Health Assessment Notes
Health Assessment Notes NSG 3309
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Chapter 13: Eyes, p. 263 Health Assessment Exam 2 The eyes—sensory organs responsible for vision. Fluid-filled sphere. Light waves enter the eye and are transmitted to the brain for interpretation Layers o Sclera—white outermost layer of the eye. Functions primarily to support and protect the structure of the eye** Cornea—transparent part of the sclera through which light enters the eye o Choroid—vascular-pigmented layer in which the iris is located Iris—responds to light by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye Pupil—center of the iris. Miosis—pupil enlarges. Mydriasis—pupil constricts o Retina—sensory portion of the eye, which changed light waves into neurological impulses for transmission to the brain Optic disc—point at which the optic nerve and retina meet Macula—responsible for central vision. Fovea centralis is the center of it Visual Fields of the Eye and the Visual Pathway to the Brain—Figure 13.3, page 266 o The refraction occurs as light passes through the aqueous and vitreous humors and the lens. The image refracted onto the retina is transformed into neurological impulses, which are conducted via the optic nerve o Vision center—occipital lobe o Emmetropia—normal refraction o Myopia—nearsighted; eye is longer than it should be. Have larger pupils o Hyperopia—farsighted; eye is shorter than it should be Accessory Structures—assess for symmetry. Are all used for protection of the eye o Brows o Lashes—protect eyes from irritants o Palpebrae—eyelids. Palpebral fissure is the open space between the eyelids and the size can be variable dependent on genetic factors (ethnicity, etc.).* o Meibomium glands—embedded in the eyelids, modified sebaceous glands that produce an oily substance to help lubricate the eyes and eyelids o Conjunctivae—thin, mucous membrane; lines the interior of the eyelids, meeting the cornea but not covering it o Lacrimal apparatus—consists of lacrimal glands and ducts. Lacrimal secretions, commonly called tears, are secreted and spread over the conjunctiva when blinking Lacrimal Glands of the Eye—see Figure 13.4, page 264 Extrinsic or Extraocular Muscles—Figure 13.5, page 264. 1 o Test 3 cranial nerves by doing H test: CN III (Oculomotor), CN IV (Trochlear), CN VI (Abducens). Keep eyes from converging and everging o Lateral rectus, Medial rectus, Superior rectus, Inferior rectus, Inferior oblique, Superior oblique Interview Questions—page 270-273 for information: READ o General Questions Vision changes Last eye examination Use of glasses or contact lenses o Specific Questions—diagnosed with disease of eye, eye infections, injuries, hx of surgeries, blurred vision, pain, light sensitivity, removal of makeup Illness or infection, Symptoms, Pain, Behaviors, Infants and children, Pregnant females (vaginal infections at time of delivery, babies should get eye ointment at birth), Older adults, Environment Developmental Considerations o Infants and Children At birth the iris has little color but changes to permanent color by 3 months Red reflex—a glowing red color that fills the pupil as light reflects off the retina. Should be elicited from birth. None could be blindness or tumor Binocular vision develops at 6 weeks of age Lateral deviations are normal until 4 o Pregnant Females Dryness of the eyes & vision changes. Symptoms are usually not significant and disappear after childbirth—hormone related o Older Adults Presbyopia—lens of eye loses elasticity and ciliary muscles become weaker, resulting in a decreased ability of lens to change shape to accommodate for near vision. Light is focused behind retina, and focus on near objects becomes difficult. Causes need for reading glasses. Aging changes Loss of fat—drooping appearance Decrease in tear production—burning sensation Decrease in pupillary response—may be smaller in size Cataracts—with aging, lens begins to thicken and yellow, forming a dense area that reduces lens clarity Macular degeneration—loss of central vision in older adults. May see narrowed blood vessels with a granular pigment in macula Psychosocial Considerations o Impact of Decreased Visual Acuity/Visual Impairment on Independence & Quality of Life. o Eye contact with people varies, especially during communication process. Age, gender, and culture influence the type and amount of eye contact people make with others. 2 Cultural and Environmental Considerations o Changes that occur normally in various races and ethnic groups— Asians have prominent epicanthic folds. Dark skinned pt’s have dark pigmented spots on sclera and retina may look darker. Light eyed people have liter retinae and better night vision, but are more sensitive to bright sunlight and artificial light o Excessive sun exposure—can lead to cataracts o Medications—side effects like dry eyes, tearing, etc. o Hygiene practices—contact lenses, makeup and applicators should be changed every 3 months o Trauma/damage—need to wear safety goggles. Welders/chemists/carpentry Assessment of the Eye o Techniques used Inspection Palpation Testing the functions of the eye Ophthalmoscope to assess internal eye structures Visual Acuity Visual Acuity: Far Vision—Snellen chart.* E chart tells which direction the eye is pointing in. o Check corrected and uncorrected, each eye, then both eyes o Have client stand 20 feet away. The numerator is the distance from the chart (20 feet) and the denominator is the distance at which a normal person with normal vision can read the last line. The higher the denominator, the poorer the vision. The numerator is pretty much always 20. o Legally blind—best vision is 20/200 with corrective lenses o Negative number=nearsighted o Positive number=farsighted o OS=left eye. OD=right eye. OU=both eyes. AS=left ear. AD=right ear. AU=both ears. Visual Acuity: Near Vision—Rosenbaum chart. Held at a distance of 12-14 inches and normal results are 14/14. Visual Fields by Confrontation—tests peripheral vision o Visual field refers to the total area in which objects can be seen in the periphery while the eye remains focused on a central point o Position client 2-3ft away from you and at eye level client will alternately cover an eye and must look directly into your open eye. A pen or penlight will be moved into the client’s field of vision, sequentially from four directions. The client is to indicate by saying “now” or “yes” when the object is first seen o Ask the client to cover one eye with a card while you cover your opposite eye with a card. Holding the penlight in one hand, extend your arm upward and advance it in from the periphery to the midline point. Be sure to keep the penlight equidistant between the client and yourself. Ask the client to report when the object is first seen. Repeat the procedure upward, toward the nose, and downward. Then repeat the entire procedure with the other eye covered 3 o *If someone has changes in visual fields, especially a young female, it is most likely due to increased intraocular pressure* Six Cardinal Fields of Gaze—stand 2 feet in front of patient. H test. Assess extraocular muscle movements for 3 cranial nerves (III, IV, and VI) when done correctly. o Nystagmus—rapid fluttering of the eyeball, occurs at completion of rapid lateral eye movement but should not occur during testing Corneal Light Reflex o Shine light into the eyes from a distance of 12 inches. Light reflection should appear in the same spot on both pupils. Appears as a “twinkle” in the eye. o *Positive consensual light reflex is simultaneous constriction of the other pupil when one eye is exposed to bright light. If you shine the light in one eye, the other eye should constrict as well.* Other Eye Tests o Cover Test—Cover one eye with a card and observe the uncovered eye, which should remain focused on the designated point. Then remove the card from the covered eye and observe the newly uncovered eye for movement – should focus straight ahead – checks for lazy eye – CN III, IV, VI. *Used to assess for muscle weakness.* o Pupil Inspection—PERRLA: pupil is equal, round, reacts to light, accommodation (change in size to adjust vision from far to near). Controlled by CN III (Oculomotor) o Pupillary Response—shine penlight directly into one eye and observe the constriction in the illuminated pupil. Also observe the simultaneous reaction (consensual constriction) of the other pupil. o Testing for Accommodation of Pupil Response—reaction should be faster and greater than the consensual reaction o Corneal Reflex—Twist sterile cotton ball into a very thin strand. Using lateral approach, gently touch the cornea on the outer aspect of each eye. Confirm that both eyes blink when either cornea is touched. Be sure not to touch the eyelashes or conjunctiva Inspection of the External Eye o Observe for symmetry, upper eyelid should cover a small part of the iris o Eyelids should symmetrically cover the eyeballs when closed. Conjunctivae should be moist and clear with small blood vessels. Lens should be clear. Sclera white. Irises round and both of the same color (usually) o Shine a penlight from the side to check the cornea. Should be clear with no irregularities o The pupils should be round and equal in size o Have pt close eyes and use fingers to gently palpate the lacrimal sacs, lids, and eyeballs. Check for swelling to tenderness and that the eyeballs feel firm. Pull down the lower lid. o Ptosis—one eyelid drooping, can be caused by dysfunction of CN III (Oculomotor) Conjunctiva o Clear, showing pink of the underlying tissue o No tenderness or irregularities 4 Eversion of the Upper Eyelid—check the conjunctiva of the upper eyelid and look for foreign bodies. *Feel like something is stuck in their eye, but can see anything. No foreign body, but can have tearing, redness, and light sensitivity. Could be corneal abrasion. Fundoscopic Examination—exam the fundus or inner deep part of the eye. Figure 13.21, p. 288 o Use right eye to assess client’s right eye, and vice versa. Set the diopter to “0” o Direct light at pupil and follow pupil until red reflex is observed. Follow red reflex into the eyes & advance until the ophthalmoscope is almost touching the client’s eyelashes o If myopic (nearsighted)—rotate diopter to minus (negative) numbers o If hyperopic (farsighted)—rotate diopter to plus numbers o *Remove your own glasses and approach pt’s left eye with your left eye. Turn off lights in exam room.* Fundoscopic Examination—Figure 13.22: The Optic Disc. o Optic disc—round or oval and yellow-orange depression with distinct margins. Is where optic disc and blood vessels exit eye. o Arterioles are brighter than veins. o Macula—area of central vision. Fovea centralis—white spot in center of macula; sharpest vision o Trace arteries to periphery in all four quadrants of eye o Use the optic disc as a clock fact for documenting the position of a finding and the diameter of the disc (DD) for noting its distance from the optic disc. For example – at 2:00, 2 DD from the disc describes the lesion Eye Abnormalities Astigmatism—Familial condition in which the refraction of light is spread over a wide area rather than on a distinct point on the retina. Cornea should be round in shape, but in astigmatism, the cornea curves more in one direction than another. Light is refracted and focused on 2 focal points on or near the retina. Vision may be blurred or doubled. Client’s View with Visual Field Loss—need to know* Figure 13.29, page 292 Strabismus—Condition in which the axes of the eyes cannot be directed at the same object. o Convergent (esotropia)/divergent (exotropia). Light when doing corneal light reflex will be seen at different axes. Can be detected in cover test. o May need eye patch to strengthen eye. Argyll Robertson Pupils—Small irregular pupils that are non-reactive to light. o Occur with CNS disorders, tumor, syphilis, and narcotic use. Aniscoria—unequal, pupillary size, which may be a normal finding or may indicate central nervous system disease Cranial Nerve III Damage—unilaterally dilated pupil. No reaction to light. Ptosis may be seen Horner’s Syndrome—unilateral, small regular pupil that is nonreactive to light. o Blockage of sympathetic nerve stimulation o Ptosis & anhidrosis of the same side accompany the pupillary signs Mydriasis—Fixed and dilated pupils. 5 o Sympathetic nerve stimulation, glaucoma, CNS damage, or deep anesthesia Miosis—Fixed and constricted pupils. o Use of narcotics, damage to the pons, or as a result of treatment for glaucoma Monocular Blindness—Results in direct and consensual response to light directed in the normal eye and absence of response in either eye when light is directed in the blind eye Acute Glaucoma—sudden increase in intraocular pressure resulting from blocked flow of fluid from the anterior chamber. o The pupil is oval in shape and dilated. There is circumcorneal redness. Cornea looks cloudy and steamy. o **Pain is sudden in onset and is accompanied by decrease in vision and halos around lights** o Required immediate intervention or can go blind. *Immediate referral should be made for any patient with a sudden onset of vision change* Basal Cell Carcinoma—Papular appearance. Usually seen on the lower lid and medial canthus Blepharitis—Inflammation of the eyelids. o Staph infection can lead to red, scaly, and crusted lids. The eyelids burn, itch and tear. *Can be a chronic condition* Cataract—Opacity of the lens. Usually occurs in aging & can do cataract surgery. o *Lens looks gray-white and opaque.* Pupil round. Chalazion—Meibomian gland infection. Causes firm, nontender nodule on the eyelid. o Can become painful if inflamed Conjunctivitis—pink eye o Conjunctiva is infected from a virus or bacteria, or chemical exposure o Bacterial infections—very contagious o *Conjunctivitis is always associated with reddened conjunctiva* Ectropion—Eversion of the lower eyelid caused by muscle weakness o Palpebral conjunctiva is exposed o Eyes water all the time. Lid loses its ability to hold tears in Entropion—Inversion of the lid and lashes caused by muscle spasm of the eyelid. o Friction from lashes can cause corneal irritation Hordeolum (Stye)—staph infection of the hair follicles on the margin of the lids. Affected eye is swollen, red, and painful Iritis—Redness around the iris and cornea o Pupil irregular. Vision decreased and client has a deep aching pain. Serious infection. Constitutes an eye emergency Periorbital Edema—Swollen, puffy lids o Occurs with crying, infection, and systemic problems including kidney failure, heart failure, and allergy. If infection, often required hospitalization for IV antibiotics Ptosis—Drooping of the lid. o Occurs with cranial nerve damage or systemic neuromuscular weakness 6 Diabetic Retinopathy—refers to the changes that occur in the retinal and vasculature of the retina including microaneurysms, hemorrhages, macular edema, and retinal exudates Hypertensive Retinopathy—changes in the retinal and vasculature of the retina in response to elevations in blood pressure that accompany atherosclerosis, heart disease, and kidney disease. o Changes include flame hemorrhages, nicking of the vessels, and “cotton wool” spots that arise from the infarction of nerve fibers Macular Degeneration—Age Related MD (ARMD) is a degenerative condition of the macula, the central retina. The central vision is gradually lost while peripheral vision remains intact. Eyes are affected at different rates. No true cure. Can be typed as wet or dry. I think the wet kind can have an eye injection to help slow the progress Objectives Outlined in Healthy People 2020 o Vision impairment o Increase the number of persons who have dilated eye exams. o Increase vision screening in preschool children. o Reduce visual impairment due to disease. o Diabetes education and treatment—diabetic retinopathy is number 1 cause of blindness in the US 7 Chapter 17: Cardiovascular System, p. 425 Health Assessment Exam 2 Cardiovascular System o Heart—intricate pump composed of a meticulous network of synchronized structures Apex—the point of maximum impulse (PMI) About the size of your clenched fist Review Figure 17.1 Layers of the Heart, page 427 o Vasculature Heart o Pericardium—thin sac composed of a fibrous material that surrounds the heart Fibrous pericardium—tough outer layer; protects the heart and anchors it to the adjacent structures such as the diaphragm and great vessels Serous pericardium—inner layer Parietal layer—outer layer Visceral layer—the inner layer, which lines the surface of the heart o Cardiac muscle o Chambers o Valves o Cardiac vessels o Conduction systems o Nerves Layers of the heart—heart wall is composed of three layers o Epicardium—outer layer, anatomically identical to the visceral pericardium o Myocardium—the thick, muscular layer made up of bundles of cardiac muscle fibers o Endocardium—innermost layer; a smooth layer that provides an inner lining for the chambers of the heart Structural components of the heart—Figure 17.3, page 429 Chambers o Right atrium—thin-walled chamber located above and slightly to the right of the right ventricle, forms right border of the heart. Deoxygenated venous blood enters R atrium via inferior and superior vena cava and coronary sinus. Blood pumped through tricuspid valve to R ventricle o Right ventricle—receives deoxygenated blood from the right atrium and sends it through the pulmonary semilunar valve to the pulmonary arteries to be oxygenated within the lungs. Its wall is much thinner than the L ventricle, reflecting the relative low vascular pressure in the vessels of the lungs o Left atrium—forms posterior aspect of the heart, slightly thicker musculature than R atrium. Receives oxygenated blood form the 1 pulmonary vascular via the pulmonary veins. Blood pumped through mitral valve to L ventricle. o Left ventricle—most muscular chamber, thick wall permits the pumping of blood through aortic semilunar valve into the aorta against high systemic vascular resistance. LV of female has about 10% less mass compared to male Heart Valves o Atrioventricular (AV) valves—separate the atria from the ventricles. Tricuspid—between R atrium and R ventricle Mitral/Bicuspid—between L atrium and L ventricle Open as a direct result of atrial contraction and the buildup of pressure within the atria. Pressure forces valvular leaflets to open. When the ventricles contract, the increased ventricular pressure forces the valvular leaflets shut, preventing backflow into the atria o Semilunar valves—separate the ventricles from the vascular system Pulmonary—separates right ventricle from trunk of pulmonary arteries Aortic—separates left ventricle from aorta Open in response to rising pressure within contracting ventricles Upon relaxation of the ventricles, the valves close, allowing for ventricular filling and preventing backflow into the chambers Heart Sounds o S1=Lub. Systole. Ventricles contract. Blood flows to body and lungs Begins with: closure of mitral and tricuspid (AV) valves (opening of semilunar) Ends with: closure of aortic and pulmonary valves (opening of AV) o S2=Dub. Diastole. Atria contract. Blood flows into the ventricles Begins with: closure of aortic and pulmonary valves (opening of AV) Ends with: closure of mitral and tricuspid valves (opening of semilunar) o Aortic—second intercostal space on the right sternal border. S2>S1 o Pulmonic—second intercostal space on the left sternal border. S2>S1 o Erb’s Point—third intercostal space on the left sternal border. S1=S2 o Tricuspid—fourth intercostal space on the left sternal border. S1>S2 o Mitral—fifth intercostal space on the left midclavicular line. S1>S2 Additional Heart Sounds o Clicks and snaps may be heard with valvular disease An opening snap may be heard in mitral stenosis Ejection clicks occur in damaged pulmonic and aortic valves, and nonejection clicks are heard in prolapse of the mitral valve o Friction rubs result from inflammation of the pericardial sac—rubbing or grating sound o Heat murmur—harsh, blowing sounds caused by disruptions of blood flow into the heart, between the chambers of the heart, or from the heart into the pulmonary or aortic systems 2 Classifications of Heart Murmurs Cardiac Cycle Auscultation Site Timing nd Aortic stenosis Midsystolic RSB, 2nd ICSrd Pulmonary stenosis Midsystolic LSB, 2 to 3 ICS Mitral regurgitation Systole Apex Tricuspid regurgitation Systole LSB, 4 ICS Mitral stenosis Diastole Apical Tricuspid stenosis Diastole Lower LSB Ventricular septal defect (L-R Systole LSB, 3 , 4 , 5 ICS shunt) rd Aortic regurgitation Diastole (early) LSB, 3 ICS Pulmonic regurgitation Diastole (early) LSB, 3 ICS Grading Heart Murmurs o Grade 1—barely audible with stethoscope; physiologic not pathologic o Grade 2—very soft but distinctly audible o Grade 3—moderately loud; there is no thrill or thrusting motion associated with the murmur o Grade 4—distinctly loud, in addition to palpable thrill o Grade 5—very loud, can hear with part of the diaphragm of the stethoscope off the chest; palpable thrust and thrill o Grade 6—loudest, can hear with the diaphragm of the chest; visible thrill and thrust Murmur Causes: o Regurgitant flow through an incompetent valve o Flow through the septal defect—hole in heart o Increased flow across a normal valve o Lub-swish-dub Circulation of the Heart o Coronary Arteries Left main Right coronary Left anterior descending Circumflex o Cardiac Veins Great cardiac Oblique Anterior cardiac Small cardiac Middle cardiac Cordis minimae Posterior cardiac o Flow of blood: superior/inferior vena cavaR atriumtricuspid valveR ventriclepulmonary semilunar valvepulmonary arterieslungspulmonary veinsL atriamitral valveL ventricleaortic semilunar valveaorta 3 Vessels of the Heart Conduction of the Heart—infarction is worse the higher up in the heart. Higher up is faster pulse o Sinoatrial (SA) node—initiates the electrical impulse, pacemaker of the heart. Located at the junction of the superior vena cava and right atrium. Discharges an average of 60-100 times a minute. A heart attack here could indicate need for pacemaker o Intra-atrial pathways—assist in the propagation of the electrical current emitted from the SA node, through the right atrium. 3 main pathways: anterior, middle, and posterior o AV node and bundle of His—intricately connected and function to receive the current that has finished spreading throughout the atria. AV node is capable of initiating electrical impulses in the event of SA node failure Intrinsic rate fires about 60 per minute o Right and left bundle branches—like expressways of conducting fibers that spread the electrical current through the ventricular myocardial tissue Capable of initiating electrical charges in both the SA node and AV node fail. Their intrinsic rate averages 40-60 per minute o Purkinje fibers—arise from the right and left bundle branches; fan out and penetrate into the myocardial tissue to spread the current into the tissues themselves Cardiac Cycle—events of one complete heartbeat: the contraction and relaxation of the atria and ventricles. Average time for each cardiac cycle is about 0.8 second o Ventricular filling—blood enters passively into the ventricles from the atria, 70% that ends up in ventricles enters at this time. 30% enters as atrial kick o Ventricular systole—electrical current stimulates the ventricles, and they respond by contracting, increasing the pressure within both ventricles. Mitral and tricuspid valves respond to this increased pressure by snapping shut (S1). Blood goes into systemic and pulmonary circulation o Isovolumetric relaxation—majority of blood is ejected, pressure in the aorta and pulmonary artery becomes higher than in the ventricles, causing the aortic and pulmonic valves to shut (S2). Atria have been filling with blood & when pressure gets higher than in the ventricles, the mitral and tricuspid valves open and cycle begins again Electrocardiogram (ECG)—paper recording of deflections that represent the cardiac cycle o Electrical deflections P wave—atrial depolarization SA node emits electrical charge causing cells to contract Initial P wave deflection caused by initiation of electrical current and atrial response to the current. Lasts an average of 0.08 second 4 PR interval—time needed for the electrical current too travel across both atria and arrive at the AV node Averages 0.12 to 0.20 second QRS interval—ventricular depolarization Atrial repolarization is hidden in the QRS interval Ventricular myocardial cells also respond to the spread of electrical current by becoming more positively charged, causing vent. dep. 0.08 to 0.11 second T wave—ventricular repolarization Atria also repolarize, but it is not recorded because it occurs at the same time as ventricular depolarization, therefore, the QRS covers it QT interval—period from the beginning of ventricular depolarization to the moment of repolarization Represents ventricular contraction Cardiac Function o Stroke volume—amount of blood that is ejected with each heartbeat o Cardiac output—amount of blood ejected from the left ventricle over a minute o Cardiac index—measurement accounting for an individual’s weight when evaluating the effectiveness of the pumping action of the heart Cardiac index=cardiac output/body surface area Pumping Action of the Heart o Preload—influenced by the volume of the blood in the ventricles and relates to the length of ventricular fiber stretch at the end of diastole o Afterload o Frank-Starling Law—rubber band; greater contractile force=greater stretching=greater volume of blood with each contraction Landmarks for Cardiac Assessment o Sternum o Clavicle o Ribs nd th o All valve areas lie between 2 and 5 intercostal spaces Developmental Considerations: Pediatric o Fetus receives oxygen and nutrients from the mother o Foramen ovale is a passageway for blood between the right and left heart that closes shortly after birth o The ductus arteriosus is an opening between the pulmonary artery and the descending aorta and closes within 24-48 hours in response to multiple physiologic events, including a decreased pulmonary resistance and decreased pressure in R atrium versus increased pressure in L atrium o Inflation of the lungs at birth causes the pulmonary vasculature to dilate. Oxygenation occurs for the first time within the newborn’s lungs o Changes occur in the newborn’s cardiovascular system in the first few days of life o Infant’s heart rate 150-120 5 Developmental Considerations: Pregnant Female o Heart is displaced to the left and upward o Blood volume increases 30%-50% o Cardiac output and stroke volume increase—CO increases 30-50% in just 1 trimester o Resting pulse may increase—by about 10-15 beats/min o Murmurs may be auscultated o Systolic BP may decrease by 2-3 mmHG and diastolic BP by 5-10 mmHg during first half of pregnancy o Edema and varicose veins Developmental Considerations: Geriatric o Loss of ventricular compliance and valvular rigidity o Conduction system loses automaticity—HR decreases w/ age from decreased SA node firing or SA node failure o With AFib, blood pools, causing chances of clots o If pt dies with pacemaker, it will keep beating Other Considerations o Psychosocial—stress increases sympathetic stimulation, increases workload of the heart o Cultural and Environmental Race—AA=higher % HTN than Caucasians Ethnicity Diet—fats contribute to CV disease; continuous aerobic exercise for at least 30-45minutes at least 3X week slows atherosclerosis Substance abuse—cocaine causes increased oxygen demand to the heart. Alcohol is associated with cardiomyopathy and ventricular ectopy (impulses originating in ventricles causing early ventricular contraction) Inspection o Inspection of the face, lips, ears, and scalp Skin & eyes should be uniform, sclera should be whitish, cornea w/o arcus (ringlike structure), conjunctiva clear & underlying tissues pinkish o Inspection of the jugular veins Obvious pulsations present during inspiration and expiration and coincide with arterial pulses are common with CHF o Inspection of the carotid arteries Bounding pulses not normal, may indicate fever. Absence may indicate obstruction. o Inspection of the hands and fingers Clubbing—many respiratory and cardiac disorders Splinter hemorrhages in nail beds=infective endocarditis, bacterial infiltration of lining of heart’s chambers o Inspection of the chest, andomen, legs, and skeletal structures Pulsations in LSB, 2 ICS=pulmonary artery dilation or excessive blood flow Pulsations in LSB, 3 to 5 ICS may indicate R ventricular overload 6 nd Pulsations in RSB, 2 ICS=ascending aortic enlargement or aneurysm, aortic stenosis, or systemic HTN PMI displaced laterally in LMCL 5 ICS rd th Heave or lift (forceful rising of landmark area) in LSB, 3 to 5 ICS=R ventricular hypertrophy or respiratory disease, such as pulmonary HTN Specific Areas of the Cardiovascular Assessment—read on page 456 o Palpation of the chest including the following Precordium (anterior chest) R & L second ICSs—Atrial & Pulmonary Left third intercostal space—Erb’s Left fourth intercostal space—Tricuspid Left fifth intercostal space at the midclavicular line—Mitral o Landmarks for palpation Same 5 areas as above th 6 area is abdominal aorta—epigastric region, below xiphoid process Auscultation—of the chest using the diaphragm and bell of various positions to include thendollowing locations: o RSB, 2 ICS=aortic—S2>S1 o LSB, 2 ndICS=pulmonic—S2>S1 o LSB, 3 ICS=Erb’s point—S1=S2 o LSB, 4 ICS=tricuspid—S1>S2 th o LMCL, 5 ICS=apex/mitral—S1>S2 o Use bell on each 5 areas to discern S3, S4, murmurs, and gallops Positions for Auscultation—lay down and sit up. Page 462 Myocardial and Pump Disorders o Myocardial ischemia—oxygen needs heightened, increases work of heart, oxygen needs are not met, and ischemic process ensues. Common, usually due to presence of atherosclerotic plaque or blood clot o Myocardial infarction—complete disruption of oxygen and nutrient flow to the myocardial tissue in the area below a total occlusion Leads to the death of the myocardial tissue unless flow of blood is reestablished o Congestive heart disease/failure—inability of the heart to produce a sufficient pumping effort. Commonly, both L and R sided heart failure are present. Left—blood backs into pulmonary system=pulmonary edema Right—blood backs into systemic circulation=distended neck veins, liver congestion, and peripheral edema o Ventricular hypertrophy—occurs in response to pumping against high pressures Right—pulmonary HTN, congenital heart disease, pulmonary disease, pulmonary stenosis, and right ventricular infarction Left—systemic HTN, congenital heart disease, aortic stenosis, MI to L ventricle Valvular Heart Diseases—narrowing (stenosis) or incompetence (regurgitation) of valve leaflets 7 o May be caused by rheumatic fever, congenital defects, MI, and normal aging o Mitral, aortic, tricuspid, and pulmonic stenosis o Mitral and aortic regurgitation o Mitral valve prolapse Valvular Disease Description Etiology Findings Mitral Narrowing of left Rheumatic fever or Murmur hear at the Stenosis mitral valve cardiac infection apical area with the (endocarditis) client in left lateral position Aortic Narrowing of aortic Congenital bicuspid Murmur at aortic area, Stenosis valve valves, rheumatic RSB, 2ndICS. Can see heart disease, vegetation on valves atherosclerosis sometimes Mitral Backflow of blood Rheumatic fever, MI, Murmur at apex. Sound Regurgita from left ventricle rupture of chordae is transmitted to left tion into left atrium tendineae axillae (loud) Pulmonic Narrowing of the Congenital Murmur at pulmonic area Stenosis opening between radiates to neck. Thrill in the pulmonary left 2dand 3 ICS artery and the right ventricle Tricuspid Narrowing or Rheumatic heart Murmur heard with bell Stenosis stricture of the disease, congenital of stethoscope over tricuspid valve of defect, right atrial tricuspid area the heart myxoma (tumor) Mitral Redundancy of the May occur with Murmur, nonejection Valve mitral valve pectus excavatum, clicks, heard (L) lower Prolapse leaflets so they often unknown. Can sternal border in upright prolapse into the be heard in position left atrium pregnancy from increased blood volume Aortic Backflow of blood Rheumatic heart Murmur with client Regurgita from aorta into left disease, leaning forward. Click in tion ventricle endocarditis, 2ndICS Marfan’s syndrome, syphilis Septal Defects—openings between the right and left atria or right and left ventricles o May result from congenital heart disease and MI 8 Ventricular Septal Defect—regurgitation occurs through the defect, resulting in a holosystolic murmur. Murmur is loud, coarse, high-pitched, and heard at LSB, 3 to 5 ICS Atrial Septal Defect—regurgitation occurs through the defect, resulting in a nd harsh, loud, high-pitched murmur heard at the LSB, 2 ICS Congenital Heart Disease—many forms, which is related to developmental defects. o Most often, valves and septal structures are affected Coarctation of the Aorta—aorta is severely narrowed in region inferior to L subclavian artery o Narrowing restricts blood flow from the left ventricle into the aorta and out into the systemic circulation, contributing to development of CHF in newborn o Can be treated surgically Patent Ductus Arteriosus—doesn’t close completely (as it should w/in 24-48 hrs after birth) o May be treated medically, through pharmacologic therapy, and surgically Tetralogy of Fallot—most severe o Involves four cardiac defects: dextroposition of the aorta, pulmonary stenosis, right ventricular hypertrophy, and ventricular septal defect. o Life-threatening for newborn, but can be treated surgically Ventricular Tachycardia—heart needs to be shocked. It’s regular “rabbit ears” and pt is often nonresponsive Ventricular Fibrillation—no coordinated ventricular beats. Pt is often nonresponsive Asystole—flatline Objectives Outlined in Healthy People 2020 o Coronary heart disease o High blood cholesterol Key Objectives for Coronary Heart Disease o Screening for risk factors o Individual, community, culturally linguistically appropriate education and screening o Education about symptoms and emergency care o Weight reduction programs o Programs to increase physical activity Key Objectives for High Total Blood Cholesterol o Educate about risks o Educate about diet and exercise o Education about screening 9 Chapter 15: Respiratory System, p. 347 Health Assessment Exam 2 Respiratory System o Exchange of gases in the body External respiration—exchange of oxygen and carbon dioxide in the alveoli level of the lung. Gases are transported from the lungs via the blood to the cells of the body Internal respiration—as the gases move across the systemic capillaries, exchange of oxygen and carbon dioxide occurs at the cellular level o Intake of oxygen and release of carbon dioxide o Central nervous system—function: Maintains acid-base balance Maintains body fluids Assists with speech Thorax—closed cavity containing the structures needed for respiration. o Extends from base of the neck to diaphragm & is surrounded by muscles and ribs. o Normal adult chest configuration for the adult is elliptical, with lateral diameter twice as large as the anterio-posterior diameter. o Mediastinum—heart, trachea, esophagus, major blood vessels, pleural cavities o Thoracic cage—bones, cartilage, muscles of the thorax Upper Respiratory Tract o Nose o Mouth o Sinuses o Pharynx o Larynx o Part of trachea Lower Respiratory Tract o Distal trachea—located in the mediastinum, 4” long and 1” in diameter. 16-20 C-shaped rings. Carina is last tracheal cartilage and separates the opening of the 2 main bronchi o Bronchi—right and left main bronchi. The right main bronchus is shorter, wider, and more vertical than the let; so aspirated objects are more likely to enter the right lung o Lungs o Pleural membranes—pleura is a thin, double-layered, serous membrane that lines each pleural cavity. Produces a pleural fluid that acts as a lubricant that allows the lungs to glide during inspiration and expiration The surface tension created by the fluid and negative pressure between the membranes helps keep the lungs expanded. As the negative pressure changes, one is able to move air into and out of the lungs 1 o Muscles of respiration—internal and external intercostals and the diaphragm o Mediastinum Lungs—elastic, spongy, cone-shaped, and air-filled structures on the left and right of the mediastinum. o Left lung has two lobes—upper and lower; because of heart o Right lung has three lobes—upper, middle, and lower Respiratory Cycle—the active process of inhalation and the passive process of expiration o Eupnea—regular, even, rhythmic pattern of breathing o Dyspnea—change in this pattern producing SOB or difficulty breathing; dysfunctional breathing Bony Landmarks o Sternum—flat, elongated bone in the middle of the thoracic cavity. Manubrium (superior), body, and xiphoid process (inferior) o Angle of Louis—bony ridge at the location where the manubrium and tth body of the sternum join; sternal angle. The inferior border of the 7 ribs and the sternal angle help identify the level of the diaphragm, the base of the lungs, and the separation of the thoracic cavity from the abdomen o Clavicles—long, slender bones that articulate with the manubrium medially and laterally from the acromion of the shoulder joint o Ribs—12 pairs; ribs 8, 9, and 10 attach to cartilage of the superior rib, while ribs 11 and 12 are free floating anteriorly. Each intercostal space is named for the rib above it. o Vertebral column—located at the midline of the posterior thoracic cage Thorax—divided into anterior, posterior, and lateral sections o Anterior—five imaginary lines: sternal, R/L mid-clavicular, and R/L anterior axillary o Posterior—five imaginary lines: vertebral, R/L scapular, and R/L posterior axillary o Lateral—three imaginary lines: anterior, posterior, and mid-axillary Review Figure 15.10 and Figure 15.11 for views of the lobes of the lungs, pages 356-357 Developmental Considerations: Infants and Children o Change from intrauterine (placenta and umbilical cord )to extrauterine breathing—first cry stimulated by increase of CO2 and decrease of O2 o Round chest and abnominal breathers until age 5-7. Inspection of abdomen will yield a more accurate RR o Typically nose-breathers o At birth, head bigger than chest o Increased RR—40-80/minute for newborn. By age 5, respiratory rate is about 35/min o *It is important to teach parents about immunizations for the baby because infants are at risk for infection due to the size and strength of their respiratory systems.* Developmental Considerations: Pregnant Females o Muscles and cartilage of ribs relaxing o Inspiratory capacity increases 2 o Expiratory reserve volume is decreased o Total lung capacity remains the same o Mild respiratory alkalosis—double O2 demand; necessary for placental gas exchange o *Respiratory pattern is faster at rest than when she is not pregnant. o *May also complain of dyspnea (SOB), which is normal in a female who is pregnant, especially in the 3 trimester. Developmental Considerations: Geriatric o Decrease in respiratory efficacy—appearance of barrel chest (kyphosis) and calcification of cartilage contribute to decrease in thoracic excursion o Changes in respiratory depth—shallow=smaller amount of air. Less O2 for body use and more CO2. Shallow breathing due to loss of vital capacity and higher respiratory rate. o Decrease in cough ability—due to weakening chest muscles (↑ risk for pneumonia) o Increase in RR Psychosocial Considerations o Exacerbation of respiratory problems Stress Anxiety Fatigue—shallow breaths Pain—can ↑ or ↓ RR and HR depending on the pain o Behavioral considerations Increase in smoking Experimentation with drugs Experimental sexual activity Increase in obesity—shallow and rapid Cultural and Environmental Considerations—incidence of respiratory disease, such as TB, asthma, COPD, and obstructive sleep apnea is greater in the non- Caucasian populations in the US, in poor rural populations, and in recent immigrant groups o Race o Ethnicity o SES o Geography and environment—influence respiratory health as a result of changes in climate and living. Higher altitudes, high humidity. In the past, people with TB used to move to the dry mountain air to help with their symptoms. Smog in larger cities. o Increase in TB—if you’ve been vaccinated with TB, you’ll have a + TB test, will have to get a chest x-ray o Smoke and pet dander—asthma triggers in home or work environment: pets, dust, and molds. Secondhand smoke. o Occupational hazards—workers exposed to caustic fumes, fungi, asbestos, coal tar, nickel, silver, textile fibers, chromate, and vinyl chlorides, known carcinogens o Clients need to be disrobed to perform an accurate respiratory examination – may want a same-sex examiner 3 o *High risk Groups for TB include residents of long-term care facilities, immigrants from third world countries, alcoholics* Inspection—starts at page 370. Nurse is gathering data at each stage o Skin color—should be consistent with the rest of the body o Inspect structures of anterior and posterior thorax—clavicles should be at same height, sternum midline, costal angle <90° Increase in costal angle in adult may indicate COPD o Symmetry—asymmetry may indicate postural problems or underlying respiratory dysfunction o Configuration—the adult transverse diameter is approximately twice that of the anteroposterior diameter (AP:T=1:2) o Respiratory Rate—normal is 12-20; respiratory distressdyspnea, SOB, gasping for breath, cyanosis, nasal flaring, wide-eyed, etc. Palpation o Palpation of the posterior thorax—do with palmar surface of the hand. Pain may occur with inflammation of fibrous tissue or underlying structures. Crepitus may be felt if there is air in the subcutaneous tissue. Ribs—spinous process of C7 is most prominent; all processes should form a straight line Intercostal spaces o Respiratory expansion—should expand symmetrically *Symmetric chest expansion is best confirmed by: placing the hands on the posterolateral chest wall with thumbs at the level of T9 or T10, then sliding the hands up to pinch up a small fold of skin between the thumbs* Unilateral decrease or delay in expansion may indicate underlying fibrotic or obstructive lung disease or may result from splinting associated with pleural pain or pneumothorax *If only one hand moves on this exam, usually means pneumothorax o Tactile fremitus—palpable vibration on the chest wall when the client speaks. Strongest over trachea, diminishes over bronchi, and becomes almost nonexistent over the alveoli of the lungs. They say 99, 123, or blue moon Decreased or absent fremitus may result from soft voice; from very thick chest wall; from obesity; or from underlying diseases including COPD; pleural effusion, fibrosis, or tumor. Increased fremitus occurs with fluid in the lungs or in infection. Increased fremitus occurs with fluid in the lungs or infection. Percussion of the lungs posterior thorax o Will yield dull sounds over solidified or fluid-filled areas, as may exist in pleural effusion. Percussion over bone will yield flat sounds. Be sure to check that finger placement is correct (not over a rib) and that the finger lies flat against the chest wall Normal Breath Sounds Sound Location Ration Inspiration to Quality Expiration 4 Tracheal Over trachea I<E Harsh, high pitched Bronchial Next to trachea E>I Loud, high pitched Bronchiovesicul Sternal border I=E Medium loudness, ar between scapula medium pitch Vesicular Remainder of I>e Soft, low pitches lungs Auscultation of Voice Sounds o Bronchophony—“ninety-nine,” sounds muffled in normal lung tissue. The words sound loud and more distinct over areas of lung consolidation o Egophony—“E,” should hear “eeeee” through stethoscope The “E” sounds like “aaaay” over areas of lung consolidation o Whispered pectoriloquy—whisper “one, two, three.” Faint, almost indistinguishable in normal lung tissue. Numbers sound loud and clear over areas of lung consolidation Adventitius Sounds Sound Occurrence Quality Causes Rales/Crackl es Fine End inspiration, do High-pitched, short, Collapsed or fluid- not clear with crackling filled alveoli open cough Coarse End inspiration, do Loud, moist, low- Collapsed or fluid- not clear with pitched, bubbling filled alveoli open cough Ronchi Wheezes Expiration/inspirati High-pitched, Blocked airflow as (sibilant) on when severe continuous in asthma, infection, foreign body obstruction Ronchi Expiration/inspirati Low-pitched, Fluid-blocked (sonorous) on. continuous, snoring, airways Change/disappear rattling* with cough Stridor Inspiration Loud, high-pitched Obstructed upper crowing heard without airway stethoscope Friction rub Inhalation/exhalati Low-pitched grating, Pleural on rubbing inflammation Abnormal Breathing Patterns Type Description Rate Precipitating Factors Eupnea Regular 12-20 breaths 5 Tachypnea Rapid, shallow >24 Fever, fear, exercise, resp. breathing insufficiency, pleuritic pain, alkalosis, pneumonia Bradypnea Slow, regular <10 Diabetic coma, drug-induced resp. respirations depression, ↑ intracranial pressure Hyperventila Rapid, deep <24 Extreme exertion, fear, DKA tion respirations (Kaussmal’s), hypoxia, salicylate overdose, hypoglycemia Hypoventilati Irregular, <10 Narcotic overdose, anesthetics, on shallow prolonged bed rest, chest splinting respirations Cheyene- Periods of deep Regular Normal children and aging, heart Stokes breathing pattern failure, uremia, brain damage, drug- alternating with induced resp. depression periods of apnea Biot’s Shallow and Irregula Resp. depression, brain damage (Ataxic) deep r respirations pattern with periods of apnea Sighing Frequent sighs Hyperventilation syndrome, nervousness Causes: dyspnea, dizziness Obstructive Prolonged COPD, asthma, bronchitis Breathing expiration Normal Chest Configurations o Adult—*elliptical in shape with a lateral diameter that is larger than the A-P diameter in a 2:1 ratio o Child—reaches adult proportion by age 6 o Infant—rounded in shape with equal lateral and A-P diameters Abnormal Chest Configurations o Barrel Chest—A-P diameter is equal to lateral diameter, and the ribs are horizontal Occurs normally with aging and accompanies COPD o Funnel Chest (Pectus Excavatum)—congenital deformity characterized by depression of the sternum and adjacent costal cartilage. All or part of the sternum may be involved, but predominant depression is at the lower portion where the body meets the xiphoid process If condition is sever, chest compression may interfere with respiration. Murmurs may be present with cardiac compression Nuss’s procedure—bar in chest. Rabbit’s Procedure—open & remove cartilage. o Scoliosis—lateral curvature and rotation of the thoracic and lumbar spine. Occurs more frequently in females. Don’t usually worry until >20° 6 May result in elevation of shoulders and pelvis Deviation >45° may cause distortion of the lung, which results in decreased lung volume or difficulty in interpretation of findings from physical assessment o Pigeon Chest (Pectus Carinatum)—congenital deformity characterized by forward displacement of the sternum with depression of the adjacent costal cartilage. Generally requires no treatment o Kyphosis—exaggerated posterior curvature of the thoracic spine. Associated with aging Severe kyphosis may decrease lung expansion and increase cardiac problems May be due to disc disease or even compression fractures in t- spine (osteoporosis). Dowager’s Hump Abnormal Findings Asthma—chronic, hyperreactive condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. Usually occurs in response to inhaled irritants or allergens o Control inhaler—everyday inhaler to keep it under control. Rescue inhaler—for flare-ups o Inspection—dyspnea, increased RR, use of accessory muscles, anxiety, audible wheeze, prolonged expiration o Palpation—decreased tactile fremitus o Percussion—resonance. Hyperresonance when chronic o Auscultation—breath sounds obscured by wheezes. Decreased voice sounds. In severe asthma, air movement may be so limited that no breath sounds are heard o *Discuss topic with the patient such as work place environment, presence of pets, type of heating/cooling system in the home, diet preferences* o Triggers – smoke, exhaust, dust, environmental allergens, flowers, fruit and candies, stuffed animals Atelectasis—obstruction of airflow. The alveoli or an entire lung may collapse from airway obstruction, such as mucous plug, lack of surfactant, or a compressed chest wall o Inspection—decreased lung expansion on affected side, increased RR, dyspnea, cyanosis. If severe, the trachea shifts to the affected side* o Palpation—lack of tactile fremitus (absent) o Percussion—dullness over affected area o Auscultation—decreased or absent breath sounds and voice sounds Chronic Bronchitis—chronic inflammation of the tracheobronchial tree, le
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