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Test 2 N100
Physical assessment Part II Lungs and Thorax
| Question | Answer |
|---|---|
| Posterior Assessment | Scoliosis, Kyphosis, Lordosis |
| Scoliosis | lateral curvature of spine |
| Kyphosis | increased convexity in curvature of thoracic spine “hump back” |
| Lordosis | anterior concavity of the lumbar spine “sway back” |
| Posterior Thorax and Lungs | Breathing pattern/Rate. Inspect shape/symmetry. Spinal alignment. Tactile fremitus. Respiratory excursion. Ausculate |
| Posterior | When assessing, start at the back watch for movement of lungs, symmetry, rate (increased or decreased) |
| Posterior Spinal Alignment | Assess for no curvatures such as kyphosis, lordosis, or scoliosis |
| Tactile fremitus | (touching) cup hands on back, ask client to state “99”. Feel for symmetrical vibration with ulnar side of hand. |
| Respiratory excursion | place hands flat on back, ask client to breathe in and watch for your hands to move symmetrically |
| Anterior | Inspect breathing pattern. Palpate. Auscultate Normal Breath Sounds:Bronchial (over trachea), Vesicular, Bronchovesicular. Adventitious Breath Sounds (Wheezes, Rhonchi, Crackles, Pleural friction rub) |
| Bronchial | best heard over the trachea; not normally heard over lung tissue (19 &20) |
| Bronchovesicular | between scapula and lateral to sternum (location of bronchi) at 1st & 2nd intercostal spaces (21 &22) |
| Vesicular | over peripheral lung tissue (15-18); out in the lower lobes |
| Wheezes | musical sounds |
| Rhonchi/Coarse | snoring sounds |
| Crackles | fine hair rubbing sounds (bases of lungs) |
| Pleural Friction Rub | dry, creaking, grating sound |
| Orthopnea | must sit or stand to breathe comfortably |
| Dyspnea | shortness of breath |
| Crackles | fine bubbling sounds |
| Pleural friction rub | adventitious; inflamed parietal and visceral pleura rubbing together on inspiration. |
| Atrophy | wasted or reduced size |
| Emaciated | very thin, wasted |
| Adventitious breath sounds | abnormal lung sounds |
| Stridor | an abnormal, high-pitched, musical breathing EMERGENCY (EPIGLOTIS CLOSES OFF AIRWAY) |
| Geriatric Considerations | ↑ kyphosis. AP diameter increases with elderly. Respiratory rate. Less powerful inspiration & more effort expiration. Small airways lose support. Cilia- doesn’t move air out of lung efficiently |
| Heart- PMI | Found by going to the midclavicular line, down to the 5th intercostal space |
| Precordium | The part of the front of the chest wall that overlays the heart and the epigastrium |
| Systole | The contraction of the heart, the first heart sound heard on auscultation |
| Diastole | The period of dilation (relaxation) of the heart shown as the lower blood pressure measurement |
| Extra heart sounds | Palpitations. Murmur |
| Palpitations | Pounding or racing of the heart |
| Murmur | gentle blowing, fluttering, or humming sound |
| Syncope | Light headedness. |
| Stenosis | (Narrowing) absent pulse wave indicates arterial occlusion. |
| Bruit | Caused by blood flow through narrowed section of the lumen causes a turbulence which creates a “blowing” sound or “swishing” sounds |
| Assess for Bruit | Place the bell of the stethoscope over the carotid artery at the base of the neck and move it gradually toward the jaw |
| Thrill | palpate for a thrill if a bruit is heard; vibrations |
| Distention | Supine: visibly protrudeStanding: veins flatten Sitting at 45 degree angle: veins distend only if patient has Right sided heart failure. |
| Cardiac | Health History. Inspect with client in supine position. Assess SOA. Apical pulse should be palpable at the PMI. Auscultate supine or sitting up leaning forward. Listen for rate and rhythm S1 (lub) and S2 (dub) |
| When rhythm is irregular compare apical and radial pulses? Pulse deficit? | Irregular pulse, listen to apical and have another nurse palpate radial. |
| Carotid Arteries/External Jugulars | Palpate using extreme caution. Auscultate for Bruit. External Jugulars-inspect for distention by lying client at a 45 degree angle (sign of congestive heart failure) |
| Peripheral Pulses (arterial blood flow) | Temporal. Brachial. Radial (thumb side). Ulnar. Femoral (groin). Popliteal (behind knee). Posterior tibial (inside near ankle bone). Dorsalis pedis (between big and 2nd toe). |
| Pulse Rating | 0 absent, non palpable, 1+ diminished, barely palpable. 2+ expected, normal. 3+ full, increased. 4+ bounding. |
| Peripheral Veins | Inspect arms and legs for presence/appearance superficial veins in Dependent- resting at side elevated. positions- Hand up in airAssess for signs of phlebitis. Report and document. Testing for Homan’s sign is contraindicated! |
| Peripheral Perfusion | Inspect skin for color, temperature, edema, skin changes. Assess capillary refill. Assess peripheral pulses. |
| Signs of Venous and Arterial Insufficency | Assessment Criterion:Color. Temperature. Pulse. Edema. Skin changes. |
| Venous Insufficency | Color: Normal or cyanotic. Temperature :Normal. Pulse: Normal. Edema: Often marked. Skin Changes: Brown pigmentation |
| Arterial Insufficency | Color: Pale, worsened by elevation of extremity; dusky red when extremity loweredTemperature: Cool (blood flow blocked to extremity). Pulse: Decreased/absent. Edema: Absent/mildSkin Changes: Thin, shiny skin; decreased hair growth; thickened nails |
| Abdomen | Health history of bowel disorder, hepatitis (liver), IBS. QuadrantsAssessment Sequence Differs. Skin Integrity. Auscultation. Light palpation. Palpate bladder |
| Assessment Sequence Differs with the Abdomen | Look. Listen. Palpate. Percussion. |
| Auscultation of abdomen | Listen to quadrants with out pain, first |
| Light palpation | 1/2 at most; using circular motions |
| Bladder palpations | (deeply palpate) (similar to water balloon) go in at an angle at the top of the bladder |
| Bowel Sounds | hyperactive. hypoactive. absence |
| Hyperactive Bowel Sounds | approximately every 2 seconds (also called borboygmi) |
| Hypoactive Bowel Sounds | approximately 1/minute |
| Absent Bowel Sounds | Listen for at least 3-5 minutes, usually with NPO or post op clients, possible obstructions |
| Melana | black tarry stool |
| Hemataemesis | bloody emesis |
| Striae | stretch marks |
| Peristalsis | normal intestinal contractions |
| Paralytic Illeus | decreased or absent peristalsis |
| Borborygmi | hyperactive sounds are loud “growling” sounds (indicates increased GI motility) |
| Pertonitis | inflammation of the peritoneum |
| Anus and Rectum | Inspection. Location of abnormal findings. 12 o’clock toward head, this helps in location. Inspect for hemorrhoids, ulcers, inflammation, rashes, or excoriation. American Cancer Society recommendations regarding colorectal cancer screening (age 50) |
| Musculoskeletal | Health History. Inspect muscles & tendons for contractures. Palpate muscles while using passive and active ROM. Test muscle strength-graded 0 to 5. Inspect bones, joints, motor strength. |
| Active ROM | Patient performs this |
| Passive ROM | Nurse moves for client, place hand on joint to see if there is any noted grinding or crepitis |
| Assess muscle strength of Neck (sternocleidomastoid) | Place hand firmly against patients upper jaw. Ask patient to turn head laterally against resistance. |
| Assess Muscle strength of Shoulder (trapezius) | Place hand over midline of patients shoulder, exerting firm pressure. Have patient raise shoulders against resistance. |
| Assess muscle strenth of Elbow(biceps & triceps) | Pull down on forearm as patient attempts to flex arm. As patient flexes arm, apply pressure against forearm. Ask patient to straighten arm. |
| Assess muscle strength of Hip(quadriceps)(Gastrocnemius) | When patient is sitting, apply downward pressure to thigh. Ask patient to raise leg up from table. Patient sits, holding shin of flexed leg. Ask patient to straighten leg against resistance. |
| Assess muscle function level | No evidence of contractility 0. Slight contractility no movement 1. Full ROM, gravity eliminated 2. Full ROM, with gravity 3. Full ROM, against gravity some resistance 4. Full ROM, against gravity full resistance 5. |
| Mental and Emotional Status Level of Consciousness | Are they alert and oriented to person, place, time, and where they are in global time (ex: who’s the president?)Look for present and distant recall |
| Mental and Emotional Status Behavior and Appearance | Disoriented: may not be well keptEmotional status altered: flat affect, unemotional |
| Mental and Emotional status Intellectual Function | Knowledge- What do they know? Abstract Thinking- It doesn’t bark like a dogJudgment- right vs. wrong |
| Motor Function Balance | Assess Balance. Romberg test: Stand, place hands at side, ask client to close eyes. EXPECTED: minimal sway. Some may not be able to do this without major swaying, this could be able to detect something isn’t correct |
| Motor Function coordination | Touching forefinger to nose eyes opened and closedAssess gait (check for arms at side, non shufflingWalk heel-to-toe (assess gait while patient is doing this) |
| Reflux Function | Deep tendon reflexes (DTR)Patellar reflex |
| Reflux Function Grading Scale | 0- No response. +1-Dimished response. +2-Normal response. +3-Response somewhat stronger than normal. +4-Response is hyperactive |
| Babinski Reflex (Plantar Reflex) Adult | Babinski reflex should not be present in the adultToes should flex inward and downward when testedUsually when this happens to an adult, it means that there could be brain stem injury or lesion. Report to MD, this is significant |
| Babinski Reflex (Plantar Reflex) Newborn- 18 months (or until walking) | Babinski reflex will be present in a newborn, but is lost during the first 18 months of lifeIf the great toe dorsiflexes and the other toes fan this is out of the expected finding and is documented as “Babinski positive” |
Created by:
Casey.finch371
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