Cardiac Auscultation and Pulse Palpation

• Pericarditis results in a friction rub heart sound.
• Pericardial friction rubs produce a rubbing sound during both diastole and systole.
• These rubs are best auscultated over the apical area and resemble scratching on sandpaper.
• S1 indicates the start of systole.
• S2 indicates the start of diastole.
• A fourth heart sound (S4) can be auscultated at the end of diastole when atrial contraction completes ventricular filling.
• S4 occurs just before S1 and sounds like "Tennessee".
• S4 is normal in children and young adults.
• In adults over 30, S4 indicates a noncompliant or "stiff" ventricle.
• A murmur is a blowing sound.
• Location during the cardiac cycle determines if a murmur is systolic or diastolic.
• S1 marks the beginning of systole, produced by the closing of the mitral and tricuspid valves, followed by ventricular contraction.
• Diastolic murmurs are heard after S2 at the beginning of diastole.

Pulse Palpation Sites

• Temporal pulse: Palpate over the temporal bone on each side of the head.
• Carotid pulse: Palpate the lateral aspect of both sides of the neck, but never at the same time.
• Brachial pulse: Palpate the inner aspect of the arm.
• Radial pulse: Palpate on the thumb side of the wrist.
• Femoral pulse: Palpate below the inguinal ligament, midway between the symphysis pubis and anterior superior iliac.
• Popliteal pulse: Palpate the popliteal artery behind the knee in the popliteal fossa to assess perfusion.

Peripheral Artery Disease (PAD) vs. Peripheral Venous Disease (PVD)

• PAD: Blood cannot reach peripheral areas, leading to cold limbs, absent distal peripheral pulses, and skin integrity issues.
• PVD: Blood pools in peripheral areas with slow return to the heart.
• PVD results in warm, seeping limbs, present but difficult to find pulses due to edema, and skin integrity issues like sores, commonly by the ankles.

Nutritional Deficiencies

• Hair loss is associated with deficiencies in zinc, protein, and essential fatty acids.
• Dry, flaky skin with patches of eczema indicates an essential fatty acids deficiency.
• Multiple bruises suggest deficiencies in Vitamin C and/or Vitamin K.

Other Nutritional Factors

• Low calcium is a risk factor for osteoporosis.
• Milk and milk products are important calcium sources.
• Height and weight determine a patient's BMI.
• Serum albumin assesses a patient's protein status.
• Skin turgor assesses hydration status.
• Dental health is a critical component of nutritional assessment in elderly patients.
• Dietary habits and food preferences should be gathered when assessing nutritional status.

Spinal Conditions

• Kyphosis: Posterior curvature of the thoracic spine.
• Scoliosis: Light shift of midline below the waist slightly toward the right feet, with the right shoulder raised somewhat.
• Lordosis: Curvature of the spine that curves toward the belly button, such as in pregnant women.

Gait Assessment

• Normal gait includes consistent stride length and arm swing.
• Abnormal gait includes unsteady movement, exaggerated limp, forward-leaning posture, and shuffling feet.
• Hip hyperextension is performed by raising one leg at a time while lying prone.

Rheumatoid Arthritis (RA)

• Signs and symptoms of RA include hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally.

Abdominal Assessment

• The order of the abdomen assessment is inspection, auscultation, percussion, and palpation.
• The preferred position to assess the abdomen is lying supine.
• Normal findings during inspection include a flat, soft abdomen with no nodes, rashes, or visible abnormalities. During palpation
  • Palpate painful areas last or not at all
  • Press the abdomen 1 cm for light palpation and 4-6 cm for deep palpation.
  • Palpate all four quadrants of the abdomen.
  • Keep fingers together and lift from one quadrant to the next.
• The nurse percusses for tympany and dullness.
• Tympany is percussed over the umbilicus in the supine position.
• A tympanic sound over an organ is normal.
• Dullness sound would be on organs or masses.
• Rebound tenderness is assessed by applying deep pressure on the abdomen and releasing quickly.
• Pain indicates peritoneal inflammation.