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SUM '20 - Health Assessment > System Return 2 > Flashcards

Flashcards in System Return 2 Deck (30)
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1

Thorax

1. Thoracic/abdominal breathing, symmetrical expansion of the thorax
2. Percuss anterior and posterior chest
3. Auscultate anterior and posterior chest
4. Describe and compare lung sounds

2

Thoracic/abdominal breathing, symmetrical expansion of the thorax

1. Inspect rate and expansion of the chest.
2. Note effort of breathing.
3. AP ratio should be 2:1
4.) Anteriorly cusp of thorax from behind and have patient take deep breath in and note movement of your thumbs as they breath in.

3

Percuss anterior and posterior chest

1. Alternate sides percussing to compare sounds.
2. Looking for resonance between ribs.

4

Auscultate anterior and posterior chest

1. Start above clavicle and work way down.
2. Anteriorly you will hear tracheal and vestibular.
3. Posteriorly you will hear tracheal and vesicular.

5

Describe and compare lung sounds.

Lungs clear bilaterally.

6

Abdomen

1. Turgor, scars, pigmentation, striae and contour
2. Auscultate bowel sounds
3. Percuss 4 quadrants, liver and spleen
4. CVA tenderness (12th rib and spine)
5. Palpate (light and deep) 4 quadrants, liver and spleen
6. Inguinal lymph nodes
7. Femoral pulses and hernias
8. Palpate for rebound tenderness
9. Palpate for McBurney's sign

7

Turgor, scars, pigmentation, striae and contour

1. Examine abdomen, note any scars, pigmentation.

8

Auscultate bowel sounds

1. Listen in all 4 quadrants for 5 minutes. If no bowel sounds are heard before saying they are "absent".

9

Percuss 4 quadrants, liver and spleen

1. Percuss in all 4 quadrants.
2. Listen for tympanic sound.
3. For liver, start MCL at the umbilicus and percuss cephalad until it changes from a tympanic to a dull sound.
4. Mark that level.
5. Percuss between ribs working down and mark it the liver border.
6. Should be 4-7 centimeters.
7. Hard to percuss spleen. Mid axillary 10th ICS. Have them deep breathe in and should be dull to indicate no spleen enlargement.

Tympany over stomach and small intestines.
Hyper-resonance over umbilicus.

10

CVA tenderness (12th rib and spine)

1. Place hand on lower back and hit fist against hand.
2. Assessing for tenderness.
** If tender may have kidney issue.

11

Palpate (light and deep) 4 quadrants, liver and spleen

1. Lightly palpate all 4 quadrants with pads of fingers.
2. For liver, press down and up under ribs.
3. Do the same thing in LUQ, but you should not be able to feel the spleen.
4. Palpate deeply in lower 2 quadrants.

12

Inguinal lymph nodes

** Don't have to do, just note that you would do it.

13

Femoral pulses and hernias

** Don't have to do, just note that you would do it.

14

Palpate for rebound tenderness

1. Put hand into abdomen and withdraw quickly to assess for pain from appendicitis.
2. Ask patient which pressure hurt more - the initial pressure or the rebound pressure.

15

Palpate for McBurney's Sign

1. Find anterior superior iliac spine and belly button.
2. Press deeply to elicit response.

16

Heart

1. Abnormal chest configuration, all visible cardiac movement
2. Palpate PMI, pulsations, thrills, heaves or retractions
3. Auscultate 5 cardiac areas
4. Identify each area and describe heart sounds
5. Jugular pulsations and distension
6. Carotid, brachial, and radial pulses
7. Describe what you would expect to observe with right sided heart failure
8. Describe what you would expect to observe with left sided heart failure

17

Abnormal chest configuration, all visible cardiac movement

1. Observe chest wall movement and look for abnormal movements or pulsations.

18

Palpate PMI, pulsations, thrills, heaves or retractions

1. Palpate with pads of fingers at all 5 heart locations.
2. Feel for thrills or heaves (pulsations that will lift fingers up).
3. PMI is felt at 5th ICS MCL.
4. If you cannot feel it, have patient lie down on left side.

19

Auscultate 5 cardiac areas

1. Aortic: Right sternal border 2nd ICS
2. Pulmonic: Left sternal border 2nd ICS
3. Erbs Point: Left sternal border 3rd ICS
4. Tricuspid: Left sternal border 4th ICS
5. Mitral: 5th ICS MCL

20

Identify each area and describe heart sounds

** S1 and S2: no murmurs

21

Jugular pulsations and distension

1. Have patient lie back 45 degrees.
2. You want o be on the right side.
3. Look for pulsation of internal jugular vein.

22

Carotid, brachial and radial pulses

1. Feel pulses bilaterally.
2. Feel for carotid in lower half on neck.

23

Describe what you would expect to observe with right sided heart failure

* Peripheral edema
* Hepatomegaly
* JVD

24

Describe what you would expect to observe in left sided heart failure

* Pulmonary edema
* SOB
* Crackles

25

Peripheral Circulation

1. Lower extremity skin color, temperature, lesions, ankle edema
2. Hair on toes and condition of toenails
3. Foot lesions, calluses and toe webs
4. Dorsalis pedis and posterior tibial pulses
5. Light touch sensation of the toes, metatarsals and heels

26

Lower extremity skin color, temperature, lesions, ankle edema

1. Skin is warm and dry.
2. No lesions.
3. No ankle edema.

27

Hair on toes and condition of toe nails

1. Observe hair on toes - if there is no hair and it (nail?) is shiny , the patient may have a vascular problem.

28

Foot lesions, calluses and toe webs

1. Observe foot for any lesions, calluses, or slow healing sores.

29

Dorsalis pedis and posterior tibial pulses

1. Feel dorsalis pedis pulse (top of foot).
2. Feel posterior tibial pulse (inside of ankle).

30

Light touch sensation of the toes, metatarsals and heels

1. Have patient close eyes and touch cotton ball to their foot and have them tell you when they feel it.