Unit 2 - Resp, Cardio, Peripheral Nerves Flashcards
(17 cards)
APETM
The 5 sites you will auscultate the heart sounds
A- aortic area: on the pt’s right sternal border, 2nd ICS Space.
P - pulmonary area. Across from the aorta at the left sternal border & 2nd ICS space.
E- Erb’s. Left 3rd ISC (right under P) This is where you will hear both S1 and S2 well.
T- tricuspid. Left 4th ICS space.
M- mitral area. Left midclavicular line. 5th ICS space. This is where you count the apical pulse
Respiratory assessment subjective questions
- Ask about personal/family history of respiratory diagnosis or procedures. Ex: COPD, Asthma, CA (cancer), TB, COVID, sleep apnea (OSA), Cystic Fibrosis, etc.
- Ask about personal use (past or present) of nicotine products. Need to know about vaping also. Ask about personal use (past or present) of inhaled drugs.
- Ask about Risk factors for respiratory issues - Environmental or occupational factors, sedentary lifestyle, where do they live? Have they traveled? Secondhand smoke exposures? Ask about environmental exposures (past or present).
- Ask about coughing. Basically a modified OLDCARTS. How long have you had it? Productive or non-productive? If productive, what color is the phlegm and what consistency is it? Does it have any blood in it? Hemoptysis - coughing up blood.
- Ask about sleeping habits - snoring (does your partner complain about you snoring?). Sleep apnea? Do they use any respiratory or breathing equipment? Do they sleep in a recliner? How many pillows do they sleep with?
- Ask about SOB with or without exertion. OLDCARTS.
- Ask about pain with breathing. OLDCARTS. (Associated s/s : fevers, chills, night sweats, sore throat. What makes it better or worse?)
Carry out the rest of the normal subjective assessment, gathering: Medications: OTCs or prescription, supplements, etc. Diagnostics: ABGs, chest X-ray, TB test, CT/MRI, etc.
How to calculate PAC years?
Calculate PACKS/year = # of cigarettes per day / 20 x number of years the patient has been smoking for.
Cardiac assessment subjective questions
- Ask about family and/or personal history of cardiac related, or peripheral vascular diagnoses or procedures (HTN, HLD, Heart disease, CHF, CAD, DM, MI - heart attack, rheumatic fever, endocarditis or pericarditis, varicose veins). Includes asking about personal history of heart defects (“holes in your heart”)
- Ask about recent chest pain/pressure or palpitations. OLDCARTS if it’s not horrible pain or a heart attack. Ask about heartburn.
- Ask about unusual fatigue or change in stamina. Do you tire easily? What time of day? Naps? Ask about lightheadedness.
- Ask about SOB WITH exertion.
Carry out the rest of the normal subjective assessment, gathering: Medications: OTCs or prescription, supplements, etc. Diagnostics: have they had any tests lately on their cholesterol or things like that? Echos, EKGs, CABG, Holter monitor, angiogram vs angioplasty, etc.
Stable vs unstable chest pain
Stable chest pain = chronic angina. Stops with rest or medication and associated with triggers.
Unstable chest pain = acute angina. Constant, no relief - more than likely a heart attack. Decreased LOC. Tachycardia and tachypnea. Diaphoresis - cool and clammy. Medical emergency.
Expected vitals for the respiratory system
RR - 12-20 breaths/min. Tachypnea: >20 breaths/min. Bradypnea: <12 breaths/min. Apnea: cessation of breath for 10 seconds.
SPO2:
Expected: >92% except in chronic or respiratory disease. Expected for COPD: 88-92%. Abnormal: 90% or lower (requires supplemental oxygen).
Normal vitals for the cardiac system
BPM: 60-100 BPM
Tachy (>100 bpm), brady (<60 bpm),
BP: <120/<80 mmHg ; abnormal is the hypertensive stages (120-129, 130-139, >140/90) or hypotension: <90/60 mmHg
Objective assessment for respiratory
I - Inspection:
1. Color of face, lips, and skin (signs of hypoxia - cyanosis).
- Work of breathing - are they trying to catch their breath? Look for nasal flaring or pursed lip breathing or accessory muscles being used to breathe (like their intercostal muscles and scalenes). COPD patients are expected to do pursed lip breathing, but nobody else should. Are they positioned so that they have to sit up to catch their breath?
- Symmetry - chest expansion / equal rise and fall of the chest. Also the shape of the chest in general
- Breathing pattern / respiratory rate
II - Palpation: tenderness or thoracic pain, symmetry of the chest.
III - Auscultation: breath sounds.
What are some abnormal breathing patterns?
Dyspnea (SOB), orthopnea (can’t breathe when lying flat), paroxysmal nocturnal dyspnea (waking up gasping for air), episodes of apnea (any break in the breathing for more than 10 seconds). Hyperpnea or hypopnea: increased/decreased volumes with or without an increased/decreased rate of
Cheyne Stokes: fast respirations followed by a period of apnea.
Kussmaul: abnormally deep, labored and quick breathing associated with DKA.
Biot: regular or irregular shallow breathing with periods of apnea.
Objective assessment for cardiac
I - Inspection & Palpation go together:
- Take upper & lower extremity pulses bilaterally (both radials and both pedals)
- Check capillary refill in upper & lower extremities bilaterally (fingers and toes unless they’re wearing socks)
- Assess color, temp, and integrity of the skin (cyanosis, mottling, etc) as you’re feeling for pulses and such
- Check for edema in the legs (palpate) or abdomen (inspect)
II - Auscultation - using our 5 landmarks (APETM), we’re going to listen for sounds for 30-60 secs. Expected: “lub-dub” = S1 & S2. Take the apical pulse and radial at the same time at M to compare them if they’re equal
What are some abnormal heart sounds?
Abnormal sounds:
S3 - Gallop. Three beats with the extra beat right after s2 (lub-dub-DAH)
S4 - atrial gallop (or a backwards gallop). Three beats with the extra beat right before s1. (DAH-lub-dub)
Murmurs - swishing or blowing sounds. Sometimes they can sound electrical.
Pericardial friction rub - grating sound.
Prosthetic heart valves - clicking sounds.
Ejection click - high-pitched crescendo-descendo type pattern heard in pulmonary stenosis
Opening snap - loud, high frequency sound heard after S2.
If a patient has pain with pulse palpation (pitting edema), or an absent pulse, what do you do?
Grab the Doppler and don’t press very hard
PAD vs PVD
PAD - dangling the legs relieves the pain. Sharper, burning pain. Worsens at night. Not much hair on the legs. Extremities are cool. Punched out borders of ulcers.
PVD - elevation relieves the pain. Heavier, duller type pain. Worsens with prolonged sitting or standing. Extremities are warm. Irregular, multicolored borders of ulcers.
Points of auscultation for the lungs:
6 anterior quadrants with two points on the sides; 6 posterior quadrants with two points on the sides (so 8 total). Don’t auscultate over bony prominences.
Breath sounds
Expected sounds: vesicular, bronchovesicular, bronchial, clear.
Abnormal: diminished or absent (diminished but clear can be expected for geriatric patients), crackles/rales (location: bases of the lungs), wheezing (location: bases of the lungs), rhonchi (sounds like snoring, heard anywhere), stridor (location: only in the trachea. Medical emergency, like in anaphylaxis.), friction rub (sounds like sandpaper; location: outer sides of the lungs).
Abnormal chest symmetries
Expected chest: anterior & posterior are 2:1 ratio.
Barrel chest: 1:1 ratio. Barrel chest is expected in COPD.
Funnel chest : chest sucked in.
Pigeon chest: chest sticking out.
Flail chest: 3+ consecutive rib fractures. Scoliosis and kyphosis.
Deviated trachea is a medical emergency.
Pulse deficit test
Performed with two nurses. One will Auscultate the apical pulse and the other will palpate the radial pulse. Count for 60 seconds and compare findings. Expected: counts are the same. Abnormal: Counts are different; there’s a radial-apical deficit
