assessment test 2
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position and surface landmarks
The thoracic cage is a bony structure with a conical shape, which is narrower at the top (Fig. 18-1). It is defined by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae. Its “floor” is the diaphragm, a musculotendinous septum that separates the thoracic cavity from the abdomen. The first seven ribs attach directly to the sternum via their costal cartilages; ribs 8, 9, and 10 attach to the costal cartilage above, and ribs 11 and 12 are “floating,” with free palpable tips. The costochondral junctions are the points at which the ribs join their cartilages.
lines on the body
- Anterior axillary line (front of body armpit)
- -midaxillary line (middle of side of body armpit)
- -posterior axillary line (back of side of body armpit)
- Midclavicular line (from clavicle down)
- Midsternal line (center of the body)
The thin, slippery pleurae are serous membranes that form an envelope between the lungs and the chest wall (Fig. 18-10). The visceral pleura lines the outside of the lungs, dipping down into the fissures. It is continuous with the parietal pleura lining the inside of the chest wall and diaphragm.
The normal stimulus to breathe for most of us is an increase of carbon dioxide in the blood, or hypercapnia. A decrease of oxygen in the blood (hypoxemia) also increases respirations but is less effective than hypercapnia.
changing chest size
- Respiration is the physical act of breathing; air rushes into the lungs as the chest size increases (inspiration) and is expelled from the lungs as the chest recoils (expiration). The mechanical expansion and contraction of the chest cavity alters the size of the thoracic container in two dimensions: (1) the vertical diameter lengthens or shortens, which is accomplished by downward or upward movement of the diaphragm; and (2) the anteroposterior (A-P) diameter increases or decreases, which is accomplished by elevation or depression of the ribs (Fig. 18-11).
- In inspiration, increasing the size of the thoracic container creates a slightly negative pressure in relation to the atmosphere, so air rushes in to fill the partial vacuum. The major muscle responsible for this increase is the diaphragm. During inspiration, contraction of the bell-shaped diaphragm causes it to descend and flatten. This lengthens the vertical diameter. Intercostal muscles lift the sternum and elevate the ribs, making them more horizontal. This increases the anteroposterior diameter.
- Expiration is primarily passive. As the diaphragm relaxes, elastic forces within the lung, chest cage, and abdomen cause it to dome up. All this squeezing creates a relatively positive pressure within the alveoli, and the air flows out.
- Forced inspiration, such as that after heavy exercise or occurring pathologically with respiratory distress, commands the use of the accessory neck muscles to heave up the sternum and rib cage. These neck muscles are the sternomastoids, the scaleni, and the trapezii. In forced expiration, the abdominal muscles contract powerfully to push the abdominal viscera forcefully in and up against the diaphragm, making it dome upward and making it squeeze against the lungs.
- 1 Cough
- 2 Shortness of breath
- 3 Chest pain with breathing
- 4 History of respiratory infections
- 5 Smoking history
- 6 Environmental exposure
- 7 Self-care behaviors
Confirm symmetric chest expansion by placing your warmed hands on the posterolateral chest wall with thumbs at the level of T9 or T10. Slide your hands medially to pinch up a small fold of skin between your thumbs. Ask the person to take a deep breath. Your hands serve as mechanical amplifiers; as the person inhales deeply, your thumbs should move apart symmetrically. Note any lag in expansion.
Assess tactile (or vocal) fremitus. Fremitus is a palpable vibration.
Decreased fremitus occurs when anything obstructs transmission of vibrations (e.g., obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema). Any barrier that comes between the sound and your palpating hand will decrease fremitus.
Increased fremitus occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). This is present only when the bronchus is patent and when the consolidation extends to the lung surface. Note that only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect fremitus.
Resonance is the low-pitched, clear, hollow sound that predominates in healthy lung tissue in the adult
- You should expect to hear three types of normal breath sounds in the adult and older child: bronchial (sometimes called tracheal or tubular), bronchovesicular, and vesicular.
- 1 When the bronchial tree is obstructed at some point by secretions, mucus plug, or a foreign body
- 2 In emphysema as a result of loss of elasticity in the lung fibers and decreased force of inspired air; also, the lungs are already hyperinflated so the inhaled air does not make as much noise
- Increased breath sounds mean that sounds are louder than they should be (e.g., bronchial sounds are abnormal when they are heard over an abnormal location, the peripheral lung fields). They have a high-pitched, tubular quality, with a prolonged expiratory phase and a distinct pause between inspiration and expiration. They sound very close to your stethoscope, as if they were right in the tubing close to your ear. They occur when consolidation (e.g., pneumonia)
- Note the presence of any adventitious sounds. These are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused by moving air colliding with secretions in the tracheobronchial passageways or by the popping open of previously deflated airways. Sources differ as to the classification and nomenclature of these sounds (see Table 18-6), but crackles (or rales) and wheeze (or rhonchi) are terms commonly used by most examiners.
- Eliciting the voice sounds is not done routinely. Rather, these are supplemental maneuvers performed if you suspect lung pathology on the basis of earlier data. When they are performed, you are testing for the possible presence of bronchophony, egophony, and whispered pectoriloquy
Symmetric chest expansion
Palpate symmetric chest expansion. Place your hands on the anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process
Tactile (vocal) fremitus
Assess tactile (vocal) fremitus. Begin palpating over the lung apices in the supraclavicular areas (Fig. 18-22). Compare vibrations from one side to the other as the person repeats “ninety-nine.” Avoid palpating over female breast tissue because breast tissue normally damps the sound.
Forced expiratory time
The forced expiratory time is the number of seconds it takes for the person to exhale from total lung capacity to residual volume. It is a screening measure of airflow obstruction. Although the test usually is not performed in the respiratory assessment, it is useful when you wish to screen for pulmonary function.
The pulse oximeter is a noninvasive method to assess arterial oxygen saturation (Spo2) and is described inChapter 9. A healthy person with no lung disease and no anemia normally has an Spo2 of 97% to 98%. However, every Spo2 result must be evaluated in the context of the person's hemoglobin level, acid-base balance, and ventilatory status.
The 6 Minute Distance (6MD) Walk
The 6-minute distance (6MD) walk is a safer, simple, inexpensive, clinical measure of functional status in aging adults.10,11 The 6MD is used as an outcome measure for people in pulmonary rehabilitation because it mirrors conditions that are used in everyday life. Locate a flat-surfaced corridor that has little foot traffic, is wide enough to permit comfortable turns, and has a controlled environment. Ensure that the person is wearing comfortable shoes, and equip him or her with a pulse oximeter to monitor oxygen saturation. Ask the person to set his or her own pace to cover as much ground as possible in 6 minutes, and assure the person it is all right to slow down or to stop to rest at any time. Use a stopwatch to time the walk. A person who walks >300 meters in 6 minutes is more likely to engage in activities of daily living.
Apgar scoring system
The newborn's first respiratory assessment is part of the Apgar scoring system to measure the successful transition to extrauterine life (Table 18-2). The five standard parameters are scored at 1 minute and at 5 minutes after birth. A 1-minute Apgar with a total score of 7 to 10 indicates a newborn in good condition, needing only suctioning of the nose and mouth and otherwise routine care.
Of particular note is a recent report (Crystal, 2010) indicating there is no level of nicotine, no matter how small, that does not begin to produce genetic changes at the cellular level.
The heart and great vessels are located between the lungs in the middle third of the thoracic cage (mediastinum).
Atrium and Ventricle
But consider that the heart is actually two pumps; the right side of the heart pumps blood into the lungs, and the left side of the heart simultaneously pumps blood into the body. The two pumps are separated by an impermeable wall, the septum. Each side has an atrium and a ventricle.
- There are four valves in the heart (see Fig. 19-4). The two atrioventricular (AV) valves separate the atria and the ventricles. The right AV valve is the tricuspid, and the left AV valve is the bicuspid or mitral valve (so named because it resembles a bishop's mitred cap). The valves’ thin leaflets are anchored by collagenous fibers (chordae tendineae) to papillary muscles embedded in the ventricle floor. The AV valves open during the heart's filling phase, or diastole, to allow the ventricles to fill with blood. During the pumping phase, or systole, the AV valves close to prevent regurgitation of blood back up into the atria.
- The SL valves are the pulmonic valve in the right side of the heart and the aortic valve in the left side of the heart. They open during pumping, or systole, to allow blood to be ejected from the heart.
The rhythmic movement of blood through the heart is the cardiac cycle. It has two phases, diastole and systole. In diastole, the ventricles relax and fill with blood. This takes up two thirds of the cardiac cycle. The heart's contraction is systole. During systole, blood is pumped from the ventricles and fills the pulmonary and systemic arteries. This is one third of the cardiac cycle.
- In diastole, the ventricles are relaxed and the AV valves (i.e., the tricuspid and mitral) are open (Fig. 19-6). (Opening of the normal valve is acoustically silent.) The pressure in the atria is higher than that in the ventricles, so blood pours rapidly into the ventricles. This first passive filling phase is called early or protodiastolic filling.
- Toward the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the “atrial kick.” It causes a small rise in left ventricular pressure. (Note that atrial systole occurs during ventricular diastole, a confusing but important point.)
- Now so much blood has been pumped into the ventricles that ventricular pressure is finally higher than that in the atria, so the mitral and tricuspid valves swing shut. The closure of the AV valves contributes to the first heart sound (S1) and signals the beginning of systole. The AV valves close to prevent any regurgitation of blood back up into the atria during contraction.
- For a very brief moment, all four valves are closed. The ventricular walls contract. This contraction against a closed system works to build pressure inside the ventricles to a high level (isometric contraction). Consider first the left side of the heart. When the pressure in the ventricle finally exceeds pressure in the aorta, the aortic valve opens and blood is ejected rapidly.
- After the ventricle's contents are ejected, its pressure falls. When pressure falls below pressure in the aorta, some blood flows backward toward the ventricle, causing the aortic valve to swing shut. This closure of the semilunar valves causes the second heart sound (S2) and signals the end of systole.
Blood circulating through normal cardiac chambers and valves usually makes no noise. However, some conditions create turbulent blood flow and collision currents. These result in a murmur, much like a pile of stones or a sharp turn in a stream creates a noisy water flow. A murmur is a gentle, blowing, swooshing sound that can be heard on the chest wall
- The ECG waves are arbitrarily labeled PQRST, which stand for the following elements:
- P wave—depolarization of the atria
- PR interval—from the beginning of the P wave to the beginning of the QRS complex (the time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles)
- QRS complex—depolarization of the ventricles
- T wave—repolarization of the ventricles
- Electrical events slightly precede the mechanical events in the heart.
- In the resting adult, the heart normally pumps between 4 and 6 L of blood per minute throughout the body. This cardiac output equals the volume of blood in each systole (called the stroke volume) times the number of beats per minute (rate). This is described as:
- CO = SV × R
Preload is the venous return that builds during diastole. It is the length to which the ventricular muscle is stretched at the end of diastole just before contraction
Afterload is the opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure. It is the resistance against which the ventricle must pump its blood.
The jugular veins empty unoxygenated blood directly into the superior vena cava.
Heart fxns in infants and children
- The fetal heart functions early; it begins to beat at the end of 3 weeks’ gestation. The lungs are nonfunctional, but the fetal circulation compensates for this (Fig. 19-13). Oxygenation takes place at the placenta, and the arterial blood is returned to the right side of the fetal heart. There is no point in pumping all this freshly oxygenated blood through the lungs, so it is rerouted in two ways. First, about two thirds of it is shunted through an opening in the atrial septum, the foramen ovale, into the left side of the heart, where it is pumped out through the aorta. Second, the rest of the oxygenated blood is pumped by the right side of the heart out through the pulmonary artery, but it is detoured through the ductus arteriosus to the aorta. Because they are both pumping into the systemic circulation, the right and left ventricles are equal in weight and muscle wall thickness.
- Inflation and aeration of the lungs at birth produces circulatory changes. Now the blood is oxygenated through the lungs rather than through the placenta. The foramen ovale closes within the first hour because of the new lower pressure in the right side of the heart than in the left side. The ductus arteriosus closes later, usually within 10 to 15 hours of birth. Now the left ventricle has the greater workload of pumping into the systemic circulation, so that when the baby has reached 1 year of age, the left ventricle's mass increases to reach the adult ratio of 2 : 1, left ventricle to right ventricle.
pregnant woman blood
Blood volume increases by 30% to 40% during pregnancy
Hemodynamic changes with aging
With aging, there is an increase in systolic blood pressure
The presence of supraventricular and ventricular dysrhythmias increases with age. Ectopic beats are common in aging people; although these are usually asymptomatic in healthy older people, they may compromise cardiac output and blood pressure when disease is present.
In the 40+ years from 1965 to 2004, U.S. smoking rates declined by 50.4% among adults 18 years of age and older.33 This results in 2008 with 23.1% of men and 18.3% of women being smokers. Nicotine increases the risk of MI and stroke by causing the following: increase in oxygen demand with a concomitant decrease in oxygen supply; an activation of platelets, activation of fibrinogen; and an adverse change in the lipid profile.
High levels of low-density lipoprotein gradually add to the lipid core of thrombus formation in arteries, which results in MI and stroke.
Type 2 Diabetes Mellitus
he risk of CVD is twofold greater among persons with diabetes mellitus (DM) than without DM.
- 1 Chest pain
- 2 Dyspnea
- 3 Orthopnea
- 4 Cough
- 5 Fatigue
- 6 Cyanosis or pallor
- 7 Edema
- 8 Nocturia
- 9 Past cardiac history
- 10 Family cardiac history
- 11 Personal habits (cardiac risk factors)
Auscultate the carotid artery
For persons middle-aged or older or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for the presence of a bruit (pronounced bru′-ee) (Fig. 19-17). This is a blowing, swishing sound indicating blood flow turbulence; normally none is present.
Jugular venous pulse
From the jugular veins you can assess the central venous pressure (CVP) and thus judge the heart's efficiency as a pump.
Palpate the apical impulse
(This used to be called the point of maximal impulse, or PMI. Because some abnormal conditions may cause a maximal impulse to be felt elsewhere on the chest, use the term apical impulse specifically for the apex beat.
- Recall the characteristics of a good stethoscope (see Chapter 8). Clean the endpieces with an alcohol wipe; you will use both endpieces. Although all heart sounds are low frequency, the diaphragm is for relatively higher pitched sounds and the bell is for relatively lower pitched ones.
- Before you begin, alert the person: “I always listen to the heart in a number of places on the chest. Just because I am listening a long time, it does not necessarily mean that something is wrong.”
- After you place the stethoscope, try closing your eyes briefly to tune out any distractions.
The rate ranges normally from 50 to 90 beats per minute.
First heart sounds (S1)
- Caused by closure of the AV valves, S1 signals the beginning of systole. You can hear it over the entire precordium, although it is loudest at the apex (Fig. 19-24). (Sometimes the two sounds are equally loud at the apex, because S1 is lower pitched than S2.)
Second heart sounds (S2)
- The S2 is associated with closure of the semilunar valves. You can hear it with the diaphragm, over the entire precordium, although S2 is loudest at the base
After auscultating in the supine position, roll the person toward his or her left side.
Infant heart rate
The heart rate is best auscultated because radial pulses are hard to count accurately. Use the small (pediatric size) diaphragm and bell (Fig. 19-30). The heart rate may range from 100 to 180 per minute immediately after birth, then stabilize to an average of 120 to 140 per minute.
Pediatric heart murmur
- Heart murmurs that are innocent (or functional) in origin are very common through childhood. Some authors say they have a 30% occurrence, and some authors say nearly all children may demonstrate a murmur at some time. Most innocent murmurs have these characteristics: soft, relatively short systolic ejection murmur; medium pitch; vibratory; best heard at the left lower sternal or midsternal border, with no radiation to the apex, base, or back.
- For the child whose murmur has been shown to be innocent, it is very important that the parents understand this completely. They need to believe that this murmur is just a “noise” and has no pathologic significance. Otherwise, the parents may become overprotective and limit activity for the child, which may result in the child developing a negative self-concept.
a sudden drop in blood pressure when rising to sit or stand.
- Decreased cardiac output occurs when the heart fails as a pump, and the circulation becomes backed up and congested.
- Signs and symptoms of heart failure come from two basic mechanisms: (1) the heart's inability to pump enough blood to meet the metabolic demands of the body; and (2) the kidney's compensatory mechanisms of abnormal retention of sodium and water to compensate for the decreased cardiac output. This increases blood volume and venous return, which causes further congestion.
- Onset of heart failure may be: (1) acute, as following a myocardial infarction when direct damage to the heart's contracting ability has occurred; or (2) chronic, as with hypertension, when the ventricles must pump against chronically increased pressure.
Patient Ductus Arteriosus (PDA)
Persistence of the channel joining left pulmonary artery to aorta. This is normal in the fetus and usually closes spontaneously within hours of birth.
Atrial Septal Defect (ASD)
Abnormal opening in the atrial septum, resulting usually in left-to-right shunt and causing large increase in pulmonary blood flow.
Ventricular Septal Defect (VSD)
Abnormal opening in septum between the ventricles, usually subaortic area. The size and exact position vary considerably.
Calcification of aortic valve cusps restricts forward flow of blood during systole; LV hypertrophy develops.
Stream of blood regurgitates back into LA during systole through incompetent mitral valve. In diastole, blood passes back into LV again along with new flow; results in LV dilation and hypertrophy.
Stream of blood regurgitates back into LA during systole through incompetent mitral valve. In diastole, blood passes back into LV again along with new flow; results in LV dilation and hypertrophy.
The heart pumps freshly oxygenated blood through the arteries to all body tissues.
The course of veins parallels that of arteries, but the body has more veins and they lie closer to the skin surface
veins in the leg
- The legs have three types of veins (Fig. 20-3):
- 1 The deep veins run alongside the deep arteries and conduct most of the venous return from the legs. These are the femoral and popliteal veins.
- 2 The superficial veins are the great and small saphenous veins. The great saphenous vein, inside the leg, starts at the medial side of the dorsum of the foot. You can see it ascend in front of the medial malleolus; then it crosses the tibia obliquely and ascends along the medial side of the thigh. The small saphenous vein, outside the leg, starts on the lateral side of the dorsum of the foot, ascends behind the lateral malleolus, up the back of the leg, where it joins the popliteal vein.
- 3 Perforators (not illustrated) are connecting veins that join the two sets. They also have one-way valves that route blood from the superficial into the deep veins.
Veins drain the deoxygenated blood and its waste products from the tissues and return it to the heart. Unlike the arteries, veins are a low-pressure system. Because veins do not have a pump to generate their blood flow, the veins need a mechanism to keep blood moving (Fig. 20-4). This is accomplished by (1) the contracting skeletal muscles that milk the blood proximally, back toward the heart; (2) the pressure gradient caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow. Each valve is a paired semilunar pocket that opens toward the heart and closes tightly when filled to prevent backflow of blood.
The lymphatics form a completely separate vessel system, which retrieves excess fluid from the tissue spaces and returns it to the bloodstream
- Lymph nodes are small, oval clumps of lymphatic tissue located at intervals along the vessels. Most nodes are arranged in groups, both deep and superficial, in the body.
- Nodes filter the fluid before it is returned to the bloodstream and filter out microorganisms that could be harmful to the body. The pathogens are exposed to B and T lymphocytes in the lymph nodes. The lymphocytes mount an antigen-specific response to eliminate the pathogens. With local inflammation, the nodes in that area become swollen and tender.
Deep venous thrombosis
Aging produces a progressive enlargement of the intramuscular calf veins. Prolonged bedrest, prolonged immobilization, and heart failure increase the risk for deep venous thrombosis and subsequent pulmonary embolism. These conditions are common in aging and also with malignancy and myocardial infarction (MI). Low-dose anticoagulant medication reduces the risk for venous thromboembolism.
- Subjective Data
- 1 Leg pain or cramps
- 2 Skin changes on arms or legs
- 3 Swelling
- 4 Lymph node enlargement
- 5 Medications
- With the person's hands near the level of his or her heart, check capillary refill. This is an index of peripheral perfusion and cardiac output. Depress and blanch the nail beds; release and note the time for color return. Usually, the vessels refill within a fraction of a second. Consider it normal if the color returns in less than 1 or 2 seconds. Note conditions that can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.
- Refill lasting more than 1 or 2 seconds signifies vasoconstriction or decreased cardiac output (hypovolemia, heart failure, shock). The hands are cold, clammy, and pale.
- Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall, and equal force (Fig. 20-8). Grade the force (amplitude) on a 3-point scale:
- 3+, increased, full, bounding
- 2+, normal
- 1+, weak
- 0, absent
- Full, bounding pulse (3+) occurs with hyperkinetic states (exercise, anxiety, fever), anemia, and hyperthyroidism.
- Weak, “thready” pulse (1+) occurs with shock and peripheral arterial disease. See Table 20-1 on p. 519 for illustrations of these and irregular pulse rhythms.
Inside the abdominal cavity, all the internal organs are called the viscera.
The bean-shaped kidneys are retroperitoneal, or posterior to the abdominal contents (Fig. 21-5). They are well protected by the posterior ribs and musculature. The twelfth rib forms an angle with the vertebral column, the costovertebral angle. The left kidney lies here at the eleventh and twelfth ribs. Because of the placement of the liver, the right kidney rests 1 to 2 cm lower than the left kidney and sometimes may be palpable.
For convenience in description, the abdominal wall is divided into four quadrants by a vertical and a horizontal line bisecting the umbilicus (Fig. 21-6). (An older, more complicated scheme divided the abdomen into nine regions. Although the old system generally is not used, some regional names persist, such as epigastric for the area between the costal margins, umbilical for the area around the umbilicus, and hypogastric or suprapubic for the area above the pubic bone.)
Lactase is the digestive enzyme necessary for absorption of the carbohydrate lactose (milk sugar). In some racial groups, lactase activity is high at birth but declines to low levels by adulthood. These people are lactose intolerant and have abdominal pain, bloating, and flatulence when milk products are consumed. Millions of American adults have the potential for lactose-intolerance symptoms, and traditional estimated rates were that 15% of whites, 50% of Mexican Americans, and 80% of African Americans had the condition. Yet a recent study found the prevalence rates in practical life settings is significantly lower than previously estimated rates.36 When subjects were screened for symptoms following a typical serving of dairy food in the home setting, lactose-intolerance prevalence estimates were 7.72% for whites, 19.5% for African Americans, and 10% for Hispanics.36 This is clinically significant because dairy foods meet crucial nutritional requirements including calcium, magnesium, and potassium. If people perceive themselves to be lactose intolerant based on racial heritage, the lowered calcium intake may affect bone health. Health care providers should encourage low-fat or fat-free daily foods and monitor any symptoms.
- 1 Appetite
- 2 Dysphagia
- 3 Food intolerance
- 4 Abdominal pain
- 5 Nausea/vomiting
- 6 Bowel habits
- 7 Past abdominal history
- 8 Medications
- 9 Nutritional assessment
Inspect the abdomen
- Stand on the person's right side and look down on the abdomen. Then stoop or sit to gaze across the abdomen. Your head should be slightly higher than the abdomen. Determine the profile from the rib margin to the pubic bone. The contour describes the nutritional state and normally ranges from flat to rounded (Fig. 21-7).
- Scaphoid abdomen caves in. Protuberant abdomen, abdominal distention
- Shine a light across the abdomen toward you, or shine it lengthwise across the person. The abdomen should be symmetric bilaterally (Fig. 21-8). Note any localized bulging, visible mass, or asymmetric shape. Even small bulges are highlighted by shadow. Step to the foot of the examination table to recheck symmetry.
- Bulges, masses.
- Hernia—protrusion of abdominal viscera through abnormal opening in muscle wall
Next, percuss to map out the boundaries of certain organs. Measure the height of the liver in the right midclavicular line. (For a consistent placement of the midclavicular line landmark, remember to palpate the acromioclavicular and the sternoclavicular joints and judge the line at a point midway between the two.)
- An enlarged liver span indicates liver enlargement or hepatomegaly.
- Accurate detection of liver borders is confused by dullness above the fifth intercostal space, which occurs with lung disease (e.g., pleural effusion or consolidation). Accurate detection at the lower border is confused when dullness is pushed up with ascites or pregnancy or with gas distention in the colon, which obscures the lower border.
Costovertebral Angle Tenderness
- Indirect fist percussion causes the tissues to vibrate instead of producing a sound. To assess the kidney, place one hand over the twelfth rib at the costovertebral angle on the back (Fig. 21-17). Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. (Although this step is explained here with percussion techniques, its usual sequence in a complete examination is with thoracic assessment, when the person is sitting up and you are standing behind.)
- Sharp pain occurs with inflammation of the kidney or paranephric area.
Light and Deep Palpation
- Begin with light palpation. With the first four fingers close together, depress the skin about 1 cm (Fig. 21-21). Make a gentle rotary motion, sliding the fingers and skin together. Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen. The objective here is not to search for organs but to form an overall impression of the skin surface and superficial musculature. Save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination.
- Muscle guarding.
- Large masses.
- As you circle the abdomen, discriminate between voluntary muscle guarding and involuntary rigidity. Voluntary guarding occurs when the person is cold, tense, or ticklish. It is bilateral, and you will feel the muscles relax slightly during exhalation. Use the relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation. If the rigidity persists, it is probably involuntary.
- Involuntary rigidity is a constant, boardlike hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit-up.
- Now perform deep palpation using the same technique described earlier, but push down about 5 to 8 cm (2 to 3 inches) (Fig. 21-22). Moving clockwise, explore the entire abdomen
The liver is the largest internal organ in the body. It has an immense capacity to heal and regenerate, but that capacity is not infinite. Signs and symptoms of liver damage and/or disease often are not apparent until the liver has been significantly harmed. The best protection for the liver is prevention!
Extends from the base of the neck superiorly to the level of the diaphragm inferiorly
Distal portion of the trachea, bronchi
Has three parts: Manubrium, the body, the xiphoid process
12 pairs-thoracic cage
Vertical reference lines
- Anterior chest: midsternal, right and left midclavicular lines
- Posterior thorax: vertebral line, right and left scapular lines
- Lateral thorax: midaxillary line, anterior and posterior axillary lines
Structure of thorax and lungs
- Mediastinum: central area in the thoracic cavity
- Lungs: two-cone shaped, elastic structures
- Pleura: thin, double-layered serous membrane lines thoracic cavity
Subjective Data Collection
- History of present health concern-COLDSPA
- Past health history
- Family history
- Lifestyle and health practices
- leading cause of death in U.S. and Europe
- Risk factors: cigarette smoking; genetic predisposition, exposure to toxins; history of previous lung cancer; recurring, gender
Lung cancer risk reduction
- stop smoking
- join smoking cessation program
- healthy, low-cholesterol diet
- limit exposure toxins
Lung cancer prevalence
- lower in Fiji than in other South pacific countries
- African American men have higher incidence and mortality rates
- U.S. Hispanics have lower rates than non-Hispanic whites
Objective data collection (lungs): preparation
- Have the client remove all clothing from the waist up
- explain procedure
- ask the client to sit in an upright position
objective data collection (lungs): equipment
- Examination gown and drape
- Gloves; stethoscope
- light source
- Mask; skin marker and metric ruler
Inspection of lungs
- position of scapulae and the shape and configuration of the chest wall
- -Spinal configurations-respiratory implications
Inspection: accessory muscles
Trapezius, or shoulder muscles-facilitate inspiration in acute and chronic airway obstruction or atelectasis
- Tripod position seen in COPD
- -Client leans forward
- -uses arms to support weight
- -lift chest to increase breathing capacity
- tenderness and sensation
- crepitus-crackling sensation
- surface characteristics
Palpation: Fremitus and Chest Expansion
- Palpate for fremitus-vibrations of air in the bronchial tubes transmitted to the chest wall
- Assess chest pain
- Diaphragmatic excursion
- Auscultate for breath sounds
- three types of normal breath sounds
- -bronchial, bronchovesicular, vesicular
- breath sounds: considered normal only in the area specified
- breath sounds, heard elsewhere-considered abnormal sounds
- Auscultate for adventitious sounds
- Added or superimposed over normal breath sounds-crackles, wheeze
Auscultation: voice sounds
- Bronchophony: "ninety-nine"
- Egophony: "E"
- Whispered Pectoriloquy "one-two-three"
- -shape and configuration
- -position of the sternum
- -slope of ribs
anterior thorax: respirations
- observe quality and pattern of respiration
- breathing characteristics-rate, rhythm and depth
- labored and noisy breathing-severe asthma or chronic bronchitis
ant. thorax: spaces and muscles
- inspect intercostal spaces
- ask the client to breathe normally and observe the intercostal spaces
- observe for use of accessory muscles
- palpate for tenderness, sensation and surface masses
- tenderness over thoracic muscles-exercising, push ups
- especially in a previously sedentary client
palpation: fremitus and expansion
- -diminished vibrations-obstruction of the tracheobronchial tree
- -decreased fremitus-emphysema
- Anterior chest expansion
- hyperresonance-emphysema, pneumothorax
- Dullness-consolidation, pleural effusion, tumor
- auscultate for anterior breath sounds, adventitious sounds, and voice sounds
- do not attempt to listen through clothing or other materials
analysis of data
- selected nursing diagnoses
- selected collaborative problems
- case study
- Bordered superiorly by the costal margins
- inferiorly by the symphysis pubis and inguinal canals
- laterally by the flanks
- four quadrants-right upper quadrant (RUQ), right lower (RLQ), left lower (LLQ), left upper (LUQ)
- 2 imaginary lines (vertical/midline; horizontal/lateral)
- regions commonly used-epigastric, umbilical, hypogastric or suprapubic
right upper quadrant
- ascending and transverse colon
- duodenum; gallbladder; hepatic flexure of colon; liver
- pancreatic head; pylorus; right adrenal gland
- right kidney; right ureter
right lower quadrant
- ascending colon; cecum
- right kidney
- right ovary and tube
- right ureter
- right spermatic cord
left upper quadrant
- left adrenal gland
- left kidney
- left ureter
- pancreas, spleen, stomach
- transverse descending colon
left lower quadrant
- left kidney
- left ovary and tube
- left ureter
- left spermatic cord
- descending and sigmoid colon
abdominal wall muscles
- 3 muscle layers from back, around flanks, to front: external and internal abdomens oblique, transverse abdominus
- Abdominal wall muscles: protect internal organs; allow normal compression of internal organs during functional activities
- Parietal peritoneum; visceral peritoneum
- different body systems:
- -reproductive (female)
- -lymphatic and urinary
- Solid viscera: liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus
- Hollow viscera: stomach, gallbladder, small intestine, colon, bladder
- Palpation of abdominal viscera depends on location, structural consistency, size
- Viscera normally not palpable
- -pancreas; spleen; stomach;gallbladder; small intestine
- Vascular structures: abdominal aorta, right and left iliac arteries
- abdominal pain
- factors that precipitate pain or make it worse
- description and location of pain
- other symptoms
- recent weight gain or loss
- -Abdominal surgery/trauma/injury/medications
- -abdominal pain and treatment
- -lab work or GI studies
- -Stomach, colon, liver cancer
- -Abdominal pain, appendicitis, colitis, bleeding, hemorrhoids
- -Nutrition responsible in family
lifestyle and health problems
smoking, alcohol use, diet, antacid, medications, fluid intake, exercise, stress
Mechanism and sources of abdominal pain
- Types of pain:
Preparing the client
- Empty the bladder
- remove cloths and to put on a gown
- lie supine with the arms folded across the chest or resting by the sides
- drape the client
- breath through the mouth; take slow, deep breaths
- Small pillow or rolled blanket
- centimeter ruler
- stethoscope (warm the diaphragm and bell)
- marking pen
- observe the coloration of the skin
- note the vascularity of the abdominal skin
- note any striae
- inspect for scars
- assess for lesions and rashes
- Inspect: umbilicus, abdominal contour, abdominal movements when client breathes
- Assess abdominal symmetry
- Observe aortic pulsations
- Observe for peristaltic waves
- auscultate for:
- bowel sounds, vascular sounds, friction rub over the liver and spleen
- percuss for tone
- percuss the span or height of the liver by determining its lower and upper borders
- percuss the spleen
- perform blunt percussion on the liver
- perform light palpation
- deeply palpate all quadrants to delineate abdominal organs and detect subtle mass
- palpate for masses
- palpate the umbilicus and surrounding area for swellings, bulges or masses
- Palpate: aorta, liver, spleen, kidneys, urinary bladder
Special abdominal tests
- test for ascites:
- test for shifting dullness
- use ballottement technique
- -single-hand method
- -bimanual method
- test for appendicitus:
- -rebound tenderness
- -Rovsing's sign
- -Referred rebound tenderness
- -Psoas sign; obturator sign
- -Perform hypersensitivity test
- Test for cholecystitis:
- -Murphy's sign
- -Accentuated sharp pain causes the client to hold breath
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