NURS 6512N FINAL EXAM REVIEW – WEEK 7 TO
11
Heart, Lungs, and Peripheral Vascular
• Examination techniques of the Heart, Lungs, and PV systems
1. Examination techniques of the Heart:
• Inspection - use tangential lighting; stand to the patient’s right, patient should sit erect and lean
forward, lye supine, and left lateral recumbent position; apical pulse midclavicular line 5th left
intercostal space; check the skin for cyanosis, venous distention, nail bed for cyanosis and
capillary refill time
• Palpation - patient supine, palpate the precordium, use proximal halves of the 4 fingers or whole
hand; being at apex, move inferior to left sternal border, then up the sternum to the base and down
the right sternal border in the epigastrium or axillae; apical pulse seen at point of maximal
impulse; feel for a thrill – fine, palpable, rushing, vibration, a palpable murmur, over the base of
the heart; locate each sensation in terms of its intercostal space and relationship to the midsternal,
midclavicular, or axillary lines; when palpating the precordium, use your other hand to palpate
the carotid artery
• Percussion - limited value by defining the borders of the heart or determining its size because the
shape of the chest is rigid; a chest radiograph useful in defining the heart border; begin tapping at
the anterior axillary line, moving medially along the intercostal spaces toward the sternal border;
resonant to dull marks the border;
• Auscultation - listen to all 5 of the cardiac areas using the diaphragm first then the bell; use firm
pressure with the diaphragm and light pressure with the bell; 5 cardiac areas – aortic valve,
pulmonic valve, second pulmonic, tricuspid, mitral; assess rate and rhythm, have patient breath
normally then hold the breath in expiration, listen for S1 while palpating the carotid pulse; have
the patient inhale deeply, listen closely for S2 during inspiration; basic heart sounds pitch,
intensity, duration, and timing in the cardiac cycle; 4 basic heart sounds S1, S2, S3, S4
1. Examination techniques of the lungs:
• Chest/Lungs – Inspect the chest, front, back, noting thoracic landmarks of and shape of
anteroposterior (AP) diameter compared with the lateral diameter, symmetry, color, superficial
venous patterns, prominence of ribs Inspection; patient sit upright, unclothed, using tangential
light
• Retractions and deformity e.g. minimal pectus excavatum are difficult to detect; pigeon chest,
funnel chest, barrel chest seen with chronic condition
• AP diameter less than lateral diameter; if they equal each other, chronic condition present – e.g.
barrel chest related to chronic asthma, emphysema
• Evaluate respirations for rate and rhythm – respiratory rate is 12-20 per minute; respirations to
heartbeats is a 1:4 ratio;
• Rhythm – breathe easily, regularly, with no apparent distress; variations – to shallow or to deep;
tachypnea – rapid breathing, Kussmal – deep and rapid, Cheyene-Stokes – regular periods of
breathing with intervals of apnea followed by a crescendo/decrescendo sequence of respiration
• Inspect chest movement with breathing for symmetry and use of accessory muscles; retractions
are seen when the chest wall seems to cave in at the sternum
,• Palpate the chest for thoracic expansion, sensations such as crepitus (palpated and heard) - gently
bubbling feeling, grating vibrations,
• Tactile fremitus (palpable vibration of the chest wall that occurs from speech), best felt
posteriorly, use phrase “99” or “Mickey Mouse”, palpate both sides simultaneously and
symmetrically; increased fremitus fluid or solid mass is present, decreased is excess air in the
lungs
• Thoracic expansion evaluation – stand behind patient, place thumbs along spinal process of the
tenth rib with palms lightly in contact with posterolateral surfaces, thumbs will diverge during
quiet and deep breathing
• Palpate for pulsations, tenderness, bulges, depressions, masses, and unusual movement
• Pleural friction rub – grating, coarse vibration, on inspiration, e.g. leather rubbing on leather
• Perform direct or indirect percussion of the chest, comparing both sides for diaphragmatic
excursion, percussion tone intensity, pitch, duration, and quality - tap sharply
and consistently from the wrist; examine back of patient while sitting with the head bent forward
and arms folded in front, then have patient raise arms overhead while percussing the later and
anterior chest
• Resonance heard over all areas of the lungs, hyperreasonance heard with hyperinflation
(emphysema, asthma), dullness or flatness suggests pneumonia or atelectasis
• Diaphragmatic excursion – the movement of the thoracic diaphragm during inhalation and
exhalation; pg. 274 Dains – pt. Take breath, hold it, percuss scapular line locating lower border,
mark the point where resonance changes to dullness, mark with a marking pen, allow the patient
to breathe, then repeat the procedure on the other side, have the patient take several breaths to
exhale as much as possible and then to hold; percuss up from the marked point and make a mark
at the change from dullness to resonance, have the patient start to breathe and then repeat on the
other side; measure and record the distance in cm between the marks on each side, distance
is usually 3-5 cm
• Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing both sides for
intensity, pitch, duration, quality of breath sounds, unexpected breath sounds (crackles, rhonchi,
wheezes, friction rubs) and vocal resonance; have pt. Sit up and breathe slowly and deeply
through the mouth; have the patient sit the same way as for percussion; also have the patient sit
erect with shoulder back for auscultation of the anterior chest
• Breath sounds – vesicular, bronchovesicular and bronchial pg. 276; adventitious breath sounds –
crackles (formerly rales), rhonchi, wheezes, friction rub
• Vocal resonance – spoken voice transmits through the lung fields that may be heard with the
stethoscope, have patient recited numbers, names and other words
Examination techniques of the peripheral vascular system:
• Peripheral Arteries – palpation occurs best over the arteries, close to the surface, that lie over
bones; when palpating the carotid, never palpate both sides simultaneously; palpate at least one
pulse point in each extremity, usually at the most distal point; perform the Allen test (pg. 340) to
ensure ulnar artery patency prior to radial artery puncture; the thumb can be used to fix the
brachial or femoral pulse; palpate the arterial pulses to assess heart rate, rhythm, pulse controu,
amplitude, symmetry, and occasiuonally sometimes obstructions to blood flow
• Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries
• Observe for signs of cyanosis, lip pursing, finger clubbing, alae nasi for flaring – any signs of this
suggest cardiac or respiratory difficulty
• Alae nasi flaring – sign of air hunger
, • Clubbing – enlargement of the terminal phalanges of the fingers/and or toes; seen
with emphysema, lung cancer, cystic fibrosis, congenital heart disease
Auscultation – use the bell of the stethoscope over the artery, auscultate for a bruit over the carotid,
subclavian, abdominal aorta, renal, iliac, and femoral arteries; when listening to the carotid, have the
patient suspend their breathing for a few seconds; assess the degree of peripheral artery degree –
patient lie supine, elevate extremity, note degree of blanching, have patient sit on edge of bed to lower
the extremity, note time for return of color to extremity; assess capillary refill; jugular venous
pressure – pg.342. Assess Homan sign, edema, and varicose veins
• Examination findings of arterial blood flow in infants
Examination findings of arterial blood flow in infants - arterial blood flow in infants; after the
umbilical chord is cut, blood flows to the lungs at a higher pace, pulmonary arteries expand and
relax which decreases the resistance of systemic circulation; the decrease leads to closure of the
foramen ovale shortly after birth, increased oxygen tension in the arterial blood usually
stimulates contraction and closure of the ductus arteriosus
Examination findings of the heart and lungs in a patient with
illegal drug use
Examination findings of the heart and lungs in a patient with illegal drug use - severe
chest pain associated with cocaine use, tachycardia, hypertension, coronary arterial
spasm and pneumothorax with acute chest pain are symptoms
• Description of types of shortness of breath (orthopnea,
platypnea. Tachypnea, bradypnea)
Description of types of shortness of breath
* Orthopnea: Shortness of breath that begins or increases when the patient lies down. Ask whether the
patient need to sleep on more than one pillow and whether it helps
* Platypnea: Dyspnea increases in the upright position
* Tachypnea: Faster than 20 breaths per min. Rapid breathing with no change in depth, and can be caused
by hypoxia, pain, fever, or anxiety. Consider PE, foreign body aspiration, anaphylaxis, pneumothorax,
heart failure, asthma, or pneumonia
* Bradypnea: Slower than 20 breaths per minutes
* Paroxysmal nocturnal dyspnea- sudden onset of SOB after a period of sleep; sitting upright is helpful
• Symptoms associated with intrathoracic infection
, Symptoms associated with intrathoracic infection
* Dyspnea
* tachypnea
* Pleuritic chest pain
* Fever
* Cough with green/rusty sputum
* Chills
* Anorexia
* Malaise
* Altered mental status
Percussion techniques when examining the lungs
Percussion techniques when examining the lungs
* Tap sharply and consistently from the wrist without excessive force
* Compare all areas bilaterally using one side as a control for the other
* Move systematically through posterior thorax, right lateral thorax, left lateral thorax, and anterior thorax
* Have the patient sitting with head bent forward and arms folded. This moves scapulae laterally,
exposing more of the lung
* Have patient raise arms overhead to percuss the lateral and anterior chest.
* For all positions percuss at 4-5 cm intervals over the intercostal spaces, moving systematically from
superior to inferior and medial to lateral
Examination findings when percussing the lungs
Part 3
1. Examination of findings when percussing the lungs
a. Tone type:
11
Heart, Lungs, and Peripheral Vascular
• Examination techniques of the Heart, Lungs, and PV systems
1. Examination techniques of the Heart:
• Inspection - use tangential lighting; stand to the patient’s right, patient should sit erect and lean
forward, lye supine, and left lateral recumbent position; apical pulse midclavicular line 5th left
intercostal space; check the skin for cyanosis, venous distention, nail bed for cyanosis and
capillary refill time
• Palpation - patient supine, palpate the precordium, use proximal halves of the 4 fingers or whole
hand; being at apex, move inferior to left sternal border, then up the sternum to the base and down
the right sternal border in the epigastrium or axillae; apical pulse seen at point of maximal
impulse; feel for a thrill – fine, palpable, rushing, vibration, a palpable murmur, over the base of
the heart; locate each sensation in terms of its intercostal space and relationship to the midsternal,
midclavicular, or axillary lines; when palpating the precordium, use your other hand to palpate
the carotid artery
• Percussion - limited value by defining the borders of the heart or determining its size because the
shape of the chest is rigid; a chest radiograph useful in defining the heart border; begin tapping at
the anterior axillary line, moving medially along the intercostal spaces toward the sternal border;
resonant to dull marks the border;
• Auscultation - listen to all 5 of the cardiac areas using the diaphragm first then the bell; use firm
pressure with the diaphragm and light pressure with the bell; 5 cardiac areas – aortic valve,
pulmonic valve, second pulmonic, tricuspid, mitral; assess rate and rhythm, have patient breath
normally then hold the breath in expiration, listen for S1 while palpating the carotid pulse; have
the patient inhale deeply, listen closely for S2 during inspiration; basic heart sounds pitch,
intensity, duration, and timing in the cardiac cycle; 4 basic heart sounds S1, S2, S3, S4
1. Examination techniques of the lungs:
• Chest/Lungs – Inspect the chest, front, back, noting thoracic landmarks of and shape of
anteroposterior (AP) diameter compared with the lateral diameter, symmetry, color, superficial
venous patterns, prominence of ribs Inspection; patient sit upright, unclothed, using tangential
light
• Retractions and deformity e.g. minimal pectus excavatum are difficult to detect; pigeon chest,
funnel chest, barrel chest seen with chronic condition
• AP diameter less than lateral diameter; if they equal each other, chronic condition present – e.g.
barrel chest related to chronic asthma, emphysema
• Evaluate respirations for rate and rhythm – respiratory rate is 12-20 per minute; respirations to
heartbeats is a 1:4 ratio;
• Rhythm – breathe easily, regularly, with no apparent distress; variations – to shallow or to deep;
tachypnea – rapid breathing, Kussmal – deep and rapid, Cheyene-Stokes – regular periods of
breathing with intervals of apnea followed by a crescendo/decrescendo sequence of respiration
• Inspect chest movement with breathing for symmetry and use of accessory muscles; retractions
are seen when the chest wall seems to cave in at the sternum
,• Palpate the chest for thoracic expansion, sensations such as crepitus (palpated and heard) - gently
bubbling feeling, grating vibrations,
• Tactile fremitus (palpable vibration of the chest wall that occurs from speech), best felt
posteriorly, use phrase “99” or “Mickey Mouse”, palpate both sides simultaneously and
symmetrically; increased fremitus fluid or solid mass is present, decreased is excess air in the
lungs
• Thoracic expansion evaluation – stand behind patient, place thumbs along spinal process of the
tenth rib with palms lightly in contact with posterolateral surfaces, thumbs will diverge during
quiet and deep breathing
• Palpate for pulsations, tenderness, bulges, depressions, masses, and unusual movement
• Pleural friction rub – grating, coarse vibration, on inspiration, e.g. leather rubbing on leather
• Perform direct or indirect percussion of the chest, comparing both sides for diaphragmatic
excursion, percussion tone intensity, pitch, duration, and quality - tap sharply
and consistently from the wrist; examine back of patient while sitting with the head bent forward
and arms folded in front, then have patient raise arms overhead while percussing the later and
anterior chest
• Resonance heard over all areas of the lungs, hyperreasonance heard with hyperinflation
(emphysema, asthma), dullness or flatness suggests pneumonia or atelectasis
• Diaphragmatic excursion – the movement of the thoracic diaphragm during inhalation and
exhalation; pg. 274 Dains – pt. Take breath, hold it, percuss scapular line locating lower border,
mark the point where resonance changes to dullness, mark with a marking pen, allow the patient
to breathe, then repeat the procedure on the other side, have the patient take several breaths to
exhale as much as possible and then to hold; percuss up from the marked point and make a mark
at the change from dullness to resonance, have the patient start to breathe and then repeat on the
other side; measure and record the distance in cm between the marks on each side, distance
is usually 3-5 cm
• Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing both sides for
intensity, pitch, duration, quality of breath sounds, unexpected breath sounds (crackles, rhonchi,
wheezes, friction rubs) and vocal resonance; have pt. Sit up and breathe slowly and deeply
through the mouth; have the patient sit the same way as for percussion; also have the patient sit
erect with shoulder back for auscultation of the anterior chest
• Breath sounds – vesicular, bronchovesicular and bronchial pg. 276; adventitious breath sounds –
crackles (formerly rales), rhonchi, wheezes, friction rub
• Vocal resonance – spoken voice transmits through the lung fields that may be heard with the
stethoscope, have patient recited numbers, names and other words
Examination techniques of the peripheral vascular system:
• Peripheral Arteries – palpation occurs best over the arteries, close to the surface, that lie over
bones; when palpating the carotid, never palpate both sides simultaneously; palpate at least one
pulse point in each extremity, usually at the most distal point; perform the Allen test (pg. 340) to
ensure ulnar artery patency prior to radial artery puncture; the thumb can be used to fix the
brachial or femoral pulse; palpate the arterial pulses to assess heart rate, rhythm, pulse controu,
amplitude, symmetry, and occasiuonally sometimes obstructions to blood flow
• Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries
• Observe for signs of cyanosis, lip pursing, finger clubbing, alae nasi for flaring – any signs of this
suggest cardiac or respiratory difficulty
• Alae nasi flaring – sign of air hunger
, • Clubbing – enlargement of the terminal phalanges of the fingers/and or toes; seen
with emphysema, lung cancer, cystic fibrosis, congenital heart disease
Auscultation – use the bell of the stethoscope over the artery, auscultate for a bruit over the carotid,
subclavian, abdominal aorta, renal, iliac, and femoral arteries; when listening to the carotid, have the
patient suspend their breathing for a few seconds; assess the degree of peripheral artery degree –
patient lie supine, elevate extremity, note degree of blanching, have patient sit on edge of bed to lower
the extremity, note time for return of color to extremity; assess capillary refill; jugular venous
pressure – pg.342. Assess Homan sign, edema, and varicose veins
• Examination findings of arterial blood flow in infants
Examination findings of arterial blood flow in infants - arterial blood flow in infants; after the
umbilical chord is cut, blood flows to the lungs at a higher pace, pulmonary arteries expand and
relax which decreases the resistance of systemic circulation; the decrease leads to closure of the
foramen ovale shortly after birth, increased oxygen tension in the arterial blood usually
stimulates contraction and closure of the ductus arteriosus
Examination findings of the heart and lungs in a patient with
illegal drug use
Examination findings of the heart and lungs in a patient with illegal drug use - severe
chest pain associated with cocaine use, tachycardia, hypertension, coronary arterial
spasm and pneumothorax with acute chest pain are symptoms
• Description of types of shortness of breath (orthopnea,
platypnea. Tachypnea, bradypnea)
Description of types of shortness of breath
* Orthopnea: Shortness of breath that begins or increases when the patient lies down. Ask whether the
patient need to sleep on more than one pillow and whether it helps
* Platypnea: Dyspnea increases in the upright position
* Tachypnea: Faster than 20 breaths per min. Rapid breathing with no change in depth, and can be caused
by hypoxia, pain, fever, or anxiety. Consider PE, foreign body aspiration, anaphylaxis, pneumothorax,
heart failure, asthma, or pneumonia
* Bradypnea: Slower than 20 breaths per minutes
* Paroxysmal nocturnal dyspnea- sudden onset of SOB after a period of sleep; sitting upright is helpful
• Symptoms associated with intrathoracic infection
, Symptoms associated with intrathoracic infection
* Dyspnea
* tachypnea
* Pleuritic chest pain
* Fever
* Cough with green/rusty sputum
* Chills
* Anorexia
* Malaise
* Altered mental status
Percussion techniques when examining the lungs
Percussion techniques when examining the lungs
* Tap sharply and consistently from the wrist without excessive force
* Compare all areas bilaterally using one side as a control for the other
* Move systematically through posterior thorax, right lateral thorax, left lateral thorax, and anterior thorax
* Have the patient sitting with head bent forward and arms folded. This moves scapulae laterally,
exposing more of the lung
* Have patient raise arms overhead to percuss the lateral and anterior chest.
* For all positions percuss at 4-5 cm intervals over the intercostal spaces, moving systematically from
superior to inferior and medial to lateral
Examination findings when percussing the lungs
Part 3
1. Examination of findings when percussing the lungs
a. Tone type:
