NCM 102 Reviewer Midterms Exam PDF

NCM 102 – REVIEWER MIDTERMS EXAM ASSESSMENT OF MOUTH, THROAT, NOSE, AND SINUSES The mouth, throat, nose, and sinuses play vital roles in breathing, digestion, communication, and immunity. A thorough assessment can identify common conditions and guide appropriate interventions. 1. Anatomy Mouth (...

NCM 102 – REVIEWER MIDTERMS EXAM ASSESSMENT OF MOUTH, THROAT, NOSE, AND SINUSES The mouth, throat, nose, and sinuses play vital roles in breathing, digestion, communication, and immunity. A thorough assessment can identify common conditions and guide appropriate interventions. 1. Anatomy Mouth (Oral Cavity): Functions: Initiates digestion, aids in speech, and acts as the entry for air and food. Key Structures: 1. Lips: Protect the opening to the oral cavity. 2. Teeth: Aid in chewing food. 3. Tongue: Facilitates swallowing, speech, and taste sensation. 4. Hard and Soft Palates: Separate the oral and nasal cavities; the soft palate ends with the uvula. 5. Salivary Glands: Produce saliva to aid digestion and keep the mouth moist. Throat (Pharynx): Divided into: 1. Nasopharynx: Behind the nasal cavity; connected to the Eustachian tubes. 2. Oropharynx: Visible when the mouth is open; contains the tonsils. 3. Laryngopharynx: Leads to the esophagus and trachea. Functions: Facilitates the passage of air and food. Nose: Functions: Warms, moistens, and filters inhaled air; provides the sense of smell. Key Structures: 1. External Nose: Made of bone and cartilage. 2. Nasal Cavity: Divided by the nasal septum; lined with mucosa and cilia. 3. Turbinates: Bony structures that increase surface area for filtration. Sinuses: Hollow, air-filled cavities in the skull. Types: 1. Frontal: Above the eyebrows. 2. Maxillary: In the cheekbones. 3. Ethmoid: Between the eyes. 4. Sphenoid: Behind the eyes. Functions: Lighten the skull, produce mucus, and enhance voice resonance. 2. Abnormalities, Their Causes, and Associated Diseases Mouth Abnormalities: 1. Dental Caries (Cavities): o Cause: Poor oral hygiene, high sugar intake. o Complications: Tooth loss, infection (abscess). 1 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM 2. Gingivitis: o Cause: Plaque buildup on gums. o Complications: Periodontitis, tooth loss. 3. Oral Thrush (Candidiasis): o Cause: Fungal infection, often due to antibiotic use or immunosuppression. o Complications: Pain, difficulty eating. 4. Cleft Lip/Palate: o Cause: Congenital defect. o Complications: Feeding difficulties, speech issues. Throat Abnormalities: 1. Pharyngitis (Sore Throat): o Cause: Viral or bacterial infections. o Complications: Tonsillitis, abscesses. 2. Tonsillitis: o Cause: Infection of the tonsils. o Complications: Breathing or swallowing difficulty. 3. Obstructive Sleep Apnea (OSA): o Cause: Blocked airway during sleep. o Complications: Daytime fatigue, heart issues. Nose Abnormalities: 1. Deviated Nasal Septum: o Cause: Congenital or trauma. o Complications: Breathing difficulty. 2. Allergic Rhinitis: o Cause: Allergens like dust or pollen. o Complications: Chronic congestion, sinus infections. 3. Nasal Polyps: o Cause: Chronic inflammation. o Complications: Blocked nasal passages. Sinus Abnormalities: 1. Sinusitis (Sinus Infection): o Cause: Infection or allergy-induced blockage of sinus drainage. o Complications: Chronic sinusitis, orbital cellulitis. 2. Mucoceles: o Cause: Blocked sinus outflow. o Complications: Pressure on surrounding structures. 3. Examinations Preparation: Ensure good lighting. Use tools such as a tongue depressor, penlight, and otoscope. Steps for Examination: 1. Mouth: o Inspect lips for color, moisture, and lesions. o Examine teeth and gums for decay, bleeding, or inflammation. 2 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM o Check the tongue for movement, lesions, or coating. o Inspect the hard and soft palates for symmetry and color. o Example: A white coating on the tongue may indicate oral thrush. 2. Throat: o Use a tongue depressor to visualize the oropharynx. o Assess tonsils for size, color, and presence of exudate. o Example: Enlarged, red tonsils with white spots may suggest tonsillitis. 3. Nose: o Inspect the external nose for symmetry and deformities. o Use a penlight to examine the nasal cavity for discharge, swelling, or foreign objects. o Check for nasal patency by asking the patient to block one nostril and breathe. o Example: Clear nasal discharge may indicate allergies. 4. Sinuses: o Palpate for tenderness over the frontal and maxillary sinuses. o Percuss the sinuses for dullness, indicating fluid or infection. o Example: Tender maxillary sinuses with green nasal discharge may indicate bacterial sinusitis. 4. Nursing Procedure: Assessment and Considerations Nursing Assessment: 1. Subjective Data: o Ask about symptoms such as pain, difficulty swallowing, congestion, or altered sense of smell. o Inquire about habits like smoking or alcohol use. o Record any history of allergies or frequent infections. 2. Objective Data: o Document findings from inspection and palpation. o Record any abnormalities like swelling, redness, or lesions. Nursing Considerations: 1. Patient Comfort: o Explain the procedure to reduce anxiety. o Position the patient properly (e.g., seated with good lighting). 2. Infection Control: o Use gloves and sanitize tools. o Dispose of tongue depressors properly. 3. Health Promotion: o Encourage regular dental visits and proper oral hygiene. o Educate on avoiding allergens and maintaining hydration for nasal health. 4. Referral and Follow-Up: o Refer patients with persistent abnormalities (e.g., white patches in the mouth) for further evaluation. o Example: A patient with suspected oral cancer should see a specialist promptly. Sample Situational Problem Scenario: A 40-year-old patient complains of persistent nasal congestion, facial pain, and a reduced sense of smell for the past two weeks. 3 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM 1. Assessment Findings: o Tenderness over the maxillary sinuses. o Yellow nasal discharge. o Dull sound on percussion of the sinuses. 2. Interpretation: o Likely acute bacterial sinusitis. 3. Nursing Interventions: o Advise the patient to stay hydrated and use saline nasal sprays. o Teach proper use of prescribed antibiotics. o Refer for imaging if symptoms persist. ASSESSMENT OF THE THORAX AND LUNGS The thorax and lungs are essential for breathing and oxygen exchange, which sustains life. Proper assessment of these structures allows nurses to detect respiratory conditions, abnormalities, or diseases, and to guide interventions that maintain respiratory health. 1. Anatomy of the Thorax and Lungs Thorax: The thorax, or chest cavity, is a bony structure housing vital organs such as the lungs and heart. It protects these organs and assists in breathing. 1. Thoracic Cage: o Includes 12 pairs of ribs, the sternum (breastbone), and thoracic vertebrae. o Provides protection and support for the respiratory system. 2. Muscles of Respiration: o Diaphragm: The primary muscle of respiration; contracts to allow air into the lungs. o Intercostal muscles: Located between the ribs; assist with expanding and contracting the ribcage during breathing. 3. Pleura: o Thin membranes that cover the lungs and line the chest cavity. o Visceral pleura: Covers the lungs. o Parietal pleura: Lines the chest wall. o The space between them (pleural cavity) contains fluid to prevent friction. Lungs: Paired organs located in the thoracic cavity. Divided into lobes: o Right lung: 3 lobes (upper, middle, lower). o Left lung: 2 lobes (upper and lower). Main function: Gas exchange. o Oxygen enters the bloodstream, and carbon dioxide is expelled. Tracheobronchial Tree: Trachea: Windpipe, which branches into the left and right bronchi. 4 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM Bronchi: Further divide into smaller bronchioles, leading to alveoli. Alveoli: Tiny air sacs where gas exchange occurs. 2. Abnormalities, Their Causes, and Associated Diseases Abnormalities: 1. Structural Abnormalities: o Barrel Chest: Often seen in chronic obstructive pulmonary disease (COPD). o Pectus Excavatum: Sunken chest, can compress the heart/lungs. o Kyphosis: Excessive curvature of the spine, reducing lung expansion. 2. Respiratory Abnormalities: o Tachypnea: Rapid breathing (e.g., due to fever, anxiety, or respiratory distress). o Bradypnea: Slow breathing (e.g., related to neurological issues or opioid use). o Dyspnea: Difficulty breathing (e.g., in asthma, heart failure). Common Respiratory Diseases: 1. Asthma: o Definition: Chronic inflammation of airways. o Symptoms: Wheezing, breathlessness, chest tightness. o Causes: Allergens, exercise, stress. o Complications: Respiratory failure, reduced quality of life. 2. Chronic Obstructive Pulmonary Disease (COPD): o Definition: Progressive lung disease including emphysema and chronic bronchitis. o Symptoms: Chronic cough, shortness of breath, sputum production. o Causes: Smoking, long-term exposure to irritants. o Complications: Frequent infections, heart problems. 3. Pneumonia: o Definition: Infection of the lungs causing inflammation and fluid build-up. o Symptoms: Cough with phlegm, fever, chills, shortness of breath. o Causes: Bacteria, viruses, fungi. o Complications: Respiratory failure, sepsis. 4. Tuberculosis (TB): o Definition: Bacterial infection causing lung tissue damage. o Symptoms: Persistent cough, weight loss, night sweats. o Causes: Mycobacterium tuberculosis. o Complications: Lung scarring, spreading to other organs. 5. Pleural Effusion: o Definition: Accumulation of fluid in the pleural space. o Symptoms: Chest pain, difficulty breathing. o Causes: Heart failure, infection, malignancy. o Complications: Lung compression, infection. 3. Examination of the Thorax and Lungs Steps of Examination: 1. Inspection: o Observe chest shape and symmetry. o Look for abnormal breathing patterns, use of accessory muscles, or cyanosis. o Example: A patient with COPD may show pursed-lip breathing and barrel chest. 2. Palpation: 5 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM o Check for tenderness, lumps, or masses. o Assess chest expansion symmetry by placing hands on the back and feeling for even movement. o Example: Unequal chest expansion may suggest a pneumothorax. 3. Percussion: o Tap on the chest to assess underlying structures. o Sounds: ▪ Resonance: Normal lung tissue. ▪ Dullness: Fluid (e.g., pleural effusion). ▪ Hyperresonance: Air trapping (e.g., emphysema). 4. Auscultation: o Use a stethoscope to listen to lung sounds. o Normal sounds: ▪ Vesicular: Soft, heard over most lung fields. ▪ Bronchial: Loud, heard near the trachea. o Abnormal sounds: ▪ Wheezing: Narrowed airways (e.g., asthma). ▪ Crackles: Fluid in alveoli (e.g., pneumonia). ▪ Stridor: Obstruction in upper airway. Special Tests: Tactile Fremitus: Feel vibrations while the patient says "99." Decreased vibrations may indicate fluid or air in the lungs. Egophony: Have the patient say "E." If it sounds like "A," it suggests fluid in the lungs. 4. Nursing Procedures: Assessment and Considerations Nursing Assessment: 1. Subjective Data: o Ask about: ▪ Difficulty breathing (dyspnea). ▪ Cough (productive or dry). ▪ Pain when breathing. ▪ History of smoking, asthma, or allergies. 2. Objective Data: o Perform inspection, palpation, percussion, and auscultation. o Record respiratory rate, oxygen saturation, and breath sounds. Nursing Considerations: 1. Patient Comfort: o Ensure the patient is in a comfortable position (e.g., sitting upright for optimal lung expansion). o Maintain a warm environment to prevent shivering. 2. Safety: o Monitor oxygen levels in patients with severe respiratory issues. o Keep emergency equipment ready for sudden respiratory distress. 3. Health Promotion: o Educate about smoking cessation and avoiding allergens. o Promote vaccinations (e.g., influenza, pneumonia). 4. Follow-Up: o Report any abnormal findings like absent breath sounds, wheezing, or crackles. o Coordinate diagnostic tests like chest X-rays or pulmonary function tests. 6 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM Sample Situational Problem Scenario: A 65-year-old male patient presents with a history of smoking and complains of shortness of breath and persistent cough. 1. Assessment Findings: o Barrel chest, use of accessory muscles. o Diminished breath sounds in both lower lobes. o Oxygen saturation: 88% on room air. 2. Interpretation: o Likely COPD exacerbation. 3. Nursing Interventions: o Administer prescribed oxygen. o Teach pursed-lip breathing to improve oxygenation. o Refer for spirometry and chest X-ray. ASSESSMENT OF BREASTS AND LYMPHATICS Assessment of the breasts and lymphatic system is a crucial component of health assessments, helping to identify early breast abnormalities, diseases, or infections. This ensures proper patient care and promotes health awareness. 1. Anatomy of the Breasts and Lymphatics Breasts Location: The breasts are situated on the anterior chest wall, extending from the second to the sixth rib and from the sternum to the midaxillary line. Main Components: o Glandular Tissue: Contains lobes and lobules that produce and store milk. o Fibrous Tissue: Includes Cooper’s ligaments that provide structural support to the breast. o Adipose Tissue: Determines the size and shape of the breast. Areola and Nipple: The central areas, with the areola containing Montgomery’s glands that secrete substances to protect the skin during lactation. Blood Supply: The internal mammary and lateral thoracic arteries provide blood to the breasts. Nerves: Sensory nerves primarily from the fourth, fifth, and sixth intercostal nerves. Lymphatic System The lymphatic drainage of the breast plays a vital role in preventing infections and metastasis. The lymph nodes involved include: o Axillary Nodes: Central, Pectoral (anterior), Subscapular (posterior), Lateral nodes. o Other Nodes: Infraclavicular, Supraclavicular, Parasternal nodes (drain the medial portions of the breast). 7 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM 2. Abnormalities, Causes, and Complications Common Breast Abnormalities 1. Fibroadenoma: o Description: Benign, noncancerous lumps common in younger women. o Causes: Hormonal changes. o Complications: Rarely becomes malignant. 2. Breast Cysts: o Description: Fluid-filled sacs often linked to the menstrual cycle. o Causes: Hormonal fluctuations. o Complications: May cause discomfort or mimic other conditions. 3. Mastitis: o Description: Infection of the breast tissue, often seen in lactating women. o Causes: Blocked milk ducts or bacterial entry through cracked nipples. o Complications: May lead to abscess formation if untreated. 4. Breast Cancer: o Description: Malignant tumors in the breast. o Causes: Genetic mutations (e.g., BRCA1, BRCA2), hormonal influences, and lifestyle factors. o Complications: Potential metastasis to lymph nodes, bones, lungs, etc. Signs of Breast Cancer Painless lump or thickening in the breast. Changes in size, shape, or symmetry of the breast. Skin changes such as dimpling or peau d'orange. Nipple discharge (especially bloody) or retraction. Enlarged axillary lymph nodes. Lymphatic Abnormalities Lymphedema: Swelling caused by lymphatic blockage, commonly seen after mastectomy. Enlarged Lymph Nodes: May suggest infection, cancer, or autoimmune conditions. 3. Examination of Breasts and Lymphatics Steps of Examination 1. Inspection: o Observe the breasts with the patient sitting with arms at sides, raised overhead, and pressed against hips. o Check for symmetry, size, shape, and skin changes (e.g., rashes, lesions, dimpling). 2. Palpation: o Position the patient supine with a small pillow under the shoulder. o Use the pads of fingers for systematic palpation: ▪ Circular Pattern: Start at the nipple and move outward. ▪ Vertical Strip Pattern: Move up and down across the breast. ▪ Wedge Pattern: Palpate from the center outward. o Palpate axillary and supraclavicular lymph nodes for any swelling or tenderness. 3. Nipple Examination: o Check for discharge by gently compressing the nipple. 8 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM o Inspect for retraction or inversion. 4. Special Tests: o Breast Self-Examination (BSE): Encouraged for early detection. o Clinical Breast Examination (CBE): Performed by healthcare professionals. 4. Nursing Procedure: Assessment and Considerations Nursing Assessment 1. Subjective Data: o Inquire about any history of lumps, pain, discharge, or previous surgeries. o Ask about menstrual, pregnancy, and lactation history. o Discuss family history of breast or ovarian cancer. o Assess lifestyle factors (e.g., smoking, alcohol use, diet). 2. Objective Data: o Conduct thorough inspection and palpation. o Document findings systematically, noting the location, size, shape, and consistency of any lumps or abnormalities. Considerations Patient Comfort: o Explain the procedure to alleviate anxiety and ensure privacy with proper draping. Technique: o Use light, medium, and deep pressure during palpation. o Avoid excessive pressure on tender areas. Screening: o Educate patients about the importance of regular mammograms (e.g., starting at age 40 or earlier for high-risk individuals). Sample Situational Problem Scenario: A 45-year-old woman presents with a lump in her left breast. Assessment Findings: o A firm, immovable lump is noted in the upper outer quadrant of the left breast. o Skin over the lump shows dimpling. o Axillary lymph nodes are palpable. Interpretation: The findings are highly suspicious for breast cancer. Intervention: o Refer the patient for diagnostic imaging, such as a mammogram and ultrasound. o Educate the patient about biopsy procedures for confirmation. o Provide emotional support and discuss potential treatment options. Additional Notes Breast Cancer Risk Factors Age, family history, genetic mutations (e.g., BRCA1, BRCA2), hormonal influences, and lifestyle factors (e.g., alcohol consumption, obesity, lack of physical activity). 9 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM Types of Breast Cancer Invasive ductal carcinoma, invasive lobular carcinoma, inflammatory breast cancer. Lymphatic Disorders Lymphedema: Common in patients who have had surgery or radiation for breast cancer. Axillary Lymph Node Metastasis: A common path for the spread of breast cancer. Patient Education Encourage regular BSE, CBE, and mammography. Teach patients the importance of early detection and the signs of breast cancer. Offer counseling and emotional support for patients undergoing breast cancer treatment or dealing with diagnoses. ASSESSMENT OF HEART AND NECK VESSELS Heart and neck vessels assessment is a crucial part of a health assessment in nursing. This focuses on identifying normal and abnormal findings in the cardiovascular system, ensuring early detection of heart-related issues. 1. Anatomy of the Heart and Neck Vessels Understanding the anatomy is essential for effective assessment. Heart Anatomy: Location: The heart lies in the thoracic cavity, between the lungs, in a space called the mediastinum. Chambers: o Right Atrium (RA): Receives deoxygenated blood from the body. o Right Ventricle (RV): Pumps blood to the lungs. o Left Atrium (LA): Receives oxygenated blood from the lungs. o Left Ventricle (LV): Pumps oxygenated blood to the body (strongest chamber). Valves: Prevent backflow of blood. o Atrioventricular (AV) Valves: Tricuspid (right) and Mitral (left). o Semilunar Valves: Pulmonic (right) and Aortic (left). Blood Flow Sequence: 1. Deoxygenated blood enters the right atrium via the superior/inferior vena cava. 2. It flows to the right ventricle → pulmonary artery → lungs. 3. Oxygenated blood returns via pulmonary veins to the left atrium → left ventricle → aorta → body. Neck Vessels: Carotid Arteries: Deliver oxygenated blood to the brain. Jugular Veins: o Internal Jugular Vein (IJV): Drains deoxygenated blood from the brain. o External Jugular Vein (EJV): Drains superficial parts of the head and neck. 10 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM 2. Abnormalities, Their Causes, and Complications Heart Sounds (S1-S4): S1 (Lub): Closure of AV valves (beginning of systole). Best heard at the apex. S2 (Dub): Closure of semilunar valves (end of systole). Best heard at the base. S3 (Ventricular Gallop): May indicate heart failure; heard after S2. S4 (Atrial Gallop): May indicate hypertension or stiff ventricles; heard before S1. Heart Murmurs: Definition: Turbulent blood flow producing swishing sounds. Grading: I (softest) to VI (loudest). Causes: Valve stenosis, valve regurgitation, septal defects. Example: Mitral stenosis may cause a low-pitched rumbling murmur. Common Cardiovascular Diseases: 1. Coronary Artery Disease (CAD): Blocked arteries, leading to angina or myocardial infarction. 2. Heart Failure: Inefficient pumping, causing fluid retention. 3. Hypertension (HTN): Chronic high blood pressure damages vessels. 4. Arrhythmias: Abnormal heart rhythms, e.g., atrial fibrillation. 5. Pericarditis: Inflammation of the pericardium (heart lining). Neck Vessel Abnormalities: Jugular Venous Distention (JVD): Indicates increased central venous pressure, common in heart failure. Carotid Bruit: Swishing sound due to atherosclerosis. 3. Examination of Heart and Neck Vessels Heart Examination: 1. Inspection: o Observe for chest wall pulsations. o Look for signs of cyanosis or clubbing (oxygenation issues). 2. Palpation: o Assess for thrills (vibrations) over precordium. o Locate apical impulse (5th intercostal space, midclavicular line). 3. Percussion: Identify heart size and borders (less commonly used). 4. Auscultation: o Use the diaphragm for high-pitched sounds (S1, S2). o Use the bell for low-pitched sounds (S3, S4, murmurs). o Systematic auscultation over 5 areas: Aortic, Pulmonic, Erb’s Point, Tricuspid, Mitral (APE To Man). Neck Vessel Examination: 1. Inspection: o Check for jugular vein visibility or distention. 2. Palpation: o Palpate carotid arteries one at a time to avoid compromising blood flow. 3. Auscultation: o Listen for bruits over carotid arteries using the bell of the stethoscope. 11 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM 4. Nursing Procedure: Assessment and Considerations Steps in Assessment: 1. Preparation: o Position the patient supine with the upper body elevated at 30-45°. o Ensure a quiet environment for auscultation. o Use proper stethoscope technique. 2. Heart Assessment: o Inspect and palpate the precordium for pulsations, heaves, and thrills. o Auscultate systematically: ▪ Aortic Area: 2nd ICS, right sternal border. ▪ Pulmonic Area: 2nd ICS, left sternal border. ▪ Erb’s Point: 3rd ICS, left sternal border. ▪ Tricuspid Area: 4th-5th ICS, left sternal border. ▪ Mitral Area: 5th ICS, midclavicular line. 3. Neck Vessel Assessment: o Observe jugular veins for distention (raise the head of the bed to 45°). o Palpate carotid arteries gently to assess pulse strength and symmetry. Considerations: Safety: Avoid excessive pressure on carotid arteries. Patient Comfort: Explain procedures to reduce anxiety. Documentation: Record findings accurately, noting any abnormalities. Sample Situational Problem: Scenario: A patient presents with shortness of breath and visible jugular venous distention. o Assessment Findings: ▪ Auscultation reveals an S3 sound. ▪ JVD observed at 45°. ▪ BP: 150/95 mmHg, HR: 110 bpm. o Interpretation: Likely heart failure. o Intervention: Notify the healthcare provider, monitor vital signs, and elevate the patient’s head to 45° to improve venous return. 5. Heart and Neck Vessels Assessment Anatomy: The heart is a muscular organ that pumps blood throughout the body. It consists of four chambers: o Atria: The two upper chambers that receive blood. o Ventricles: The two lower chambers that pump blood out of the heart. Blood Vessels: o Arteries: Carry oxygenated blood away from the heart. o Veins: Carry deoxygenated blood back to the heart. Neck Vessels: Carotid Arteries: Supply blood to the head and neck. Jugular Veins: Drain blood from the head and neck. Abnormalities, Heart Sounds, and Murmurs: 12 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM Heart Conditions: o Coronary Artery Disease (CAD): Narrowing of the coronary arteries, reducing blood flow to the heart muscle. o Heart Failure: The heart's inability to pump enough blood to meet the body's needs. o Arrhythmias: Irregular heart rhythms. o Valvular Heart Disease: Damage to the heart valves, affecting blood flow. Heart Sounds: o S1: The first heart sound, caused by the closure of the mitral and tricuspid valves. o S2: The second heart sound, caused by the closure of the aortic and pulmonic valves. o S3: An abnormal heart sound, often heard in heart failure or other conditions. o S4: An abnormal heart sound, often heard in conditions like hypertension or aortic stenosis. Heart Murmurs: Abnormal heart sounds caused by turbulent blood flow through the heart or great vessels. Examinations: Inspection: o Jugular Venous Distention (JVD): Assess for distention of the jugular veins, indicating increased venous pressure. o Precordial Movement: Observe for any visible pulsations or heaves over the heart. Palpation: o Apical Impulse: Palpate for the point of maximal impulse (PMI), the location where the cardiac impulse is most strongly felt. o Thrills: Palpate for vibrations over the heart or vessels, indicating turbulent blood flow. Percussion: o Cardiac Borders: Percuss the heart borders to estimate heart size. Auscultation: o Heart Sounds: Listen to heart sounds (S1, S2, S3, S4) and murmurs using a stethoscope. o Carotid Arteries: Auscultate for bruits, abnormal sounds indicating turbulent blood flow. Nursing Procedures: Health History: Ask about risk factors for heart disease, such as family history, smoking, hypertension, diabetes, and high cholesterol. Symptoms: Inquire about chest pain, shortness of breath, fatigue, palpitations, and edema. Physical Examination: ASSESSMENT OF THE PERIPHERAL VASCULAR SYSTEM Assessing the peripheral vascular system is an essential part of a physical exam, as it evaluates the blood vessels outside the heart and brain, including arteries, veins, and capillaries. This ensures the identification of circulation issues, vascular diseases, and related complications. 13 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM 1. Anatomy of the Peripheral Vascular System Components of the Peripheral Vascular System Arteries: Carry oxygen-rich blood away from the heart to the body. These have thick, muscular walls to handle high-pressure blood flow. o Major Arteries: ▪ Upper Extremities: Brachial, radial, ulnar. ▪ Lower Extremities: Femoral, popliteal, posterior tibial, dorsalis pedis. Veins: Carry oxygen-poor blood back to the heart. These vessels have thin walls with valves to prevent backflow. o Types of Veins: ▪ Deep Veins: Femoral, popliteal. ▪ Superficial Veins: Great saphenous vein. ▪ Perforator Veins: Connect deep and superficial veins. Capillaries: Microscopic vessels where nutrient and gas exchange occurs between blood and tissues. Lymphatic System: Drains excess fluid from tissues, filters it through lymph nodes, and returns it to the bloodstream. Components include lymph vessels and nodes, such as inguinal and axillary nodes. 2. Abnormalities, Causes, and Complications Common Peripheral Vascular Abnormalities 1. Peripheral Artery Disease (PAD): o Definition: Narrowing or blockage of arteries, often due to atherosclerosis. o Symptoms: Leg pain during walking (claudication), cold feet, poor wound healing. o Complications: Gangrene, amputation. 2. Deep Vein Thrombosis (DVT): o Definition: Blood clot formation in a deep vein, typically in the legs. o Symptoms: Swelling, redness, warmth, and pain in the affected leg. o Complications: Pulmonary embolism (PE) if the clot travels to the lungs. 3. Varicose Veins: o Definition: Enlarged, twisted veins caused by valve dysfunction. o Symptoms: Visible, swollen veins; aching; heaviness in legs. o Complications: Chronic venous insufficiency, ulcers. 4. Chronic Venous Insufficiency (CVI): o Definition: Poor blood return due to damaged valves in veins. o Symptoms: Edema, skin discoloration, venous ulcers. o Complications: Infection, cellulitis. 5. Lymphedema: o Definition: Swelling due to lymphatic obstruction. o Symptoms: Painless swelling, thickened skin. o Complications: Infection, impaired mobility. 6. Other Conditions: o Aneurysms: Bulging of a weakened arterial wall (e.g., abdominal aortic aneurysm). o Raynaud's Disease: Spasm of small arteries, causing color changes in fingers/toes (white, blue, red). 3. Examination of the Peripheral Vascular System 14 | HA by CJAA NCM 102 – REVIEWER MIDTERMS EXAM Preparation: Ensure a warm, well-lit environment (cold can cause vasoconstriction). Position the patient comfortably, with extremities exposed. Inspection: Observe skin color (pallor, cyanosis, redness), texture, and temperature. Look for swelling, ulcers, or abnormal vein patterns. Assess nail beds for capillary refill (normal: