Exam 2: Respiratory, Cardiac, Immunizations Flashcards Preview

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Flashcards in Exam 2: Respiratory, Cardiac, Immunizations Deck (111):
1

Cardiac: What do you listen for with the client in LLD?

mitral stenosis, S3, S4 - with bell

2

Cardiac: What do you listen for with the client leaning forward?

Aortic regurgitation murmurs - with diaphragm. "breathe in, breathe out, hold"

3

What heart sounds do you hear with the diaphragm?

high pitched: S1, S2, murmurs of AR and MR, AS, friction rubs, VSD

4

What heart sounds do you hear with the bell?

low pitched: S3, S4, diastolic murmurs (e.g. MS)

5

Cardio: what are the characteristics of sounds to be described?

Frequency (pitch) Intensity (loudness) Duration Timing (systole, diastole)

6

What are the valves of the heart?

Atrioventricular: tricuspid & mitral/bicuspid Semilunar: pulmonic & aortic

7

Name the areas of the heart

Q image thumb

RV is most of anterior chest 

Base is superior aspect of heart at R & L 2nd IS

Xiphoid process is good landmark for RV. 

A image thumb
8

Tell me about a normal PMI

4th or 5th interspace, 7-9cm lateral to midsternal (at or just medial to midclavicular) 

Supine diameter: 1-2.5 (about a quarter)

A image thumb
9

Tell me about an abnormal PMI

Larger than 2.5cm (evidence of LVH, or enlargement, as seen in HTN and AS)

Lateral to midclavicular or >10cm lateral to midsternal (LVH)

Xiphoid/epigastric area (COPD)

 

10

Sinus arrhythmia

varies with respiration

normal HSs, though S1 may vary with the HR

11

Atrial or nodal premature contractions

Rhythm: atrial/nodal beat before next expected heart beat. Pause. Rhythm resumes

Heart Sounds: S1 may differ in intensity from normal S1. S2 may be decreased.

12

PVC (sporadic or regularly irregular)

Rhythm: ventricular beat comes before next expected beat. Pause. Rhythm resumes.

Heart Sounds: S1 may differ from normal, S2 may be decreased. Both likely split.

13

Afib & Aflutter w/varying AV block (Irregularly irregular)

Rhythm: ventricular rhythm is totally irregular, though possible short runs of regular-seeming 

Heart Sounds: S1 varies in intensity

14

Paradoxical Pulse

decrease in pulse's amplitude on quiety inspiration (st palpable, but possibly need BP cuff)

Systolic pressure decreases >10mmHg during inspiration

Causes: pericardial tamponade, exacerbatins asthma & COPD, st in constrictive pericarditis

15

pulsus alternans

pulse alternates in amplitude beat to beat even though rhythm is basically regular (must be). 

Indicates LV failure, usually accompanied by S3

16

Normal Pulse Pressure

~30-40 mmHg pulse pressure

 

17

small, weak pulse

Pulse pressure diminished, upstroke may feel slowed, peak prolonged

causes: decreased SV (HF, hypovolemia, severe AS); increased peripheral resistance (exposure to cold and severe HF)

18

Large, bounding pulse

pulse pressure increased, rise and fall may feel rapid, peak brief

Causes: increased stroke volume, decreased peripheral resistance, or both (fever, anemia, hyperthyroidism, AR, AV fistulas, PDA); increased stroke volume d/t slow HRs (bradycardia, complete heart block); decreased compliance/increased stiffness of aortic walls (aging, atherosclerosis)

19

Systolic click

Usually MVP (systolic ballooning into LA from both leaflet redundancy & elongations of chordae tendineae)

Mid to late systolic

High pitched, often followed by MR murmur

several positions recommended: supine, seated, squatting, standing (squatting delays click & murmur, standing moves them closer to S1)

20

Opening snap

very early diastolic sound

stenotic mitral valve

listen with diaphragm medial to apex along lower left sternal border

21

intermittently irregular beats

e.g., ectopic beats - PAC, PVC

22

Continuously irregular beats

a.k.a. "regularly irregular"

Afib: palpittions that warrant ECG

23

Superior view of heart valves

A image thumb
24

What happens during diastole (+atrial kick)

AV valves open, passive flow (about 75% of volume) move into relaxed ventricles, then atria contract & active flow accounts for about 25% into ventricles (atrial kick)

25

isovolumic phase of ventricular systole

interval between closing of AV valves and opening of semilunar valves

26

ECG: define p, qrs, t, u

p: atrial depolarization

qrs: ventricular depolarization

t: ventricular repolarization

u: ventricular diastole

A image thumb
27

ECG leads

6 limb leads, 6 precordial leads

A image thumb
28

CAD risk factors for women

DM, smoking, HTN, obesity

29

questions you ask if chest pain

O: when did pain start? having pain now?

L: where is pain located? Does it radiate?

D: how long have you had pain?

C: what does it feel like? Pressure, tightness, heaviness, stabbing? Associated symptoms?

A: aggravates/alleviates? rest? Nitro?

R: travel to any part of your body?

T: when did you notice? Intermittent or persistent?

 

characteristics: squeezing, discomfort, burning, stabbing

Associated symptoms: cough

Relieved by: rest or nitrogylcerin

30

Special considerations on pediatric cardiac exam

Listen in at least 2 positions

S3 heard through thin chest walls

S4 indicates poorly compliant ventricles - always abnormal

murmurs: should disappear when supine, be systolic, not be assoc w/clicks, rubs, or other sx

school age: may disappear w/sitting

31

What causes S3?

passive flow of blood from atria

slight resistance to filling d/t ventricular overload and/or systolic dysfunction

32

What causes S4? 

vigorous atrial ejection of blood d/t resistance to filling at end of diastole (presystole): decreased ventricular compliance

33

Normal vs abnormal S3

Normal: young adults, children, increased HR, late pregnancy

abnormal: older adult, HTN, volume overload (CHF), MR, high output states (thyroid, anemia)

34

Listening for S3

"Kentucky"

Hooked on back of S2 (after opening snap)

low pitch - apex, LLD, bell

does not vary w/respiration, persists when sitting upright, increases w/isotonic exercise (e.g., sit-ups)

35

Normal vs abnormal S4

Normal: trained athletes, elderly (ventricles become stiff)

Abnormal: systemic or pulmonary HTN, CAD/ischemia, AS/cardiomyopathy, delayed conduction

36

Listening for S4

Q image thumb

"Tennessee"

Hooked on front of S1

Low pitch: LLD, bell

37

What is Split S2?

widening of normal interval beween aortic and pulmonic components of S2 - A valve closes before P valve 

38

Normal vs Abnormal S2 - who and on exam

Physiologic: who - athletes, <40yo; on exam - pulmonic area, on inspiration, louder on reclining, disappears during slow breathing or holding breath

Pathologic: who -  >40; on exam - appears or persists during expiration. May indicate pulmonary stenosis, ASD, RT BBB

 

39

Squatting valsalva and its effect on murmurs

Increases LV volume & increased vascular tone

MVP: delays click, murmur shortens (dec prolapse, harder to hear)

hypertrophic cardiomyopathy: Decreases intensity of murmur (dec outflow obstruction)

Aortic stenosis: increases intensity (inc blood volume ejected into aorta)

40

Standing valsalva and its effect on murmurs

decreseased LV volume, decreased vascular tone

MVP: click earlier, murmur longer (inc prolapse)

hypertrophic cardiomyopathy: increased intensity of murmur (inc outflow obstruction)

Aortic stenosis: decreased intensity of murmur (dec blood volume into aorta)

41

Physiologic murmurs: example causes

exercise, fever, hyperthyroidism, pregnancy, children, anemia

42

Grading of Heart Murmurs

  1. Very faint
  2. Quiet but heard immediately w/stethoscope on chest
  3. Moderately loud
  4. Loud, w/palpable thrill
  5. Very loud, w/thrill. May be heard w/stethoscope partly off chest
  6. Very loud, w/thrill. May be heard w/stethoscope off chest

43

What type of murmur might you hear in each area of the heart?

A image thumb
44

Systolic murmurs: mid, holo, and late

Midsystolic: AS, PS, ASD, HOCM*

Holosystolic: MR, TR, VSD

Late systolic: MVP

 

*Hypertrophic obstructive cardiomyopathy - most common cause of MIs in pediatric population

45

Diastolic murmurs: early, mid/late, other

Early diastolic: AR, PR, Austin-flint

Mid/late diastolic: MS, TS

Other/rare: PDA

46

Murmurs in infants and children

S3 common - be concerned if increased intensity

Murmurs common in newborns until 48h of age - if

Most common cause: CHD. Acquired - rheumatic fever

 

47

Benign pediatric murmurs

Still's murmur: vibratory, groaning, musical. Heard best btwn LLSB and apex. 3-7yo.

Pulmonary: harsh systolic ejection at 2nd/3rd left IS

Venous Hum: continuous humming. Heard best at upper right sternal border in sitting position. Decreases/disappears supine.

48

Vesicular breath sounds

inspiratory longer than expiratory

Soft intensity of expiratory

Relatively low pitch

covers most of both lungs

49

Bronchovesicular breath sounds

inspiratory & expiratory about equal

intermediate intensity of expiratory

intermediate pitch

located 1st & 2nd ICS anteriorly & between scapulae

50

Bronchial

Expiratory longer than inspiratory

loud intensity of expiratory

relatively high pitch

heard over manubrium, larger proximal airways

51

Tracheal breath sounds

Inspiratory & expiratory about equal

very loud expiratory intensity

relatively  high pitch

heard over trachea

52

At what gestational age do alveolar cells secrete surfactant?

24-26 weeks

53

Newborns/Infants & respiration

Newborns: Thorax barrel shaped (shaped like adult at 6yo)

chest & head circumference match

obligate nose-breathers x4 weeks

irregular breathing patterns (apnea 10-15sec)

crackles may be normal

Newborns & infants: thin chest wall, little musculature, ribs soft & pliant, some abd breathing (if increased - possible pulm dz). Chest circumference 30-36cm; Respiratory tree - bifurcation of distal trachea at T3 (adults T4-5)

54

Pregnant women & Respiration

Dyspnea: breathes more deeply but not more frequently

asthma - worse or unaffected

Functional residual capacity decreases

55

Types of immunity

Active Natural: had the dz. Life long immunity

Active Artificial: immunization via altered dz antigen against which body made antigens (most IZs)

Passive Natural: maternal - infant. Short lifespan - infant unprotected at about 2-3mths.

Passive Artificial: Preformed Abs - immune globulins or dz specific globulins. Human or animal products - protect 1-2mths.

56

Types of Vaccines

Live Attenuated: live weakened strain injected. Stimulates memory B and T cells. Immunity typically long-term. E.g., MMR, Varicella

Inactivated: bacteria or virus isolated & inactivated using heat or chemicals. Can't cause infection , buts stimulates B cells to produce Abs. Usually need several doses or booster shots. E.g., polio, hep A

Subunit/conjugate: also inactivated. Use only part of pathogen that evokes immune response. E.g., HIB, pertussis

57

Vaccines for Health Care Workers

HEp B: 3 doses (1 now, 2 in one month, 3 approx 5 months after dose 2)

Tdap: single dose + booster q10y

Influenza: annually

MMR: 1-2 doses if born after 1957

Varicella: 2 doses, 4w apart

Meningococcal: if routinely exposed to N. meningitidis

58

Required record keeping for IZs

Edition & date of VIS

Date VIS is provided (date of IZ)

Office address & name of person who administers

Date vaccine administered

Vaccine manufacturer & lot #

59

Diptheria

Transmitted respiratory droplets (or on objects)

Sx: weakness, sore throat, fever, swollen glands in neck

Thick coating builds up on throat or nose in 2-3 days (pseudomembrane - formed from dead tissue) making it hard to breath

Prognosis: may cause damage to heart, kidneys, and nerves, paralysis. 1 in 10 w/Tx die. W/o 1 in 2 die.

Diagnosis: throat swab or skin lesion

Tx: isolation 48hrs, antitoxin & antibiotics (erythromycin), respiratory support & airway mgmt 

*give diptheria toxoid booster to all close contacts

60

Tetanus

Transmission: not person-person. Bacteria found in soil, dust, manure, enters body through break in skin

Sx: HA, jaw cramping, sudden involuntary muscle tightening, trouble swallowing, seizures, fever

Dx: clinical exam

Tx: medical emergency - hospitalization, immediate human tetanus immune globulin or equine antitoxin, tetanus vaccine, drugs to control muscle spasm, aggressive wound care, Abx, supportive care (possible intubation)

61

Pertussis

"Whooping cough"

Transmission: air droplets, most contagious up to 2 weeks after cough starts

S/s: w/in 5-10 days post exposure, runny nose, low grade fever, violent rapid cough, vomiting, exhaustion, apnea 

Prognosis: most sever in infants/children. May last 10+weeks

Dx: swab secretions at back of throat or nasopharyngeal flush

Tx: strongly recommended before test results. Antibiotics if >1 yo w/in 3weeks cough onset. <1 y and pregnant w/in 6 weeks of cough onset. Azithromycin, clarithromycin, erythromycin, trimethoprim-sulfamethoxasole; vaporizer, suctioning. cough syrup will NOT help

62

Haemophilus Influenza Type B (HIB)

Types: bacteremia, meningitis, cellulitis

Transmission: droplets, cough

Risk: sickle cell, asplenia, HIV, chemo, radiation, post transplant

S/s: fever, cough, SOB, chills, sweating, HA, muscle pain, excessive tiredness, anxiety, alt MS

Dx: one or more lab tests: blood, spinal fluid

Tx: Antbx 10 days 

Prognosis: even w/tx, 3-6% chldren w/meningitis die

63

Measles

"Rubeola"

Transmission: droplet 4 days before & 4 days after rash; incubation 7-21 days, lives on objects 2 hours

S/s: classic prodrome of fever (up to 105F), malaise, three Cs - cough, coryza (inflammation mucous membranes & loss of smell), conjunctivitis, & pathognomonic enanthema (koplic spots - white sposts in mouth) followed by maculopapular rash

complications: pneumonia, hearing loss, enchepalitis

Dx: serology lab confirmation, throat, nasopharyngeal swab

Tx: isolation, supportive care

*post exposure prophylaxis: vaccine w/in 72hrs, IG w/in 6 days

*hcp must report to health dept w/in 24 hours

64

Mumps

Transmission: droplet. Incubation 12-25 days

S/s: fever, HA, muscle aches, tiredness, loss of appetite, swelling of salivary glands

complications: encephalitis/meningitis, oophoritis and mastitis

Dx: serologic testing

Tx: isolation for 5 days after glands swell, supportive care

65

Rubella

"german measles"

Transmission: droplet

S/s: rash starting on face, spreads to body, low fever, lasting 2-3 days; older persons swollen glands

Complications: birth defects: deafness, heart defects, mental retardation

66

Hep B

Transmission: body fluids

S/S: fever, fatigue, loss of appetite, nausea, emesis, abdominal pain, dark urine, clasy-colred stool, joint pain and jaundice. Appear 90 days after exposure, but can occur 6 weeks to 6 months, lasting 6 months

Dx: serologic testing (HBsAg, anti-HBs, etc)

Tx: acute: supportive; chronic: close surveillance (infx dz f/u, hepatologist, VA clinics)

Prognosis: can cause lifelong infxn, cirrhosis, liver cancer, liver failure, death

67

Hep A

Transmission: fecal matter- even microscopic 

S/s: jaundice, tiredness, stomach ache, loss of appetite, nausea, joint pain

Dx: serologic testing

Tx: supportive, fluids, rest

68

Polio vaccine

Transmission: person to person

S/s: 72% have none. Some have fever, nausea, HA, stiffness in back. <1% permanent paralysis of limbs, of those 5-10% die

69

Pneumococcal

Transmission: air droplets

S/s: fever, chills, cough, rapid breathing, chest pain, stiff neck

Complications: meningitis, bacteremia, pneumonia

Dx: serum, spinal fluid

Tx: based on severity. Antibx, caution w/resistance

*immunocompromised, chronic illness, cochlear implants are high risk - should get 23 (can't get 23 until 2y - get 13

70

Influenza vaccines

Shot: inactivated

Nasal spray: live attenuated (5-49yo, healthy immune system)

71

Who should not get certain flu shots

Anyone not feeling well

Inactivated: anyone with Guillai-Barre syndrome

Nasal: long term health problems, received other vaccines w/in 4weeks, age <2, >50, long term aspirin tx, people who care for immunocompromised pts, allergy to eggs

72

Meningococcal Dz

Risks: community settings (e.g., college dorms)

Transmission: close contact w/throat secretions, spit, kissing; sx present 3-7 days after exposure

S/s: N/V, photophobia, altered MS, neck pain, HA

Dx: serum testing, blood or lumbar puncture, CSF

Tx: antibx (before test results)

Prognosis: 10-15% die even w/tx; 11-19% of survivorshave long term disabilities, loss of limbs, deafness, brain damage

 

73

Herpes Zoster

"Shingles"

Transmission: can spread by direct contact. caused by virus reactivation - greater risk w/dec immune function

S/s: blistering clear rash in dermatome, pain. Lesions usually crust over/heal in 2-4 weeks

Complications: postherpetic neuralgia (PHN), ophthalmic involvement (medical emergency!), bacterial superinfection, cranial nerve palsy

 

74

Rabies

Transmission: saliva or brain/nervous system tissue

S/s: flu-like, fever, HA, cerebral dysfunction, delirium, confusion, agitation

Onset: acute 2-10 days, once signs of rabies appear, nearly always fatal

Dx: locate animal & euthanize, examine brain tissue; in humans ante-mortem - serum, spinal fliud, need more than one. Post-mortem - brain biopsy

Tx: wash wounds immediately. Give passive Ab & vaccine

 

75

Rotovirus

Transmission: fecal-oral

S/s: severe acute gastroenteritis, watery diarrhea, vomiting, abdominal pain, dehydration, lasts several days

Tx: supportive care

do not give vaccine to severe combined immunodeficiency or intususseption

76

Pregnancy Vaccinations

Hep A

Hep B

HPV

Influenza IIV, LAIV (live)

MMR (live)

Meningococcal (polysaccharide, conjugate)

Pneumococcal (polysaccharide)

Tdap (toxoid/inact)

Tetanus/diptheria TD (toxoid)

Varicella (live)

77

Pregnancy vaccinations - BEFORE

Influenza IIV

Influenza LAIV (live)

If indicated: the rest

*Avoid conception 4 weeks for all LIVE

78

Pregnancy Vaccinations - DURING

Influenza IIV 

Tdap 27-36 weeks gest, each pregnancy 

(or Tetanus/diptheria Td, but prefer Tdap)

If indicated: meningococcal, pneumococcal, Hep A/B

Contraindicated: Influenza LAIV, HPV, MMR, Varicella, Zoster

79

Pregnancy Vaccinations - AFTER

Influenza IIV & LAIV 

If indicated: the rest (avoid conception 4 weeks for all live)

Special Considerations: MMR immediately PP if not rubella immune; Tdap immediately PP if not given before, Varicella immediately PP if not immune 

 

80

Adult Vaccinations - GENERAL

Influenza annually

Tdap: one time Tdap then booster Q10y

Varicella: 2 doses

 

81

Adult Vaccinations 19-21 yo

HPV 3 doses M &F

MMR 1 or 2 doses

82

Adult Vaccinations 22-26 yo

HPV 3 doses, females

MMR 1 or 2 doses

 

83

Adult Vaccinations 27-49 yo

MMR 1 or 2 doses

84

Adult Vaccinations 50-59yo

MMR 1 or 2 doses (to about 55yo)

85

Adult Vaccinations 60-64yo

Zoster 1 dose

86

Adult vaccinations >= 65yo

Zoster (1 dose)

Pneumococcal polysaccharide (PPSV23) 1 dose

 

87

Vaccinations immunocompromised (except HIV)

Influenza IIV

HPV Males & Females through 26yo

Pneumo 12 or 23

*Hib if post-HSCT

C/I'd: varicella, zoster, MMR

88

Vaccinations HIV 

CD4 count <200

Influenza IIV

HPV through 26yo (M & F)

Pneumo 13 or 23

Hep B

C/I'd: varicella, zoster, MMR

89

Vaccinations HIV

CD4 >200

Influenza IIV

Varicella

HPV through 26yo (M & F)

MMR

Pneumo 13 or 23

Hep B

No C/I

90

Vaccinations MSM

HPV through 26 yo

Hep A/B

91

Vaccinations: Kidney Failure

Influenza IIV

Zoster

MMR

Pneumo 13 or 23

Hep B

92

Vaccinations: Heart Dz, Chronic Lung Dz, Chronic ETOH

Influenza IIV

Zoster

MMR

Pneumo 23

93

Vaccinations asplenia

Influenza IIV

Zoster

MMR

Pneumo 13 or 23

Meningococcal

Hib

94

Vaccinations Chronic Liver Dz

Influenza IIV

Zoster

MMR

Pneumo 23

Hep A/B

95

Vaccinations: Diabetes

Influenza IIV

Zoster

MMR

Pneumo 23

Hep B

96

Vaccinations: Birth 

Hep B 1

97

Vaccinations: 1 mth

Hep B2 (1-2mo)

98

Vaccinations: 2 mo

Hep B2 (1-2mo)

Rotavirus 1

DTaP 1

Hib 1

PCV13 1

IPV 1

99

Vaccinations 4 mo

Rotavirus 2

DTaP 2

Hib 2

PCV13 2

IPV 2

100

Vaccinations: 6mo

Hep B3 (6-18mo)

Rotavirus 3 (if necessary)

DTaP 3

Hib 3 (depending)

PCV13 3

IPV 3 (6-18mo)

Influenza IIV

101

Vaccinations: 9mo

Hep B3 (6-18 mo)

IPV 3 (6-18mo)

Influenza IIV

102

Vaccinations: 12 mo

Hep B3 (6-18 mo)

Hib 3/4 (12 - 15)

PCV13 4 (12 - 15)

IPV 3 (6-18mo)

Influenza IIV

Varicella (12-15)

MMR (12-15)

Hep A 2 doses (12-23mo)

103

Vaccinations: 15 mo

Hep B3 (6-18 mo)

DTaP 4 (15-18mo)

Hib 3/4 (12 to 15)

PCV13 4 (12 to 15)

IPV 3 (6-18mo)

Influenza IIV

Varicella (12-15)

MMR (12-15)

Hep A 2 doses (12-23mo)

104

Vaccinations: 18mo

Hep B3 (6-18 mo)

DTaP 4 (15-18mo)

IPV 3 (6-18mo)

Influenza IIV

Hep A 2 doses (12-23mo)

105

Vaccinations: 19-23 mo

Influenza IIV​

Hep A 2 doses (12-23mo)

106

Vaccinations: 2-3yo

Influenza IIV or LAIV

107

Vaccinations: 4-6yo

Influenza IIV or LAIV

DTaP 5

IPV 4

MMR 2

Varicella 2

 

108

Vaccinations: 7-10

Influenza IIV or LAIV

109

Vaccinations: 11-12

Influenza IIV or LAIV

Tdap

HPV (3 doses)

Meningococcal 1

110

Vaccinations: 13-15

Influenza IIV or LAIV

111

Vaccinations: 16-18

Influenza IIV or LAIV

Meningococcal booster at 16yo