nine” while listening with the stethoscope over the chest wall (esp. if you suspect pathology)  Normal voice transmission is soft, muffled, and indistinct – can heard sound through the stethoscope but cannot distinguish exactly what is being said

Bronchial sounds  Resonance – low pitch hollow sound; normal lung sounds  Hyper-resonance – sound of dullness; indicative of pathology (pleural effusion or pneumothorax) Why would someone have unequal chest expansion? How would we assess that?  Occurs with marked atelectasis, pneumonia, pleural effusion, thoracic trauma  Palpate for symmetric chest expansion – any limit in thoracic expansion is easier to detect on anterior chest because a great ROM exists with breathing (hands around waist have them breath in and out and watch hands move out symmetrically)

What would a pulmonary embolism show in an assessment?  Pulmonary embolism – undissolved materials originating in legs or pelvis detach and travel through venous system – returning blood to right heart and lodge to occlude pulmonary vessels; 95% arise from DVT in lower legs as a result of stasis of blood, vessel injury or hypercoagulability  Subjective – chest pain, worse on deep inspiration, dyspnea  Inspection – apprehensive, restless, anxiety, mental status changes, cyanosis, tachypnea, cough, hemoptysis, PaO2 < 80%; ABGs show respiratory alkalosis  Palpation – diaphoresis, hypotension  Auscultation – tachycardia, accentuated pulmonic component S2  Adventitious sounds – crackles, wheezes Pleuritis – caused by pleural friction rub accompanied by pain with breathing (rub disappears after a few days if pleural fluid accumulates and separates pleurae) Mouth Lesions - where do we look - which are cancer and which are not (look at the pictures in the book!)  Tongue, oropharynx, tonsils  Kaposi sarcoma = bruise like, dark red or violet, confluent macule, usually on hard palate – may be among earliest lesions to develop with AIDS  Cancerous o Leukoplakia = chalky, white thick raised patch on tongue o Carcinoma (lesion on lip/on tongue = could be cancerous)  Not cancerous o Epulis = benign, nontender, fibrous nodule of the gum o Gingival hyperplasia = painless enlargement of gums, sometimes overreaching the teeth o Gingivitis = gum margins red and swollen o Aphthous ulcers = common canker sore in mouth o Kolpik spots in measles = small blue white spots with irregular halo scattered over mucosa o Candidiasis or monilial infection = white cheesy curd like patch in mouth o Herpes simplex 1 = common cold sores on lip o Retention cyst = round nodule that is a pocket of mucus that forms in mouth o Cleft lip – congenital deformity o Angular cheilitis = painful fissures at corners of mouth Tonsils – mass of lymphoid tissue – appear more granular – not visible at birth but enlarge during childhood until puberty Ducts in the mouth – where they are what do they do

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Parotid gland – lies within the cheeks in front of the ear – extending from the zygomatic arch down to the angle of the jaw o Stensen duct – runs forward to open on the buccal mucosa opposite the second molar Submandibular gland – lies beneath the mandible at the angle of the jaw o Wharton duct – runs up and forward to the floor of the mouth and opens at either side of the frenulum Sublingual gland – lies within the floor of the mouth under the tongue – has many small openings along the sublingual fold under the tongue

Sinuses  2 pairs accessible to examine o Frontal sinuses – in frontal bone above and medial to the orbits o Maxillary sinuses – the maxilla (cheekbone) along the side walls of the nasal cavity  Ethmoid sinuses – between the orbits  Sphenoid sinuses – deep within the skull and sphenoid bone  Only maxillary and ethmoid are present at birth How the face grows  The nose becomes more prominent as we age because of loss of adipose tissue  Kids noses begin to grow at 12 and stop for girls at 16, boys at 18  Sinuses formed at age of puberty Assessment of:  Nose o Inspect external nose for symmetry, any deformity, or lesions o Palpation – test patency of each nostril o Inspect with nasal speculum  Color and integrity of nasal mucosa  Septum – any deviation, perforation, bleeding  Turbinates – note color, any exudate, swelling or polyps o Palpate the sinus area – note any tenderness  Throat o Inspect with penlight  Lips, teeth and gums, tongue, buccal mucosa – note color – whether structures are intact – any lesions  Palate and uvula – note integrity and mobility as person phonates  Grade tonsils  Pharyngeal wall – note color, exudate, or lesions o Palpation  When indicated in adults – bimanual palpation of mouth  In neonate – palpate for integrity of palate and to assess sucking reflex  Sinuses o Inspection

Expected assessment differences in:  Black/African American clients o Normally have bluish lips and a dark line on gingival margin o Leukoedema more common  Other racial differences we spoke about (things seen in some races more than others) Leukoedema – is a benign, milky, bluish-white opaque appearance of the buccal mucosa that occurs commonly in African Americans Leukoplakia – chalky white raised patch of leukoplakia is abnormal – chalky white, thick, raised patch with well-defined borders – lesion is firmly attached and does not scrape off – may occur on the lateral edges of tongue  Caused by chronic irritation of smoking and alcohol use  Lesions are precancerous, must refer to a specialist Torus palatinus – benign bony ridge running in the middle of the hard palate and occurs in 2035% of the US population (more in females) Bifid uvula – uvula is split either completely or partially and occurs in about 2% of the general population and up to 10% in some American Indian groups Koplick spots – small blue-white spots with irregular red halos scattered over mucosa opposite the molars  An early sign, and pathognomonic of measles Aphthous ulcers – Bednar aphthae are traumatic areas or ulcers on the posterior hard palate on either side of the midline (canker sores) Candidiasis – white, cheesy, curd like patch on the buccal mucosa and tongue  It scrapes off, leaving a raw, red surface that bleeds easily (termed thrush in a newborn)  Opportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed people Sucking area on newborn’s lip – sucking tubercle – small pad in the middle of the upper lip from friction of breastfeeding or bottle-feeding (normal finding) Assessment of tonsils in tonsilitis  With penlight observe the oval, rough-surfaced tonsils behind the anterior tonsillar pillar – color = pink (like oral mucosa); surface = peppered with indentations (crypts); some people collect small plugs of whitish cellular debris – there should be no exudate  Grading: o 1+ = visible o 2+ = halfway between tonsillar pillars and uvula o 3+ = touching the uvula o 4+ = touching one another

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With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots Tonsils are enlarged 2-4+ with acute infection

What can be a sign of HIV/AIDS seen in an oral assessment  Oral Kaposi sarcoma lesions # of teeth expected by age for a baby:  Both sets of teeth begin to develop in utero  Children have 20 deciduous (temporary) teeth – erupt between 6-24 months o All 20 should appear by 2 ½ o Deciduous teeth are lost from 6-12 and replaced with permanent ones  Starting with the central incisors  Appear earlier in girls than boys  Appear earlier in black children than white o Adults have 32 permanent teeth Cardiac Blood flow through heart  From liver to right atrium through inferior vena cava  From RV, venous blood flows through pulmonic valve to pulmonary artery  Lung oxygenate blood  From left atrium, arterial blood travels through mitral valve to left ventricle  From left atrium, arterial blood travels through mitral valve to left ventricle  Aorta delivers oxygenated blood to body  Circulation is continuous loop; moving by continuous shifting pressure gradients Electric flow through heart:  SA node near superior vena cava initiates electrical impulse, flows first across the atria to the AV node – it’s delayed slightly so atria have time to contract before ventricles are stimulated – then goes to bundle of His to right and left bundle branches and then through ventricle  P-wave = depolarization of atria  P-R interval = beginning of P wave to beginning of QRS complex  QRS = time necessary for atria depolarization plus time for impulse to travel through  AV node = depolarization of ventricles  T-wave = repolarization of ventricles  SA node = pacemaker Vessels:

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Great vessels o Super vena cava/inferior vena cava – return unoxygenated blood to right side of heart o Pulmonary artery – leaves right ventricle, bifurcates and carries venous blood to lungs o Pulmonary veins – return oxygenated blood to left side of the heart o Aorta – carries to the body

Right vs left heart failure  Failure on the right – edema; nocturia – my shoes and rings are tight, I pee at night, JVD when upright o JVD, inferior vena cava not draining back into right side  Left – backing up into lungs = crackles and adventitious sounds – can’t breathe when laying down/changing positions – left ventricle hypertrophies and backs up into pulmonary system Pericarditis – inflammation of sac around the heart  Pleural friction rub when auscultating  Leaning forward can help because it takes pressure off  Pain is substernal and can radiate to trapezius muscle region  Symptoms may include dry cough, muscle/joint aches and fever Ribs – intercostal spaces  Pleural spaces naming – by the rib above JVD (jugular venous distention) – common with right sided heart failure as blood backs up into superior vena cava and jugular Heart Sounds:  S1- beginning of systole (pumping phase); heard at apex (bottom) in mitral and tricuspid (AV) valves when they close  S2 – beginning of diastole (rest/refill phase); heard at base (apex) in aortic and pulmonic valves (semilunar) when they close  S3 – vibrations during ventricular filling when the ventricles are resistant to filling during protodiastole (just after S2)  S4 – occurs at end of diastole (presystole) – when ventricle is resistant to filling – atria contracts and pushes blood into noncompliant ventricle – heard after S1  Atrial kick – toward the end of diastole, the atria contract and push the last amount of blood (~25%); active filling phase is called presystole – causes a small rise in left ventricular pressure  Systole – pumping phase, S1, semilunar valves are open  Diastole – rest and refill, S2, AV valves are open All-People-Eat-Taco-Meat

Fetal circulation – 2 accommodations that allow heart to pump blood to baby’s body while in utero  Oxygenation takes place in placenta  Foramen Ovale – hole where 80% of blood flows through  Ductus arteriosus - 20% of blood detoured through here to aorta How do babies with cardiac problems show signs during feedings?  Fatigue while feeding, fewer ounces each feeding  Becomes dyspneic while sucking, may be diaphoretic  Falls into exhausted sleep, awakens after short time hungry again  If baby is not eating, can’t breathe through nose  Or something is wrong with heart, so it is exhausting because not getting proper blood Know your valves – how do we assess heart sounds and valves?  Diaphragm for normal heart sounds  Bell for murmurs Differences in structure of heart and position in body  Infant is more horizontal then in adult, apex is higher at 4th intercostal Risk factor for hypertension  Obesity, smoking, sedentary lifestyle, poor diet, alcohol Modifiable vs non-modifiable risk factors for heart disease  Non-modifiable = gender, genetics, ethnicity  Modifiable = smoking, exercise, diet Arteries vs veins  Veins have valves and are under lower pressure Carotid assessment  Murmur o Listen over each valve with bell for a blowing swooshing sound that occurs with turbulent blood flow  Bruits o Listen on carotid with bell in 3 places Changes expected in pregnancy in vitals, what do hormones do to the vessels?  Increase blood volume by 30-50%  Increase stroke volume and cardiac output, increased pulse rate (10-20 BPM)  Bleeding gums, hemorrhoids, edema, varicose veins  Arterial BP decreases due to peripheral vasodilation Lymph system  Lymphadenopathy  How should lymph nodes without disease feel?

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o Without disease lymph should feel small and barely palpable How do they feel when a systemic infection? o Enlarged How do they feel with cancer? o Enlarged Lymph ...