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1. Discuss specific assessments performed during examination of a patient’s perfusion status
- • Perfusion: oxygenated capillary blood passes through the tissues of the body
- a. Palpate the apical impulse
- 1. Localize the apical impulse using one finger pad
- b. Palpate across the precordium
- Gently palpate using the palmar aspects of your four fingers
- • Apex
- • Left sternal border
- • Base
- Auscultate Heart Sounds
- 1. Use the anatomic locations (look at diagram in question #3)
- 2. Follow routine:
- • Note rate and rhythm
- • Identify S1 and S2
- • Assess S1 and S2 separately
- • Listen for extra heart sounds
- • Listen for murmurs
- Anterior Chest
- a. Palpate the apical impulse
- b. Palpate across the precordium
- Heart Sounds
- a. Second right interspace - Aortic valve area
- b. Second right interspace - Pulmonic valve area
- c. Left lower sternal interspace - Tricuspid valve area
- d. Fifth interspace around left midclavicular line - Mitral valve area
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2. Describe normal heart sounds (S1and S2) and the location in which they are heard best
- • First heart sound (S1) is 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
- • Second Heart Sound (S2) is associated with closure of the semi lunar valve
- You can hear it with the diaphragm over the entire precordium, although it is loudest at the base
- Splitting of S2
- • A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people
- • Recall that closure of the aortic and pulmonic valves is nearly synchronous
- • Because of the effects of respiration on the heart, inspiration separates the time of the two valves’ closure, and the aortic valve closes .06 seconds before the pulmonic valve
- • Instead of one “DUP”, you hear a split sound-“T-DUP”
- • During expiration synchrony returns, and the aortic and pulmonic components fuse together
- • A split S2 is heard only in the pulmonic valve area, the second left interspace
- • the split S2 occurs about every 4th heartbeat fading in with inhalation and fading out with exhalation
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3. Describe extra heart sounds S3 and S4
- S3
- • due to rapid ventricular filling: ventricular gallop
- • S1 – S2-S3 (“ken—tuc-ky”)
- • may be present in CHF
- S4
- • due to slow ventricular contraction: atrial gallop
- • S4-S1 – S2 (“Ten-nes—see)
- • may be present in MI, HTN, CAD
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4. Define murmurs and the specific assessment of a client with a murmur.
- turbulent blood flow within the heart
- blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels
- listen for murmurs in same auscultatory sites: APETM
- • Grade
- -1/5 – 5/5
- 1: barely audible
- 2: clearly audible, but faint
- 3: moderately loud
- 4: loud, associated with a thrill palpable on chest wall
- 5: very loud
- 6: loudest
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5. Discuss specific assessments performed during examination of the peripheral vascular system (Taylor , 674)(Jarvis , 149)
- *This requires the checking of Circulation
- o Inspect in this order:
- 1) Arms
- 2) Legs
- 3) Leg Veins
- o Inspect and Palpate the ARMS
- 1. Note color of skin and nail beds
- Temperature, texture
- Turgor of skin, lesions
- 1. Note the symmetry of both arms
- 1. Check Capillary Refill
- Depress and blanch nail beds and release
- • Note the time for color return
- * **Consider it normal if it refills within 1-2 seconds
- * **Room temp., decreased body temp., peripheral edema, smoking can skew your findings
- * ***Refill lasting more than 1-2 seconds indicates vasoconstriction or decreased cardiac output
- 4) Palpate both radial pulses
- Note rate, rhythm
- Grade force on a point scale
- • 3+ increased
- • 2+ NORMAL
- • 1+ weak
- • 0 absent
- o Inspect and Palpate the Legs
- 1. Inspect both legs together noting:
- Skin color, hair, venous pattern, size (swelling or atrophy)
- Lesions and ulcers
- Venous Pattern
- • they are normally flat and barely visible
- • Note varicosities ( twisted, enlarged superficial veins)
- Leg Symmetry
- Palpate leg temperature along the legs and down the feet
- Palpate the peripheral arteries (Grade on 3 Point Scale)
- • Femoral: upper portion of thigh
- • Popliteal: difficult to palpate, behind the knee cap
- • Dorsalis pedis:
- • Posterior tibial: between the malleolus & achilles
- Check for Pretibial edema
- • Depress pretibial area of medical malleolus for 5 sec.
- • If Pitting Edema exists rate as follows:
- 1+ Mild Pitting, slight indentation, no swelling of leg
- 2+ Moderate pitting, indentation subsides rapidly
- 3+ Deep Pitting, indentation remains, leg is swollen
- 4+ Very Deep pitting, indentation lasts, leg is grossly swollen
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6. Review the structure and function of the respiratory system (Taylor , 1398)
- • Nose —> Terminal Branchioles: the pathway for transportation and exchange of oxygen and carbon dioxide
- • Split into Upper and Lower
- • Upper Airway
- Nose, Pharynx, Larynx and Epiglottis
- • Function: warm, filter and humidify inspired air
- • Lower Airway aka Trachiobronchial Tree
- Trachea, (R)(L) Stem of Bronchi, segmental bronchi, terminal bronchioles
- • Function: conduction of air, mucociliary clearance, and production of pulmonary surfactant
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C. Breathing through the nose can falsely produce abnormal breath sounds
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10. Discuss and describe adventitious breath sounds and identify conditions/disease in which these may be present (Ch. 38, pp. 1411)
- A. Adventitious breath sounds (extra, abnormal sounds of breathing)
- 1. Examples: crackles or wheezing
- 2. Crackles
- a. Usually heard on inspiration, are soft, high-pitched, discontinuous (intermittent) popping sounds
- b. Produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli
- c. Occur during inflammation or congestion
- d. Associated with pneumonia, heart failure, bronchitis, and COPD
- 3. Wheezes
- a. Continuous musical sounds
- b. Produced as air passes through airways constricted swelling, narrowing, secretions, or tumors
- c. Associated with asthma, tumors, or buildup of secretions
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