NURS 306 Health Assessment Exam 2 STUDY GUIDE.

● Ear ● Mouth, throat, sinuses ● Thorax and Lungs - Chapter 19 ● Breast and Lymphatics - Chapter 20 ● Heart and Neck Vessels - Chapter 20 & 21 ● Peripheral Vascular System - Chapter 22 Chapter 17: Ear Structures of the Ear External Ear: auricle and external auditory canal ● Auricle or pinna ○ Visible part of ear that is outside of head ● External auditory canal: where you put a Q-tip ○ S-shaped structure ■ Tube running from outer ear to middle ear ● Sound waves captured by auricle are collected here and cause tympanic membrane to vibrate ■ Modified sweat glands: secrete cerumen= wax to make tympanic membrane soft ● Cerumen defends against foreign bodies ○ With age, cerumen turns darker in color ○ Cerumen sitting in person for long time→ black ● Tympanic membrane (eardrum): membrane separates middle and external ear ○ Normal: translucent, pearly gray appearance ○ Cone of light reflects to otoscope light Middle Ear: ● Tympanic cavity: small air-filled chamber in temporal bone ● Round/ oval windows ○ Receives vibration from stapes and transmits sound to inner ear ● Auditory ossicles transmit sound waves: ○ Malleus, incus and stapes: tiny bones responsible for transmitting sound waves from the eardrum to inner ear through oval window ● Eustachian tube: equalizes air pressure on both sides of the tympanic membrane; connects middle ear to nasopharynx ○ Ex: swallow or chew gum when flying to equalize pressure when flying on airplane Inner Ear ● Bony labyrinth: cochlea, vestibule and semicircular canals ○ Semicircular canals- responsible for balance ■ Sensory receptors: located in vestibular and semicircular canals which sense position and head movements to maintain equilibrium ○ Cochlea- “body’s microphone”; converts sound pressure impulse from outer ear into electrical impulses passes onto brain via auditory nerve ■ Organ of Corti- necessary for hearing ■ Acoustic or Vestibulocochlear nerve: connects with cochlear nerve to form cranial nerve VIII ● Detects balance issues/ equilibrium problems Hearing ● Transmission of Hearing ○ Sound vibration travel through air are collected funneled through external ear causing eardrum to vibrate ○ Sound waves are transmitted → auditory ossicles ○ Stapes will vibrate at oval window, sound waves enter inner ear ○ Movement of fluid stimulates hair cells in Organ of Corti and initiates nerve impulses that travel to the brain via acoustic nerve ● Conductive Hearing (mechanical): transmission of sound waves through external and middle ear ○ Conductive Loss: impacted ear wax, otitis media, foreign object, perforated eardrum (tympanic membrane), drainage in middle ear, otosclerosis ● Sensorineural Hearing (perceptive): transmission of sound waves to inner ear ○ Sensorineural Loss: related to dysfunction of Organ of Corti ■ Cranial Nerve VII or temporal lobe of brain is affected ● Ex: Presbycusis (gradual nerve degeneration) Subjective Data: Health History ● Current level of hearing/ ear health ● Common or concerning symptoms of ear ○ Hearing loss ○ Otalgia- earache ● Ear infections, cerumen blockage, sinus infection, teeth or gum problems ● Otitis externa: infection of outer canal ○ Purulent, bloody discharge ○ Ex: swimmer’s ear ● Otitis media: infection of air-filled space behind eardrum (middle ear infection) ○ Popping sensation with purulent drainage and pain ○ Tenderness behind ear (mastoid process): suggests otitis media ○ Otorrhea- ear drainage or pain ■ Looking for blood, liquid discharge, new wax is light yellow and as ages it gets darker; purulent can be from tear in TM ● CSF- positive for glucose ○ Tinnitus- ringing of ear: ask patient if they are taking aspirin-- can cause ringing in the ear ■ Benign: unknown cause ■ Possible causes : excessive ear wax, high BP, antibiotics- aspirin ○ Vertigo- balance issues ■ “Room is spinning” ■ Disequilibrium ■ Be careful not to confuse with dizzy “pre-syncopy” ■ Vaso-vagal ■ Psychiatric disorders may cause symptoms - anxiety, panic attacks, hyperventilating ● Review of systems ○ Past history of client ■ Any deformities at birth ■ Specific problem with ear ■ Any surgeries? Or Traumas to ear? ■ Occupation - exposure to hazardous materials ■ Allergies- build up of cerumen ■ Repeated infection/ ear aches ○ Family history ■ Hx of infections, allergies, smoking (secondhand) ■ Age related hearing loss tends to run in families ○ Lifestyle habits and health practices ■ Shooting range ■ Loud music ■ Loud noises ■ Headphones vs. earbuds ■ Otitis externa “swimmer’s ear” ■ How do they clean their ears *How loud is too loud handout* - any prolonged exposure to any noise at or above 85 decibels can cause gradual hearing loss Objective Data: Physical Exam ● Preparation ○ Position ○ Cleaning of the ear canal ● Equipment needed ○ Use otoscope with bright light to inspect inner ear ○ Pneumatic bulb attachment (sometimes needed with infants/ young children) ○ Tuning fork to evaluate bone/ air conduction ● External ear- inspect and palpate ○ Size, shape, position (low set ears are indicative of mentally challenged) ■ Microtia- external ear not fully developed ■ Macrotia- external ear excessive enlargement ○ Skin condition ...look at piercings ○ Tenderness- tragus and mastoid ○ Discharge ● Otoscopic Examination ○ Position head and ear ■ Kid- pull ear straight down; Adults: pull ear up and back ○ Method of holding and inserting otoscope ○ External auditory canal- should be slightly pink, cerumen, hair ■ Swollen= swimmers ear ○ Tympanic membrane- appears reddish ■ Color, shape ● TM should be pearly pinkish gray, shiny, translucent ○ Elderly= cloudy ™ - normal aging process ○ Should NOT be bright red--indicates infection ● Cone of light (right ear 4-5 o’clock; left ear 7-8 o’clock) should be bright light, not dull ● TM should be flat (non-bulging) ○ Bulging--could be blood or drainage; ○ Concave- could be blockage ● Umbo- creamy colored ● Malleus- creamy colored ● White dots-- scar tissue from previous ear infections that were not treated ■ Consistency ■ Landmarks ● Handle and short process of the malleus ● Umbo ● Cone of light ● Pars flaccida and pars tensa Hearing Acuity ● Whisper Test ○ Ask client to occlude the ear not being tested and rub tragus with finger in a circular motion ○ Start with testing the better hearing ear before the bad one ○ Stand 2 feet behind the client (so they do not see your lips move) whisper a two-syllable word like “popcorn” or football” ○ Ask client to repeat it back to you ■ If the response is incorrect the 1st time, whisper the word one more time ■ Identifying 3/6 words= passing test ● Tuning Fork Tests ○ Use 256 or 512 Hz (don’t activate on metal) ○ Weber Test ■ When client reports diminished/ lost hearing one ear ● Evaluates the difference between conductive vs. sensorineural ■ Test ● Strike a tuning fork with the back of your hand and place tuning fork midline on patient’s head (use forehead if hair is too thick) ● Ask whether the client hears the sound better in one ear or the same in both ears ○ Should hear equally on both sides: “lateralization” ● Conductive loss: hear better with poorer ear via bone conduction; sound lateralizes to impaired ear ● Sensorineural loss: hear better with ear that does not have nerve dysfunction; sound lateralizes to good ear ○ Rinne Test ■ Compares air and bone conduction sounds ■ Test ● Place vibrating tuning fork on mastoid process ○ Mastoid right over cochlea- giving direct conduction ● Ask the client to tell you when the sound is no longer heard ● Move the prongs of the tuning fork to the front of the external auditory canal ● Ask the client to tell you if the sound is audible after the fork is moved ● Normal: air conduction (AC) is heard longer than bone conduction (BC) ○ AC BC ○ Air conduction- hearing occurs through air near ear ○ Bone conduction- hearing occurs through vibrations ● Abnormal ○ Conductive: BC AC ○ Sensorineural: ACBC ○ Romberg Test ■ Examining client’s equilibrium ● Testing semicircular canals in ear aka balance ■ Test ● Ask the client to stand with feet together, arms at side, have them keep their eyes open for 15 seconds then keep eyes closed for 15 seconds ● Normal ○ Client maintains position for 20 seconds without swaying or with minimal swaying ● Abnormal (Positive Romberg) ○ Client moves feet apart to prevent falls or start to fall from loss of balance ■ May indicate vestibular disorder “Patterns of Hearing Loss” handout “Hearing Test Handout” Aging Changes ● Outer Ear: elongated lobule with linear wrinkles, loss of flexibility of pinna, hairs stiffer, drying and thinning of tissue, cerumen of thicker consistency, tufts of wirelike hair at entrance of ear canal ● Middle Ear: decreased flexibility of the tympanic membrane, dull, retracted tympanic membrane, stiffness of the ossicles ● Inner Ear: Presbycusis- gradual hearing loss with age; hard to hear high pitches; don’t raise voice ○ Cerumen may become oxidized or hardened → conductive hearing loss ● Age-Related Disorders ○ Hearing ■ Tinnitus ■ Otosclerosis: abnormal bone growth→ hearing loss ■ Cerumen is decreased, dry, hard ○ Vestibular System ■ Dysequilibrium ■ Faintness ■ Vague lightheadedness ■ Vertigo ■ Meniere’s Disease- dysfunction of bony labyrinth --causes vertigo, nausea/vomiting, neurosensory loss; feel like you have pressure inside your ear External Ear Normal Abnormal Inspect auricle, tragus and lobule Ears equal in size, usually 4- 10 cm ● Ears smaller than 4 cm ○ Microtia: ear is not fully developed ● Ears larger than 10 cm ○ Macrotia ● Low-set ears may indicate chromosomal defect ● Post auricular cysts- blocked sebaceous glands ● Otitis externa- redness, swelling, itching, pain on palpation, pus ● Frostbite- pale, blue ear color *examine UNAFFECTED ear 1st** Auricle aligns with corner of the eye Palpate auricle, lobule and tragus Normally all are not tender to touch ● Otitis media- tenderness behind ear ● Otitis externa or postauricualr cysts- painful auricle/ tragus Internal Ear Normal Abnormal Inspect auditory canal with otoscope ● Small amount of odorless cerumen ● Consistency- soft, moist, dry/ flaky ● Otitis externa- foul smelling, sticky yellow discharge ● Otitis media- purulent/ bloody discharge ● Conductive hearing loss- cerumen blocking view of external ear canal Color/ consistency of ear canal ● Pink and smooth without nodules ● Otitis externa- reddened, swollen canals ● Polyps- block of view of eardrum Tympanic Membrane Normal Abnormal Inspect for color, shape, consistency ● Pearly grey, shiny, translucent ● No bulging, retraction ● Cone of light ○ Right ear: 5 o’clock ○ Left ear: 7 o’clock ● Short handle malleus and umbo are visible → otoscope ● Red, bulging eardrum and diminished/ absent light reflex= acute otitis media ● Yellow, bulging membrane= serous otitis media ● White spots- scarring ● Perforations- trauma Hearing Tests Normal Abnormal Whisper Test: gently occlude ear not being tested and rub tragus with finger in circular motion ● Stand 2 feet behind patient Able to repeat word back Unable to repeat word after 2 tries Weber Test: evaluate conduction sound waves through bone ● Strike tuning fork and place on head or forehead Vibrations heard equally in both ears Conductive hearing loss- lateralization of sound to poor ear ● hearing louder sound in bad ear Sensorineural hearing loss- lateralization of sound to good ear Rinne Test: tuning fork placed at mastoid process ● Ask client to say when sound is no longer heard Air conduction heard longer than bone conduction Conductive hearing loss- bone conduction sound heard longer Sensorineural hearing loss- damage to inner ear, air conduction heard longer Romberg Test: client stands with eyes closed to measure balance Maintains position for 20 seconds ● Client moves/ falls ● Could mean vestibular disorder “Patterns of Hearing Loss handout” Abnormalities of Ear ● Sebaceous Cyst: damaged hair follicles or oil glands cause them ○ Usually harmless ● Purulent Otitis Media ○ Middle ear fluid is infected ○ Absent light reflect ○ Redness, bulging, earache, fever ● Perforation of Drum ○ Result from purulent infections of the middle ear ○ Reddened tissue surrounds eardrum, scarred eardrum, no landmarks visible, may have discharge Chapter 17 Mouth, Nose/Throat, Sinuses: NOSE The nose and the paranasal sinuses constitute first part of the respiratory system ● Functions: Receiving, filtering, warming, and moistening air ● Cranial Nerve I (Olfactory Nerve) is related to the sense of smell ● ● Common or Concerning symptoms: ○ Rhinorrhea: drainage ○ Congestion: difficulty breathing ○ Epistaxis: nosebleed ○ People can have change in sense of smell ○ People can have pain ■ You would do your COLDSPA for these: (Character, Onset, Location, Duration, Severity, Pattern and Associated Factors (illness assessment) ○ Ask for any past history regarding: trauma that they have had to the nose, any difficulty smelling certains foods or odors, any surgery on the nose, see if they have done drugs through the nose (cocaine), previous nasal drainage and character of the drainage; Hx of polyps, smoking ○ Family history mostly has to deal with allergies and smoking : Nosebleeds (do they have a history of a blood disorder? and allergies (what happens and when) ○ Lifestyle and Health Practices: how do you blow your nose? (should be one nostril at a time) SINUSES ● “Notice that the frontal sinuses are on the medial aspect, whereas the lacrimal apparatus (the tear gland) was on the lateral aspect” ● The only sinuses you are able to evaluate physically in the frontals and the maxillary ● The ethmoids and the sphenoids you have to do an X-ray to inspect ● ● Common or Concerning symptoms: ○ Nose and sinuses ■ Change in sense of smell ■ Pain in process of breathing (headache over eyebrows = frontal sinuses) ○ Need to know specifically if they have sinus infections ■ Possibility if they have chronic sinus infections ● If so.. What are they doing for it? Are they on medications for it? Did they go in and get their sinuses drained? (netti-pots) ■ Family history of sinusitis (inflamed sinuses) MOUTH / THROAT Entrance/Start of the digestive system ● Functions: Ingestion (receiving the food), taste, preparing food for digestion, and aiding speech ● When you are inspecting the mouth in a physical exam you are focusing on: the lips, cheeks, palates (hard and soft), tongue, teeth, gums, tonsils, and salivary glands ● ● ○ Need to know where your wharton's ducts (makes saliva) are and your stenson's ducts are (located at your upper buccal mucosa aligned with your second molar. ● Cranial Nerves assisting with mouth and throat: CN V (Trigeminal), CN VII (Facial), CN IX (Glossopharyngeal), CN X (Vagus), CN XII (Hypoglossal) ● Common Concerning Symptoms ○ Sore Throat: Can be bacterial or viral (must be very specific in regards to documenting their symptomatology because of this) ○ Hoarseness: How long has it occured for? Remember hoarseness can occur with sore throats, the problem how long has it been going on for! Hoarseness that has been treated with antibiotics and hasn’t gone away they must go see an otolaryngologist to see if there are polyps on the larynx which can lead to cancer ○ Lesions/Sores: Buccal mucosa The most common place is the tongue are. Remember that this can turn into cancer. You could also see candidiasis (like a white thrush) ○ ○ Sore Tongue: regarding movement could be cancer ○ Bleeding Gums ○ Toothache ○ Dysphagia: Difficulty swallowing. Why is it occuring? Is it occuring due to the sore throat? Or for other reasons? ● Past History of the Client: Any dentition problems? Root canals? Teeth that has been removed? Have they ever had thrush? Problems with their tonsils? Have they been taken out? Do they use chewing tobacco or smoke? Etc. ● Family History: Ask about past throat/mouth cancer history of the mouth or throat; allergies ● Lifestyle and personal Habits: How do they care for their mouth? Are they going to the dentist regularly. Do they brush their teeth regularly? Use floss, mouthwash etc. AGE RELATED CHANGES ● Smell- decreases ● Taste- Decreases ● Mouth- oral mucosa is drier, gums recede THE PHYSICAL EXAM: NOSE, SINUSES, MOUTH AND THROAT ● Equipment needed ○ Otoscope (with nasal speculum attached): Used to assess the inside of the nose. ○ Pen Light ○ Tongue Blade/ gauze pad/ gloves ● NOSE ○ Inspect and palpate the external nose ■ Look for flatness where the bone is not the cartilage see if it’s straight (look for any deviations). ■ Press and palpate the nose for any pain ○ Test Patency of nostrils ■ Have them sniff with each nostril to see if they breathe well ● Make sure they blow their nose before to rid of any exudate ○ Nasal cavity ■ Use the otoscope with the nasal speculum to view the cavity ■ You want to look for: ● Mucus membranes and hair- should be pinkish and flat. Abnormal would be red and inflamed/swollen ● Turbinates- you will always see the inferior turbinate (concave component), possibly medial, never superior ○ Within the turbinates you want to look for any polyps which will decrease their ability to breathe ● Septum- view the septum is should be midline; if holes→ ask what snorting? What ya snortin?! ● Overall look for swelling, discharge, or foreign body Assessment Procedure Normal Findings Abnormal Findings Inspect and palpate the external nose. ● Note the nasal color shape, consistency, and tenderness Color same as the rest of the face; smooth and symmetrical structure; no tenderness Nasal tenderness on palpation accompanies a local infection Check patency of airflow through the nostrils ● Occlude one nostril at a time asking the pt to sniff ● Have them blow their nose first Client is able to sniff through each nostril while other is occluded Client cannot sniff through a nostril that is occluded, nor can they sniff or blow air through the nostrils. May be a sign of swelling, rhinitis, or an obstruction of a foreign object Inspect internal nose Nasal Nasal mucosa Use an otoscope with nasal mucosa will be speculum and pen light should be swollen pale dark pink, moist, and free of exudate. Nasal septum should be intact and free of pink, or bluish gray in pt’s with allergies. Red and swollen with upper resp. Infection. Exudate seen ulcers or with perforations infections. Turbinates Purulent should be discharge dark pink, with bacterial moist, and rhinosinusitis. free of Any crust or lesions. bleeding. A deviated Ulcers. Small, septum may pale, round, be firm over considered a growths or normal masses on finding if it mucosa is not (polyps) seen obstructing in clients with the airway. chronic allergies. ● SINUSES ■ You palpate the sinuses by pushing up (Only able to physically assess frontal and maxillary) ■ ■ You can also percuss these points ■ Transillumination- you do this if the patient complains of pain after palpating the sinuses; ONLY for a “PROBLEM” GOT IT! Assessment Procedure Normal Findings Abnormal Findings Palpate the sinuses (frontal and maxillary) by pressing with the thumbs upward Percuss sinuses Both sinuses are non tender to palpation and no crepitus is evident Not tender to percussion Both sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. When there is large amounts of exudate crepitus will be felt over maxillary. Tender upon percussion with allergies and sinus infections Transillumination (do this if tenderness is present) Hold light source snugly under the eyebrows in a dark room, use the other hand to shield the light. Transilluminate the maxillary by holding light over maxillary sinus and asking patient to open their mouth A red glow transilluminates the frontal sinuses, this indicated air filled sinus A red glow transilluminates max sinus, red glow will be seen on the hard palate Absence of red glow which indicates sinus filled with fluid, pus, or in maxillary also could be thick mucus ● MOUTH Physical Assessment Normal Findings Abnormal Findings Inspect mouth for symmetry and alignment while asking client to open and close mouth Lips and surrounding tissue relatively symmetrical in net position and with smile. No lesions, swelling, or drooping Asymmetrical mouth may indicate neurological condition, tumors, infections, or dental abnormalities Malocclusions of teeth, separation of individual teeth, or protrusion of upper or lower incisors. Upper teeth resting on the top of the lower teeth with upper incisors slightly overriding lower ones Inspect and palpate lips for: color & consistency In white skin: pink In dark skin: bluish hue or freckle like pigmentation Moist, smooth, with no lesions Cyanotic, pale lips in shock or anemia; reddish in ketoacidosis or carbon monoxide Dry, cracked, nodules, fissures, or lesions present. Cheilosis- cracking in the corners (seen in riboflavin deficiencies); broken vesicles with crusting in herpes type 1; scaly nodular lesions or ulcers occur with lip carcinoma. Cleft Lip Inspect and palpate buccal mucosa Color & Landmarks (Stensen’s duct) Pink (increased pigmentation often noted in dark-skinned clients) Smooth, moist, without lesions Stensen's duct opening are seen as small papillae located near upper second molar (seeds can plug pinhole and lead to sepsis) Pale, cyanotic, or reddened mucosa Ulcers, dry mucosa, or white patches are present. Thick, elevated white patches (leukoplakia) that does not scrape off is precancerous. Curdy patches that scrape off indicate thrush. Red spots over red mucosa (koplik spots) indicate measles. Canker sores. Elevated, markedly reddened area near second upper molar Inspect and Palpate gums for Color & Consistency Pink Moist, clearly defined margins Pale, markedly reddened. Swollen gums that bleed are seen with gingivitis. Periodontitis- recessed red gums with tooth loss. Bluish black gum line with lead poisoning. Dry, edema, ulcers, bleeding, white patches, tenderness Inspect and palpate teeth Number Position and condition color 32 teeth Stable fixation, smooth surfaces, and edges Pearly white, and shiny Missing teeth Loose or broken teeth, jagged edges, dental caries Darkened, brown, or chalky white discoloration. Teeth may be yellow or brown due to staining from coffee smoking etc. Chalky white areas are seen with beginning cavity. Inspect protruded tongue (sticking out) 1. Color, symmetry, & texture 2. Movement 3. Color 1. Pink moist, papillae present, symmetrical appearance; midline fissures present Common variation: fissured, geographic tongue 2. Smooth 3. Pink 1. Dry, nodules, ulcers present; papillae or fissures absent, asymmetrical. Deep longitudinal fissures seen in dehydration. Black hairy tongue (seen with conditions that cause hyposalivation). Smooth red shiny tongue seen in niacin or vitamin b12 deficiency. Raised whitish feathery areas on the side of the tongue that cannot be scraped off suggest hairy leukoplakia 2) jerky or unilateral movement 3) markedly reddened; white patches; pale. Smokers may have brown/yellow coating on the tongue Inspect ventral surface of the tongue and mouth floor 1)Color, consistency, lesions 2)Landmarks 3)size 1. Smooth, shiny, pink, or slightly pale with visible veins and no lesions. Slightly pale 2. Wharton's ducts (submandibular ducts) openings are located on both sides of the frenulum. Tongue is free of lesions or increased redness frenulum is centered 3. Moderate size with papillae (little protuberances) present 1. Markedly reddened, cyanotic, or extreme pallor, lesions 2. Lesions, ulcers, nodules, or hypertrophied duct openings are present on either side of the frenulum. A smooth reddish, shiny tongue, without papillae indicative of niacin or b12 deficiency, certain anemia, and antineoplastic therapy. 3) An enlarged tongue suggests hypothyroidism, acromegaly, or down syndromes, and angioneurotic edema of anaphylaxis, A very small tongue suggests malnutrition. An atrophied tongue or fasciculation point to cranial nerve damage. Inspect and palpate sides of tongue for color and lesions Pink, smooth, moist; no lesions White or reddened areas, ulcerations, or induration present. Leukoplakia indicates precancerous lesions; may see canker sores. Carcinoma of the tongue Inspect hard and soft palates Color & Consistency Hard palate: Pale Soft palate: Pink Hard Palate: firm with irregular transverse rugae Soft palate: spongy texture with symmetrical elevation or phonation Extreme pallor, white patches, or markedly reddened areas Softened tissue over hard palate; lesions present; absence of elevation with phonation. Thick white plaques are seen in candida infection; deep, purple lesions may indicate kaposi sarcoma Common variation: palatine torus on hard palate ● THROAT Physical Assessment Normal Findings Abnormal Findings Inspect Oropharynx Color & Consistency Pink Tonsillar pillars symmetrical; tonsils present (unless removed) and without exudate; uvula at midline and rises on phonation (patient says “ahh” and it rises midline cranial nerve X Markedly reddened with exudate seen in pharyngitis; yellow mucus seen with post nasal sinus drainage. Enlarged tonsils (enlarged, red, and covered with exudate in tonsilitis); asymmetrical; uvula deviates from midline; edema, ulcers, lesions Inspecting tonsils 0- not visible, 1+ visible, 2+ halfway to uvula, 3+ touching uvula, 4+ touching each other Chapter 20: Breast and Lymphatics Breast cancer incidence: ● Caucasians have highest incidence rates of breast cancer ○ Followed by African Americans, Hispanics and Asians ○ Hispanics have highest mortality rate Structure and function: ● Surface anatomy ○ Location of breasts on chest wall-lie in front of pectoralis muscle & between ribs 2-6 ○ Axillary tail of Spence- projects up into the axillae ○ Nipple- tiny opening of lactiferous ducts which milk passes through ○ Areola- contains elevated sebaceous glands that secrete protective lipids during lactation ○ Cooper’s ligaments—fibrous bands that support breast tissue ● Function ○ Female: ■ Produce and store milk that provides nutrients to newborns ■ Aid in sexual stimulation ○ Male: no functional capabilities Internal anatomy ● Glandular tissue ○ Functional part of breast, allowing for milk production (alveoli) ○ Mammary Ducts ■ Lactiferous duct that conveys milk to nipple ■ Lactiferous sinus: duct before milk reaches nipple ● Milk can be stored in these ducts until stimulated ● Fibrous tissue ○ Support for glandular tissue via Cooper ligaments ● Adipose tissue ○ Fat tissue ■ Glandular tissue is embedded in fatty tissue ■ Provides substance of breast, determining size and shape Quadrants of the breasts: ● Four quadrants of the breast ● Map of breast and how we document masses ○ Upper outer/inner ○ Lower outer/inner ● Most common site of cancer is upper outer quadrant Lymphatics of the breast: ● Lymphatics ○ Axillary nodes ■ Central (midaxillary) ■ Anterior (pectoral) ■ Posterior (subcapsular) ■ Lateral (brachial) ○ Drainage patterns-most of lymph drain into axillary nodes ■ From central axillary nodes, drainage flows up to the infraclavicular nodes and supraclavicular nodes ○ Lymph node may become enlarged, appearing as lumps or swelling with infection and breast cancer ■ May normally be palpable but should be normal size (pea size), non-tender and movable ■ Age-related changes of the female breast: ● Muscular and glandular tissue diminish ● Skin less elastic—sagging of breasts Subjective data health history: ● Common or concerning symptoms ○ Lump or mass ○ Pain or discomfort- ask where are they within their ovulation cycle; are you pregnant? ○ Change in shape—symmetrical ○ Edema ○ Rashes ○ Scaling ○ Dimpling: same as retraction --indication of cancer ○ Retraction of nipple- not normal unless person is born that way. ○ Discharge ■ NO discharge should be present ● When menstruation ends—perform self breast exam ● Must have a doctor evaluate breast examination every year ● Tenderness, lump or swelling—folliculitis (infection of a hair follicle) ○ Red, increased warmth ○ Lump usually isn’t visible—you just feel something there Subjective data: health history: ● Past Medical History ○ Trauma to the breast, history of lumps ○ When was their last mammogram (yearly) ○ Ever seen a change in breast contour ○ Fibrocystic disease (lumps and bumps)? ○ Any surgery? ○ How do they care for their breasts? Bras? Any cosmetic surgery (reduction/enhancement)? ○ Do they do self-exams (should be done 3-7 days within cycle based on when you stopped menstruating) ○ What type of birth control? ● Family History ○ Level I first degree relative cancer history- mother sister or daughter ■ Should not be put on estrogen/progesterone BC pills-- can activate/accelerate cancer markers ○ Maternal and paternal sides ○ Get BRCA 1+2 genes tested 2—ovarian cancer ○ Males—watch for GI cancer (BRCA testing) ● Lifestyle Habits—do they go for mammo? ○ Ever on progesterone/estrogen drugs—birth control pills ○ Mammographies? ● If a client comes to you with pain in their breast—you send them for a mammogram and potential ultrasound Objective data: the physical exam: ● Preparation ○ Positions- several positions are needed to assess lumps in the breast ■ Supine position ○ Draping- only uncover areas to be examined ● Equipment needed ○ Small pillow—under head and under breast ○ Ruler marked in centimeters ○ Pamphlet or teaching aid for Breast Self Exam (BSE) Inspection: ● Look at size, symmetry, shape, color and texture ○ Have them in sitting position with hands at side ● Even pigmentation and smooth skin ● Areolas round, Montgomery Tubercles, color ● Nipples symmetrical and no deviation ● Supernumerary nipple- “3rd nipple” along milk line ● Look for retracted tissue Inspection- 6 Positions for Retraction/ Dimpling 1) Sitting with hands down 2) Hands on hips 3) Hands over head 4) Leaning forward: ideal for large breasts 5) Pushing palms against each other 6) Supine with pillow under shoulder ● Inspect the axillae ○ Have them lean forward and have breasts hang to inspect symmetry and shape ■ For people with large breasts or elderly Inspection Normal Abnormal Inspect size and symmetry ● Variety of sizes ● Breasts should be round and pendulous ● Recent increase in size → inflammation, abnormal growth Inspect color and texture ● Texture is smooth with no edema ● Striae may be seen during and after pregnancy, weight gain or loss ● Redness is associated with breast inflammation ● Pigskin-like or orange- peel (peau d’orange) appearance ○ From edema which is seen in metastatic breast disease ○ Edema-caused by blocked lymphatic drainage Inspect superficial venous pattern ● Observe visibility and pattern of breast vein ● Veins should radiate horizontally and toward axilla (transverse) or vertically (longitudinal) ● Prominent venous pattern may result from increased circulation due to malignancy ● Asymmetric venous pattern may be due to malignancy Inspect areolas ● Note color, size, shape and texture ● Areolas vary from dark pink to dark brown ● Round, vary in size ● Small Montgomery tubules present ● Orange-peel skin (peau d’ orange) in areola associated with carcinoma ● Red, scaly, crusty area of nipple- Paget disease Inspect nipples ● Size and direction ● Note any dryness, lesions, bleeding or discharge ● Nipples are nearly equal bilaterally in size and same location in each breast ● Nipple can be everted, ● Recently retracted nipple that was previously everted- malignancy ● Spontaneous discharge inverted or flat should be referred to cytologic study Inspect for nipple retraction ● Ask client to raise arms overhead ● Have her press hands into hips ● Have her press her hands together ● Ask client to lean forward from waist ● Client’s breasts should rise symmetrically with no sign of dimpling or retraction ● Breasts should hang freely and symmetrically ● Dimpling or retraction- malignant tumor that has fibrous strands ● Restricted breast movement or retraction of skin- fibrosis of underlying tissue, malignant tumor Guidelines for palpating the breasts: ● Client supine- one arm overhead on of side of examination ● Small pillow under breast to be palpated ● Use finger-pads to examine ● Exam nipple last ● Use vertical method ● Start at sternum ● Include axillary line Palpation techniques: ● Palpate all areas of the breast ○ Texture and elasticity ○ Tenderness and temperature ● Do not lift the fingers off the breast when palpating ● Use one of the methods –circular, vertical, or horizontal ○ Vertical: (preferred) and done past mid axillary line ● Have to go below the breast line ● Bimanual- for well endowed patients Describing lumps: (from handout) ● Location- quadrants-- can make breast like a clock to identify specific location ● Size ● Shape—is it round/oval or matted--one starting to grown on another; or irregular/no shape? ● Number—how many lumps are found ● Consistency—hard (solid) or squishy ● Definition/Delineation- do you have well borders or irregular borders ● Mobility—can you pick it up? - we want moveable; fixed is more indicative for cancer ● Tenderness ● Erythema/overlying skin ● Dimpling or Retraction—concave component ● Lymphadenopathy—when you palpate lymph nodes, are you feeling them? ● 1st—say what quadrant you are in (location) describe location by diagram of a clock Breast Cancer/ Malignancy ● Prominent asymmetric venous pattern from increased circulation ● Thickening of tissue on palpation ● Thickening of skin on breast and ridged/ dimpled skin: peau d’ orange ● Inverted nipple ● Recently retracted nipple that was previously everted ● Retracted breast tissue ● Pain or itchiness ● masses/ tumors ○ Usually found in upper outer quadrant ○ Unilateral, irregular, poorly delineated borders ○ Hard, immobile and non-tender; fixed to skin in underlying soft tissue Palpate Normal Abnormal Palpate texture and elasticity ● Smooth, firm, elastic tissue Thickening of tissue- malignant tumor Palpate for tenderness and temperature ● Generalized increase in nodularity and tenderness ○ Associated with menstrual cycle or hormones ● Painful, tender breasts- fibrocystic breasts right before menstruation ● Pain- malignant tumor ● Heat- inflammation Palpate for masses ● Location, size, shape, mobility, consistency, tenderness ● No masses should be palpated ● Malignant masses: hard, immobile, fixed, poorly defined ● Fibroadenomas- round/ oval, mobile, firm, solid, elastic, nontender (benign) ● Milk cysts- sacs filled with milk and infection ● Lipomas- collection of fatty tissue Palpate nipples ● Note any discharge ● Nipple may become erect and areola may pucker ● Milky discharge is only normal during pregnancy and lactation ● Nipple discharge ○ Hypothyroidism, adenoma, oral contraceptives, tranquilizers ● Bloody ○ Papilloma ● Green discharge ○ Draining breast cyst ● Clear ○ Cancer (guaiac positive) Palpate mastectomy or lumpectomy site ● Palpate scar and tissue for any redness, lesions, lumps, swelling or tenderness ● Scar is white with no redness or swelling ● No lesions, lumps or tenderness ● Redness and inflammation- infection ● Lesions, lumps, tenderness- need further evaluation Bimanual palpation: ● Have the client sit up and palpate the breasts using two hands ● Assess for lumps or masses Axillae: ● Palpate for Lymph Nodes ○ Central Nodes (Midaxillary)— most palpable, lay along chest wall, will feel if problem exists; stick hands into armpit ○ Pectoral Nodes (Anterior)—interior by nipple; in the crevice of arm and pec mm. ○ Subscapular Nodes (Posterior)- lateral border of the scapula, palpated deep in posterior axillary fold ○ Lateral Nodes (Brachial)—located along humerus--underneath arm (drain most of arm) ○ Infraclavicular—below clavicle ○ Supraclavicular—above clavicle Inspect and palpate the axillary Normal Abnormal ● Hold client’s elbow with one hand and use 3 fingerpads of your other hand to palpate firmly the axillary lymph nodes ○ 1st- palpate high into axillae ○ Move downward against ribs to feel central nodes ○ Move down to posterior axillae for posterior nodes ○ Use bimanual palpation to feel for anterior axillary nodes ● No rash or infection noted ● No palpable nodes or one or two small, discrete, non- tender, movable nodes ● Redness and inflammation- infection in sweat gland ● Dark, velvet pigmentation- malignancy ● Enlarged lymph nodes- infection in hand or arm ● Large nodes are hard and fixed- malignancy Teach breast self-examination: ● Describe correct technique ● Return demonstration ● BSE a few days after menses ● Post menopausal- same day each month ● Can feel lumps in-between mammograms ● Assess risk for breast cancer Men: ● Do not forget about men ● Men can get breast cancer too! ● Gynecomastia—enlargement of male breast tissue-occurs with hormonal changes- puberty ● Obese male-fatty tissue not glandular tissue ● Cant have mammograms—would have to do an ultrasound ● Family history (mom/grandma) get GI checked-- can develop into GI cancer Chapter 19 - Thorax and Lungs Anatomy Suprasternal Notch - you can physically feel it right at the top. Manubrium and the sternal angle (also called angle of Louis) ○ The first rib is felt along with the clavicle. ■ The first 7 ribs are attached to the sternum, 8, 9, 10 are connected at the costal margin. The distance between the costal margins is the costal angle which should be 90 degrees or less. ○ Ribs move through the costal cartilage because they are bone and can’t move themselves. Accessory muscles are in the neck ○ Someone with “air hunger” (having difficulty breathing) will have protruding accessory muscles Mechanics of Breathing ○ On inspiration, the costal cartilage allows the ribs to move, the diaphragm moves down so that the lungs can expand ○ On expiration, the diaphragm goes up to help push air out of the lungs. Landmarks Anterior Posterior ● The red line is outlining the diaphragm. ● Ribcage attaches to the thoracic vertebrae (T1 of thoracic column connects with rib 1) ● Scapula is almost right in line with the hip, you can’t hear or feel anything over it. ● You can feel two lumps in the back of your neck: ○ First: C7 ○ Second: C7 and T1 Reference Lines Anterior Midaxillary Posterior ● Midsternal - right down the middle of the sternum ● Midclavicular - middle of the clavicle ● Anterior axillary - armpit fold ● Posterior axillary line - the back of the armpit fold ● Midaxillary - straight through the armpit ● Vertebral - down spinal column ● Scapular line - starting at the TIP of the scapula - T7/T8 Lobes of the Lung ● 3 lobes on right lung (upper, middle, lower) ○ Upper lobe: from the top down to the 4th and 5th ribs. ○ Only way to listen to the middle lobe is laterally because the breast is covering it from the front and there’s no middle lobe in the back. ○ Very minimal lower lobe anterior wise ● 2 lobes on the left (upper and lower) → heart is taking up the extra space ● Lungs end at T10, when you take in a deep breath it goes to T12. They will never leave the ribcage. ● Anterior assessment- assessing upper lobes mostly ● Most of lower lobe is posterior ● Infection usually starts at the posterior lower lobe - need to evaluate to know there’s a problem ● T3 is the mark to show the end of the upper lobe posteriorly. Everything below is lower lobe. Midaxillary Data collection Subjective Data Common Symptoms Difficulty breathing ● Dyspnea (SOB) could indicate COPD, asthma, pneumonia, pneumothorax, PE, CHF, CHD, MI. ● They could feel dyspnea during sleep, with exertion, etc. (find out what they mean by SOB) ○ AT what point do they become short of breath? ○ How long has it been going on for? ○ Gradual onset is indicative of permanent lung changes ○ Sudden onset is indicative of: acute lung problems; pulmonary emboli ○ Any comorbidities ? ● Severity: Dyspnea with activity is okay if it goes away with rest. ○ If they get dyspnea with non strenuous activity, it could be indicative of lung disease or CHF ● Associated factors: ○ Dyspnea with edema or angina indicates CV issue ○ Orthopnea might mean heart failure, dyspnea could be from sleep apnea, etc. Chest pain ● Could be true cardiac, GI, musculoskeletal, etc. ● True cardiac chest pain is substernal ● First rule out cardiac ischemia! ● There are no nerves in the lungs, only in muscles and pleura around them so if they have chest pain due to a respiratory problem it could be a late sign of pulmonary disease. ● Differentiate between different systems: ○ Cardiac will be substernal and will radiate down the arms or up the neck ○ Females experience pain going up the neck more than going down left arm ○ Musculoskeletal will be on inspiration (fractured ribs, bruised muscle)--more of a localized pain; costochondritis ○ GI tract will be because of abdominal area or lower thoracic area (GERD- hydrochloric acid starts going up into esophagus)--can be caused by high acidic foods Cough ● Usually due to a stimulus ● Dry cough? Productive cough? ● Dry Cough: ask if pt is taking meds for hypertension; could be due to allergies of dust or mold/ dry or cold air ● Continuous cough: acute infections. ● Early morning cough: chronic bronchial inflammation. ● Late evening coughs: exposure to irritants during the day. ● Night coughs: postnasal drip or sinusitis ● Acute: less than 3 weeks ● Subacute: 3-8 weeks ● Chronic- greater than 8 weeks ● Sputum: ○ White or gray → mucoid sputum ○ Translucent → virulent ○ Purulent → yellow, green = BAC infection i.e. pseudomonas ○ Blood- hemoptysis→ Coming from lungs or stomach? (from stomach → hematemesis) ○ non-productive coughs mean URI or CHF. ○ Color indicates bacterial infections, blood, TB, pulmonary edema. ○ Increase in amount is usually because of irritants, chronic bronchitis, or pulmonary abscess. ○ Note the smell of the sputum-- could indicate pulm abscess ● Wheezing: CHF, asthma, or excessive secretions. Daytime Sleepiness of Snoring Do you get very tired during day? How much sleep at night? Do you have to nap by ⅔ pm? Ask spouse if they snore, don’t rely on patient to know Paroxysmal Nocturnal Dyspnea - air hungry; woken up from sleep from need for air GI symptoms ● Acid reflux is common with asthma Personal Health History Prior respiratory problems ● History increases risk for recurrence. ● Also trying to differentiate between disorders that present similarly (ex. asthma vs emphysema) ● Have they ever had fluid in their lungs ● TB? ● History of lung cancer? ● Have they had any diagnostic tests done? Surgeries and trauma ● Could result in altered thorax appearance, changes in respiratory sounds, or lung tissue changes Allergies ● Allergic reactions have respiratory symptoms Smoking history ● Do they smoke? ● How many pack years --how many cigs do they smoke per day Current medications/home treatments ● Antihypertensive drugs can cause a cough Recent travel ● Travel to high risk countries may have exposed the patient to SARS - severe acute respiratory syndrome ● TB Family history History of lung disease ● Some chronic or acute respiratory conditions are genetic ● Lung cancer? ● Asthma/COPD? History of smoking in the home ● Secondhand smoke puts the patient at risk for COPD or lung cancer Lifestyle and Health Practices Diet ● Severe weight loss and obesity is frequently seen in COPD Smoking ● Use the 5 As: “ask, advise, assess, assist, arrange” to see if they are ready to try to stop smoking ● Pipes, cigars, chewing tobacco, eCigarettes Environment ● Irritants like coal dust, insecticides, paint, air pollution, asbestos, dust ● Are they using a CPAP machine? Do they clean it? ● Using humidifier? Do they clean it often? Stress ● Stress can cause SOB, might need to be educated on relaxation techniques Objective Data General Inspection Nasal flaring/pursed lip breathing ● No nasal flaring because diaphragm and external intercostals are doing the work. ● Abdomen and lower ribs move out during inspiration, move in during expiration ● Nasal flaring means labored respirations and possible hypoxia ● Pursed lip breathing is seen in asthma, emphysema, CHF as a compensatory mechanism ● Facial expression will be panicked ● Assess capillary refill Color of face, lips, chest ● Even colored skin tone, no discoloration ● Ruddy to purple - COPD or CHF because of polycythemia ● Cyanosis - cold or hypoxic (dark skin looks blue and dull) Color and shape of nails ● Pink and normal shape ● Pale or cyanotic with clubbing could be hypoxia Shape of chest ● Normal shape ● Barrel chest ● Scoliosis ● Kyphosis ● Pectus Excavatum Inspection of Posterior Thorax (Assess Posterior first) Position of scapulae and shape and configuration of chest wall ● Scapulae are symmetric and nonprotruding. ● Anteroposterior to transverse diameter is 1:2 (AP diameter) ● Spine is straight, thorax is symmetric, ribs slope downward ● Vertebrae that deviate laterally in thoracic area could be from scoliosis ● Ribs that look horizontal are usually due to 1:1 AP diameter which happens with COPD, emphysema (inflammation of the lungs) Accessory muscles ● Diaphragm is major muscle at work, see the abdomen and lower chest moving ● Tripoding is indicative of COPD Posture ● Should be sitting up and relaxed, breathing easily, arms at sides ● Tender or painful areas could indicate inflamed tissue ● Pain over intercostal spaces could be from inflamed pleurae ● Pain over ribs at costal chondral junctions could be fractured ribs Palpation of Posterior Thorax Tenderness or sensation ● None, temperature should be equal ● Muscle soreness from exercise or excessive work from breathing (COPD) ● Increased warmth may be related to local infection Crepitus - when air is passing through fluid or exudate ● none ● If air escapes into subcutaneous tissue (injury, chest tube, tracheostomy) ● You might be able to feel it in areas of extreme congestion or consolidation. Surface characteristics - lesions and masses ● none ● Refer to physician Tactile fremitus - use the ulnar edge of your hand and feel for vibrations by having the patient repeat “ninety-nine” ● Symmetric and easily identifiable. Should fade as you move toward the base of the lungs ● Unequal fremitus means: ○ Increased: consolidation ○ Decreased: bronchial obstruction, air trapping in emphysema, pleural effusion, pneumothorax ○ Diminished: obstruction of tracheobronchial tree Chest expansion - thumbs at T7/8 or T10 and press together ● When pt breathes in, pt’s breathing should move your thumbs 5-10 cm apart but symmetrically ● Unequal: severe atelectasis (collapse, incomplete expansion), pneumonia, chest trauma, pneumothorax ● Decreased at base: COPD because diaphragm function is impaired Percussion of Posterior Thorax ”ladder effect” Tone - start at apices, percuss intercostal spaces, percuss the bases Use 3rd finger to percuss at last joint ● Resonance over lung tissue, flatness over scapulae ● Hyperresonance in cases of trapped air (emphysema, pneumothorax) ● Dullness with fluid ● Flatness heard over bone Diaphragmatic excursion: measuring descent of the diaphragm ● In a quiet room, start on one side ● Exhale all the way out ● Percuss from top to bottom until the sound changes from resonance to dull and mark the spot - indicates the top of the diaphragm ● Inhale all the way in ● Repeat percussion until you hear dullness again and mark the spot ● 3-5 cm, well conditioned could be 7-8 ● Level may be higher on the right because of the liver ● Diaphragm stays low - atelectasis of lower lobes or by emphysema, pain, abdominal changes (ascites, tumors, pregnancy) ● Uneven - inflammation from unilateral pneumonia, damage to phrenic nerve, splenomegaly) (should pass first mark) ● Repeat on the other side, and compare results. Auscultation of Posterior Thorax Breath sounds: ● Use the diaphragm of the stethoscope to listen to one full inspiration and expiration ● Compare side to side ● Listen laterally ● Cant listen to bronchial from posterior ● Bronchial: over trachea, inspiration is shorter than expiration IE ● Bronchiovesicular: over major bronchi, inspiration is as long as expiration I=E ● Vesicular: over periphery, inspiration is longer than expiration IE ● Diminished or absent - little or no air is moving because of: obstruction from secretions/mucus plug/foreign object, abnormalities of pleural space like pleural thickening, pleural effusion, pneumothorax. ● Diminished breath sounds from emphysema is because the lungs are hyperinflated ● Increased breath sounds happen with consolidation or compression that lead to denser lung area that can better transmit the sound Adventitious sounds ● none ● crackles/rales, wheezes/rhonchi Bronchophony - repeat ninety nine and auscultate chest wall ● Soft, muffled, indistinct, ● Words are easily understood and louder over increased density meaning consolidation from pneumonia, atelectasis or tumor Egophony - repeat “eee” while auscultating ● Soft, muffled, but you hear the letter “E” ● Over areas of consolidation or compression the sound will be louder and sounds like “A” Whispered pectoriloquy - whisper “one-two-three” while auscultating ● Faint and muffled, possibly inaudible ● Over areas of consolidation or compression, the sound is transmitted clearly and distinctly Inspection of Anterior Thorax Shape and configuration ● AP diameter is 1:2 ● AP is 1:1 resulting in barrel chest. Happens because of hyperinflation of the lungs Inspect position of the sternum ● Sternum is positioned at midline and straight ● Sunken sternum (funnel chest) is a congenital malformation ● Forward protrusion (pigeon chest) ● Both can restrict lung expansion and decrease lung capacity Sternal retractions ● None ● Sternal retractions with accompanying labored breathing Slope of the ribs ● Slope downward, costal angle is 90 degrees at the most ● Barrel chest results in a more horizontal position of the ribs and a larger costal angle, usually from emphysema Quality and pattern of respiration ● Relaxed, effortless, quiet, 10- 20 per minute ● Labored and noisy breathing is seen with asthma or chronic bronchitis ● Tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes, Biot Intercostal spaces ● None ● Retraction means it’s harder for the patient to breathe in. It could be because of an obstruction of the respiratory tract or atelectasis. ● Bulging could mean trapped air like in emphysema or asthma Accessory muscles ● No use of accessory muscles ● Use of accessory muscles to help breathe in is seen with acute or chronic airway obstruction or atelectasis ● Use of accessory muscles to breathe out is seen with COPD Palpation of Anterior Thorax sitting or supine position Tenderness, sensation, surface masses ● None ● Tenderness could be from exercise ● Masses could be from tumors Crepitus - same way as in posterior ● None ● Felt in areas of extreme congestion or consolidation Tactile fremitus - same way as in posterior --in between breast tissue ● Symmetric and easily identifiable, decreases at the bases ● Diminished: obstruction of tracheobronchial tree ● Decreased: air trapping due to emphysema Anterior chest expansion - same way in posterior, except in the middle of the chest ● Thumbs move out symmetrically ● Unequal: severe atelectasis, pneumonia, chest trauma, pleural effusion, pneumothorax ● Decreased at the bases: COPD Percussion of Anterior Chest Tone Go laterally! ● Resonance over lung tissue ● Dullness over breast tissue, heart, liver ● Tympany over stomach ● Hyperresonance in cases of trapped air like in emphysema or pneumothorax ● Dullness in areas of increased ● Flatness over bones density (consolidation, pleural effusion, tumor) Auscultation of Anterior Thorax Anterior breath sounds, adventitious sounds, voice sounds (egophony, bronchophony, whispered pectoriloquy) ● Normal breath sounds ● No adventitious sounds ● Normal voice sounds ● Same abnormalities as posterior Adventitious Sounds (abnormal) Sound What it sounds like Why it happens What is it associated with Crackles/Rales ● Fine Discontinuous, intermittent, nonmusical, brief. Sounds like dots in time “ ” Popping bubble wrap, the alveoli are popping open. High pitched short pops that don’t clear with coughing. Heard during inspiration. Inhaled air opens up small deflated air passages that are coated with exudate If heard on early inspiration, it is associated with COPD. If heard on late inspiration it is associated with restrictive. ● Coarse Low pitched, bubbling, moist. Heard during early inspiration to early expiration Inhaled air comes into contact with secretions in the large bronchi and trachea Pneumonia, pulmonary edema, pulmonary fibrosis Wheezes (high pitch)/ Rhonchi (low) Continuous, musical, prolonged (not necessarily persisting through respiratory cycle) Air is passing through constricted airways caused by swelling, secretions, or tumor Asthma, COPD ● Sonorous Low pitched snoring/moaning mainly during expiration and may clear with coughing Air passing through constricted airways; usually from secretions or inflammatory processes Bronchitis, single obstructions, before an episode of sleep apnea ● Sibilant High pitched musical sounds mainly during expiration Air passing through constricted airways Acute asthma, chronic emphysema Pleural Friction Rub: Low pitched dry, grating sound heard during inspiration and expiration Pleura are inflamed Heard with pleuritis, the patient complains of pain with inspiration Check location (lobe), see if it clears with coughing, change position Transmitted Voice Sounds Sounds Normal Abnormal Bronchophony - repeat “ninety- nine” Muffled Clear and distinct sound heard over areas of increased density, means consolidation Egophony - repeat long eee (e changes to ay, sounds nasal) Whispered pectoriloquy - whisper 1, 2, 3 Abnormal Findings Configurations of the Chest Barrel chest ● Associated with COPD ● AP = TD ● Will complain of respiratory difficulty with exercise Kyphosis ● Exaggerated thoracic curvature ● Client complains of back pain ● Patient will have a history of osteoporosis or arthritis ● Severe deformities can result in respiratory or cardiac problems Scoliosis ● Severe deformities of 50 degrees or more can result in respiratory problems and abdominal or cardiac problems ● Usually corrected when client rapidly develops curvature or curvature is 50 degrees or larger ● Client may be braced before 50 degrees, resulting in respiratory difficulty Respiratory patterns **know these** Tachypnea RR 24 and shallow Bradypnea RR 10 and regular Hyperventilation Increase in rate and depth Hypoventilation Decrease in rate, irregular and shallow Cheyne-Stokes Regular pattern deep rapid breathing followed by periods of apnea Biot’s Irregular pattern with periods of apnea Kussmaul Rapid and deep labored Tactile fremitus Increased Consolidation conduct sound vibration Decreased Obstruction of air and therefore sound waves as in a pneumothorax Aging Changes ● Decreased elasticity - capacity for exercise decreases ● Chest wall is stiffer and harder to move ● Increased residual volume - speed of breathing out with max effort gradually decreases ● Less surface area for gaseous exchange - decreases the client’s capacity for exercise and cause the client to complain of increasing dyspnea on exertion ● Decreased ability to cough effectively Disorders ● COPD ● Chronic bronchitis ● Emphysema ● Pulmonary tuberculosis ● Pneumonia ● Lung cancer Chapter 21: Heart and Neck Vessels Precordium, Heart & Great Vessels ● Large veins and arteries leading directly to and away from the heart are referred to as the great vessels ● Superior and inferior vena cava bring blood to R-atrium from upper and lower torso ● Pulmonary artery exits the R-ventricle and brings blood to the lungs ● Pulmonary veins return oxygenated blood from the lungs to the L-atrium ● Aorta transports the oxygenated blood from the L-ventricle to the body Apex (bottom) and Base (top) Cardiac Cycle (always talking about ventricles) ● Diastole (or filling) → ventricles are relaxed; S1 → S2 ● Tricuspid valve and mitral valve are open (AV valves) ○ Tricuspid + pulmonic on the R ○ Mitral + aortic on the L ● Blood is flowing from atrium into the ventricles ● Atria contract and last amount of blood goes into ventricles ○ Pressure gradient in ventricles closes the tricuspid + mitral valves ● Tricuspid and mitral valve snap shut ○ Closure of the valves causes the sound of S1 ● First heart sound = S1 ○ What you hear is more closure of mitral valves than the tricuspid valve ● Systole-pressure in ventricles rises, briefly all valves are closed ● Pressure rises causing aortic valve and pulmonary valve to open (semilunar valves) ○ As the pressure rises for systole, tricuspid + mitral valves have closed and the pressure gradient in that ventricle is now going to open up the aortic and pulmonic valve ○ Now blood can either go out from the ventricles into the pulmonary or systemic circulation ● Blood goes into aorta and pulmonary artery ○ Pressure falls and pulmonary valve and aortic valve snap shut ○ Aortic + pulmonic form the sound S2 (aortic first and then pulmonic) ● Second valve close = S2 ● Effect of respiration → split S2 → aortic valve closes before pulmonary valve and you can hear a split S2 ○ When you listen to S2, you can actually hear 2 sounds which is the closure of the aortic and then the closure of the pulmonic Subjective Data: Health History Chest pain* ● If client is experiencing chest pain, use COLDSPA* ● Analyze the chest pain: ○ Is it a true chest pain occurring substernal w/ some form of radiation going down L-arm? ○ Females - up neck ○ Is it musculoskeletal bc they were hit in the chest? ■ Possibility of fractured rib ○ GERD ■ Chest pain starts in lower thoracic cavity ○ Angina ■ Chest pain that lasts only a few seconds ■ Coronary arteries may be going through a spasm (the spasm of the artery that is causing the angina) Pain or discomfort radiating to the neck/L- shoulder/L- arm/back When someone describes chest pain, they say “I feel like an elephant is sitting on my chest” ● Crushing sensation Nausea Occurs often when someone is having true chest pain Diaphoresis Excessive sweating (perspiration) without having a fever Palpitations; Skipped Beat People may state that they feel their heart is actually skipping a beat ● May occur w/ an abnormality of the heart’s conduction system (arrhythmias) or during the heart’s attempt to increase CO by increasing the HR ● Palpitations can cause client to feel anxious Dyspnea Find out when it occurs: at rest, during exercise? ● May result from congestive heart failure ○ In CHF, you have so much fluid and your heart is not pumping properly to get rid of all the blood in the chambers so it stays in the systemic circulation ● Dyspnea could also could result from pulmonary disorders, coronary disease, myocardial ischemia, MI ● Can occur at rest, during sleep, w/ extreme exertion Orthopnea How many pillows do you sleep with? ● 2-pillow orthopnea = you need 2 pillows in order to breathe properly when lying down ● The need to sit more upright to breathe easily due to fluid accumulation in the lungs Paroxysmal nocturnal dyspnea In the middle of the night, you wake up, can't breathe and run to the window to get some air ● Waking up from dyspnea during the night ● Is seen with heart failure due to redistribution of fluid from the ankles to the lungs when one lies down at night Cough Productive or nonproductive cough ● Anti-hypertensive medications can give you a cough (i.e. ACE inhibitors such as Lisinopril, Enalapril) Edema Swelling ● Swelling on the feet → is the pt on their feet all day? ● Edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart, causing blood returning to the heart to back up in the organs and dependent areas of the body ● Anti-hypertensive meds can also cause edema ● Pitting or non-pitting edema? ○ Pitting - push thumb into skin, makes indentation ○ Non-pitting - press into skin and does not make indent ● Unilateral or bilateral? ○ Bilateral - problems w/ the heart ○ Unilateral - problems w/ arterial system ● How far does the edema come up? ○ Localized to foot ○ Spreading, coming up into leg area ● Lymphedema = non-pitting ○ Lymph system is not working properly ○ Instead, it stays in the lymphatic system and cannot go anywhere ○ Stays there and gets hard, never goes down Nocturia Do you get up at night and go to the bathroom? ● Anti-HTN medications taken at night can cause pts to go to the bathroom during the night ● Increased renal perfusion during periods of rest or recumbent positions may cause nocturia, which occurs w/ heart failure ● For male population, do they have BPH (Benign prostatic hyperplasia) ○ An enlargement of prostate gland ○ Prostate gland goes over ureters ○ As it enlarges, it constricts so they are not completely emptying the bladder every time they go to the bathroom Fatigue Look at fatigue in relation to what you use to do versus what you can do now ● Look at pathological problems ○ Cardiac? GI? Exercise? Respiratory? Anemia? ● May result from compromised CO ● Fatigue related to decreased CO is worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing throughout the day ● When does it happen? At rest? With physical activity? Cyanosis/pallor Blue-ish tint color ● Seen in mucosa of mouth, around the lips Pallor ● No ruby complexion in skin ● Pale colored ● Blood loss? Enough blood circulating? Heartburn SUBJECTIVE DATA: HEALTH HX - REVIEW OF SYSTEMS PERSONAL HEALTH HX Question Rationale *Have you been diagnosed with: ● Heart defect or a murmur?