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health assessment
nursing
| Question | Answer |
|---|---|
| thoracic cage | bony structure with a conical shape, which is narrower at the top |
| diaphragm | floor of the thoracic cage, and separates the thoracic cavity from the abdomen |
| ribs 1-7 attach | directly to the sternum |
| ribs 8-10 | attach to the costal cartilage above |
| ribs 11, 12 | floating ribs |
| costochondral junctions | the points at which the ribs join their cartilages, not palpable |
| The thoracic cage consists of | the sternum, 12 pairs of ribs, 12 thoracic vertebrae, and the diaphragm, which forms the floor. |
| The sternum (or breastbone), which has three parts | a manubrium, body, and xiphoid process; |
| The sternal angle (or angle of Louis), which | is continuous with the second rib; |
| the costal angle is where | the right and left costal margins meet at the xiphoid process. |
| On the anterior chest use landmarks such as | the midsternal and midclavicular lines. |
| On the posterior chest use landmarks such as | the vertebral and scapular lines. |
| on the lateral chest use landmarks such as | the anterior axillary, posterior axillary, and midaxillary lines. |
| the angle of louis also marks the | site of tracheal bifurcation into the right and left main bronchi |
| the midclavicular line bisects | the center of each clavicle at a point halfway between the palpated sternoclavicular and acromioclavicular joint |
| The right lung is shorter | than the left lung |
| The right lung has | three lobes |
| the left lung has | 2 lobes |
| The lobes are | stacked in diagonal sloping segments and are separated by fissures that run obliquely. |
| the mediastinum is the | middle section of the thoracic cavity containing the esophagus, trachea, heart and the great vessels |
| Anteriorly, the lung borders, the apex (or highest point) of the lungs lies | 3 or 4 centimeters above the inner third of the clavicles. |
| The base (or lower border) rests | on the diaphragm at about the fifth intercostal space in the right midclavicular line and at the sixth rib in the left midclavicular line. |
| Laterally, the lungs extend from | the apex of the axilla to the seventh or eighth rib. |
| Posteriorly, C7 marks | the apex, and T10 usually corresponds to the base. On deep inspiration, the base descends to T12. |
| The pleurae form | an envelope between the lungs and the chest. |
| The pleural cavity is a | potential space that contains a few milliliters of lubricating fluid. |
| The lubricating fluid | prevents friction as the lungs move during respiration. |
| The bronchial tree protects the alveoli from small particulate matter | by using mucus and cilia, which sweep particles upward for swallowing or expulsion. |
| The functional unit of the respiratory tract is | the acinus. |
| The respiratory system has four major functions | 1st, it supplies oxygen to the body for energy production; 2nd, it removes carbon dioxide as a waste product of energy reactions; 3rd, maintains homeostasis (or acid-base balance) in arterial blood. 4th maintains heat exchange. |
| During pregnancy, the growing uterus elevates | the diaphragm 4 centimeters |
| Objective data, inspect the | posterior and anterior chest, and Note the shape, configuration, and symmetry of the thoracic cage, including the anteroposterior ratio, placement of the scapulae, angle of the ribs, and development of the neck and trapezius muscles. |
| percuss over the lung fields to determine | the predominant note. |
| the visceral pleura | lines the outside of the lungs |
| the parietal pleura | lines the outside of the chest wall |
| costodiaphragmatic recess | potential space, when it abnormally fills with air or fluid, it compromises lung expansion |
| the acinus consists of | bronchioles, alveolar ducts, alveolar sacs and the alveoli |
| hypoventilation | slow, shallow breathing that causes carbon dioxide to build up in the blood |
| hyperventilation | rapid, deep breathing causes carbon dioxide to be blown off |
| physical act of breathing | respiration |
| inspiration | air rushes into the lungs as the chest size increases |
| expiration | air expelled from the lungs as the chest recoils |
| at 32 weeks of a babies life | surfactant is present in adequate amounts |
| surfactant | is a complex lipid substance needed for sustained inflation of the air sacs |
| orthopnea | difficulty breathing when supine; state the number of pillows needed to achieve comfort |
| paroxysmal nocturnal dyspnea | is the awakening from sleep with SOB and needing to be upright to achieve comfort |
| chest pain of chest origin occurs with | muscle soreness from coughing or from inflammation of pleura overlying pneumonia |
| smoking history states | whether the person smokes cigarettes or cigars, what age they started and how long, and how many packs per day they smoke |
| being the respiratory examination just after | palpating the thyroid gland when you are standing behind the person |
| the spinous process should | appear in a straight line |
| the thorax is symmetric | in an elliptical shape, with downward sloping ribs, about 45 degrees relative to the spine |
| the anteroposterior diameter should be | less than the transverse diameter; ratio of 1:2 to 5:7 |
| orthopnea | difficulty breathing when supine; state the number of pillows needed to achieve comfort |
| paroxysmal nocturnal dyspnea | is the awakening from sleep with SOB and needing to be upright to achieve comfort |
| chest pain of chest origin occurs with | muscle soreness from coughing or from inflammation of pleura overlying pneumonia |
| smoking history states | whether the person smokes cigarettes or cigars, what age they started and how long, and how many packs per day they smoke |
| being the respiratory examination just after | palpating the thyroid gland when you are standing behind the person |
| the spinous process should | appear in a straight line |
| the thorax is symmetric | in an elliptical shape, with downward sloping ribs, about 45 degrees relative to the spine |
| the anteroposterior diameter should be | less than the transverse diameter; ratio of 1:2 to 5:7 |
| people with COPD often sit in a | tripod position |
| confirming symmetrical chest expansion | hands on posterolateral chest wall, with thumbs at T9 or T10, pinch a small amount of skin and ask patient to take a breath in. watch for thumbs to separate |
| tactile fremitus | palpable vibrations |
| sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchyma to the chest wall | tactile fremitus |
| decreased fremmitus | occurs when anything obstructs transmission of vibrations (obstructed bronchus, pleural effusion or thickening, pneumothorax or emphysema) |
| crepitus | coarse, crackling sensation palpable over the skin surface |
| resonance | is a low pitched, clear, hollow sound that predominates in healthy lung tissue in the adult |
| a dull note signals | abnormal density in the lungs (pneumonia, pleural effusion, atelectasis) |
| diaphragmatic excursion should be | equal bilaterally and measure about 3-5 cm in adults |
| bronchial (tracheal) breath sounds | have a high pitch with a low amplitude. inspiration is < than expiration and it is located in the trachea and larynx |
| bronchovesicular breath sounds | has a moderated pitch and moderate amplitude. inspiration = expiration and it is located over major bronchi where fewer alveoli are located. |
| vesicular breath sounds | have a low pitch with a soft amplitude. inspiration > expiration and is located over peripheral lung fields where air flows through smaller bronchioles and alveoli. Rustling, like the sound of the wind in the trees |
| adventitious sounds | any added sounds that are not normally heard in the lungs (i.e., wheezing or crackles |
| normal voice sounds should be | soft, muffled and indistinct, you can hear sound through the stethoscope but cannot distinguish exactly what is being said |
| barrel chest has a horizontal ribs and costal angle > | 90 degrees |
| kyphosis | outward curvature of the thoracic spine |
| pectus excavatum | sunken sternum and adjacent cartilages |
| pectus carinatum | forward protrusion of the sternum, with ribs sloping back at either side of vertical depressions along costochondral junctions |
| scoliosis | S-shaped curvature of the thoracic and lumbar spine |
| bronchophony | listening to a persons chest as they say 99. normal voice transmission will be muffled, soft and indistinct. |
| egophony | auscultate the chest while the person says "ee-ee-ee-ee" , normal sound should be heard as eeee |
| whispered pectoriloquy | ask the person to whisper a phrase while you auscultate. normal response should be faint, muffled, and almost inaudible |
| the precordium is | the area on the anterior chest directly overlying the heart and great vessels |
| the heart extends from the | 2nd to 5th intercostal space and from the right border of the sternum to the left midclavicular line |
| base of the heart | broader, top part of the heart |
| apex of the heart | the bottom part of the heart |
| the apex is normally palpable at the | 5th intercostal space, 7-9 cm from the midsternal line |
| the superior and inferior vena cava return | unoxygenated venous blood to the right side of the heart |
| the pulmonary veins return | freshly oxygenated blood to the left of the heart |
| aorta carries blood | out the the body |
| pericardium | tough, fibrous, double walled sac that surrounds and protects the heart |
| pericardial fluid | ensures smooth, friction free movement of the heart muscle |
| myocardium | muscular wall of the heart. does the pumping |
| endocardium | is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves |
| atrioventricular valves | separate the atria and the ventricles |
| right AV valve is the | tricuspid valve |
| the left AV valve is the | mitral valve |
| valves are anchored by collagenous fibers called | chordae tendineae |
| the hearts filling phase | diastole |
| the hearts pumping phase | systole |
| semilunar valves are | set between the ventricles and the arteries |
| SL valve on the right side of the heart | pulmonic valve |
| SL valve on the left side of the heart | aortic valve |
| SL valves open during | systole |
| the rhythmic movement of blood through the heart is the | cardiac cycle |
| the relaxation of the ventricles and fill with blood | diastole |
| the closure of the AV valve contributes to the first heart sounds called | S1 |
| the closure of the semilunar valves contributes to the second heart sound called | S2 |
| S1 is usually loudest at the | apex of the heart |
| S2 is usually loudest at the | base of the heart |
| A third heart sound due to the vibration of ventricles that resist early, rapid filling | S3 |
| S4 is at | presystole |
| S1 is at the beginning | of systole |
| S2 is at the beginning | of diastole |
| S3 is at the | rapid filling stage (protodiastolic) |
| atria contract and push blood into non compliant ventricles, creating vibrations called | S4 |
| what are gentle, blowing or swooshing sounds due to turbulent blood flow | murmurs |
| the SA (sinoatrial) node is known as the | pacemaker of the heart |
| depolarization of the atria | P wave |
| time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles | PR interval |
| depolarization fo the ventricles | QRS complex |
| repolarization of the ventricles | T wave |
| the stroke volume (volume of blood in each systole) times the number of beats per minute (rate) equals | the cardiac output |
| the venous return that builds during diastole is called | preload |
| the opposing pressure the ventricles must generate to open the aortic valve against the higher aortic pressure is called | afterload |
| located in the groove between the trachea and the sternomastoid muscle | carotid artery |
| empty unoxygenated blood directly into the superior vena cava | jugular veins |
| internal jugular vein is | not visible, lies deep and medical to the sternomastoid muscle, may be seen at the sternal notch |
| external jugular vein is | more superficial, lies lateral to the sternomastoid muscle, above the clavicle |
| the fetal heart begins to beat at the end of | the 3 week gestation |
| Before birth, the foramen ovale allows | oxygenated blood from the placenta to be shunted to the left side of the heart and out to the general circulation. |
| before birth, The ductus arteriosus lets | any remaining blood being directed to the lungs to be shunted into the aorta |
| arteriosclerosis | calcification of vessel walls |
| The major risk factors for heart disease and stroke are | high blood pressure, smoking, high cholesterol levels, obesity, and type 2 diabetes mellitus. |
| syncope | sudden loss of strength and temporary LOC, due to lack of cerebral blood flow, |
| dyspnea | Shortness of Breath |
| chest pain | angina |
| orthopnea | the need to assume a more upright position to breathe |
| cyanosis or pallor occurs with | MI or low cardiac output states as a result of decreased tissue perfusion |
| palpate each carotid artery medial to | the sternomastoid muscle in the neck |
| auscultate each carotid artery for | the presence of a bruit |
| bruit is a | blowing, swishing sound indication blow flow turbulence |
| internal jugular pulse is not palpable where as | a carotid pulse is |
| a heave or a lift is a | sustained forceful thrusting of the ventricle during systole |
| during hepatojugular reflux, if heart failure is present, the jugular veins will | elevate and stay elevated for as long as you push |
| apical impulse is the | pulsation created as the left ventricle rotates against the chest wall during systole |
| the apical impulse occupies what space | the 4th or 5th intercostal space, or inside the midclavicular line |
| to help find the apical pulse, ask the pt to | exhale and then hold their breath, while you find the pulse |
| a thrill is a | palpable vibration |
| the valve in the second right intercostal space is the | aortic valve |
| the valve in the second left intercostal space is the | pulmonic valve |
| the valve in the left lower sternal border is the | tricuspid valve |
| the valve in the 5th interspace at round the left midclavicular line is the | mitral valve |
| erbs point can be heard at the | 3rd intercostal space |
| a pulse deficit signals a | weak contraction fo the ventricles |
| S1 is caused by the closure of the | AV valves |
| S2 is causes by the closure of the | SL valves |
| A split S2 is a | normal phenomenon that occurs toward the end of inspiration in some people |
| A split S2 sounds is heard only in the | pulmonic valve, 2nd left intercostal space |
| innocent murmur indicates | having no valvular or other pathological cause |
| functional murmur is due to | increased blood flow in the heart |
| decreased cardiac output occurs when the | heart fails as a pump, and the circulation becomes backed up and congested |
| acute onset of heart failure may be associated with | as following a MI when direct damage to the heart's contracting ability has occurred |
| chronic onset of heart failure may be associated | with hypertension, when the ventricles must pump against chronically increased pressure |
| vessels are tubes for transporting | fluid, such as blood or lymph |
| the heart pumps | freshly oxygenated blood through the arteries to all the body tissues |
| arteries contain | elastic fibers, which stretch during systole and recoil with diastole |
| the pressure wave sent through arteries | a pulse |
| the temporal artery is palpated | in front of the ear |
| the carotid artery is palpated | in the groove between the sternomastoid muscle and the trachea |
| the major artery suppling the arm is the | brachial artery |
| the brachial artery bifurcates into the | ulnar and radial arteries |
| the major artery in the leg is | the femoral artery |
| intraluminal valves ensure | unidirectional blood flow in veins |
| the right lymphatic duct empties into | the right subclavian vein, |
| the right lymphatic duct drains the | right side of the head and neck, right arm, right side of the thorax, right lung and pleura, right side of the heard and the right upper section of the liver |
| the left lymphatic duct empties into | the left subclavian vein |
| the left lymphatic duct drains | the rest of the body |
| the functions of the lymphatic system are | 1, conserve fluid and plasma proteins that leak out of the capillaries. 2, form a major part of the immune system that defends the body against disease. 3, absorb lipids from the intestinal tract |
| small, oval clumps of lymphatic tissue located at intervals along vessels | lymph nodes |
| cervical nodes | drain the head and neck |
| axillary nodes | drain the breast and upper arm |
| epitrochlear node | drain the antecubital fossa and drains the hand and lower arm ( at the elbow) |
| inguinal nodes | in the groin, drain most of the lymph of the lower extremities |
| the spleen is located in the | left upper quadrant of abdomen |
| the spleen has four function | destroy old red blood cells, produce antibodies, store red blood cells, and filter microorganisms from the blood |
| ateriosclerosis is | peripheral blood vessels grow more rigid with age |
| atherosclerosis | or deposition of fatty plaques on the intima of the arteries |
| prolonged bedrest, prolonged immobility and heart failure increase the risk for | deep venous thrombosis and subsequent pulmonary embolism |
| claudication distance is the | number of blocks walked or stairs climbed to produce pain |
| edema is bilateral when the cause | is generalized (heart failure) |
| edema is unilateral when it is the result | of a local obstruction or inflammation |
| edema in the upper extremities occurs when | lymphatic drainage is obstructed |
| when palpating the brachial pulse, the | force should be equal bilaterally |
| modified allen test is used | to evaluate the adequacy of collateral circulation before cannulating the radial artery |
| anchor your thumbs on the knee and curl your fingers around into the popliteal fossa | popliteal pulse |
| posterior tibial pulse is | on the side of the foot by the ankle |
| dorsalis pedis pulse is | on top of the foot, just lateral to and parallel with the big toe |
| 1+ pitting | mild pitting |
| 2+ pitting | moderate pitting |
| 3+ pitting | deep pitting, leg looks swollen |
| 4+ pitting | very deep pitting, leg is grossly swollen and distorted |
| varicosities occur in the | saphenous veins |
| lymph nodes are | small, firm (shotty) mobile and nontender |
| enlarged, warm, tender nodes | indicate current infection |
| raynauds's phenomenon is | episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration or stress |
| lymphedema is | hight protein swelling of the limb, most commonly due to breast cancer treatment |
| occlusions in the arteries are caused by | atherosclerosis, which is chronic gradual buildup of fatty streaks, fibroid plaque, calcification of the vessel wall |
| an anerurysm is a | sac formed by dilation in the artery wall |
| most common site for atherosclerosis | is the aorta |
| large, oval cavity extending from the diaphragm down to the brim of the pelvis | abdomen |
| solid viscera are those | that maintain a characteristic shape (liver, pancreas, sleep, adrenal glands, kidneys..) |
| hollow viscera | depends on the contents (stomach, bladder, small intestine, colon) |
| soft mass of lymphatic tissue on the posterolateral wall of the abdomen | spleen |
| soft, lobulated gland located behind the stomach | pancreas |
| posterior to the abdominal contents, retroperitoneal, and bean-shaped | kidneys |
| 12th rib forms an angle with the vertebral column | costovertebralangle |
| because of the placement of the liver, the right kidney | rests 1-2cm lower than the left kidney |
| epigastric area | area between the costal margins |
| umbilical area | area around the umbilicus |
| hypogastric, or suprapubic area | area above the pubic bone |
| bad cholesterol | LDL |
| normal range for cholesterol | 120-200mg/dl |
| hematocrit HCT for infants 1-3 days | 44%-72% |
| HCT for children 6-12 years is | 35%-45% |
| HCT for adult male | 37%-49% |
| HCT for adult female | 36%-46% |
| Good cholesterol | HDL-C |
| normal values for HDL-C for adult male | 35-65 mg/dl |
| normal values for HDL-C for adult female | 35-80 mg/dl |
| serum triglycerides (TGs) or | blood fats used to screen for hyperlipidemia and the risk for coronary artery disease |
| TG levels for ages 20-65 are | <150 mg/dl |
| serum TG levels are associated with | Coronary artery disease |
| hemoglobin Hb determination is used | to detect iron deficiency anemia |
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