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NURS 6512 Final Exam Review (Week 7-11) Latest 2020. Download to Score A

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Heart, Lungs, and Peripheral Vascular

·      Examination techniques of the Heart, Lungs, and PV systems

  1. Examination techniques of the Heart:  
  •  Inspection  - use tangential lighting; stand to the patient’s right, patient should sit erect and lean forward, lye supine, and left lateral recumbent position; apical pulse midclavicular line 5th left intercostal space; check the skin for cyanosis, venous distention, nail bed for cyanosis and capillary refill time
  • Palpation -  patient supine, palpate the precordium, use proximal halves of the 4 fingers or whole hand; being at apex, move inferior to left sternal border, then up the sternum to the base and down the right sternal border in the epigastrium or axillae; apical pulse seen at point of maximal impulse; feel for a thrill – fine, palpable, rushing, vibration, a palpable murmur, over the base of the heart; locate each sensation in terms of its intercostal space and relationship to the midsternal, midclavicular, or axillary lines; when palpating the precordium, use your other hand to palpate the carotid artery
  • Percussion -  limited value by defining the borders of the heart or determining its size because the shape of the chest is rigid; a chest radiograph useful in defining the heart border; begin tapping at the anterior axillary line, moving medially along the intercostal spaces toward the sternal border; resonant to dull marks the border;
  • Auscultation -  listen to all 5 of the cardiac areas using the diaphragm first then the bell; use firm pressure with the diaphragm and light pressure with the bell; 5 cardiac areas – aortic valve, pulmonic valve, second pulmonic, tricuspid, mitral; assess rate and rhythm, have patient breath normally then hold the breath in expiration, listen for S1 while palpating the carotid pulse; have the patient inhale deeply, listen closely for S2 during inspiration; basic heart sounds pitch, intensity, duration, and timing in the cardiac cycle; 4 basic heart sounds S1, S2, S3, S4
  1. Examination techniques of the lungs:  
  • Chest/Lungs – Inspect the chest, front, back, noting thoracic landmarks of and shape of anteroposterior (AP) diameter compared with the lateral diameter, symmetry, color, superficial venous patterns, prominence of ribs Inspection; patient sit upright, unclothed, using tangential light 
  • Retractions and deformity e.g. minimal pectus excavatum are difficult to detect; pigeon chest, funnel chest, barrel chest seen with chronic condition 
  • AP diameter less than lateral diameter; if they equal each other, chronic condition present – e.g. barrel chest related to chronic asthma, emphysema 
  • Evaluate respirations for rate and rhythm – respiratory rate is 12-20 per minute; respirations to heartbeats is a 1:4 ratio;  
  • Rhythm – breathe easily, regularly, with no apparent distress; variations – to shallow or to deep; tachypnea – rapid breathing, Kussmal – deep and rapid, Cheyene-Stokes – regular periods of breathing with intervals of apnea followed by a crescendo/decrescendo sequence of respiration 
  • Inspect chest movement with breathing for symmetry and use of accessory muscles; retractions are seen when the chest wall seems to cave in at the sternum 
  • Palpate the chest for thoracic expansion, sensations such as crepitus (palpated and heard) - gently bubbling feeling, grating vibrations,  
  • Tactile fremitus (palpable vibration of the chest wall that occurs from speech), best felt posteriorly, use phrase “99” or “Mickey Mouse”, palpate both sides simultaneously and symmetrically; increased fremitus fluid or solid mass is present, decreased is excess air in the lungs 
  • Thoracic expansion evaluation – stand behind patient, place thumbs along spinal process of the tenth rib with palms lightly in contact with posterolateral surfaces, thumbs will diverge during quiet and deep breathing 
  • Palpate for pulsations, tenderness, bulges, depressions, masses, and unusual movement 
  • Pleural friction rub – grating, coarse vibration, on inspiration, e.g. leather rubbing on leather 
  • Perform direct or indirect percussion of the chest, comparing both sides for diaphragmatic excursion, percussion tone intensity, pitch, duration, and quality - tap sharply and consistently from the wrist; examine back of patient while sitting with the head bent forward and arms folded in front, then have patient raise arms overhead while percussing the later and anterior chest  
  • Resonance heard over all areas of the lungs, hyperreasonance heard with hyperinflation (emphysema, asthma), dullness or flatness suggests pneumonia or atelectasis 
  • Diaphragmatic excursion – the movement of the thoracic diaphragm during inhalation and exhalation; pg. 274 Dains – pt. Take breath, hold it, percuss scapular line locating lower border, mark the point where resonance changes to dullness, mark with a marking pen, allow the patient to breathe, then repeat the procedure on the other side, have the patient take several breaths to exhale as much as possible and then to hold; percuss up from the marked point and make a mark at the change from dullness to resonance,  have the patient start to breathe and then repeat on the other side; measure and record the distance in cm between the marks on each side, distance is usually 3-5 cm 
  • Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing both sides for intensity, pitch, duration, quality of breath sounds, unexpected breath sounds (crackles, rhonchi, wheezes, friction rubs) and vocal resonance; have pt. Sit up and breathe slowly and deeply through the mouth; have the patient sit the same way as for percussion; also have the patient sit erect with shoulder back for auscultation of the anterior chest 
  • Breath sounds – vesicular, bronchovesicular and bronchial pg. 276; adventitious breath sounds – crackles (formerly rales), rhonchi, wheezes, friction rub 
  • Vocal resonance – spoken voice transmits through the lung fields that may be heard with the stethoscope, have patient recited numbers, names and other words 

Examination techniques of the peripheral vascular system: 

  • Peripheral Arteries – palpation occurs best over the arteries, close to the surface, that lie over bones; when palpating the carotid, never palpate both sides simultaneously; palpate at least one pulse point in each extremity, usually at the most distal point; perform the Allen test (pg. 340) to ensure ulnar artery patency prior to radial artery puncture; the thumb can be used to fix the brachial or femoral pulse; palpate the arterial pulses to assess heart rate, rhythm, pulse controu, amplitude, symmetry, and occasiuonally sometimes obstructions to blood flow
  • Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries 

Observe for signs of cyanosis, lip pursing, finger clubbing, alae nasi for flaring – any signs of this suggest cardiac or respiratory difficulty 

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