Assessing Cardiovascular & Peripheral Vascular Systems PDF

Assessing the Cardiovascular & Peripheral Vascular Systems AMANDA ROHDE, DNP, AGNP, CRNP, CNE ThePhoto by PhotoAuthor is licensed under CCYYSA. Assessing the Heart and Neck Vessels Objectives u Discuss risk factors for coronary artery disease (CAD) acros...

Assessing the Cardiovascular & Peripheral Vascular Systems AMANDA ROHDE, DNP, AGNP, CRNP, CNE ThePhoto by PhotoAuthor is licensed under CCYYSA. Assessing the Heart and Neck Vessels Objectives u Discuss risk factors for coronary artery disease (CAD) across cultures, considering SDOH, and ways to reduce one’s risks u Discuss case study and patient presentation as they relate to cardiovascular assessments u Interview a client for an accurate history of the heart and neck vessels u Perform a physical assessment of the heart and neck vessels using the correct techniques of inspection, auscultation, palpation, and percussion u Differentiate between normal and abnormal findings of the heart and neck vessels u Describe findings frequently seen when assessing the older client’s heart and neck vessels Heart Disease Causes and Symptoms Subjective Data Objective Data Pathophysiology Potential Diagnosis Chest pain or Abnormal VS Obstruction of Coronary Artery discomfort Abnormal EKG Flow Disease or Occlusion Chest pain Abnormal VS Myocardial STEMI or discomfort Abnormal EKG Ischemia / infarct NSTEMI Fatigue Abnormal VS Myocardial Cardiomyopathy SOB Edema relaxation / Heart Failure Extra heart sounds contraction Palpitations Abnormal VS Abnormal cardiac Atrial fibrillation Fatigue Abnormal EKG rate or rhythm Tachycardia Coronary Artery Disease u Risk factors u Subjective & Objective Findings u Myocardial Ischemia (cell injury) vs. Myocardial Infarction (cell death) o Chest pain (same for all patients?) o EKG changes: STEMI or NSTEMI o Labs: elevated cardiac enzymes (troponin) o Interventions (time sensitive?)  Cath lab (imaging, stent placement, angioplasty)  Coronary Artery Bypass Graft (CABG)  Medications (antilipidemics, anticoagulants)  Heart Transplant CAD and Social Determinants of Health (SDOH) u Culture/Ethnicity u Income/Employment u Education u Living Environment u Community/Neighborhood u Transportation u Social Support u Access to care u Opportunities to learn throughout the lifespan  The 5 A’s of Smoking Cessation  Ask about current smoking status  REDUCE Risk Factors:  Advise to quite; provide information on benefits of quitting - Consider lifestyle  Assess willingness to quit risk factors  Assist with finding resources and making a plan - Assess readiness to quit for change - Educate on risk  Arrange for follow-up appointments to help with adherence to plan for quitting reduction Left Ventricular Hypertrophy uLeft Ventricle wall thickening oHeart muscle overworked (why/how?) oStiff and/or weak LV muscle oAffects cardiac output uSubjective Findings oSOB w/ activity oFatigue oChest pain oHeart palpitations oDizziness or fainting uObjective Findings oDisplaced apical pulse oChange in heart rhythm Case Study Mrs. Lim is a 63 yo female who was admitted to your unit with complaints of fatigue, shortness of breath, and leg swelling PMH: Hyperthyroidism, High Cholesterol, Obstructive Sleep Apnea You are the nursing student who is sent to take a history of the patient's current illness and conduct a focused physical exam. Let's follow her case... Case Study: History Taking What SUBJECTIVE data would you collect for a focused cardiac exam? u C O L D S P A & Focused ROS o Ask about presence of chest pain! u Lifestyle o Diet & exercise o PO intake (fluid, sodium) o Preventative healthcare o Tobacco & alcohol use u Family history o Cardiac disease What else do you want to know? o Obesity o Diabetes o Varicose veins Case Study: Mrs. Lim's HPI (Subjective) u About three days ago I was unable to get my shoes on because my feet were so swollen. I've been wearing slippers since then u I've been sleeping on my recliner chair because I feel like I'm drowning when I'm lying flat in bed u I couldn't catch my breath going upstairs to my bedroom, so I slept in the living room last night u My chest doesn't hurt but I feel really tired, and my legs feel heavy u This has only happened to me once before, but it was during vacation, so I just thought it happened because it was so hot there u What other questions do you have for Mrs. Lim? Case Study: Physical Exam What OBJECTIVE data would you gather for a focused cardiac exam? u VS u Fluid Status u Heart Sounds o Edema  Extra Heart Sounds—S3, S4 o Weight gain (sudden?)  Murmurs o Jugular Venous Pressure/Distention u Cardiac Rhythm  EKG, telemetry? u Considerations for Older Adults o Caution palpating head and neck u Lung Sounds vessels (avoid occluding vessel)  Crackles o Difficult to get apical pulse (d/t increased chest diameter) Inspection & Palpation of head and neck vessels u Inspect & Palpate o Carotids o Jugular vein u Auscultate for bruits o BEFORE palpating u Measure Jugular Venous Pressure Auscultation of heart sounds u Produced by valve closure o Normal heart sounds: “lub, dub” (S1, S2) o Extra heart sounds: gallops (S3, S4) u Auscultate to identify o “Normal” S1, S2 o Abnormal sounds Case Study: Mrs. Lim's Physical Exam Findings (Objective) u Vital Signs: o Pulse Ox = 93% on RA, Respirations 24/min o BP 150/96, HR = 79 u 3+ pitting edema u S3 heart sounds u Crackles in bilateral lung bases u Up 18 lbs from her "dry weight" u Decreased sensation in lower extremities u Unable to palpate apical impulse u Weakened lower extremity pulses (1+), bounding upper extremity pulses (4+) u Dry and cracking skin on BLE u Jugular Venous Distention (JVD) u EKG: normal sinus rhythm Physical Exam: Normal vs Abnormal Findings Normal Findings Abnormal Findings u Inspection u Inspection o No JVD o Prominent Jugular Vein pulsations/JVD u Auscultation u Auscultation o S1, S2 o Extra Heart Sounds (S3, S4) o No murmurs, clicks, rubs o Adventitious Heart Sounds o Aortic pulse at 4th/5th ICS o Aortic pulse displaced o No carotid bruits o Carotid bruits u Palpation u Palpation o No lift, heave, or thrill o Palpable lift, heave, or thrill o Lymphnodes soft, movable, non-tender o Lymphnodes firm, tender, unmovable Murmurs & Grading Grading = 1 – 6 (Sometimes referred to as I – VI) Case Study The cardiologist comes to examine Mrs. Lim... When leaving the room, she confirmed your finding of an intermittent S3 heart sound, but also noted the presence of a Stage II diastolic murmur, which is new. She thinks the patient's new murmur is associated with Aortic regurgitation u What causes a diastolic murmur? o Weakened heart valve or chamber o Increased blood velocity (d/t increased fluid volume) u Where would you place your stethoscope to auscultate for an Aortic murmur? o Left sternal border, 3rd or 4th ICS (Erb's Point) o Sound is heard where blood flows back into the Left ventricle from the Aortic valve Case Study: The Nursing Process What are some priority When would you need to interventions that you expect notify the provider? to perform while caring for Mrs. Lim? u Increased need for supplemental oxygen u Restrict fluid intake u Hypotension u Strict I/O's u Chest pain u Daily weights u Changes in cardiac rhythm u O2 supplementation u Changes in mental status u Administer diuretics u Decreased urine output Case Study: Diagnosis & Plan of Care Mrs. Lim was diagnosed with Acute Heart Failure & Stage II Diastolic Murmur. Before discharge, you will provide patient education for continued care at home and follow up. What will you prioritize? u Fluid Restrictions u Medications u Diet changes u Physical activity u When to seek emergency care Assessing the Peripheral Vascular System Learning Objectives Discuss risk factors associated with peripheral vascular disease across the cultures and ways to reduce one’s risks. Interview a client for an accurate nursing history of the peripheral vascular system. Perform a physical assessment of the peripheral vascular system using the correct techniques. Differentiate between normal and abnormal findings of the peripheral vascular system. Describe the findings frequently seen with assessing the older client’s peripheral vascular system.  Review: Arteries u Carry oxygenated, nutrient- rich blood from the heart to the capillaries u Major arteries of arm: brachial, radial, ulnar u Major arteries of the leg: femoral, popliteal, dorsalis pedis, posterior tibial https://study.com/academy/lesson/major-arteries-of-the- body.html Review: Veins u Carry deoxygenated, nutrient- depleted, waste-laden blood from the tissues back to the heart u Three types of veins o Deep veins  Femoral & Popliteal o Superficial veins  Saphenous veins o Perforator veins  Connect superficial + deep veins https://www.alamy.com/stock-photo-human-veins-artwork- 55438792.html Review: Lymphatic system Lymphatic capillaries, lymphatic vessels, lymph nodes Capillaries and fluid exchange Small blood vessels Form the connection between the arterioles and venules Allow the circulatory system to maintain vital equilibrium Peripheral Vascular System: Risk Factors Peripheral Vascular System: Reduce Risk Factors Diet Eat foods low in saturated fats Weight Maintain a healthy weight management Exercise Exercise regularly: aim for >30 min at least 5 times/week, after getting provider approval Smoking cessation Quit smoking if you're a smoker Blood sugar If you have Diabetes, keep blood sugar under control Cholesterol levels Lower your cholesterol and blood pressure levels, if elevated Ask your healthcare provider about screening with an Ankle-Brachial Index (ABI) measurement once you Screening reach 50 yrs of age Case Study Mr. Pars is a 59 yo male who came to the community clinic with complaints of skin discoloration on his legs and changes in sexual function PMH: Hypertension, Diabetes, CAD, High Cholesterol, COPD You are the nursing student who is sent to take a history of the patient's current illness and conduct a focused physical exam. Let's follow his case... Case Study: History Taking What SUBJECTIVE data would you collect for a focused peripheral vascular exam? u C O L D S P A & Focused ROS  Lifestyle o Skin changes (discoloration) o Diet & physical activity levels o Changes in hair distribution o Preventative healthcare o Leg pain, heaviness, or aching o Smoking, etoh intake o Varicose veins o Stress & coping mechanisms o Leg sores or open wounds o Medications (oral birth control) o Swelling in legs or feet  Family history o Swollen glands or nodules o Cardiovascular & Peripheral vascular disease (vericose veins, PAD) o Sexual function/activity changes o Obesity o Diabetes, HTN, CAD, elevated What else do you want to know? cholesterol/triglycerides Case Study: Mr. Pars' HPI (Subjective) u About six months ago, my son noticed that the skin on my feet and lower legs was changing color u There is also this dark wound where I stubbed my toe last month. It doesn't seem like it's healing u When I walk home from the parking garage or go up the stairs at work, I get a sharp pain behind my knees u Honestly, I was dealing with all of those other things just fine. But when I started having issues with my performance in the bedroom, I decided I really needed to come see you about all this stuff u What other questions do you have for Mr. Pars? Case Study: Physical Exam What OBJECTIVE data would you gather for a focused peripheral vascular exam? u Upper extremities o Inspect: size, edema, venous pattern, skin color, clubbing o Palpate: temperature, cap refill, pulses, epitrochlear lymphnodes u Lower extremities Inspect: color, hair distribution, edema, lesions/ulcers, thrombophlebitis, varicose veins Auscultate: femoral artery for bruit Palpate: temperature, pulses, superficial lymphnodes  If pulses nonpalpable, locate with doppler u Considerations for Older Adults?? (hair distribution, lymphnodes, variscosities) Inspection & Palpation of the Upper Extremities: Performing an Allen's Test A. Occlude radial and ulnar arteries while client makes a fist. B. Continue occluding arteries while client releases fist. C. Remove pressure on ulnar artery while observing color return to palm. Inspection & Palpation of the Lower Extremities: Testing for Arterial Insufficiency u Test for arterial insufficiency by elevating the legs (A) u Followed by having client dangle the legs (B) u Marked pallor of foot when elevated—seen in arterial insufficiency (C) u Persistent rubor of dependent foot—seen in arterial insufficiency (D) C D Arterial vs Venous Insufficiency Finding Arterial Insufficiency Venous Insufficiency Pain Ranges from: Intermittent Aching or cramping pain Claudication --> sharp, Feeling of heaviness unrelenting, constant pain Pulses Diminished Present? Absent May be difficult to palpate with presence of edema Skin Characteristi Dependent rubor Diaphoresis cs Discoloration (red/purple) Discoloration (darkened) Shiny, thin skin Varicose veins Necrotic wounds Edema Sparse or absent hair Lesions/Ulcers (non-healing) Inspection & Palpation of the Lower Extremities: Arterial vs Venous Disease PAD PVD Case Study: Mr. Pars' Physical Exam Findings (Objective) u Skin on lower extremities is cool to touch, thin, and shiny u Dry, black wound on Left big toe u Decreased hair on lower extremities u Nonpalpable Left pedal pulse—found w/ doppler; 2+ Right pedal pulse u Dependent rubor u Varicose veins on bilateral lower extremities u Presence of a Left femoral artery bruit u Decreased sensation in lower extremities u Positive (+) Allen's Test in upper extremities u No signs of DVT or thrombophlebitis in BLE Physical Exam: Normal vs Abnormal Findings Normal Findings Abnormal Findings u Warm to touch u Cool to the touch u Presence of hair u Absence of hair u Dry u Diaphoretic u Appropriate color for ethnicity u Discoloration, mottling u 2+ pulses u Pulses less than 2+ u Absence of bruit u Presence of bruit u Cap refill < 2 sec u Delayed cap refill u No clubbing u Clubbing u Skin intact u Skin breakdown Case Study The Nurse Practitioner comes to examine Mr. Pars... When leaving the room, they confirmed your finding of a Left femoral bruit and nonpalpable Left pedal pulse. The NP also wants to schedule a diagnostic test (penile doppler Ultrasound) to check for blood flow to the penis, during and after erection. In addition to this, blood tests will be ordered to assess the progression of Mr. Pars diagnosis of Diabetes. u What could be some causes of Erectile Dysfunction, other than PAD? Stress or other mental health concerns Chronic diseases such as Diabetes, Hypertension, High cholesterol, or Sleep Apnea Structural abnormalities or defects of the penis u Why are we assessing his diabetes status in relation to PAD? Diabetic neuropathy could be the cause of decreased sensation or non-healing wounds Uncontrolled Diabetes increases the risk of cardiovascular problems, including PAD Case Study: The Nursing Process What are some priority What findings might require Mr. interventions that you expect Pars to be referred to a to perform while caring for Mr. specialty provider or to the Pars? hospital? u Assess for decreased or absent u Loss of sensation to lower extremity peripheral perfusion u Significantly changes in VS u Offer comfort measures: warm u Infection or gangrene of wound blanket, pain management (assess for osteomyelitis) u Perform wound care on Left toe u Absent lower extremity pulses, even u Explain purpose/procedure of with doppler further diagnostic testing u Changes in bowel and/or bladder u Offer reassurance about function treatment options for ED u Chest pain, SOB or other u Educate on risk reduction cardiovascular symptoms Case Study: Diagnosis & Plan of Care Mr. Par was diagnosed with Peripheral Artery Disease & Erectile Dysfunction Before he leaves the clinic, you will provide patient education for continued care at home and follow up. What will you prioritize? u Quit smoking if you’re a smoker; seek a smoking cessation program u If you have diabetes, keep your blood sugar in good control u Exercise regularly. Aim for 30 minutes at least five times a week with approval of health care provider u Maintain normal cholesterol and blood pressure levels if elevated u Eat a well-rounded diet and foods that are low in saturated fat u Maintain a healthy weight u Ask your health care provider about screening with an ABI measurement u DO NOT take medications prescribed for ED with other fast-acting vasodilators (Nitroglycerin tabs) questions? This Photo by Unknown author is licensed under CC BY-NC. Welcome to Week 2 Johns Hopkins School of Nursing Learning Objectives 1. Obtain an accurate nursing history of the nutrition status, skin, hair, nails, neck, Head, Eyes, Ears, Nose, Throat (HEENT), mouth, and sinuses. 2. Perform a physical assessment of the skin, hair, nails, neck, mouth, sinuses, and HEENT. 3. Differentiate between normal and abnormal findings of the skin, hair, nails, neck, mouth, sinuses, and HEENT. 3  Week 2: Assessing Nutritional Status Johns Hopkins School of Nursing Assessing Nutritional Status – Highlights ► Nutrition The process by which substances in food are transformed into body tissues and provide energy for the full range of physical and mental activities that make up human life. – Essential nutrients: carbohydrates, proteins, fats, vitamins, minerals, and water ► Nutritional Status Results from the relationship or balance between nutrient intake and the body’s requirements, and the body’s ability to digest, absorb, and use the nutrients. ► Nutritional Assessment Identifies risk factors for obesity (excessive body fat) and for dietary deficits (malnutrition and undernutrition). Assesses hydration status. 5 Assessing Nutritional Status – Highlights ► Hydration - Recommend at least 64 ounces daily (8 glasses) ► Dehydration Clinical findings: electrolyte imbalances, tenting (skin turgor), thready pulse, low BP, increased HR, sunken eyes, dry tongue ► Overhydration or fluid retention Increased risk in those with kidney, liver, and cardiac diseases (heart failure) – Clinical findings: pitting edema, visible neck veins, ascites, difficulty breathing (heart failure), increased BP, HR can be increased, decreased, or no change ► Food allergies vs intolerances Allergies: mild (hives, eczema, redness, pruritis, N/V/D, abdominal pain) – Severe: anaphylaxis including swelling (lips, tongue, mouth), cyanosis, hypotension, dyspnea… Intolerances result from digestive system irritation (inability to break down) – bloating, N/V/D… 6 Nutritional Status – Subjective Highlights ► What are your height and ► Do you have food allergies ► Describe how your food is usual weight? and/or foods that you stored, cooked, and served. ► Have you lost or gained cannot eat? How is it dated and labeled? weight recently? How much? ► Do you have any chronic ► Do your religious beliefs or Over what period of time? illnesses? culture have dietary ► Are you now or have you ► What current medications, restrictions or recently been on a specific natural herbs, and requirements? diet? 24-Hour Diet Recall. vitamins/supplements are ► Do you follow an exercise ► Any recent changes in you taking? regimen? appetite, taste, or smell? Any ► Do any closely related family recent difficulties chewing or members (grandparents, swallowing? parents, or siblings) have ► Have you had any recent chronic illnesses such as occurrences of vomiting, digestive disorders, heart diarrhea, or constipation? disease, or diabetes? 7 Nutritional Status – Objective Highlights ► Observe client’s general status and appearance. ► Measure height, weight, waist circumference, and BMI Height begins to wane in the fifth decade of life because the intervertebral discs become thinner and spinal kyphosis increases. ► Measure skin turgor, pitting edema, and other signs of fluid imbalances ► Intake and Output (inpatient settings) Fluid is normally retained during acute stress, illness, trauma, and surgery. Imbalances in either direction suggest impaired organ function and fluid overload or inability to compensate for losses, resulting in dehydration. 8 Assessing Nutritional Status – Diabetes Resources USDA - MyPlate Diabetes Plate – American Diabetes Association 9  Week 2: Assessing Skin, Hair, and Nails Johns Hopkins School of Nursing Assessing Skin, Hairs, and Nails – Highlights ► Skin The skin is the largest organ of the body. It is a physical barrier. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The skin also provides individual identity to a person’s appearance. ► Hair Consists of layers of keratinized cells, found over much of the body except for the lips, nipples, soles of the feet, palms of the hands, labia minora, and penis. ► Nails Located on the distal phalanges of fingers and toes, are hard, transparent plates of keratinized epidermal cells that grow from the cuticle 11 Skin, Hairs, and Nails – Subjective Highlights ► Are you experiencing any current skin ► Have you had any hair loss, problems such as rashes, lesions, dryness, unusual increase in hair growth, or oiliness, drainage, bruising, swelling, or change in the condition of your changes in skin color? hair? Describe. ► How long have you had this symptom? ► Are you experiencing any pain, ► What aggravates the problem? itching, tingling, or numbness? ► What relieves it? ► Have you had any change in the ► Have you tried any over-the-counter condition or appearance of your remedies or been prescribed any nails? Describe. medication for the problem? 12  (Cyanosis, Jaundice, Macule, Purpura, Hematoma, Objective Highlights Papule, Petechia, Vesicle, Ecchymosis, Cyst, Pustule, Wheal/Hive) 13  (Spider angioma, Fissure, Keloid scar, Ulcer, Name That Skin Lesion Telangiectasis, Cherry angioma) 14  (Mole, Skin tag, Vitiligo, Striae) Name That Skin Assessment 15  Skin Cancer What is the most serious skin cancer? Skin Cancer risk factors: ABCDE Sun exposure Malignant Melanoma A = Asymmetry Moles Fair skin B = Border Light hair Basal Cell Carcinoma (BCC) C = Color Age Actinic keratosis D = Diameter Family History/genetics E = Evolving Ultraviolet radiation Squamous Cell Carcinoma (SCC) 16  (Folliculitis, Alopecia, Tinea capitis, Lice) Name That Hair Assessment 17  (Paronychia, Koilonychia, Pitting, Name That Nail Condition Longitudinal ridging, Yellow nail syndrome) 18 Methicillin Resistant Staphylococcus aureus (MRSA) ► Clinical manifestations Appear as an infected area (can be from broken skin such as a cut) Erythema Edema Pain Warm to the touch Pus and drainage (blister) Patient may have a fever ► Serious infection that requires antibiotic treatment (e.g., Vancomycin) Complications include sepsis, respiratory failure, amputation, death 19 Assessing Skin, Hair, and Nails – Highlights 20  Week 2: Assessing the Head and Neck Johns Hopkins School of Nursing Assessing the Head and Neck – Highlights Family History of Headaches/Migraines Concussion, stroke, head injury Medications, supplements, herbs Headaches, nosebleeds, nasal drainage, sinus pressure Lifestyle/Health practices Any new lumps or lesions Dizziness, lightheadedness, loss of consciousness Trouble chewing or swallowing Weakness or numbness Radiation Smoking/ETOH/Recreational drugs Posture Movement of head and neck 22 Assessment - Head Headache? HIT it! 23  Assessment - Face Inspection of the Face Symmetry Features Movement Expression Skin condition You are speaking to your patient and suddenly you notice one side of their face has a slight droop and although their voice sounds a bit garbled, it seems they are saying they are having trouble with their vision. What is your assessment? 24 Assessment - Face Palpation Temporal artery Tenderness, warmth, thickness TMJ What is the TMJ assessment process? Place index finger over front of each ear, have patient open and close jaw What are you palpating for? Crackling, ROM, pain 25 Assessment - Neck Inspection/Observation ROM - smooth movement Lymph nodes Trachea - looking for deviation from midline Thyroid - “Adam’s apple” - usually assessed from behind patient ( in front of patient if necessary) - have patient swallow water - looking for symmetrical movement 26 Assessment – Thyroid Dysfunction 27 Lymphatic System Palpation of Lymph Nodes Have patient sit in upright position Palpate in a walking, gentle, circular manner Compare size/shape, delimitation, mobility, consistency and tenderness What is the term for lymph nodes that are > 1cm? 28  (Cushing Syndrome, Lymphadenopathy, Abnormal findings of head and face Acromegaly, Goiter) 29  Week 2: Assessing the Eyes Johns Hopkins School of Nursing Subjective data assessment of the eyes What questions would you ask in collecting subjective data during your eye assessment? Any recent visual changes? Do you experience floaters? Do you experience blind spots? Do you have difficulty seeing at night? Are you experiencing double vision? Do you experience any sensitivity to light? Do you have any eye pain or itching? Do you have any redness, swelling or discharge? What medications do you take? Have you been tested for glaucoma? Do you wear glasses? 31 Assessment - Eyes What is this? Snellen chart What are we testing for? Distant Visual Acuity How is it used? ü Client covers one eye and reads chart top to bottom ü Top number is? always 20 as it represents distance from chart ü Bottom number is? the last full line the client could read ü Document if patient was wearing glasses 32 Assessment - Eyes What is this test? Jaeger test What are we testing for? Near visual acuity How is it used? ü Held approximately 14 inches from eye, read with alternate eye covered then both eyes together ü Documented by smallest line read 33  Assessment - Eyes q Eyelids and eyelashes Unequal q Alignment of eyeball pupils q Lacrimal apparatus This is called… q Sclera Anisocoria q Conjunctiva q Pupils Dilation of the Constriction pupil. This is of the pupil. called… This is Mydriasis called… Miosis 34 Assessment - Eyes What are we testing for in this picture? Accommodation and convergence of pupils How is this test performed? ü Hold object away from client ü Slowly move toward nose ü Look for accommodation and convergence 35 Assessment - Eyes What are we assessing in this picture? Cardinal fields of gaze How is this performed? ü Have patient track object with eyes What are we looking for? Smooth and Symmetrical eye movements What is this? Nystagmus What may be the cause if eye movements are not smooth and symmetrical? What is Weak extraocular muscles; dysfunction of nystagmus? cranial nerve Oscillating movement of the eye 36 Assessment of Eyes You ask the patient to stare at your eye or nose with one eye closed (your corresponding eye closed as well). Hold your hand off to the side and have them tell you how many fingers you are holding up. What is this test? What are we testing? 37  (Pterygium, Ptosis, Exophthalmus, Ectroption, Abnormalities of the eye Arcus Senilis, Blepharitis) 38 Abnormalities of the eye (Scleral jaundice, Subjunctival hemorrhage, Cataracts, Glaucoma) 39  Week 2: Assessing the Ears Johns Hopkins School of Nursing Assessment of Ears – Subjective Data What question would you ask? ü How is your hearing? ü Have you had any trouble hearing? ü Have you had any ear infection, discharge from ears, pain? ü Any dizziness? ü Ever feel like the room is spinning? ü Ever hearing a buzzing, crackling, whistling or ringing sound? ü Any pain? ü Ear infections? ü Trauma to ears? 41  What is happening here? Patient A states, “Sometimes, I suddenly feel like the room is spinning. I feel like I am being pulled to one side and can’t keep my balance. I even get nauseous.” What do you think your patient is experiencing? What may cause this? Labyrinthitis (inflammation of inner ear or auditory nerve) Ear infection Meniere’s Disease (inner ear disorder) 42 Inspection and Palpation Inspection Auricle – redness, swelling Ear canal - use of otoscope to inspect ear canal and tympanic membrane for redness, swelling, discharge, foreign bodies Tympanic membrane – use of otoscope to inspect for color and contour Grasp auricle firmly but gently and pull upward and outward to straighten ear canal Palpation Auricle – lumps, tenderness 43 Assessment - auditory What is the Whisper test and how do you perform the Whisper test? Have patient cover tragus Stand 1-2 feet behind patient Whisper two syllabus word Ask patient to repeat word Repeat on opposite ear 44  Assessment - Auditory What is the Weber test and how do you perform the Weber test? Evaluates conduction of sound waves through bone Strike tuning fork with back of hand and place in center of head or forehead Sound is heard better in affected ear with conductive hearing loss Sound is heard better in unaffected ear with sensorineural hearing loss 45  Assessment - Auditory What is the Rinne test and how do you perform the Rinne Test? Place the base of a struck tuning fork on the mastoid bone behind the ear. Have the patient indicate when sound is no longer heard. Move fork (held at base) beside ear and ask if now audible. In a normal test, AC > BC; patient can hear fork at ear. With conductive loss, BC > AC; patient will not hear fork at ear. AC = Air conduction BC = Bone conduction https://www.uptodate.com/contents/image?imageKey=PC%2F58032&topicKey=PC%2F15359&source=see_link 46 Assessment - Auditory What is the Romberg test and how do you perform the Romberg Test? Inner ear problems Patient stands with feet together and arms at sides Closes eyes for approximately 20 seconds Observe for swaying If significant swaying or need to step forward, Romberg test is positive – possible vestibular disorder 47 Abnormal findings What is Otalgia? Earache What is Tinnitus? Ringing or other noises in one or both ears What is Presbycusis? Gradual hearing loss commonly related to aging 48  Otitis Media, Otorrhea, Otitis Externa, Cerumen. Abnormal findings Tophi 49  Week 2: Assessing the Mouth, Throat, Nose, and Sinuses Johns Hopkins School of Nursing Gathering Subjective Data for Mouth, Nose and Throat What questions would you ask? Pain Change or loss of taste or smell Drainage from nose Difficulty breathing through nostrils Mouth lesions/ulcers Redness, swelling, bleeding Swallowing Sore throat Allergies Cancer Smoker/ETOH Grind teeth Dentures Bad breath 51 Vocabulary Epistaxis Odynophagia Anosmia Gingivitis Ageusia Halitosis Dysphagia Xerostomia 52 Nose Throat and Sinuses Equipment: Penlight Nasal speculum attached to otoscope Gloves Cotton gauze pads Tongue blade Inspection Palpation 53 Objective data collection of mouth Inspect the lips Inspect the teeth Inspect the buccal mucosa Inspect and palpate the tongue Palpate and percuss sinuses 54  (Vitamin B12 deficiency, Candida Albicans, Abnormalities of the mouth Acute tonsillitis, Canker sore, Black Hairy tongue) 55 Assessment of Throat and Tonsils Throat Inspect for color consistency Where is the Uvula? Midline Tonsils Grading scale: 0 Tonsil have been removed 1+ Tonsils are visible 2+ Tonsils are midway between tonsillar pillars and uvula 3+ Tonsils touch the uvula 4+ Tonsils touch each other (kissing tonsils) 56 Assessment of Nose Inspect and palpate Color Shape Tenderness Symmetry Patency of airflow Septum Mucosa Masses/polyps 57 Assessment of Sinuses Palpate for tenderness (Frontal and maxillary sinuses) 58 Question 1 ► You are completing a health assessment on a new client. You note that the client has dry, brittle hair and dry, flaky skin with poor turgor. What might this indicate? a) Excessive physical activity b) Poor personal hygiene c) Poor nutritional status d) Damage from an environmental cause 59 Question 2 ► The nurse is using the mneumonic ABCDE to assess a client’s mole. What should the nurse document for the C? a) Color b) Category c) Consistency d) Characteristics 60 Question 3 ► A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the least several months. She claims to frequently feel lethargic and listless and states that, “I can never seem to get warm, no matter what the thermostat is set at.” How should the nurse proceed with assessment? a) Order tests to rule out an overactive thyroid gland b) Assess for other signs and symptoms of Cushing’s syndrome c) Palpate the patient’s parotid gland for enlargement d) Assess the patient for hypothyroidism 61 Question 4 – NGN (Bowtie) 62 Question 4 63 Question 5 ► An older adult client presents at the clinic, reporting otalgia in the right ear. Physical assessment reveals cerumen impacted in the client’s ear. Removing this mechanical blockage may have what outcome for this client? (Select all that apply). a) Increase the size of ear canal b) Provide less rigidity in outer ear c) Improve hearing d) Enhance socialization e) Prevent injury 64 Question 6 ► A clientis having their tonsils removed. The client asks the nurse what function the tonsils serve. Which of the following would be the most accurate response? a) “The tonsils aid in digestion.” b) ”The tonsils help to guard the body from invasion of organisms.” c) “The tonsils contain nerves that provoke sneezing.” d) “The tonsils regulate the airflow to the bronchi.” 65  ► Silvestri, L. A., & Silvestri, A. E. (Eds.). (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). References Elsevier, Inc. ► Weber, J. & Kelley, J. (2022). Health assessment in nursing (7th ed.). Philadelphia: Lippincott, Williams, & Wilkins. ► Image credits are listed in the notes section on applicable slides. Otherwise, image credits are for Weber & Kelley, 2022. 66 Questions? Week 3 Thorax, Lungs and Breasts  Subjective Data – Lung Assessment HX of present illness When did symptoms begin What symptoms are you experiencing How have symptoms changed What makes symptoms better or worse Any recent infections or illness PMHX Hx of respiratory conditions Chronic respiratory illness Lifestyle and Health Practices Lung or chest surgery Smoker Ever had TB or exposure to TB Secondhand smoke Family HX Work environment Family members with respiratory illness Diet Any genetic respiratory conditions Exercise Stress Medications Current medications Any adverse effects from new meds Any home remedies Reference lines Anterior Posterior Lateral  Lungs Which lung has three lobes? Right Why? Parietal Pleura Visceral pleura Pleural space Pt is dehydrated. What sound might you hear when auscultating lungs? Hint: Sounds like a rough grating sound. Answer: Pleural rub Pt has the pneumonia (PNA). Pt complains of pain with breathing. What is this called?  Lung Assessment Adventitious breath sounds Vocabulary words of particular interest Dyspnea Cough Orthopnea Paroxysmal Nocturnal Dyspnea Sleep apnea Patient has no history of respiratory issues and is basically healthy. The nurses is auscultating lung sounds and hears some adventitious breath sounds. What might be the cause? What might you ask the patient to do?  Objective data – Lung Assessment Explain Remove clothing from waist up Sit in an upright position Inspection Gown What would you observe related to Stethoscope assessment of the lungs? Color Chest Nails Behavior Respiration Chest expansion What is the order of the lung assessment? Accessory muscles Inspection Palpation Percussion Auscultation Thoracic Assessment - Inspection Pectus excavatum (funnel chest) Barrel chest You are observing your patient during respiration and you notice their chest appears to sink in just below the neck and under the breastbone. You also observe this under the Kyphosis rib cage and in the intercostal spaces. Why is this happening? Scoliosis Patient is attempting to bring more air into the lungs.  Objective data – Lung Assessment Palpation Why are we palpating? What are we palpating for? While palpating, you feel a crackling sensation. What could this be? Crepitus General techniques Examine the posterior thorax and lungs while the patient is sitting Examine the anterior thorax and lungs with the patient supine Compare one side of the thorax and lungs with the other, so the patient serves as his or her own control Proceed in an orderly fashion: Inspect, Palpate, Percuss, and Auscultate  Objective data – Lung Assessment Palpation What is tactile fremitus? You are assessing your patient for tactile fremitus. You place your hands on your patient’s back and ask them to say “99.” Why did you do that? What would be a normal assessment? What does it mean if it is unequal? Objective data – Lung Assessment Percussion What is percussion? Tone Hyperresonance Dullness Resonance Diaphragmatic excursion What is emphysema? During your assessment of your patient with emphysema, what sound would you expect to hear? Objective data – Lung Assessment Auscultation A Apices B Bases Bronchial Vesicular Bronchovesicular Objective data – Lung Assessment You ask your patient to whisper “one- two-three.” What is this called? Auscultation Answer: Whisper pectoriloquy. You ask your patient to repeat “99” while you It is faint, muffled and difficult to hear. auscultate their chest. What is this called? Should you be concerned? Answer: Bronchophony Answer: No. This is normal. During auscultation, you notice it is very easy to Your patient’s documentation states understand the “99” sound. Should you be concerned? “adventitious breath sounds.” What is Answer: Yes. A clearly heard “99” may indicate that? pneumonia Answer: Abnormal breath sounds such as crackles or wheezes. You ask your patient to repeat the letter “E.” What is this called? What can you do to be sure you are Answer: Egophony hearing adventitious breath sounds? Answer: Have patient cough The “E” sounds like “A.” Should you be concerned? Answer: Yes. This is abnormal.  Adventitious Breath Sounds What is asthma? Your patient is admitted to the ED with During your respiratory assessment, you exacerbation of asthma. auscultate a high pitched sound during inspiration. What is the most prominent adventitious How would you document this sound? breath sound you are most likely to hear? Stridor Wheezing What causes wheezing? Inflammation and bronchospasms What factors may have contributed to the Wheezing exacerbation of the patient’s asthma symptoms? Weather, exercise, illness Stridor Crackles  What is happening? (Kussmaul, Cheyne Stokes, Biot) The patient has been admitted to the ICU with a A patient is brought into the Traumatic Brain Injury (TBI). Their respirations are Emergency Department in Diabetic sometimes deep and sometimes shallow with Ketoacidosis (DKA). Their breathing occasional apnea. How will you document this? is rapid and labored.. They appear to be hyperventilating. Answer: Biot How will you document this? Answer: Kussmaul You are a hospice nurse. You have been called to the patient’s home because the family reports the patient’s breathing is now deep and rapid, followed by periods of not breathing at all (apnea). How will you document this? Answer: Cheyne Stokes Breathing Lungs – Patient Education Smoking Dangers of smoking Vaping Resources to quit smoking Environmental Factors Pollution, dust Vaccination Managing chronic respiratory conditions Physical Activity Anaphylaxis Stress Common Thorax and Lung Variations in Older Adults Increased anteroposterior chest diameter Increase in the dorsal spinal curve (kyphosis) Decreased thoracic expansion Use of accessory muscles to exhale At risk for fractures (osteoporosis) Experience dyspnea with aging lungs decreased lung resiliency, loss of elasticity, fewer capillaries) Decreased ability to cough Weakened muscles & increased thoracic wall rigidity  Question What is the difference between kyphosis and scoliosis? Why is it important to know the difference?  Answer Kyphosis- is a rounding of the thoracic spine involving the thoracic vertebrae. Scoliosis – is a lateral deviation of the spine involving the cervical, thoracic, and lumbar vertebrae. Kyphosis may affect the ability to breathe.  Question Which of the following statement about percussion is true? a. Use the lightest percussion that produces a clear note b. Percussion should be done up and down each side of the chest rather than side to side (one side of the chest to the other) c. Strike using the pad of your tapping finger d. The heart normally produces an area of tympany to the left of the sternum from the 3rd to 5th rib interspaces  Answers a. Use the lightest percussion that produces a clear note Percussion should be done side to side (one side of the chest to the other) for comparison Strike using the tip of your tapping finger The heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces  Question Which of the following statements are true about chest pain? a. It originates only from cardiac issues b. It is only associated with anxiety. c. It may arise from cardiac, vascular, gastrointestinal, musculoskeletal or skin pathology. d. Surrounding structures have no affect on chest pain.  Answers C - It may arise from cardiac, vascular, gastrointestinal, musculoskeletal or skin pathology. Chest pain may be associated with anxiety Lung tissue has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura Other surrounding structures may also irritate the parietal pleura leading to pain. Question Which of the following clues would suggest pulmonary or cardiac difficulties? a. Clubbing in fingers b. Cyanosis or pallor in skin, nails, & lips c. Pursed lips d. Flaring nostrils  Answer All are correct a. Clubbing in fingers b. Cyanosis or pallor in skin, nails, & lips c. Pursed lips d. Flaring nostrils  Question Which of the following breath sounds are most often auscultated over the majority of both lungs? a. Vesicular b. Bronchial c. Bronchovesicular d. None of the above  Answer Answer: a. Vesicular Bronchial - usually heard over the manubrium Bronchovesicular - usually heard over the 1st and 2nd interspaces  Question Which physical assessment technique is used to assess temperature, turgor, texture, moisture, vibrations, and shape? a. Inspection b. Percussion c. Palpation d. Auscultation  Answer Answer: C. Palpation Rationale: Palpation is an assessment technique that uses the sense of touch. Inspection is the process of performing deliberate, purposeful observation in a systematic manner. Percussion is the act of striking one object against another to produce sound. Auscultation is the act of listening with a stethoscope to sounds produced in the body Question What are facts regarding Kussmaul respiratory pattern? a. It is irregular breathing b. It is a rapid, deep, labored type of hyperventilation associated with diabetic ketoacidosis. c. It is a decreased rate of breathing. d. This is a breathing pattern usually associated with meningitis. Answer Answer b – Kussmaul breathing pattern - It is a rapid, deep, labored type of hyperventilation associated with diabetic ketoacidosis. Auscultation YouTube Quiz https://www.youtube.com/watch?v=YjfcMYG5aqY  Health Assessment – Breast Subjective Data Current complaint/concern (CC) Swelling or masses Change in shape or size Pain or tenderness Discharge Tender with menses Redness, warmth or dimpling Rash Your patient tells you that one of her breasts Mammograms is larger than the other. She asks you if she should be concerned. What is your History (HX) response? Age of menarche Age of menopause Answer: No. Breasts are often asymmetrical Cancer or biopsy Surgeries/implants/explants/augmentation/reduction What would you ask next? Breastfeeding Mastitis or abscess Answer: Is this new? Family history of breast cancer If complaint of lumps or swelling, ask if changes occur during menstrual cycle Anatomical Landmarks Breasts are paired mammary glands that lie over the muscles of the anterior chest wall. At puberty, female breast tissue enlarges in response to the hormones. Male breast has no true functional capability. Female breast – has 2 functions. For purposes of identifying or describing the location of assessment findings, breasts are divided into 4 quadrants. The upper outer quadrant extends into the axillary area and is called the tail of Spense. Breast Tissue Three types Glandular functional part of the breast that allows for milk production. Fibrous provides support for the glandular tissue (Cooper’s ligaments) Fatty provides most of the substance of the breast and determines size & shape of the breast.  Breasts Examination Techniques Inspection Examine the breasts with arms in various positions. Compare one side to other. Proceed in the order of Inspection then Palpation Breast Palpation Vertical Circular Radial Patient Education Breast Awareness Identify changes Pain Appearance Size Redness Recent Changes Self Breast Exam (SBE) Breast Cancer – Patient Education Male Breast Assessment Breast Cancer Gynecomastia Health Assessment – Lymphatics Lymph Nodes Palpation of Lymph nodes Stages of Lymphedema Your patient had a right side mastectomy. While assessing the patient’s lymph nodes, you notice the right arm circumference is larger than the left and you note some non-pitting edema. Should you be concerned? Why or why not?  Common Variations in Older Adults May have a decrease in size and firmness of breasts (due to decreased estrogen levels) Glandular tissue ↓ and fatty tissue ↑ May have more pendulous and saggy breasts May have smaller, flatter nipples that are less erectile. Breasts may feel more granular  Question Which of the following statements about palpation is true? a. The pads of two fingers are used. b. A side to side swiping motion technique is recommended to palpate the breast. c. It’s important to know the Last Menstrual Period (LMP) when doing palpation. d. Deep palpation is used on all areas of the breast.  Answers c. It’s important to know the LMP. Rationale: Those with fibrocystic breasts may have painful, tender, & lumpy areas in the breasts 2 weeks prior to cycle. Pads of three fingers are used. Circular, Wedge or Vertical strip motion are recommendations. Palpation is light, medium or firm  Question You have a 20 year old female present to the clinic who states that one breast is larger than the other. Your first response should be: a. To reassure her that it is not a problem. b. To ask if this if this is a new problem. c. Make an appointment immediately for the specialty clinical. d. Ask if there are any other symptoms.  Answers b. – Ask if this is a new problem  Question Glandular breast tissue is responsible for a.Providing support b.Determining size c.Determining shape d.Milk production  Answers a.Providing support b.Determining size c. Determining shape d.Milk production  Question Vertical, Circular and Radial are all descriptions of a.Lymph node location b.Mammography angles c. Breast palpation d.Breast tissue  Answers a.Lymph node location b.Mammography angles c. Breast palpation d.Breast tissue  Question Breast cancer risk factors include (Choose all that apply) a.Genetics b.Obesity c. Number of pregnancies d.Caffeine  Answers a.Genetics b.Obesity c. Number of pregnancies d.Caffeine  Question In older adults, common breast variations include a.Decreased glandular breast tissue b.Increased firmness of breast tissue c. Increased estrogen levels d. Decreased fatty tissue  Answers a.Decreased glandular breast tissue b.Increased firmness of breast tissue c. Increased estrogen levels d. Decreased fatty tissue Jeopardy Link https://jeopardylabs.com/play/ha-lecture-review-bltl Thank you for your attention