NURS 222 Lung Assessment

NURS 222 Lung Assessment history (ROS) of lungs - Correct Answer-- shortness of breath with activity - cough (productive/nonproductive, sputum (phlegm) analysis - chest pain with breathing what do we ask patients about their symptoms? - Correct Answer-- "do you have any problems with breathing?" - if so, "do you have it at rest or with activity?" - "do you have a cough?" - if so, "do you cough up any phlegm or sputum?" - if so, "how much?" ; "what color is it?" ; "what is the consistency?" ; "are you coughing up any blood?" what do we do with the patient's signs during lung assessment? - Correct Answer-- explain what you're about to do - ask "please raise your hand if you feel lightheaded during the exam" - clean stethoscope (alcohol) - auscultate posterior and anterior lung (breath ) sounds on bare skin lung assessment purpose: - Correct Answer-assess ventilation, respiratory function, and detect possible respiratory problems what are the lung assessment techniques? - Correct Answer-- inspection - palpation - percussion - auscultation what equipment do you need in a lung assessment? - Correct Answer-a stethoscope what is the purpose of auscultation in the lung assessment? - Correct Answer-to auscultate air coming in and out of a person's lung lung assessment: posterior land marks - Correct Answer-the apices at C7 and extend to the bases where do you start the posterior sequence of lung assessment? - Correct Answer-on the left side of the deltoid lung assessment: anterior landmarks - Correct Answer-apices in the supraclavicular areas down to the 6th rib where do you start the anterior sequence of lung assessment? - Correct Answer-left side on the clavicle what are the "normal" breath sounds? - Correct Answer-bronchial, bronchovesicular, and vesicular where is the bronchial? - Correct Answer-trachea and larynx (only for anterior) where is the bronchovesicular? - Correct Answer-over the major bronchi where few alveoli are located where is the vesicular heard? - Correct Answer-over peripheral lung fields where air flows through the smaller bronchioles and alveoli what are some findings you would use for lung sounds? - Correct Answer-- presence of lung sounds - quality (clear, diminished, adventitous) - symmetry or location why is palpating systolic BP useful? - Correct Answer-for patients whose arterial pulsations are too weak to create korotkoff sounds do we assess the diastolic BP? - Correct Answer-no what are examples as to why we need to palpate systolic BP? - Correct Answer-- severe blood loss - decreased contractibility how would you document SBP only? - Correct Answer-- SBP = 120/P or - SBP 120 by palpations history (ROS) of heart - Correct Answer-- chest pain - shortness of breath - orthopnea - fatigue - edema - nocturia purpose of heart assessment: - Correct Answer-assess cardiovascular function what is the assessment technique for heart? - Correct Answer-inspection, palpation, and auscultation what is the equipment for heart assessment? (just) - Correct Answer-just a stethoscope where is the base of the heart? - Correct Answer-at the top where is the apex of the heart? - Correct Answer-at the bottom where are the landmarks for heart assessment? - Correct Answer-- suprasternal notch - 2nd intercostal space - sternal angle (angle of louis) where are the auscultation areas of the heart? - Correct Answer-- aortic area - pulmonic area - erb's point - tricuspid area - mitral area where is the aortic valve? (semi-lunar valve) - Correct Answer-2nd intercostal space at the right sternal border (at the base of the heart) where is the pulmonic valve area? (semi-lunar valve) - Correct Answer-2nd intercostal space at the left sternal border (base of the heart) where is the tricuspid valve area? (atrioventricular valve) - Correct Answer-4th intercostal space at the lower left sternal border where is the mitral valve area? (apical) (atrioventricular) - Correct Answer-5th intercostal at or around the left midclavicular line (the apex of the heart) what is the heart valve sound mnemonic? - Correct Answer-Aortic Pulmonic E Tricuspid O MitralAN (APE TO MAN) what is the first heart sound? - Correct Answer-lub what is the second heart sound? - Correct Answer-dub what causes the "lub" sound - Correct Answer-closing of AV valves what causes the "dub" sound - Correct Answer-closure of semi-lunar valves where is the "lub" sound the loudest? - Correct Answer-at the apex of the heart where is the "dub" sound the loudest? - Correct Answer-at the base of the heart when do you use the diaphragm of the stethoscope during heart assessment? - Correct Answer-high pitch sounds (breath sounds, normal sounds, bowel sounds) when do you use the bell of the stethoscope during heart assessment? - Correct Answer-low pitched sounds (abnormal heart sounds, ex: heart murmurs) heart assessment elements: - Correct Answer-- heart sounds: listen for S1 and S2 - rate: identify rate (eucardia, tachycardia, bradycardia) - rhythm: regular or irregular where do you measure apical pulse? - Correct Answer-on the 5th intercostal space, on the midclavicular line at the apex of the heart what makes one heartbeat? - Correct Answer-lub-dub how many counts are used for apical pulse? - Correct Answer-30 seconds minimum how do we document findings for heart sounds? - Correct Answer-- presence of S1 and S2 - rate (apical pulse rate only in mitral area) - rhythm **document each valve** what is perfusion? - Correct Answer-perfusion is when the cardiovascular system pumps freshly oxygenated blood to the tissues and return deoxygenated blood to the lungs history (ROS) of vascular - Correct Answer-- leg pain - leg cramps - edema - color changes what is the purpose of peripheral vascular assessment? - Correct Answer-to assess adequacy of blood flow assessment technique for peripheral vascular assessment - Correct Answer-inspection and palpation what are the three peripheral vascular assessments? - Correct Answer-- arterial pulse - capillary refill - edema inspection and palpation elements of vascular - Correct Answer-- color - temperature - skin texture - hair distribution - presence of lesions - symmetry where are the pulses for arterial pulse? - Correct Answer-- carotid - brachial - radial - femoral - popliteal - post tibial - dorsalis pedis pulse assessment elements - Correct Answer-- elasticity - force (strength) - equality (symmetry) how are these pulse assessments graded? - Correct Answer-3+ = full, bounding 2+ = normal pulse 1+ = weak (and thready) 0 = absent pulse pulse assessment grade: 3+ - Correct Answer-full, bounding pulse assessment grade: 2+ - Correct Answer-normal pulse pulse assessment grade: 1+ - Correct Answer-weak (and thready) pulse assessment grade: 0 - Correct Answer-absent pulse how is the pulse when it comes to older results? - Correct Answer-peripheral blood vessels tend to grow more RIGID with age, resulted in a condition called arteriosclerosis what is capillary refill? - Correct Answer-an index of peripheral perfusion and cardiac output what do we do with capillary refill? - Correct Answer-depress and blanch the nail med how long should the vessel refill to get a good finding? - Correct Answer-less than 2 seconds what is edema? - Correct Answer-swollen skin from built up fluid in the interstitial space how do you assess peripheral vascular assessment? - Correct Answer-- inpsect -palpate (no pitting or pitting) how many seconds should you palpate for edema? - Correct Answer-5 seconds what does it mean if theres an indentation in the skin left behind? - Correct Answer-pitting edema pitting edema: grading +1 - Correct Answer-- mild pitting, slight indentation, no perceptible swelling in the leg; 2mm depression that disappears rapidly pitting edema: grading +2 - Correct Answer-- moderate pitting, indentation subsides rapidly; 4mm depression that disappears in 10-15 seconds pitting edema: grading 3+ - Correct Answer-- deep pitting, indentation remains for a short time, legs look swollen; 6 mm depression that may last more than 1 minute pitting edema: grading 4+ - Correct Answer-- very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted; 8 mm depression that can last more than 2 minutes pitting edema: grading 0 - Correct Answer-- no pitting edema documenting peripheral circulation (perfusion): pulses - Correct Answer-- location (radial, brachial, femoral, popliteal, dorsalis pedis, post tibial) - force/strength: 0, 1+, 2+, 3+ - equality (symmetry) how to document pulse (perfusion)? - Correct Answer-bilateral radial pulses 2+ documenting peripheral circulation (perfusion): capillary refill - Correct Answer-- number of seconds (<2 seconds) - symmetry how to document capillary refill? - Correct Answer-good bilateral cap refill of <2 seconds documenting peripheral circulation (perfusion): edema - Correct Answer-- presence - pitting vs non pitting - grade of pitting (0, 1+, 2+, 3+ ,4+) - symmetry how to document edema? - Correct Answer-2+ pitting edema to right lower leg