Knowledge Check Exam 2 - Thorax and Lungs PDF

**Knowledge Check for Exam 2:** Thorax and Lungs: - Explain the mechanics of respiration The primary muscles of respiration are the diaphragm and intercostal muscles. 4 main functions: supplying oxygen, removing CO2, maintaining acid-base balance, and maintenance of heat exchange. By supplying...

**Knowledge Check for Exam 2:** Thorax and Lungs: - Explain the mechanics of respiration The primary muscles of respiration are the diaphragm and intercostal muscles. 4 main functions: supplying oxygen, removing CO2, maintaining acid-base balance, and maintenance of heat exchange. By supplying oxygen to the blood and eliminating excess carbon dioxide, respiration maintains the pH or acid-base balance of the blood. The normal stimulus to breathe is an increase of carbon dioxide in the blood, or hypercapnia. A decrease of oxygen in the blood or hypoxemia also increased respirations but is less effective than hypercapnia. Respiration is the physical act of breathing: - Inspiration: Air rushed into the lungs as the chest size increases - Expiration: air is expelled from the lung as the chest recoils - Identify pulmonary complications associated with the aging adult Lung infections- weakened immune system makes it more likely to get pneumonia or bronchitis Shortness of breath- the diaphragm weakens over time Low oxygen levels- aging can lead to this Abnormal breathing patterns- aging can lead to this Chronic lung diseases- aging increases this risk Acute respiratory disease- aging increases this risk Lung abscess- pneumonia can lead to this Pulmonary hypertension- increases with age The costal cartilage becomes calcified which makes the thorax less mobile Respiratory muscle strength declines Decrease in elastic properties making them less expandable Tissue (histologic) changes - Outline key subjective data to collect for a health history regarding respiratory health Cough Shortness of Breath Chest Pain History of Respiratory Infections, Breathing Trouble, or Lung Diseases Smoking History Environmental Conditions That May Affect Breathing Self-Care Behaviors Privacy Considerations - Explain how to protect client modesty during a thoracic assessment Have a private examination room, only uncover parts that are being examined, warm room, have female lift gown rather than removing whole thing - Correlate anatomy with expected objective health assessment findings - Compare and contrast ease of respirations and signs of respiratory distress Normal breathing has a rate of 10-20 breaths per minute with an even pattern. Bradypnea- respiratory rate less than 10 breaths per minute Hyperventilation- increased rate and depth of breaths Hypoventilation- irregular shallow breathing Cheyenne-Stokes- increasing rate and depth and then decreasing, alternating cycle Chronic Obstructive Breathing- normal inspiration and prolonged expiration - Differentiate various thoracic cage shapes Normal adult thorax: elliptical shape, anteroposterior to transverse diameter of 1:2 Kyphosis: exaggerated posterior curvature of the thoracic spine, humpback Scoliosis: lateral S shaped curvature of the thoracic and lumbar spine, unequal shoulder and scapular height and unequal hip levels - Describe healthy and unhealthy percussion notes over lung fields Resonance is the low-pitched, clear, hollow sound that predominates in healthy lung tissue Flat sound over muscles or bones Dullness over organs - Specify strategies to promote accurate auscultation of breath sounds The person should be relaxed and leaning forward slightly in the sitting position or lying on the side if they cannot get out of the bed. You want to listen to at least one full respiration in each location, both inhalation and exhalation. It is important to do a side-to-side comparison. You will move the stethoscope side to side and then down. Anterior chest, start over the large airways first - Compare and contrast bronchial, bronchovesicular, and vesicular breath sounds Bronchial- heard over the trachea and larynx, expiration is heard longer than inspiration and is not heard on the posterior side Bronchovesicular- heard over the main bronchi, inspiration and expiration are about equal, fewer alveoli are present Vesicular sounds- heard over the peripheral lung fields, inspiration is heard louder and longer than expiration - List and define adventitious breath sounds Crackles- discontinuous popping sounds heard over inspiration due to fluid in lungs Pleural Friction Rub- coarse and low pitched, grating quality of two pieces of leather being rubbed together. Can be heard on inspiration and expiration. Roughened plural surfaces. Wheeze- high pitched wheezing is predominant in expiration (airway obstruction-acute asthma or chronic emphysema), low pitched wheezing is prominent in expiration (bronchitis) Stridor- high pitched inspiratory crowing sound that is louder in the neck than over the chest wall (airway obstruction) Heart and Great Vessels: - Describe the location of the heart & great vessels in the thoracic cage The heart and the great vessels are located between the lungs in the middle third of the thoracic cage or mediastinum. - Outline blood flow through the heart and systemic circulation Body -- to superior and inferior vena cava -- to the right atrium -- through the tricuspid valve -- to the right ventricle -- through the pulmonary valve -- to the pulmonary arteries -- to the lungs -- to the pulmonary veins -- to the left atrium -- through the mitral valve -- to the left ventricle -- through the aortic valve -- to the aorta -- to the body - Explain the cardiac cycle Protodiastolic Phase is the first part of diastole. This is when all the chambers of the heart are relaxed, and the blood fills the ventricles with passive filling. AV valves (tricuspid & mitral) are open and semilunar valves (aortic and pulmonary) are closed. Pre systole phase is the second part of diastole. This is when the atria contract and push the last amount of blood in the ventricles. This is active filling. AV valves are open, semilunar valves are closed. Systole begins now that there is so much blood in the ventricles that the pressure is higher than the atria. This causes the AV valves to shut. The shutting of these valves creates the first heart sound S1. Ventricular Isovolumetric Contraction is a small movement when all four valves are closed. The ventricle begins to contract, which raises ventricular pressure. Ejection occurs when the semilunar valves open and the blood is ejected from the ventricles to the body via the aortic valve and aorta or to the lungs via the pulmonic valve and pulmonary artery. After blood is ejected, the pressure falls. The semilunar valves shut and creates the second heart sound S2. This sound marks the end of systole. Diastole is the state of all four valves once again closing. Ventricles relax after ejection called isometric relaxation. The atria fill with blood from the body and lungs. Once the pressure is higher in the atria than the ventricles, the AV valves open and begin the process again. - Relate heart sounds to the cardiac cycle. S1 occurs when the AV valves close at the beginning of systole. This is the "lub" sound that is heart loudest at the apex of the heart. S2 occurs when the semilunar valves close at the end of the systole. This is the "dub" sound heard loudest at the base of the heart. S3 is a sound of ventricular filling in early diastole. It is best heard at the apex of the heart with the bell of the stethoscope. (volume overload) S4 is also heard during ventricular filling, but in late diastole. It is heard best at the apex of the heart with the bell of the stethoscope. (stiffened heart muscles) - Explain hemodynamic changes associated with aging Increase in systolic blood pressure due to stiffening of large arteries Decrease of diastolic blood pressure Decreased ability for the heart to adapt cardiac output to keep up with demand from exercise Supraventricular and ventricular dysrhythmias Ectopic heart beats (extra or skipped beats) Lowered ability to tolerate tachydysrhythmias Increased risk of cardiovascular disease Increased risk for orthostatic hypotension (sudden drop in BP when rising to sit or stand) - Specify key characteristics of heart sounds APE to Man A= aortic valve (S2 louder) P= pulmonic valve (S2 louder) E= Erb's point (S1=S2) To= Tricuspid (S1 louder) Man= Mitral (S1 louder) - Outline key subjective data to collect information about the heart & great blood vessels Chest pain or tightness Dyspnea Cough Fatigue Cyanosis or pallor Nocturia Past cardiac history Risk factors Family history - Explain key assessments to make during inspection of the heart and great vessels Look for pulsations or movements - Describe expected findings for palpation of the precordium Apical pulse may or may not be visible but is located at the 4^th^ or 5^th^ intercostal space at the left midclavicular line. It should be brief lasting less than two-thirds of systole. You might see gentle flickers on the chest wall skin. You might not feel any cardiac impulses against the chest wall. - Outline key characteristics of heart tones during auscultation APE to Man Abnormal heart sounds: blowing, swooshing sounds - Specify how to effectively describe heart murmurs. Timing of murmur, whether it is in systole or diastole Describe the loudness or intensity and describe the pitch as high, medium, or low. Note the pattern, the quality and what it sounds like The location, if it radiates and if the murmur enhances or disappears with posture or position changes - Outline strategies to promote the health of the cardiovascular system. Blood pressure screenings Not smoking Maintaining a healthy BMI Avoid illicit drug use Consume a heart healthy diet which is low in fat, sodium, cholesterol, and trans fat Maintaining a healthy blood sugar Early screening tests for persons with a family history of cardiovascular disease Getting regular aerobic exercise Taking a low dose of aspirin if not contraindicated and approved by your doctor Peripheral Vascular Lymphatic Assessment - Describe the modified Allen's test and its clinical significance. The purpose is to see if we are going to be able to cannulate that artery for any sort of testing or procedure. Testing for adequate blood flow even when the cannula is in the other artery. The examiner occludes the radial and ulnar arteries on one hand. As the examiner occludes both arteries, the client should slowly open and close the hand about 10 times. After that the client should open their hand without hyperextending it because this can cause a false positive. Then, one artery is released either the radial or ulnar. A normal result is blood return in the hand within 5 seconds. - Identify alternate methods of assessing a patient's pulses. Doppler Simultaneously or at the same time and some pulses need to be assessed at one time separate from each other, but still bilaterally - Specify how to assess pulses, body temperature, capillary refill, and edema efficiently. Assess pulses: bilaterally or on both sides radial, brachial, femoral, posterior tibial can be assessed simultaneously carotid artery, femoral (if patient is obese), popliteal pulse assessed one at a time Assess body temperature: Use back of hands Palpate extremities Assess capillary refill: On both fingernails and toenails Pinch nails until it turns white and watch cap refill, normal is less than 3 seconds Assess edema: Firmly depress the skin over the tibia or medial malleolus for 5 seconds and release, should leave no indentation - Explain the pulse rating system. - Outline key subjective data to collect to assess the health of the peripheral vascular and lymphatics systems. Leg pain or cramps Recent change in exercise History of vascular problem Skin changes in legs or arms Change in temperature of extremities Veins bulging or crooked Support hose or TED hose Sores or ulcers Swelling or edema Lymph node enlargement Medications History of smoking - Identify the location of major arteries, veins and lymph nodes in the human body. Arteries: Brachial artery, radial artery, ulnar artery, temporal artery, carotid artery, femoral artery, popliteal artery, anterior tibial artery, dorsalis pedis artery, posterior tibial artery, Veins: Femoral, popliteal veins (deep veins); Saphenous vein, small saphenous vein (superficial); Pulmonary veins Lymph nodes: Cervical nodes (head and neck), axillary nodes (breast and upper arm), epitrochlear node (hand and lower arm), inguinal nodes (groin, lower extremities, external genitalia, anterior abdominal wall). Head, neck, axilla, abdomen, and inguinal area. - Compare and Contrast the Peripheral Venous Disease with Peripheral Arterial Disease (signs and symptoms, treatments) PVD- edema, warm temp, browning/yellowish, venous stasis ulcers (irregular shaped), no gangrene, elevate veins for treatment PAD- no edema, cool temp, pale, round red sores, gangrene, dangle arteries for treatment - Describe the lymphatic assessment with normal and abnormal findings Normal: symmetrical, no visible or palpable lymph nodes, no swelling, no pain, moveable and nontender, small 1 cm or less Abnormal: visible lymph nodes, asymmetry, hard, matted, tender, enlarged, fixed in area Abdominal Assessment - List subjective data that should be obtained during an abdominal assessment Appetite Dysphagia Food intolerances Abdominal pain Nausea/vomiting Bowel habits Bloating or indigestion Medications Most recent screening for colon cancer Nutritional assessment - State the sequence of assessment techniques for the abdominal exam and why there is a difference in sequencing. Inspection, Auscultation, Percussion, Palpation We auscultate before percussion and palpation because they can create extra bowel sounds - Describe relaxation techniques for an effective abdominal exam. Have client empty their bladder Keep room temperature comfortable Have person lay on their back with knees bent Warm your hands and stethoscope and have short fingernails Distract the client while holding a conversation Watch for discomfort Save any painful areas for final part of assessment You can use guided imagery or distraction if client is in pain Ticklish clients let them do some palpation with their hand under yours - Outline key observations during abdominal inspection. Shape/contour of the abdomen Umbilicus Symmetry Skin Pulsation or movement Demeanor - Explain how to auscultate bowel\ sounds effectively Begin in the right lower quadrant of the abdomen and at the ileocecal valve, the valve between the ileum and cecum. Auscultate clockwise from RLQ-RUQ-LUQ-LLQ - Describe the expected percussion notes Dull notes over solid organs. Tympany will be heard over gas filled structures such as the intestine and over the stomach. - Compare & contrast light & deep palpation Light palpation: use your first four fingers (minus the thumb) and press on the skin (about 1 cm) Deep palpation: use your first four fingers (minus the thumb) and press on the skin a little firmer than with light palpation Apply pressure using a rotating motion while sliding the fingers and skin together - Identify changes seen in the aging adult Increased abdominal fat Dry mouth Reduced taste due to reduced salivation Delayed esophageal emptying leading to an increased risk for aspiration or regurgitation Decreased gastric acid secretion can lead to the risk for reduced vitamin B12 absorption, reduced iron absorption and difficulty absorbing calcium Gi mobility/motility leads to constipation Impaired drug metabolism - Outline ways to promote abdominal\ health A BMI between 18.5 and 24.99 is important Eating foods rich in fiber Washing food items before cooking/eating Practicing hand-hygiene Performing a refrigerator audit Avoid excessive alcohol intake as it taxes the liver Avoid high fatty foods which make the gallbladder work harder Monitor required screening times related to clients age Stay hydrated and drink plenty of water Kegel exercised for women Avoid prolonged bladder distension, bladder spasms, and infection by emptying the bladder frequently Breast and Regional Lymphatic Assessment - Examine the importance of the breast examination for women and men Breast cancer. Breast exams help to screen and often determine someone's chance of survival. - Outline subjective data to obtain health information about a patient's breasts and regional lymphatics Pain Lump Discharge Rash Swelling Trauma History of Breast Disease Surgery or Radiation Medications Client-Centered Care - Identify nonmodifiable and lifestyle risk factors for breast cancer Non-modifiable: age, biopsy-confirmed atypical cell growth, certain genetic mutations, mammographically dense breasts, personal history of early onset breast cancer, two or more first degree relatives with breast cancer, high endogenous estrogen or testosterone levels, high-dose radiation to the chest, Ashkenazi Jewish heritage, early menarche, height, no full term pregnancies Modifiable: alcohol consumption, late age at first full-term pregnancy, late menopause, personal history of endometrial-ovarian-or-colon cancer, never breastfed a child, obesity, recent and long term use of menopausal hormone therapy, recent oral contraceptive use - Examine the importance of mammograms and preparation required (tips) They can reveal cancers too small to be detected by the most experienced examiner and can discover small, potentially curable breast cancers Preparation tips: No deodorant, cream, lotion or powder on the underarms or breast area prior to exam Schedule the test during the time of the month when breasts are not tender Bring films of previous mammograms Avoid excessive caffeine Come prepared to give family breast health history Before exam, inform providers of any problems Bring a list of places and dates for any breast treatments - Outline the preparation required for a clinical breast exam (CBE) Be sure to have the equipment required for the examination. Highly suggested equipment includes a small pillow, a ruler marked in cm, a short gown, a pamphlet or teaching aid - Specify the different arm positions for inspection and key observations (normal and abnormal). First have the client sit or stand with the arms at the side and turn from side to side. Note symmetry. Then have the client lift her arms slowly over her head. Breasts should move up symmetrically. Next ask her to push her hands onto her hips and to push her two palms together. A slight lifting of both breasts should occur. - Outline palpation techniques during a breast exam. Vertical Strip Pattern: Start high in the axillary area and palpate down the midaxillary line just lateral to the breast down to the bra line. Then proceed medially in overlapping vertical lines ending at the sternal edge. Wedge technique: start palpation from the nipple area then moving outward is if following spokes on a wheel. Concentric circles pattern: begin at the nipple and then palpate a circular pattern ending at the axillary area Bimanual technique: support the inferior or lower part of the breast with one hand while using the other hand to palpate the breast tissue against the supporting hand. - Identify situations when bimanual palpation is warranted. Most effective for clients with pendulous breasts, this requires the client to be in a seated position and leaning forward - Review characteristics that should be noted with a lump or mass Location Size Shape Consistency (feels like?) Mobility (movable?) Distinctness Skin over lump Tenderness Lymphadenopathy (palpable?) - Specify strategies for effective education on self-breast exams. - Explain that the best time to perform BSE is right after the menstrual period (day 4 to 7 of cycle) - Instruct the woman not having menstrual periods to choose a familiar date as a reminder - Tell the client what to look for as she inspects her breasts in front of a mirror - At home she can palpate while in the shower, soap and water assist palpation - Examine the male breast exam and key observations. Inspect the chest wall, noting the skin surface and any lumps or swelling. Palpate the nipple area for any lumps or tissue enlargement. Should feel even with no nodules. Note any nipple discharge, which is rare. The normal male breast has a flat disk of undeveloped breast tissues beneath the nipple. - Outline health promotion strategies for optimal breast health. Maintain a healthy weight Take vitamin D supplements Minimize alcohol intake Get at least 30 minutes of moderate exercise 5 times weekly Avoid tobacco products and secondhand smoke exposure Practice stress management and get enough sleep at night Head, Face, and Neck Assessment - Generate questions to obtain health history and subjective data about\ a patient's head, face & neck health. Ask the client if they experience unusually frequent or severe headaches? Ask about the location of pain and duration? Ask about associated symptoms, such as nausea or vomiting? Ask about precipitating factors? Ask about any medications taken and family history? Ask the client to describe any recent or past head injury and details about the event? Ask the client if there is any sort of dizziness associated with headache? Ask the client about the onset of neck pain? Location? Numbness or tingling in arms, shoulders or hands? Ask the client if they have experienced recent infection? Ask if lumps or swelling have changed? Ask the client if they have any history of smoking or chewing tobacco? Ask the client if they regularly consume alcohol? Ask the client if they have been diagnosed with thyroid issues? Ask the client if there is any history of neck or head surgery? - List key observations to make during inspection, and palpation of the\ head, face, and neck. Head: Size and shape of skull (normocephalic, microcephaly, macrocephaly) Face: Facial expression, symmetrical features, document any abnormal features Neck: head should be centered in the midline and the accessory neck muscles should be symmetric - Outline ways to assess trachea, ROM of the neck and strength of\ the neck muscles. Trachea: have client swallow and observe for midline trachea movement, should not deviate ROM: Flexion, extension, rotation, lateral bending (should be smoothed and controlled) Strength: have client shrug the shoulders and perform ROM against resistance - List and describe the location of the regional lymph nodes of the\ head, face & neck. Preauricular Posterior auricular Occipital Submental Submandibular Jugulogastric Superficial cervical Deep cervical Posterior cervical Supraclavicular - Describe the best way to assess the carotid pulse, trachea, and lymph\ nodes of the head, face & neck. - Outline expected findings for a healthy head, face & neck. - Specify information to teach patients about promotion health of their\ head and neck. Teach your patients about using ergonomic techniques if they are in an office setting and sitting at a desk Practice good body mechanics when lifting Stress can cause neck pain so take measures to reduce stress Lift weights using proper techniques Wear protective gear Wear seatbelt - Identify expected changes with aging to the head, face, neck, and eyes The facial bones and orbits appear more prominent The facial skin starts to sag from decreased elasticity Decreased subcutaneous fat Decreased moisture in the skin - Describe methods to assess the function of Cranial nerves XI (Spinal Accessory Nerve) and VII (Facial Nerve) Cranial Nerve VII: innervates facial muscles, bells palsy (lower motor neuron lesion) and stroke (upper motor neuron lesion) Stoke: can wrinkle forehead and close eyes, paralysis of lower facial muscles Bell's palsy: cant's raise eyebrow or close eyelid, complete paralysis of one side of the face Cranial Nerve XI: spinal accessory nerve, range of motion and strength of neck and shoulders Eye Assessment and Health Promotion - Generate questions to obtain health history and subjective data about a patient's eye health Blurred vision or difficulty seeing? Any blind spots? Focus or cloudy objects? Grayness of vision? Spots in front of eyes? Halos or rainbows around objects? Loss of peripheral vision? Night blindness? Eye pain? Redness or swelling? History of eye problems? Glasses or contact lenses? Last eye exam? Excessive watering? History of glaucoma? - List key observations to make during inspection, and palpation of the eyes. Nonverbal signs of visual loss Symmetry eyebrows Upper eyelid overlaps the superior part of the iris and approximates completely with the lower lid closed. Skin should be free of redness, swelling, discharge, or lesions. Moist glossy eyeball with pink blood vessels on the transparent conjunctiva and a white sclera. - Explain how to test vision, extraocular eye muscles and use the ophthalmoscope. - Specify the cranial nerve responsible for each extraocular eye muscle Oculomotor nerve (cranial nerve III)- controls the superior, inferior, and medial recti, and the inferior oblique Trochlear nerve (cranial nerve IV)- controls the superior oblique Abducens nerve (cranial nerve VI)- controls lateral rectus - Outline methods to test visual acuity, movement of eye muscles, eye alignment, visual fields, and eye protective mechanisms. - Outline expected findings for healthy eyes. Vision 20/20 Normal structures for the cornea, iris, and lens Normal eye pressure Proper eye muscle coordination Ability to identify different colors White sclera, pink conjunctiva, and no drainage No redness, swelling, lumps, or discharge Adequate lubrication/tear production Eyes appear symmetric - Specify key information to teach patients about promoting eye health Encourage regular eye exams Make sure client is aware of any family history of eye disease or visual acuity problems A healthy diet to promote eye health Encourage clients to quit smoking Encourage wearing sunglasses that block UV rays Remind clients to take regular breaks for the eyes Remind clients to clean hands when handling contact lenses Remind clients that tears are an excellent way to prevent eye irritation and infection