NURS 3100 Health Assessment Exam 2 Study Guide:

*Remember, the end result of REALLY learning material is that you will be an expert & confident practitioner. You will identify problems early, minimize complications, provide comfort, & even Save Lives!

· 55 Multiple Choice Questions. This list covers the most important topics, but may not cover every possible test item.

· Using power points, lecture notes, and text book, familiarize yourself with the following concepts:

· Respiratory System:

· Signs of respiratory distress (flaring, use of accessory muscles, retractions, cyanosis)

· Flaring= labored respiratory; hypoxia

· Use of accessory muscles= facilitate inspiration in chronic airway obstruction or atelectasis

· Retractions= when the area between neck and ribs sinks due to not getting enough air and struggling to breathe

· Cyanosis= cold or hypoxia

· Observe chest wall for deformities (AP vs Transverse dimensions & significance of). Know how to assess for equal expansion, trachea midline, equal scapulae

· Normal chest= AP< lateral (1:2 ratio)

· Barrel Chest= AP> lateral (1:1 ratio)

· Pectus excavatum = funnel chest

· Pectus carinatum = pigeon chest

· Tactile fremitus: findings, possible interpretations (when this would be decreased or increased)

· Fremitus- vibrations of air in bronchial tubes

· Use hand to palpate as client repeats “99”

· Should be symmetrical and easily felt in upper lobes

· Normal to diminish toward base of lungs

· Percussion findings: (when might hear hyper-resonance, dullness over lungs?)

· Resonance- low-pitched, normal over lungs

· Tympany- drum-like, normal over abdomen

· Dullness- fluid or solid, normal over heart and liver

· Consolidation, pleural effusion, tumor if heard over lungs

· Hyper resonance- trapped air

· COPD, emphysema, pneumothorax if heard over lungs

· Know lung sounds: Where you expect to hear, pitch, significance/what to do for abnormals:

· Vesicular- low pitched, normally over peripheral lung fields

· Bronchial (tracheal)- over trachea, loud, harsh

· Broncho-vesicular- by sternum & between scapulae

· Fine Crackles- (Fine Rales); high pitched, (rubbing hair by ear, fire)

· Coarse Crackles- (Coarse Rales): loud, low pitched, bubbling; may clear with coughing. Inhaled air collides with secretions in trachea & large bronchi

· Wheezes- high, musical whistling; air passing thru constricted airway (asthma)

· Stridor- inspiratory wheeze associated with obstruction of airway

· If you hear abnormal breath sounds, ask the client to cough as this can clear the airways. Then listen again and note any change.

· Respiratory signs such as clubbing, cyanosis, barrel chest, pursed-lip breathing, tri-pod positioning

· Auscultation of lungs- location/# of lobes, use diaphragm, pattern, compare side to side for symmetry. Know steps of respiratory assessment.

· Right lung: 3 lobes

· Left lung: 2 lobes

· Palpate, percuss, auscultate

· Move in a ladder pattern

· How to assess chest expansion, including normal findings & significance

· Place hands on back with thumbs pointing in toward spine

· Patient breathes in and your hands should move apart

· How to perform voice transmission tests-normal findings & significance

· Listen while patient says 99 and E

· As you move toward base of lungs sound should diminish

· Should be hard to understand what they are saying

· If you can hear what they are saying, something is abnormal

· Discuss signs of pleural effusion, pneumothorax, pneumonia, asthma, COPD

· Pleural Effusion

· Collection of excess fluid in intrapleural space with compression of lung

· fluid settles in bottom of thoracic cavity

· fluid subdues lung sounds

· tachypnea, dyspnea, tachycardia, cyanosis, tactile fremitus

· percussion- dull; no diaphragmatic excursion on affected side

· auscultation- breath sounds decreased or absent, crackles

· Pneumothorax

· Air in the pleural cavity resulting in partially or completely collapsed lung

· Usually unilateral

· Caused by trauma to chest wall or spontaneous rupture

· Causes unequal chest expansion

· Tachypnea, cyanosis, apprehension, anxiety

· Breath sounds decreased or absent

· Tactile fremitus absent or decreased

· Hemothorax- same symptoms but its blood instead of air

· Pneumonia

· Infection in lung causing alveolar membranes to fill with fluid/pus which replaces space for air exchange

· Tactile fremitus- INCREASED

· Percussion- dull over affected lobe

· Auscultation- loud bronchial breathing, diminished lung sounds in some cases

· Cough, fever, tachycardia, dyspnea, pleural pain, respiratory distress

· Asthma

· Retractive Airway Disease

· Triggers activate inflammatory response- bronchospasm, edema in bronchioles, secretion of highly viscous mucus, increase in airway resistance

· Symptoms:

· Increased respiratory rate, sob, wheezing, accessory muscles used, retractions, labored and prolonged expiration

· Palpation- tactile fremitus decreased

· Percussion- resonance

· Auscultation- diminished air movement, breath sounds decreased, wheezing

· COPD

· Chronic Airflow Limitation

· Emphysema and chronic bronchitis

· Symptoms

· Easily fatigued, frequent respiratory infections, use of accessory muscles to breathe, thin, fingernail clubbing, chronic cough, pursed lip breathing, wheezing, barrel chest

· Know risks of lung cancer & education to provide to patient on decreasing risk

· LEADING CAUSE OF DEATH IN THE US & EUROPE

· Risk Factors:

· Cigarette smoking (self or 2nd hand)

· Genetic predisposition

· Exposure to toxins (asbestos, radon, environmental factors)

· Workplace pollutants

· Poor diet

· Decrease Risk:

· Stop smoking! Avoid 2nd hand smoke!

· Check for occupational or home exposure to asbestos or radon

· Seek care for prolonged cough or pain in chest area

· Affects more men than women

· Black men have more incidence and mortality rates

· Affects mainly elderly patients (over 60)

· Respiratory assessment landmarks (sternal angle, costal angle, sternal notch, C7 (vertebral prominens)

· Sternal angle- bony ridge a few centimeters below the suprasternal notch; also called angle of Louis

· Costal angle- angle between ribs

· Sternal notch- u shaped indention on top of sternum

· C7- sticks out on back of neck

· Cardiac, Neck Vessels, Peripheral Vascular:

-Know basic landmarks (expected location of heart, midclavicular lines, apex, base, aortic, pulmonic, erb’s point, tricuspid, mitral) “All People Enjoy Time Magazine”

· Heart is between left 2nd and 5th intercostal space

· Apex is bottom of heart

· Base is top of heart

· Aortic valve = 2nd right intercostal space

· Pulmonic valve = 2nd left intercostal space

· Erb’s point = 3rd ICS at left sternal border

· Tricuspid valve = 4th or 5th ICS at left sternal border

· Mitral valve = 5th ICS at left midclavicular line

-Know which intercostal spaces the valves are heard best over

· See above

-Know which heart sounds correspond with which valve closures

· S1 – “LUB”; Tricuspid and Mitral valves (R&L AV valves)

· S2- “DUB”; Aortic and Pulmonic valves (R&L SL valves)

-Heart sounds (Normal vs. Abnormal): S1, S2- what makes sound? Where heard loudest? What is S3, S4, Murmurs (what are they, how to grade; Technique/sequence to auscultate). Is S3 ever normal and/if in who?

· S1 and S2 are normal

· Makes lub dub sound

· S1 loudest at apex

· S2 loudest at base

· S3 Ventricular Gallop

· Vibrations from resistance to ventricular filling heard over the chest

· Occurs immediately after S2

· Can be a normal finding in young athletes

· Otherwise it is abnormal

· S4 Atrial Gallop

· At the end of diastole, just before S1

· Occurs in a non-compliant ventricle: CAD, hypertension, cardiomyopathy

· Abnormal

· Murmurs

· Swishing or blowing sound caused by turbulent backflow of blood

· Can be caused by

· Increased blood velocity (exercise, thyrotoxicosis)

· Narrow or incompetent valve

· Decreased blood viscosity (thickness, as in anemia)

· Abnormal chamber openings

· Grading Murmurs

· I – difficult to hear; experienced examiner and quiet environment are needed

· II – can be heard upon laying stethoscope on chest, but it is very quiet; examiner must listen closely

· III – requires no effort to hear; is readily heard when stethoscope is placed on chest

· IV – loud with a thrill

· V – very loud; easily palpated thrill

· VI – audible with stethoscope only near chest

-Capillary refill- purpose, how & where to check, what does it indicate

· If the refill takes longer than 1-2 seconds it indicates poor circulation

· Press nail bed, blanch, let go, color should return within 1-2 seconds

-Sequence of Cardiovascular exam: inspect, palpate, percuss, auscultate

· Inspect

· Auscultate

· Palpate

· Percuss

-Define bruit & thrill; Where do you assess for these & how; indicates what?

· Bruit- a blowing, swishing sound indicating blood flow turbulence

· Auscultation over carotid artery

· Indicates plaque build-up in artery

· Thrill- purr-like vibration feeling indicating turbulent blood flow

· Palpate over apex, left sternal border, and base of heart

-Know signs/how to identify MI, heart failure, Allen’s test, Homan’s Sign

· Myocardial Infarction (MI)

· Coronary Artery Occlusion

· Crushing chest pain that does not subside

· Heart Failure

· Cough- pink, frothy sputum

· JVD

· Pitting edema

· Falling O2 saturation

· Crackles or wheezes

· Dyspnea

· Orthopnea

· Stress/Anxiety

· Allen’s test

· Occlude radial and ulnar pulses and have patient pump hand

· Let go of ulnar pulse

· Color should return to pinky side of hand within 2-5 seconds

· This shows whether or not the patient has good circulation in that artery

· Homan’s sign

· Used to test for deep vein thrombosis (DVT)

· Dorsiflexion of foot will cause pain in the back of knee

· Be careful with this as it can let loose a blood clot

-Pulses- Be able to locate/name all. Assess for rate, regularity, and amplitude.

-Cautions for examining carotids

· Only feel one at a time

· Never take pulse bilaterally; could cut off blood flow to brain

· Palpate GENTLY

· Pulse amplitude and strength should be the same bilaterally

-How to locate & assess apical pulse, how to locate & palpate apical impulse

· Position client supine or on left lateral side

· Use 1-2 finger pads to palpate in the mitral area

· Feels like a gentle tap

· 5th left ICS and midclavicular line

-Be able to trace/list the proper sequence of blood flow through the heart

·

· Sup VC Right Atrium Tricuspid (R AV) valve Right Ventricle Pulmonic (R SL) valve Pulmonary artery Lungs Pulmonary veins Left Atrium Bicuspid/Mitral (L AV) valve Left Ventricle Aortic (L SL) Valve Aorta Body

-Know what defines Jugular Venous Distention

· Bulging jugular vein

· Sign of increased central venous pressure in vena cava

-What occurs during diastole? Systole?

· Diastole- ventricles relax, AV valves open, SL valves shut, fill with blood

· 2/3 of cardiac cycle

· Systole- ventricles contract, AV valves snap shut, SL valves open, pump blood out

· 1/3 of cardiac cycle

-Characteristics of Arterial versus Venous systems

· Arteries

· Carry OXYGENATED, nutrient-rich blood from the heart to the capillaries

· High pressure

· Maintain BP by constricting or dilating in response to the parasympathetic nervous system

· Veins

· Carry DEOXYGENATED, nutrient-depleted blood from tissues back to heart

· Much lower pressure

· Act as a reservoir for extra blood

·

-Define pulse deficit and lymphedema

· Lymphedema- high protein swelling of limb

· Lymph builds up in interstitial spaces after a surgical removal of lymph nodes

· Pulse deficit- difference in palpable pulse and heart rate

· Usually seen in atrial fibrillation

-Know how Ankle Brachial Index is calculated and what normal results include

· Systolic blood pressure taken using a doppler ultrasound and cuff from arm and ankle on both sides

· Highest number for each is kept

· Ankle divided by arm

· .9-1.9 is normal and means circulation is good

· Tests for PAD- a condition where arteries in arms and legs are narrowed or blocked by plaque

-Characteristics & risks of venous versus arterial ulcers/skin appearance

· Venous Insufficiency/ PVD

· Inadequate return of venous blood from legs to heart

· Tired/heavy legs

· Cramping/aching in legs

· Pain worsens with standing

· Pain improves with elevation

· Venous (stasis) Ulcer

· Shallow ulcer with irregular border

· Bleeding

· Seen on legs

· Thin and blue surrounding skin

· Darkening of legs

· Arterial Insufficiency/ PAD

· Narrowing of arteries commonly the pelvis and legs

· Cramping

· Worsens with exercise

· Subsides with rest

· Arterial (ischemic) Ulcer

· Have a punched out appearance

· Tendons, bones, underlying joints exposed

· Covered with minimal granular tissue

· Pallor, dry skin, loss of hair, fissuring of nails

· Usually on toes and ankles

· Can be on legs

-Risk factors for cardiovascular disease (modifiable versus non-modifiable)

· Modifiable- things you can control/change; modify (smoking, weight, cholesterol, nutrition, exercise, alcohol, drugs, etc.)

· Non-modifiable- things you cannot change (age, race, gender, etc.)

· Breast Exam:

· Breast exam-method of assessment and palpation techniques, including what to do if a lump is found.

· All lumps should be further assessed and referred

· Inspection

· Palpation

· Patient lays supine

· Palpate for texture and elasticity: look for thickening from tumor

· Tenderness and temperature

· Masses: location, size in cm, shape, mobility, consistency, tenderness

· Nipples: wear gloves, compress nipple gently

· Mastectomy or lumpectomy site

· Use a sensitive but matter of fact approach

· Wedge technique, circular or vertical strip

· Have client lay supine with arm overhead. Place small pillow under breast being palpated. Use flat pads of 3 fingers to palpate breasts in one of 3 patterns. Palpate every square inch in each level of pressure (light, medium, firm)! Use bimanual technique if there are large breasts.

· Know what abnormal lymph node findings can be associated with breast cancer.

· Lumps

· Swelling

· Redness

· Warmth

· Dimpling

· Pain

· Prominent or asymmetric pattern

· Retraction

· Be familiar with Tail of Spence and how to document locations on breast (quadrants)

·

· Know the site of most breast tumors

· UPPER OUTER QUADRANT

· Know signs of breast cancer (dimpling, bloody nipple discharge, retraction, lump, etc)

· Retraction- when nipple starts out as raised but begins to pull inward

· Dimpling- dimpling of breast tissue

· Discharge

· Know signs of Paget’s, Peau D’orange

· Paget’s Disease

· Redness and flaking of nipple

· Late signs are tingling, itching, sensitivity, burning, discharge, and pain

· Underlying invasive ductal carcinoma

· Peau D’orange

· Inflammatory cancer

· Accumulation of excess lymph fluid inside breast tissue cause pores to enlarge due to edema

· HEENT Exam:

· Cervical lymph nodes: Normal vs. worrisome (How to assess, Lymphadenopathy, characteristics to check)

· Swelling and tenderness are abnormal

· Assess by feeling, palpating

· Lymphadenopathy:

· Thyroid: Know the steps on how to assess (how to palpate, how/when to auscultate)

· Usually nonpalpable, nontender

· Reach from behind the client to palpate

· Auscultate for bruits if enlarged

· Auscultate only if enlargement is seen

· Headaches: Cluster vs. Tension vs. Migraine vs. Sinus

· Cluster Headache:

· Stabbing, sudden onset at same time of day

· may have reddened eye/drooping,

· in orbit of eye

· more common in young males

· Tension Headache:

· Dull/tight/diffuse pattern

· Occur with stress and anxiety

· Aching

· More common in women

· Migraine:

· Severe throbbing, may have N/V

· Sensitive to light; aura (visual changes associated with migraines)

· One spot where the pain is

· More common in women

· Can last for days

· Sinus:

· Pressure, tenderness on face

· May have nasal drainage/bad breath

· Worse when bending over

· Tumor related:

· May worsen with cough/sneeze

· May have neurologic symptoms

· Commonly occurs in the morning

·

· Characteristics of Pharyngitis (Strep vs viral sore throat)

· Strep is caused by bacteria; can see white patches on throat and tonsils

· Viral is caused by virus

· PERRLA: Know what each letter stands for & how to assess each test

· PERRLA = Pupils Equal, Round, Reactive to Light, Accommodation

· Corneal light reflex test- have patient look at a penlight. The light reflex should fall within the pupils bilaterally equal

· Esotropia- light reflex is in the interior of a pupil

· Exotropia- light reflex is toward outer edge of pupil

· Know how to check of mydriasis, anisocoria, miosis-what do these indicate?

· Mydriasis- dilated pupils

· Anisocoria- unequal pupils

· Miosis- pinpoint pupils; seen with narcotic usage

· How to check Visual acuity testing (Snellen) & what documentation means (Ex: 20/20 vs 20/80)

· Person stands 20 feet away from the chart

· 20/40 or worse = need corrective lenses

· 20/80 means that a person can read at 20 ft what a person with normal eyesight could read at 80 ft away

· Terms- Ptosis, chalazion, hordeolum, conjunctivitis, ectropion, cataracts (what will red flex look like if cataracts are present?)

· Ptosis- droopy eyelid, can be born with it or can be caused by tumor

· Ectropion- eyelid is pulling away from eye so you can see the inside of eyelid; no treatment unless patient is uncomfortable

· Hordeolum- (aka sty) infected external eyelid gland

· Chalazion- similar to hordeolum; occurs UNDER eyelid, inflamed sebaceous (Meibomian) gland

· Conjunctivitis- (AKA Pink Eye) inflammation of the conjunctiva; can be due to allergies or bacteria

· Cataract- leading cause of blindness worldwide, Black spots or spokes against the background of the red light reflex is indicative of cataracts.

· Define Consensual reaction, Presbyopia, Corneal light reflex

· Presbyopia- age related change in the eyes in which the lens can’t accommodate for near vision

· Corneal light reflex- use pen light to observe parallel alignment of light reflection in corneas

· Consensual reaction- when light is shined in the right eye, the left eye pupil should also react and vise versa

· Otoscopic exam: (such as positioning & what you are expected to visualize): normal and abnormal findings of tympanic membrane, outer ear, how to hold otoscope

· Inspection

· Inspect the external auditory canal for discharge, color, consistency of cerumen, canal walls, and nodules

· Inspect the tympanic membrane for shape, consistency, and landmarks

· Tympanic membrane should be a pearly gray color if normal

· Terms: pinna, tragus, otitis media, otitis externa, presbycusis, types of hearing loss & signs of each

· Pinna- auricle, basically the outer ear

· Otitis media- infection of middle ear

· Otitis externa- infection of outer ear

· Presbycusis- hearing loss associated with aging, hard to heat high pitched sounds

· Conductive hearing loss- something blocks or impairs the passage of vibrations from getting to the inner ear

· May result in bone conduction being better than air conduction in the affected ear and the Weber would lateralize to that side)

· Sensorineural (perceptive) hearing loss- damage is located in the inner ear

· Due to a disease process

· AC>BC and Weber lateralized to non-affected side

· Can be congenital or acquired

· Know how to conduct Rinne & Weber tests (expected findings related to air and bone conduction)

· Weber Test

· Strike the tuning fork

· Use tuning fork placed on the center of the head or forehead

· Ask whether the client hears the sounds better in one ear or the same in both

· Rinne Test

· Use the tuning fork and place at the base of clients mastoid process

· When the client can no longer hear the sound, note the time interval and move the tuning fork in front of the external ear

· Note how long they can hear the sound

· Expected to hear the sound longer in front of ear than when tuning fork was on bone bc air conduction is better than bone

· Know how to conduct Romberg test; what it means & what a positive test is

· Have client stand with feet together and arms at side, close eyes for 20 seconds

· Check for swaying

· Tests equilibrium

· If the patient loses their balance or sways, it is a positive test

· Sinuses-how to assess in steps; know signs of sinus infection

· Palpate for tenderness and crepitation

· Percussion and transillumination for air vs. fluid or pus

· Mouth: Signs of Abnormal findings (fungal infection like yeast; leukoplakia) vs. normal findings (soft, spongy palate)

· Abnormal

· Cheilosis- sides of mouth cracking and sore

· Carcinoma of lip or tongue- cancer

· Leukoplakia- thick white patches in your mouth from smoking

· Fungal infection- black hairy tongue

· Gingivitis

· Smooth, red, shiny tongue- vitamin B12 deficiency

· Normal

· Soft, spongy palate

· Pink

· No receding gums

· Has all teeth

· Know how to grade tonsils

· 1+, 2+, 3+, 4+

·

·

· Know signs & risks of oral cancer

· Risks

· Tobacco products!!!

· Heavy alcohol use

· HPV infection

· Poor oral hygiene

· Poor diet/nutrition

· Weak immune system

· Age 55+

· Use of mouthwash with alcohol content

· Signs

· Sores that do not heal

· Lump

· Red or white patch on inside of mouth or tongue

· Ulcers

· Bad breath

· Pain

· Know how to locate and name lymph nodes in head and neck

· Preauricular nodes- in front of ears

· Postauricular nodes- behind ears

· Occipital nodes- posterior base of skull

· Tonsillar nodes- angle of mandible, on the anterior edge of the sternocleidomastoid muscle

· Submandibular nodes- medial border of the mandible

· Submental nodes- a few centimeters behind the tip of the mandible

· Superficial cervical nodes- superficial to the sternomastoid muscle

· Posterior cervical nodes- posterior to the sternocleidomastoid muscle and anterior to the trapezius in the posterior triangle

· Supraclavicular nodes- hook fingers over clavicles and feel deeply between the clavicles and sternomastoid muscle

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·

· Know where and how to assess the TMJ

· Should be nontender without crepitation or swelling

· Mouth should open/close fully and jaw move smoothly laterally

· Should not hear any popping or clicking

· Fingers in front of ears, instruct patient to open and close jaw

· Know facial abnormalities (signs of Parkinson’s, Acromegaly, CVA)

· Acromegaly- enlargement of facial bones; can be seen in feet and hands too

· Parkinson’s- mask-like facial appearance, shuffling gate and diminished reflexes

· CVA (cerebrovascular accident)- stroke; can be caused by a clot or by bleeding on the brain (hemorrhage); paralysis or droopiness on one side of face