Florida University: Chapter 18-25|NUR 3125 Health Assessment Exam 3,100% CORRECT

Florida University: Chapter 18-25|NUR 3125Health Assessment Exam 3 Chapter 18: Breasts, Axillae, and Regional Lymphatics Breasts: made up of glandular tissue, fibrous tissue (including suspensory ligaments) and adipose tissue ● Glandular tissue: contains 15-20 lobes radiating from the nipple and these are composed of lobules that empty into a lactiferous duct (for milk) ● Fibrous tissue: includes suspensory ligaments or Cooper ligaments that extend vertically from skin surface to attach on chest wall muscles ● Adipose tissue: subcutaneous and retromammary fat that provide most of the bulk of the breast ● Four quadrants ○ Upper, outer quadrant is the site of most breast tumors ○ Axillary tail of spence: cone shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary nodes ○ Upper outer quadrant most likely to get tumors ○ Nipple: surrounded by areola for a 1-2m radius ● Montgomery glass: small, elevated, sebaceous glands in the areola that secrete a protective lipid material during lactation Lymphatics: the breast has extensive lymphatic drainage, 75% drains into the ipsilateral (same side) nodes so if there is an infection the same side nodes would enlarge ● Four groups of axillary nodes ○ Pectoral: lower middle of outer breast, anterior axillary ○ Subscapular: posterior axillary ○ Central: central axillary, where armpit creases, over ribs ○ Lateral: upper axillary, along humerus inside the upper arm Developmental competence ● Birth: the only breast structure present are the lactiferous ducts within the nipple; nipple is inverted, flat, and rises above the skin during childhood ○ Supernumerary nipple: extra niple along mammery ridge, insignificant finding ● Adolescence: breast development usually begins around 8-10 years of age ○ Overweight girls have higher occurrence of early onset breast development (before 8 for AA, 10 for white), and early menarche ○ Breast development precedes menarche by approx 2 years, full development takes an average of 3 years but can be 1.5-6 years ○ One breast may grow faster, producing temporary asymmetry; reassure them that this is normal ○ Tenderness is common ○ Development: 5 stages ■ Preadolescent: small, elevated nipple ■ Breast bud: small mount of breast and nipple develops, areola widens ● Mean onset 8.8 yrs for AA, Hispanic 9.2 yrs, Caucasian 9.6 yrs, Asians 9.9 yrs ● Higher BMI = earlier budding ■ 3: breast and areola enlarge, nipple flush with breast ■ 4: secondary mounds of areola and nipple ■ 5: mature, only nipple protrudes, areola is flush ● Non-pregnant women: different breast sizes by as much as 1 cup is normal unless the change is sudden growth ○ Larger breast is usually left. Nurse should verify asymmetry is new ○ Breast size changes with flow of hormones ■ 3-4 days before menstruation breasts feel full, tight, heavy, sore ■ Day 4-7 of menstrual cycle is when breasts are smallest ● Pregnant women: ductal expansion and supporting fatty tissue expands; breasts enlarge and feel more nodular; development of true secretory alveoli ○ Areola becomes larger and grows darker brown as pregnancy progresses, tubercle becomes more prominent; brown color fades after lactation but they never return to the original color ○ Venous pattern is prominent over the skin surface ○ Colostrum: thick yellow fluid that is the precursor for milk, can appear after 4th month of pregnancy; same amount of protein and lactose but practically no fat ■ Rich with antibodies that protect the newborn against infection, breastfeeding important ■ Produced 1st few days after delivery ● Aging women: hormonal changes of menopause cause glandular tissue to atrophy making breasts more pendulous, flattened, flabby, and saggy making inner structures more prominent ○ After menopause glandular tissue is replaced with fibrous connective tissue ○ Fat envelope also atrophies beginning in middle years and becoming significant in the 70s and 80s ○ Axillary hair decreases ● Men ○ During adolescence the tissue may enlarge temporarily producing gynecomastia; may reappear in aging men and may be the result of testosterone deficiency ○ Gynecomastia can also appear from the use of anabolic steroids, alcohol, marijuana use, estrogen treatment for prostate cancer, antibiotics (metronidazole and isoniazid), digoxin, ACE inhibitors, diazepam, TCAs, cushing’s, liver cirrhosis, adrenal disease, and hypothyroidism Culture and genetics ● Breast cancer ○ Incidence and survival varies by group, stage at diagnosis ■ Asian and pacific islanders have highest survival rates ■ Hispanic women have the lowest rate ■ Black and hispanic women have lower screening and utilization compared to white women ○ BRCA1 and 2 ■ BRCA1: 72% chance of breast cancer, 44% ovarian ■ BRCA2: 69% chance of breast cancer, 17% ovarian ■ Ashkenazi jewish women have a higher BRCA1 and 2 prevalence ○ 5 year survival ■ 83% black women: tend to be diagnosed at later stages, higher rates of aggressive, triple negative breast cancer ■ 92% white women ○ Other important factors: low income, low education levels, unemployment, pain, embarrassment, lack of insurance, residence area, weight (1.5x overweight, 2x obese), smoking, etc ○ Reduce risk: regular activity lowers risk by 10-20%, high levels of fruit and veggies can lower risk Subjective data ● Pain: mastalgia occurs with trauma, infection, and benign breast disease ○ Cyclic pain is common with normal breasts, oral contraceptives, and benign breast disease (fibrocystic) ● Lump: examine unaffected breast first to learn a baseline of normal consistency for this individual ○ Lumps that have been present for years and have not changed may not be serious but should still be explored ○ Any new lump should be evaluated with suspicion ● Discharge: ○ if any, ask ■ When they first noticed it ■ Color of discharge, consistency, odor ○ Galactorrhea: discharge from breast or nipple ■ oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, calcium channel blockers may cause clear nipple discharge ○ Bloody or blood tinged is significant especially with presence of lumps ● Rash: location where it first appeared is determined ○ Ask where it started (nipple, areola, skin) ○ Paget disease: starts with small crust on nipple apex and spreads to areola ○ Eczema or other dermatitis rarely starts at nipple unless it is caused by breastfeeding, usually start on areola or surrounding skin and spread to nipple ● History of breast cancer ○ Presence of benign disease makes it hard to examine breasts, lumpiness can conceal new lumps ○ Past breast cancer can increase risk; ask what type, how it was diagnosed, when it occurred, how treatment went ○ Familial history and age of onset ● Swelling: is it related to menstrual cycle, pregnancy, breastfeeding; changes in bra size ● Trauma: lump from injury, breaks in skin, swelling ● Surgery or radiation ● Medications ○ Oral contraceptives can increase risk by 20%; combined hormone therapy after menopause (especially soon) can increase risk, longer use means longer risk ○ Drinking increases risk ● Patient centered care: ○ BSE, CBE, mammograms are complimentary screening measures ○ Breast self examination: teaching, performance ■ A woman who knows how her breasts normally feel can detect changes ○ Mammography results, most recent ■ Mammograms can reveal cancers too small to be detected by women or examiners ● Additional history for pregnant women: breast changes? ○ Breastfeeding if any: perfect food and antibodies for 6 months, promotes bonding, decreases risk for ear infections, provides relaxation, protective against breast and ovarian cancer, eco friendly ○ Inverted nipples if present and normal for person may need special care ● Additional history for menopausal women ○ Any change in contour, size, firmness? ○ Decreased estrogen causes decreased firmness, rapid decrease estrogen causes actual shrinkage ● Risk factor for breast cancer- Table 18.2 ○ Five year survival for localized breast cancer has increased from 78% to 99% ○ Regional spread survival rate is 85% ○ Highest risk is increasing age and 1st degree relatives ○ ● Axillae: tenderness, lump, swelling, rash Objective data ● Note general appearance, often left is slightly larger than right ● Skin: normally smooth and even ○ Note redness, bulging, or dimpling ○ Fine, blue vascular network is normal is pregnant women ○ Edema exaggerates hair follicles, can give orange peel look ● Lymphatic drainage areas ● Nipple: should be symmetrically placed on the same plane on the two breasts ○ Deviation in pointing or recent nipple retraction signifies acquired disease or cancer ■ Fibrosis in the mammary duct can pull the nipple towards it ○ Distinguish between recently retracted nipple vs one that has been inverted for many years or since puberty ○ Normal inversion can be unilateral or bilateral, can usually be pulled out ○ Explore discharge, supernumerary nipples ● Palpate the axilla, examine axillae ○ Palpate axilla: right hand for left axilla, left hand right axilla; reach fingers high into axilla and move firmly down in four directions ■ Down chest wall in life from middle of axilla ■ Along anterior border of axilla ■ Along posterior border of axilla ■ Along inner aspect of the upper arm ○ Check ROM of arm to increase palpable area ○ Usually nodes are nonpalpable but sometimes a small, soft, non-tender node can be felt in the central group. Some tenderness can occur in the high axilla ■ Nodes enlarge with local infection of the breast, arm, hand, and breast cancer metastases ● Maneuvers to screen for nipple retraction ○ Lift arms slowly over her head, both breasts should move up symmetrically ■ Retraction signs caused by fibrosis usually caused by growing neoplasms ■ Note for lags in movement ○ Ask her to push hands on hips and push palms together to contract pectoralis muscle; slight lift of breast should occur ■ Note dimpling or puckering of skin which indicates retraction ○ Ask women with pendulous breasts to lean forward while supporting her arms; not free movement ● Breast palpation ○ Woman should be supine, tuck small pad under side and raise arm over head to flatten tissue and displace it medially ■ Significant lumps and feel more distinct ■ Pendulous breasts: ask women to rotate hips opposite to side you are palpating ○ Use the pads of 3 fingers to palpate or make a rotary motion on breasts, vary pressure; nipple out or concentric circles out ○ Palpate unaffected breast if examining lump ○ In women who haven't had pregnancy normal breast tissue feels firm, smooth, elastic ○ After pregnancy tissue may feel soft and loose ○ Premenstrual engorgement: normal; enlargement, tenderness, generalized nodularity, lobes feel more prominent and margins more distinct ○ Inframammary ridge: a firm, transverse ridge of compressed tissue in the lower quadrants especially noticeable in larger breasts, do not confuse with abnormal lumps ○ Vertical strip pattern: especially effective at finding lumps ○ Bimanual technique: leaning forward, support with one hand and palpate with the other against supporting hand (large breasts) ● Nipple palpation: with your thumb and forefinger gently depress the nipple tissue into the well behind the areola, fingers should move inward easily ● Documentation of a lump ○ Location ■ Ex: R breast at 2 o’clock, 2cm away from nipple ○ Size: judge width, length, thickness in cm ○ Shape ○ Consistency: firm, rubbery, soft ○ Mobility: fixed, freely movable ○ Distinctness: solitary or multiple ○ Nipple: displaced or retracted, discharge ○ Skin over lump: erythematous, dimpled, retracted ○ Tenderness ○ Lymphadenopathy Breast self exam ● American Cancer Society: no longer recommends BSE every month because many women have detected breast cancer lumps by chance when they are bathing or dressing ● Should still be taught to women and they may choose to perform it regularly or occasionally ● Cheap, available to almost all women, especially valuable to those older or younger than recommended ages for mammography or those who have barrier to access a mammography ● WHY? Goal is that women become familiar with look and feel so they can promptly report changes ● WHEN? The best time is right after period (4-7 day of menstrual cycle) because the breasts are smallest and least congested ○ Pregnant/menopausal women should be advised to select a familiar date each month ● Male Breast ● Examination may be abbreviated but not omitted ● Gynecomastia: about ½ of boys 13-14 years old, unilateral or bilateral, and temporary Health promotion and patient teaching ● Risk factors and increased risk ● Tools can estimate risk but cannot predict whether she will get breast cancer Documentation: pdf pg 529 ● Subjective: States no breast pain, lump, discharge, rash, swelling, or trauma. No history of breast disease herself or in mother, sister, daughter. No history of breast surgery. Never been pregnant. Performs BSE occasionally. ● Objective ○ Inspection: Breasts symmetric. Skin smooth with even color and no rash or lesions. Arm movement shows no dimpling or retractions. No nipple discharge, no lesions. ○ Palpation: Breast contour and consistency firm and homogeneous. No masses or tenderness. No lymphadenopathy. Abnormal findings ● Disorders occurring during lactation ○ Mastitis: inflammatory mass before abscess formation, usually occurs in single quadrant, erythema in quadrant ■ Area is red, swollen, tender, hot, and hard; woman may have headache, malaise, fever, chills, sweating, increased pulse, flu-like symptoms ■ Stems from infection or stasis caused by plugged duct esp during first 4 months of lactation ■ Treatment: rest, antibiotics, heat, and frequent nursing to keep breast empty ○ Breast abscess: rare complication from infection of mastitis if not treated ■ Pocket of pus that feels hard, looks red, and is tender; accumulates in one local area ■ Abscess can “point” and nipple may have edema ■ Breastfeeding can be ok depending on location of abscess, pain, and medicine but may want to breastfeed on unaffected side ■ Can be treated with antibiotics, surgical incision and drainage ● Signs of retraction and inflammation: pdf pg 532 ○ Dimpling (skin tether): caused by cancer fibrosis contracting suspensory ligaments ■ May be apparent at rest, with compression, or during lifting of arms ○ Nipple retraction: nipple looks flatter and broader like an underlying traitor, can occur with benign lesions ○ Edema: orange peel look from skin infiltration of cancer and skin edema ■ Lymph obstruction produces edema which thickens skin and exaggerates hair follicles ■ Usually begins in skin around and under areola, most dependent area of the breast ● Breast lumps: pg 533 ○ Benign (fibrocystic) breast disease: may cause dull, heavy pain on palpation and a mass with a rubbery texture and irregular border ■ Some women have nodularity but no pain, nodularity is not premalignant but can make detection of cancerous lumps difficult ■ Cysts: discrete, fluid filled lumps ○ Cancerous masses: solitary, unilateral, 3-dimensional, usually nontender, solid, hard, dense, and fixed to underlying tissues and skin; grow constantly ■ Borders are irregular and poorly delineated ■ Some women may have pain ■ Most common in upper, outer quadrant ○ Differentiating lumps ■ ● Abnormal nipple findings pg 535 ○ Bloody discharge that is unilateral and from single lump requires investigation. Sometimes no palpable lump but mammography reveals mass ○ Paget disease: intraductal carcinoma ■ Early stages: lesion is unilateral, clear yellow discharge, scaling crusts, freeable at nipple apex, spreads outward to areola with erythematous halo on areola and crusted, eczematous, retracted nipple ■ Late: nipple reddened, ulcerated with bloody discharge, erythematous plaque surrounds nipple ■ Symptoms: tingline, burning, itching ■ Any dermatitis or redness and cracking, except form breastfeeding, should be explored and referred ● Male abnormalities ○ Gynecomastia: in older men it is bilateral, tender, firm, but not as hard ■ Cushing syndrome and cirrhosis: because estrogen cannot be metabolized ■ See other causes earlier in chapter ○ Breast cancer: less than 1% in men, usually presents as painless but palpable mass, hard, immobile, and nontender, fixed to area; may have retraction, ulceration; discharge is especially significant ■ Mean age 67 years diagnosis ■ Spread early to axillary lymph nodes due to minimal breast tissue Chapter 19: Thorax and Lungs Structure and function ● Thoracic cage: ○ 12 ribs ■ 1-7 connected to sternum ■ 8-10 attached to cortal cartilage above ■ 11-12 floating ○ Thoracic vertebra ● Anterior thoracic landmarks ○ Supraternal notch: the U ○ Sternum: manubrium, body, xiphoid process ○ Sternal angle: angle of louis; articulation of the manubrium and body of the sternum, continuous with second rib; useful place to start counting ribs ■ Marks site of tracheal bifurcation into right and left main bronchi, corresponds with upper border of atra of the heart, and lies above the 4th thoracic vertebra ○ Costal angle: where right and left costal margins meet at xiphoid process, usually 90 degrees or less; increases when rib cage is chronically over inflated like in emphysema ● Posterior thoracic landmarks ○ Vertebra prominens: flex head and feel for most prominent bony spur protruding at base of the neck; is the spinous process of C7 ■ If two bumps are equally prominent the upper one is C7 and the lower one is T1 ■ Can use site to start counting ribs and intercostal spaces ○ Spinous process: Align with same numbered ribs to T4, after T4 they point downward and overlie the rib below ○ Inferior border of the scapula: located symmetrically, lower tip is usually at 7th or 8th rib ○ 12th rib: you can feel the tip! ● Thoracic Cavity ○ Lung borders ■ Anterior chest: apex or highest point is 3-4 centimeters above the inner third of clavicles ■ Base: lower border rests on diaphragm at about the 6th rib in the midclavicular line ■ Laterally: lung tissue extends from apex of axilla down to 7th or 8th rib ■ Posterior chest: location of C7 (vertebral prominens) marks apex and T10 corresponds to the base ● Deep inspiration can lower border to T12 ○ Lobes of the lungs ■ Right lung: shorter because of the underlying liver; has 3 lobes ■ Left lung: narrower than the lung because the heart bulges to the left, longer; two lobes ● No middle lobe ○ Posterior chest: The most remarkable point about the posterior chest is that it is almost all lower lobe ■ Lower lobes begin at T3 or 4 and reach T10 on expiration and T12 on inspiration ■ Right middle lobe does not project onto the posterior chest at all ○ Anterior chest: mostly upper and middle lobes with very little lower lobe ○ Trachea and bronchial tree ■ Trachea: lies anterior to esophagus and is 10-11 cm long in the adult; begins at cricoid cartilage in the neck and bifurcated just below the sternal angle into the L/R bronchi ● Posteriorly bifurcation is at T4 or T5 ■ Right main bronchus: shorter, wider, and more vertical than the left main bronchus ■ Transport gases from environment and lung parenchyma, constitute the dead space that is filled with air but not available for gas exchange ● Muscles of Respirations ○ Diaphragm: major muscle ○ Intercostal muscles: lift sternum and elevate ribs during inspiration, making them more horizontal and increasing the anterior/posterior diameter Developmental Competence ● Infants and children ○ At 32 weeks gestation the fetus develops surfactant ■ Surfactant: complex lipid substances needed for sustained inflation of the air sacs ○ By birth the lungs have 70 million primitive alveoli ready to start respiration ○ Infant: obligatory nose breather until age of 3 months ○ No flaring, intercostal retraction, stridor, or sternal retraction occurs; significant retraction indicates increased inspiratory effort like in pneumonia, acute airway obstruction, or atelectasis - immediate referral to physician is needed ○ Table 19.2 pg - APGAR ■ 1 minute 7-10 = good, suction nose and mouth, routine care ■ 1 minute of 3-6= moderately depressed, more resus, close observation ■ Score 0-2 = full resus, vent, intensive care ● Pregnant women ○ Physiologic dyspnea: pregnant women may develop increased awareness of the need to breathe early on ■ Some women may interpret this as dyspnea or difficulty breathing even though structurally nothing is wrong ■ Does not alter ADLs, not associated with cough, wheezing, or exercise ○ Increased estrogen levels relax chest cafe ligaments, causing an increase in transverse diameter by about 2cm and the costal angle widens ■ Total chest circumference increases by 6 cm ■ Horizontal increase compensated for decreased vertical diameter from elevated diaphragm ● Diaphragm moves even more during pregnancy ○ 40% increase in tidal volume ● Aging adult: costal cartilage becomes calcified resulting in a less mobile thorax and a slight decrease in thoracic expansion ○ Respiratory muscle strength declines after 50 and continues to decrease into the 70s ○ More significant: decrease in elastic properties within lungs make them less distensible and lessening tendency/ability to collapse and recoil ○ Vital capacity is decreased in residual volume is increased ○ Loss of intra-alveolar septa (and decreased # of alveoli) causes less surface area for gas exchange ○ Lung bases become less ventilated and there is an increased risk for dyspnea on exertion beyond his or her usual workload ○ Beyond all aging lung is more rigid and harder to inflate ○ Normal findings still include: symmetrical chest expansion, resonant percussion tones, vesicular breath sounds over peripheral lung fields, muffled voice sounds, and no adventitious sounds Culture and genetics ● Lung cancer: second most commonly diagnosed cancer in both men and women ○ Leading cause of cancer death in the US ○ 90% caused by tobacco smoking; smoking causes high mutational burden ● Tuberculosis: airborne lung disease that has infected ⅓ of the world's population ○ Social and migratory disease ○ Occurs in crowded living conditions with scant physical space between persons ○ Spread in countries with armed conflicts because thousands of civilians are living together in crowded refugee camps ○ Incidence declined each year through 2016 in the US ■ Among US born person TB incidence is stable in Caucasians and Asians and has decreased in all other groups ■ 68% of US cases occur among foreign born persons; top 5 countries of origin: mexico, philippines, vietnam, india, china ● 90% of these case are attributable to reactivation of latent TB ■ Other risks for development of TB ● HIV patients ● Homeless ● Group settings: shelters, prisons, long term care facilities ■ US Goal is elimination within the century: increase efforts to identify and treat active TB cases and increase target testing and treatment of latent TB in high-risk populations ● Asthma: most common chronic disease in children ages <18 ○ Highest asthma burden is among those living at or below federal poverty level ○ Increased risk of chronic airflow obstruction and possibly COPD by early adulthood ○ Adult asthma is a chronic lung condition of airflow obstruction and airway inflammation ■ Is usually reversible and managed by avoidance of known triggers (smoking, pets, chemical, household allergens) and drug therapy ● Read the culture and genetics sections Subjective data ● Cough: is it gradual or sudden, how long have you had it?; Even if person does not report a cough ask about cough ○ Acute: <2 or 3 weeks ○ Chronic: >2 months ■ Chronic bronchitis: productive cough for 3 months of the year for 2 consecutive years ○ Timing ■ Continuous throughout day: acute illness like respiratory infection ■ Afternoon/evening: may be exposure to irritants at work ■ Night: postnasal drip, sinusitis ■ Early morning: chronic bronchial inflammation of smokers ○ Sputum production: color, amount, consistency ■ Hemoptysis: blood! ■ White/clear: colds, bronchitis, viral infections ■ Yellow/green: bacterial infections ■ Rust colored: could be TB if with other symptoms like night sweats, low grade fever in the afternoon; could also mean pneumococcal pneumonia ■ Pink/frothy: pulmonary demea, some sympathomimetic medications that have the side effect of pain-tinged sputums ○ Characteristics ■ Mycoplasma pneumonia: hacking cough ■ Early heart failure: dry cough ■ Croup: barking cough ■ Colds, bronchitis, pneumonia: congested cough ○ Palliation or provocation, accompanying symptoms ● Dyspnea: a common burdensome symptom and a predictor of negative outcomes, especially in hospitalized patients ○ Ask if they are having it, and when? During the last day have you been short of breath? Is it affected by position? Does it occur at specific times of day or night? Is it associated with night sweats? Is there cough, chest pain, bluish color around lips or nails? Wheezing sounds? Related to food, pollen, dust, animals, season, emotion, or exercise? What do they do when they are short of breath? ○ People with smoking history, dyspnea, or cough: provider can use short 5 item lung function questionnaire (pg 416 text or 555 pdf) to determine who should be assessed with spirometry for COPD ■ How often do you cough up mucus ■ Noisy chest ■ SOB during physical activity ■ Smoking years ■ Age ○ Chronic: >1month ■ May have neurogenic, respiratory, cardiac origin ■ May be associated with anemia, anxiety, and deconditioning ■ Table 19.7: Diagnostic Clues to Chronic Dyspnea and Associated Systems (expand as needed) ● ● Cardiac: she read over Heart Failure, GI aspiration, Neuro, and psych specifically but brushed them all ○ Orthopnea: difficulty breathing when supine ■ Asking how many pillows they need to breathe easier and achieve comfort ■ # pillow orthopnea (3 pillow orthopnea) ■ Ask where they usually sleep, if they say they sleep in recliner they may be suffering from orthopnea ○ Paroxysmal nocturnal dyspnea: patient is awakened from sleep with SOB and needs to be upright to achieve comfort ■ If they report this condition the nurse should assess for other symptoms, can point to heart failure ○ Cyanosis signals hypoxia: ask patient color of lips/nails during SOB episodes ● Chest pain ● History of respiratory infections or lung disease ● Smoking history ● Environmental exposure: work/home, protective measures ● Patient centered care: Vaccines, TB test, Chest X-rays ● Infants/children: freq/severe colds, history of allergy, new foods, breast vs bottle fed, smokers near them, etc ● Aging adult: new SOB, physical activity, existing lung disease, chest pain w/ breathing Objective data ● Inspection ○ Posterior chest: look for shape, configuration of chest wall, skin color (should be consistent with genetic background but may have sun exposure changes, should have no cyanosis or pallor, no lesions) and condition; AP diameter should be less than transverse diameter. Neck and trapezius muscle should be developed normally with age and occupation. ■ Take note of person’s position they take to breathe ● Normal: usually in a relaxed posture and able to support own weight with arms comfortably at sides or in lap ○ Anterior chest: includes shape and configuration of chest wall, patients LOC, skin color and condition, quality of respirations, presence/absence of retractions, bulging of intercostal spaces, use of accessory muscles ○ Anteroposterior to transverse diameter ratio is about 0.7-0.75 in adults and increases with age ■ A ratio of 1:1 or barrel chest is found in individuals with COPd due to hyperinflation of lungs. Ribs are more horizontal and the chest appears as if it is held in continuous inspiration ● Palpation ○ Symmetric expansion: from the posterior place your warmed hands sideways on the posterolateral chest wall with thumbs pointing together at T9 or T10. Slide your hands medially to pinch up a small fold of skin between your thumbs. (pg 417 book 557 pdf) ■ Ask the person to take a deep breath, hands should serve as mechanical amplifier ■ Normal finding: thumbs move apart ○ Anterior symmetric expansion: place hands on anterior lateral wall with thumbs along costal margins and pointing towards xiphoid process; ask person to take deep breath and watch your thumbs move apart symmetrically (pg 424 figure 19.21; pdf ○ Unequal chest expansion: occurs with marked atelcstatis, lobar pneumonia, pleural effusion, thoracic trauma (pneumothorax or fractured ribs), obstructed of collapsed lungs (pneumonia or guarding to prevent post surgical pain) ○ Should be no lag in expansion but could occur because of atelectasis, pneumonia, or post-surgical guarding ○ Tactile (or vocal) fremitus: a palpable vibration, sounds generated rom larynx transmitted through a patent bronchi and lung parenchyma to the chest wall where you feel them as vibrations; Felt by using palmar base (the ball) of the fingers of the ulnar edge of one hand and touch the person’s chest while he or she repeats the words “ninety nine” or “blue moon” - these are resonant phrases that generate strong vibrations (textbook- posterior pg 418 figure 19.15, anterior pg 425 figure 19.22) ■ Start over lung apices and palpate from one side to the other (pg 557 pdf) ■ Avoid palpating over scapulae because bone damps out sound transmission; asymmetric findings suggest dysfunction that can be assessed further with the stethoscope ■ For females avoid breast tissue because breast tissue dampens sound. ■ Normal: ● Most prominent between scapula at the back and sternum at the front; these are sites where the major bronchi are closest to the chest wall ● Normally decreases as one progresses down the chest because more tissue impedes sound transmission ● Symmetry is most important; vibrations should feel the same in the corresponding area on each side ● Loud, low pitch voice generates more fremitus than soft, high pitch one ■ Feels greater over a thin chest wall than over a obese/muscular wall because thick tissue dampens vibration ■ Abnormal findings pg 418 ● Decreased fremitus: occurs with obstructed bronchus, pleural effusion, thickening, pneumothorax, emphysema. Any barrier that comes between sound and palpating hand decreases fremitus, including clothes ● Increased fremitus: occurs with compression or consolidation of lung tissue (like lobar pneumonia). Present only when the bronchus is patent and the consolidation extends to the lung surface. ○ Only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect it ● Pleural friction fremitus is palpable with inflammation of the pleura ● Rhonchal fremitus is palpable with thick bronchial secretions ● Pg 436/576 pdf - table 19.5 Abnormal Tactile Fremitus illustrations ○ Crepitus: a coarse crackling sensation palpable over the skin surface ■ Occurs: subcutaneous emphysema when air escapes the lung and enters the subcutaneous tissue; after thoracic injury or surgery ● Percusion: need to percuss side to side with a 5 cm interval, start at the apices and of both posterior and anterior sides ○ In women do not percus directly over the breasts ○ Resonance: normal, low pitched, clear, hollow sound that predominates healthy lung tissue in the adult ○ Hyperresonance: a low-pitched booming sound that occurs when there is too much air present such as in emphysema or pneumothorax ○ Dull note: signals abnormal density in the lungs as with pneumonia, pleural effusion, atelectasis, or tumor ● Auscultation: instruct patient to deep breathe through mouth (but no hyperventilation), listen for at least one full respiration in each location; side to side comparison is most important when auscultating chest; hold diaphragm firmly against chest; start at APICES, posterior C7 and anterior supraclavilularly; offer times to breath normally to prevent dizziness ○ Posterior: pg 560 pdf figure 19.8 ■ Start at apices and work to bases; laterally from axilla to 7th rib ○ Anterior: figure 19.23 ■ Start at apices at supraclavicular area (3-4cm above at midclavicular line) down to 6th rib ○ Infants and children: the bronchovesicular sounds can be heard in peripheral lung field of children up to 5y years old because their chest is thin and underdeveloped, do not dampen sound like adults ■ Breath sounds loud and harsh ■ Fine crackles are commonly heard in immediate newborn period as the result of opening airways and clearing of fluid ○ Decreased or absent breath sounds occur when the bronchial tree is obstructed as in emphysema and when sound transmission is obstructed as in pleurisy, pneumothorax ○ If a sound is heard over an abnormal field it is still abnormal ○ Increased sounds: sound close to stethoscope as if they are right in tubing close to the ear, will be seen in persons with consolidation (pneumonia) or compression (fluid in intrapleural spaces) ■ Dense area enhances transmission of sound from bronchi ■ When inspired air hits the alveoli it hits solid tissue that conducts sound better to surface ○ Table 19.1 Normal Breath Sounds pg ■ ■ ■ ○ Voice sounds: table 19.8; can be auscultated over chest wall and felt in tactile fremitus; normal voice transmission is muffled, soft, and indistinct; you can hear sound through the stethoscope but cannot distinguish what is being said; dense lungs = better transmission but this is bad; not a routine maneuver ■ Bronchophony: “ninety nine” words are more distinct and sound close to ear ■ Egophony: “eeeeee” sounds like aaaaaaa ■ Whispered pectoriloquy: person whispers but it is heart very clearly and distinctly ○ Adventitious sounds: added sounds that are not normally heard in the lungs, caused by moving air colliding with secretions or by popping open of deflated airways - Table 19.6; Described as inspiratory/expiratory, by loudness, pitch, and location ■ Crackles: discontinuous popping sounds ● Rales (fine crackles): discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing ○ Inspiratory crackles: inhaled air collides with previously deflated airways ■ Late inspiratory crackles occur with restrictive disease: ● Pneumonia, heart failure, and interstitial fibrosis ■ Early inspiratory crackles occur with obstructive disease: ● Chronic bronchitis, asthma, and emphysema ○ Expiratory crackles: sudden airway closing ○ Posturally induced crackles (PICs) are fine crackles that appear with a change from sitting to the supine position or with a change from supine to supine with legs elevated ○ Roll strand of hair between fingers near your ears or my moistening thumb and index and separating near ear ● Coarse crackles: loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration ○ Inhaled air collides with secretions in the trachea and large bronchi ■ Pulmonary edema, pneumonia, pulmonary fibrosis, and the terminally ill who have a depressed cough reflex ○ Opening velcro sound ● Atelectatic crackles: crackles sound like fine crackles but do not last and are not pathologic; disappear after the first few breaths and heard in axilla and bases ○ When sections of alveoli are not fully aerated, they deflate and accumulate secretions ■ In aging adults, in bedridden persons, or in persons just aroused from sleep (ask person to cough, if it goes away it is atelectatic crackles) ■ Pleural friction rub: very superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together; sounds just like crackles, but close to the ears ● Sound louder if you push harder into chest wal, can be inspiratory and respiratory ● Caused when pleurae become inflamed and lose their normal lubricating fluid; their opposing roughened pleural surfaces rub together during respiration ○ Pleuritis, accompanied by pain with breathing (rub disappears after a few days if pleural fluid accumulates and separates pleurae) ■ Wheeze: a continuous musical sound hearn mainly over expiration; caused by air squished or compressed through passageways that are narrowed almost to closure by collapsing, swelling, secretions, tumors (asthma, emphysema) pg 578 pdf ● Sibilant: high pitched, musical, squeaking sounds polyphonic predominant in expiration ○ Air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumor (diffuse airway obstruction from asthma or emphysema) ● Sonorous: low pitched, monophonic, single note, musical snoring, moaning sound heard throughout cycle ○ Airflow obstruction caused by: bronchitis, single bronchus obstruction from airway tumor ● Stridor: high pitched, monophonic, inspiratory, crowing sound; louder in neck than over chest wall; originates in upper larynx or trachea ○ Obstruction of upper airway from swollen inflamed tissue or large foreign bodies; croup, acute epiglottitis in children, foreign inhalation ○ Life threatening Health Promotion and Patient Teaching pg 569 pdf ● Secondhand smoke (SHS) is a mixture of sidestream and mainstream smoke and contains over 7000 chemicals, of which hundreds are toxic and 70 can cause cancer. ○ There is no safe level of SHS for nonsmokers, pregnant women, babies, or children. ○ Nonsmokers exposed to SHS at home or work increase their risk of heart disease by 25%-30% and their risk of stroke by 20%-30%. ○ Pregnant women exposed to SHS increase their risk of low-birth-weight infants, as well as the risk of sudden infant death syndrome (SIDS). ○ Babies and children exposed to SHS are at increased risk for upper and lower respiratory tract infections, otitis media, asthma, dental caries, hearing loss, metabolic syndrome, attention deficit/hyperactivity disorder, behavioral disorders, learning disabilities, and school difficulties ● Ways to help yourself and your family: ○ Do not allow anyone to smoke near your children ○ Do not allow anyone to smoke in the home or car with you or your children, even with the window rolled down because the smoke lingers (thirdhand smoke) ○ Make sure your children's daycare and schools are tobacco-free ○ Do not go to a restaurant, mall, or public place that allows smoking ○ Talk to your teenagers about these same methods and not to engage in smoking Documentation pg 570 ● Sample Charting ○ Subjective: No cough, shortness of breath, or chest pain with breathing. No history of respiratory diseases. Has “one or no” colds per year. Has never smoked. Works in a well-ventilated office on a smoke-free campus. Last TB skin test 4 years PTA, negative. Never had chest x-ray ○ Objective ■ Inspection: AP < transverse diameter. Resp 16/min, relaxed and even. ■ Palpation: Chest expansion symmetric. Tactile fremitus equal bilaterally. No tenderness to palpation. No lumps or lesions. ■ Percussion: Resonant to percussion over lung fields. ■ Auscultation: Vesicular breath sounds clear over lung fields and = bilaterally. No adventitious sounds. ○ Assessment ■ Intact thoracic structures ■ Lung sounds clear and equal Abnormal findings ● Configurations of the thorax ○ Barrel chest: equal AP to transverse diameter, ribs horizontal instead of downward ■ Associated w/ normal aging and also with chronic emphysema and asthma as a result of hyperinflation of the lungs ○ Pectus excavatum: sunken sternum and cartilages, usually begins at second intercostal space; most depressed at junction of xiphoid and sternal body and more noticeable on inspiration ■ Congenital, normally asymptomatic; if severe can cause embarrassment and a negative self- concept ■ Can be corrected w/ surgery ○ Pectus Carinatum: forward protrusion of sternum (pigeon chest) ■ Minor deformity that requires no treatment but if severe surgery may be indicated ○ Scoliosis ○ Kyphosis ● Table 19.4 Respiratory Patterns - pg 575 pdf ○ Tachypnea: rapid, >24 RR; can happen with fever, fear, exercise, respiratory insufficiency, pneumonia, alkalosis, pleurisy, lesions in the pons ○ Hyperventilation: increased rate and depth of respirations; extreme exertion, fear, anxiety, DKA (kussmaul’s), hepatic coma, salicylate OD (compensation for metabolic acidosis that produces resp alkalosis), lesions of the midbrain, ABG alterations (increased CO2, decreased O2) ■ Leads to alkalosis ○ Bradypnea: slow breathing as in drug induced depression of medulla, increased ICP, and diabetic coma ○ Hypoventilation: irregular shallow pattern caused by OD of narcotics, anesthetics, prolonged bed red, or conscious splinting of chest to avoid pain ○ Cheyne’s Strokes: wax and waning with periods of apnea ○ Biot’s respiration: like cheyne’s but pattern is irregular; seen with head trauma, brain abscess, heat strokes, meningitis, and encephalitis ○ Chronic obstructive breathing: normal inspiration and prolonged expiration to overcome increased airway resistance ● Table 19.9 Assessment of common respiratory conditions - pg 580 pdf ○ Pulmonary embolism ■ ○ Pneumothorax ■ ○ Asthma ■ ○ Heart failure ■ ○ Pulmonary TB ■ Chapter 20: Heart and Neck Vessels Anatomy ● Heart and great vessels: located between lungs and middle third of the thoracic cage ● Heart: extends from the 2nd to the 5th intercostal space, and from the right border of the sternum to the left midclavicular line ○ Heart is rotated so the right side is anterior and the left side is posterior ○ Top of the heart is the broad base and the bottom is the apex (points down and left) ○ During contracted the apex beats against the chest wall and produces the apical pulse ■ Palpable and normally located at the 5th intercostal space about 7-8 cm from the midclavicular line ● Blood vessels: two continuous loops ○ Pulmonary circulation ○ Systemic circulation ○ Blood flow ■ Returning blood from the body empties into the right atria from the inferior and superior vena cava ■ The blood flows into the right ventricle from the atria and goes into the lungs and pulmonary arteries for pulmonary circulation ■ In the lungs the blood is oxygenated and returns to the left atria through the pulmonary vein ■ From the left ventricle it is pumped into systemic circulation through the aorta ○ Blood keeps moving by continuously shifting pressure gradients ■ Flows from area of higher concentration/pressure to lower ● Heart wall ○ Pericardium: tough, fibrous double wall sac that surrounds and protects the heart ■ Two layers (visceral and parietal) with around 15mL of pericardial fluid ○ Myocardium: muscular wall of the heart ○ Endocardium: thin layer of endothelial cells that lines the inner surface of the heart chambers and valves ● Chambers: work simultaneously ○ Right side of the heart pumps blood into the lungs ○ Left side of the heart pumps blood into the body system ○ Right and left are separated by the septum ○ Atrias: upper receiving/holding chambers ○ Ventricles: lower, pump into circulation ● Valves: separate chambers, unidirectional, ○ Atrioventricular valves: between atria and ventricles; open and close passively in response to pressure of moving blood; automatically let blow flow into ventricles if full; open during filling phase (diatole) and close during pumping phase (systole) ■ Tricuspid: separate RA and RV ■ Bicuspid (mitral): separate LA and LV ■ Chordae tendineae: anchor the leaflets of the valves to the papillary muscles by collagenous fibers ○ Semilunar valves: between ventricles and vessels; 3 caps ■ Pulmonic: RV -> pulmonary artery ■ Aortic: LV -> systemic circulation ○ No valves between vena cava and RA or between pulmonary veins and LA -> disease Cardiac cycle: two stages ● Diastole: right and left ventricles are relaxed, AV valves are open; atria have higher pressure than ventricles ○ Early/pre-diastolic filling: stage where blood pours from atria into ventricles rapidly ○ ⅔ of the cardiac cycle ○ Pre-systole/atrial systole/atrial kick: towards the end of diastole, just before completion, the atria contract and push the last bit of blood (about 25% of the stroke volume) into the ventricles ■ Consider conditions where this ability is lost: stroke volume is lost ■ Atrial systole occurs during ventricular diastole; atria is contracting and ventricles are relaxed and filling ● Both cannot occur at the same time ○ Pressure in the right side of the heart is lower because less energy is needed to pump blood into pulmonary circulation ○ Events occur on the right side slightly later because of myocardial depolarization; as a result we sometimes get the distinct sounds in S1 (mitral closing before tricuspid) ● Systole: phase where the ventricles are filled with blood and ventricular pressure is higher than atrial pressure ○ AV valves close to prevent backflow ○ S1: sound produced by closing of the AV valves, signals systole of the ventricles; heard at apex ○ S2: sound signals closure of the semilunar valves; heard at base ■ Isometric contraction: when pressure falls in the LV compared to the aorta some of the blood flows towards the ventricles causing it to swing shut ○ Diastole occurs again when all 4 valves are closed and atria begin to fill, ventricles relax ○ On the left side the aortic valve closes slightly before the pulmonic valve; occurs almost simultaneously Heart Sounds ● S1: first heart sound, signals closure of AV valves; more prominent and signals the start of systole ○ M1: mitral component that slightly precedes tricuspid ○ T1: tricuspid component ○ M1 and T1 usually heard together unless abnormality is present ○ Coincides with carotid artery pulse ○ Can be heart over all the precordium but is usually loudest at the apex ● S2: closure of the semilunar valves, signals the end of systole ○ A2: aortic component that slightly precedes the pulmonic ○ P2: pulmonic component ○ Heard all over the precordium but usually loudest at the base ● Split S2: normal phenomenon that occurs towards the end of respiration in some people; heard only in pulmonic valve area ○ Occurs because of increased blood return to the right side of the heart, delaying closure of the pulmonic valve ○ If heard: concentrate on split while watching the patient’s chest rise and fall; ask the patient not to hold their breath because the ejection times would equalize and the split would go away ● Extra heart sounds ○ S3: (normally silent) occurs when ventricles are resistant to filling during early rapid filling phase, immediately after S2 when the AV valves open and atrial blood first pours into the ventricle ■ S1 -> S2 -> S3 ○ S4: occurs at the end of diastole, at presystole, when the ventricles are resistant to filling at the time the atria are pushing ■ Atria contact and push blood into the noncompliant ventricle, creates vibrations that are heard as S4 ■ Very soft whooshing sound that occurs just before S1: S4 -> S1 -> S2 ■ Heard best using bell of stethoscope with patient at left lateral position ○ Murmurs: a gentle blowing or swooshing sound that can be heard on the chest wall, heard with bell of the stethoscope ■ Causes ● Flow murmur: velocity of blood increases (exercise, thyrotoxicosis) ● Viscosity of blood decreases (anemia) ● Structural defects in the valves (stenotic or narrowed valves, incompitent or regurgitant valve) or unusual openings occur in the chamber (dilated chamber, septal defect) ■ Characteristics to take note of ● Frequency (pitch): high or low ● Intensity (strength): loud or soft ● Duration: very short for heart sounds, silent periods are longer ● Timing: systole or diastole ■ Some murmurs are common in healthy kids or adolescents and termed innocent/functional murmurs; they are heard around the second or third intercostal space when the person is sitting; no sign of cardiac dysfunction ○ Apical pulse at 5th intercostal, (mitral valve) Heart Conduction ● Automaticity: the ability of the heart to generate a electrical response and contract by itself ● SA node: pacemaker of the heart because of intrinsic rhythm ○ Specialized cells near the entrance on the vena cava initiate an electrical impulse that travels across the atria and then to the AV node where it is delayed ● AV node: delays the impulse transmission to give time for the atria to contract before the ventricles are stimulates ● Bundles of his -> R/L bundles -> Purkinje fibers ● Electrical events precede mechanical events because they are the stimulants ○ Electrical activity can be seen on an EKG ■ P wave: depolarization of the atria ■ PR interval: beginning of P wave to beginning of QRS complex, time for atrial depolarization and impulse to travel through AV node into the ventricles ■ QRS complex: depolarization of the ventricles ■ T wave: repolarization of the ventricles Pumping of the Heart ● Healthy adult heart: pumps between 4-6L of blood per minute throughout the body ○ Cardiac output: volume of blood in each systole (stroke volume) x heart rate per minute ○ The heart can alter its output to adapt to the metabolic needs of the body ● Preload: the volume of venous return that builds during diastole in the atrium and goes into the ventricular muscle, length to while ventricular muscle is stretched at the end of diastole just before contraction ● Afterload: pressure the ventricle must generate to open the aortic valve against its higher pressure, resistance against which the ventricle must pump ○ Inside the ventricle is 5-10 mm and the ventricle must overcome the 70-80 mm in the aorta Neck vessels: assessment of the cardiovascular system includes the vascular structures in the neck ● Carotid artery: the right and left carotid arteries branch from the aorta ○ Located near the thyroid, between the groove of the trachea and sternocleidomastoid muscles ○ Palpate one at a time to prevent occlusion of blood flow to the brain, fainting, syncope ○ Bruit: angle of jaw, midcervical, base of neck ● Jugular veins: empty oxygenated blood directly into the superior vena cava; external and internal on both sides ○ Give information on right side of the heart because of the lack of valves between the superior vena cava and right atrium ○ Interal: lies deep and medial to the sternomastoid muscle, next to the carotid arteries; usually not visible ○ External: more superficial, lies lateral to the sternomastoid muscle, above the clavicle ○ Reflect filling and volume changes, pulsate ○ Normal venous palpation is 2 cm Developmental Competency ● Pregnant women: blood volume increases by 30-50% during pregnancy, most rapidly during the second trimester (4th-6th months); increased cardiac output ○ BP will drop to its lowest point during the 2nd trimester and rises afterward; the drop is caused by peripheral vasodilation ○ Pulse increases 10-20 beats/min ● Aging adult: atherosclerosis of the vessels leads to increased in systolic blood pressure known as irolated systolic hypertension; stiffening leaves arteries less compliant and requires greater pulse wave velocity ○ LV wall thickens ○ Diastolic BP may decrease starting around age 50 ○ Together, the events lead to a widening pulse pressure ○ No significant changes in resting heart rate or cardiac output during rest ● Infants and children: ○ Fetal heartbeat begins to beat at the end of 3 weeks gestation - however, oxygenation takes place at the placenta and the arterial blood (opposite of the adult) is returned to the right side of the heart, bypassing nonfunctional lungs ■ ⅔ bypass through an opening in the atrial septum called the foramen ovale into the left side and out through the aorta ● Should close within the first hour after birth due to new lower pressure on the right side of the heart compared to the left ■ ⅓ through the right side of the heart to the pulmonary artery and into the aorta through the ductus arteriosus; should close within 10-15 hours of birth ● If ductus arteriosus fails to close it is called patent ductus arteriosus ○ Heart is more horizontal in infant than the adult, but reaches adult position at about 7 years; apex is higher at 4th intercostal then apex lowers to 5th ○ As a fetus the heart sides are equal because both pump into the systemic circulation, should become a 2:1 ratio of the ventricles (left:right) by the time the kid turns 1 Culture and genetics ● Hypertension: causes damage to the arterial system, contributes to accelerating atherosclerosis, increases workload and oxygen demand on the heart ○ Prevalence among Black Americans is among highest in the world; compared to whites AA develop high BP earlier in life and their average BPs are much higher, resulting in greater rate of stroke, death from heart disease, and end stage kidney disease ■ Non-hispanic black men and women: 45% and 46.5% ■ Non-hispanic white men and women: 34.5% and 32.3% ● Cardiovascular disease: most common underlying cause of death in the world, 31.5% of all global deaths ○ Favorable lifestyles decrease the chance and lowering the risk of cardiac diseases in those who have increased potential for myocardial infarction, coronary revascularization, and death ■ No current smoking ■ No obesity ■ Physical activity at least once per week ■ Healthy diet: fruit, vegetables, whole grains, fish, dairy > refined grains, red meats, processed meats, sugary drinks, trans fat, and sodium ○ Sex and gender differences ■ Gender differences involve ethnicity, culture, socioeconomic status ● These factors closely involved in cardiac risk factors and cardiac risk lifestyle factors such as obesity, smoking, lesser physical activity, delay in seeking treatment, and cardiac rehabilitation participation ■ 80% of heart disease is preventable ■ Women tend to delay seeking care because their symptoms are clustered differently than men ● Less likely to experience the well publicized symptom of crushing chest pain ● More likely to experience prodromal symptoms (those that are intermittent or resolve spontaneously) for weeks or months before acute cardiac syndrome occurs ○ ACS prodromal symptoms ■ Unusual fatigue (most common) ■ Discomfort in jaw or teeth ■ Arm pain ■ Shortness of breath ● At time of ACS they are more likely to report fatigue, nausea, neck pain, right arm pain, jaw pain, dizziness, and syncope in comparison to men ● Providers are less likely to consider that women’s symptoms may be related to a cardiac event because the symptoms are not commonly seen in men, and may not take them seriously ○ This shakes the confidence in women that symptoms are cardiac related and can further delay treatment and care Subjective Data ● Chest pain: Any chest pain or tightness? ○ Onset: When did it start? How long have you had it this time? Have you had this type of pain before? How often? ○ Location: Where did the pain start? Does the pain radiate to any other spot? ○ Character: How would you describe it? Crushing, stabbing, burning, viselike? Or aching, heaviness? ■ Allow the person to offer adjectives before you suggest them, note if uses clenched fist to describe pain. ○ Angina: occurs when the heart’s own blood supply cannot keep up with metabolic demands ■ A squeezing “clenched fist” sign is characteristic of angina, but the symptoms below may be anginal equivalents in the absence of chest pain: ● Diaphoresis, cold sweats, pallor, greyness, palpitations, dyspnea, nausea, tachycardia, fatigue ○ Chest pain may also have pulmonary, musculoskeletal, or GI origins ● Dyspnea: Any shortness of breath? Which type of activity and how much brings on shortness of breath? How much activity brought it on 6 months ago? ○ Onset: Does the shortness of breath come on unexpectedly? ○ Duration: Constant or does it come and go? ○ Does it seem to be affected by position? Lying down? ○ Does it interfere with ADLs ○ Dyspnea on exertion (DOE): quantify exactly ■ Ex: Dyspnea on exertion after after walking two level blocks or climbing stairs ○ Paroxysmal: ask about history of heart problems ■ Paroxysmal nocturnal dyspnea (PND) occurs with heart failure ■ Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. ■ Typically, the person awakens after 2 hours of sleep with the perception of needing fresh air. ● Orthopnea. How many pillows do you use when sleeping or lying down? ○ Orthopnea is the need to assume a more upright position to breathe. ○ Note the exact number of pillows used. ● Cough: Do you have a cough? ○ Duration, frequency, type, mucus, activity, palliation, meds ○ Sputum production: mucoid or purulent. ○ Hemoptysis is often a pulmonary disorder but also occurs with mitral stenosis. ● Fatigue: onset, recent or gradual ● Cyanosis or pallor: Have you ever noted your facial skin turning blue or ashen? ○ Cyanosis or pallor occurs with MI or low cardiac output states as a result of decreased tissue perfusion ● Edema: Any swelling of your feet or hands? ○ Edema is dependent when caused by heart failure ○ What time of day does the swelling occur? Do your shoes feel tight at the end of day? ■ Cardiac edema is worse in the evening and better in the morning after elevating legs all night ○ How much swelling would you say there is? Are both legs equally affected? ■ Cardiac edema is bilateral; unilateral swelling has a local vein ● Nocturia: Do you awaken at night with an urgent need to urinate? ○ Recumbency at night promotes fluid resorption and excretion; this occurs with heart failure in the person who is ambulatory during the day. ● Past cardiac history: history of HTN, elevated cholesterol or triglycerides murmur, congenital disease, rheumatic fever, unexplained joint pains as child or use, recurrent tonsillitis, anemia ○ Last ACG, stress ECG, other tests ● Family cardiac history: HTN, obesity, CAD, sudden death at young age ● Patient-centered care (cardiac risk factors) ○ Risk factors for CAD: collect data regarding elevated cholesterol, elevated BP, blood sugar levels above 100 mg/dL or known DM, obesity, cigarette smoking, low activity level, and length of any hormone replacement therapy for postmenopausal women ■ Collect data on nutrition, smoking, alcohol, exercise ● Drugs: Do you take any antihypertensives, beta-blockers, CCBs, digoxin, diuretics, antiplatelets/anticoags, OTC drugs or illegal drugs ○ Encourage men ages 45 to 79 years and women age 55 to 79 years to use low-dose aspirin if the potential benefit of preventing MI outweighs the potential risk of GI bleeding. This is called Benefit/Risk Ratio. ○ Vitamin D replacement is important, vitamin D deficiency increases risk of CVD and is associated with hypertension. ● Additional History for Infants ○ Questions and s/s of heart Failure: ■ Have you noted any cyanosis while nursing, crying? Is the baby able to eat, nurse, or finish the bottle without tiring? ■ Has this baby grown as expected? ■ To screen for heart disease in infants, note fatigue during feeding. ● Infant with heart failure takes fewer ounces each feeding; becomes dyspneic with sucking; may be diaphoretic, then falls into exhausted sleep, awakens after a short time hungry again. Poor weight gain. ● Additional history for children ○ Growth, Activity/keeping up, Chest pain, Respiratory infections, Family history ● Additional History for the Pregnant Woman ○ Gestational hypertension and preeclampsia history or currently ○ Faint/dizziness ● Additional History for the Aging Adult ○ Do you have any known heart/lung diseases, history of HTN, CAD, emphysema, bronchitis? ■ Symptoms/treatment ■ Effects on ADLs ○ Do you take any medications for your illness such as digitalis? Are you aware of side effects? Have you recently stopped taking your medication? Objective Data ● Palpate the Carotid Artery: palpate each carotid artery medial to the sternomastoid muscle in the neck ○ Avoid excessive pressure on the carotid sinus area that is higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. ○ Take care to palpate gently. ○ Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain. ○ Abnormal Findings: Carotid sinus hypersensitivity is the condition in which pressure over the carotid sinus leads to decreased heart rate, decreased BP, and cerebral ischemia. ■ More common in older adults or with occlusion of the carotid artery. ● Auscultate the Carotid Artery: for people middle-age or older or who show symptoms or signs of CVD, auscultate each carotid artery for the presence of a bruit. This is a blowing, swishing sound indicating blood flow turbulence; normally none is present ○ Keep the neck in a neutral position. Lightly apply the bell of the stethoscope over the carotid artery at three levels: ■ Angle of the jaw ■ Mid-cervical area ■ Base of the neck ○ Avoid compressing the artery because this could create an artificial bruit and compromise circulation if the carotid artery is already narrowed by atherosclerosis. ○ Ask the person to take a breath, exhale, and hold it briefly/lightly while you listen so tracheal breath sounds do not mask or mimic a carotid artery bruit. (Holding the breath on inhalation also tenses the ○ Carotid bruit is audible when lumen is occluded by 1/2-2/3. After that it decreases. Bruit disappears with complete occlusion. ● THRILL: a vibratory sensation felt on the skin overlying an area of turbulence, usually indicated a loud heart murmur caused by an incomptent valve; to assess ● Inspect the Anterior Chest ○ Pulsations: you may or may not see the apical impulse; the pulsation created as the left ventricle rotates against the chest wall during systole. ■ When visible: it occupies the 4th or 5th intercostal space, at or inside the midclavicular line. ■ It is easier to see in children and in those with thinner chest walls. ■ A lift or a heave occurs with right ventricular hypertrophy - as found in pulmonic valve disease, pulmonary hypertension, and chronic lung disease. ● You feel a diffuse lifting impulse during systole at the left lower sternal border. ● It may be associated with retraction at the apex because the left ventricle is rotated posteriorly by the enlarged right ventricle. ● Right ventricular heave is seen at the sternal border, Left ventricular heave is seen at the apex. ● Palpate the Apical Pulse: ○ To palpate the apical pulse in a pregnant woman, go to the 4th/5th intercostal space. Palpitation will be higher and more lateral because of displaced diaphragm. ○ In a normal patient, location of the apical pulse should occupy only one interspace, either the 4th or 5th, and be at or medial to the midclavicular line ○ Abnormal: ■ Cardiac enlargement places apical pulse laterally and over wider area with left ventricular hypertrophy and dilation ■ Thrill in the 2nd and 3rd right intercostal spaces occurs with severe aortic stenosis and systemic hypertension. ■ Thrill in the 2nd and 3rd left interspaces occurs with pulmonic stenosis and pulmonary hypertension. ● Percussion - no longer performed. Limited usefulness in individuals who are obese, muscular, or have breasts. ○ Echocardiogram or chest X-ray is better for detecting heart enlargement ● Auscultation points ○ ○ Valve areas ■ Second right intercostal space, sterna