EXAM 3_316
Ch. 19 & 20
 Base- top
 Apex- bottom, apical pulse- 5th intercostal midclavicular
 There are four valves in the heart. 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. 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
papillary muscles contract at this time so the valve leaflets meet and unite to form a perfect
seal without turning themselves inside out.
 The semilunar (SL) valves are set between the ventricles and the arteries. Each valve has
three cusps that look like half moons. 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.
 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. Heart 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.
 The closure of the AV valves contributes to the first heart sound (S1) and signals the
beginning of systole. Matches up with carotid pulse. BEST HEARD: APEX
 This closure of the semilunar valves causes the second heart sound (S2) and signals the end
of systole. BEST HEARD: BASE
 Third Heart Sound (S3). Normally diastole is a silent event. However, in some conditions
ventricular filling creates vibrations that can be heard over the chest. These vibrations are S3.
S3 occurs when the ventricles are resistant to filling during the early rapid filling phase
(protodiastole). This occurs immediately after S2, when the AV valves open and atrial blood
first pours into the ventricles. Abnormal in adults may indicate HF (Right HF- peripheral
edema, Left HF- lung sounds (bubbling, crackles)) Abnormal in persons over age 35.
 Fourth Heart Sound (S4). S4 occurs at the end of diastole, at presystole, when the ventricle is
resistant to filling. The atria contract and push blood into a noncompliant ventricle. This
creates vibrations that are heard as S4. S4 occurs just before S1.
 Murmurs: A murmur is a gentle, blowing, swooshing sound that can be heard on chest wall
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.
Conditions resulting in a murmur are as follows: 1. Velocity of blood increases (flow
murmur) (e.g., in exercise, thyrotoxicosis) 2. Viscosity of blood decreases (e.g., in anemia) 3.
Structural defects in the valves (a stenotic or narrowed valve, an incompetent or regurgitant
valve) or unusual openings occur in the chambers (dilated chamber, septal defect). A murmur
sounds much the same but is caused by a cardiac disorder. Some aortic valve murmurs (aortic
stenosis) radiate to the neck and must be distinguished from a local bruit. The murmur of
mitral stenosis is low-pitched and rumbling, whereas that of aortic stenosis is harsh.
 Sounds: Frequency or pitch: high or low pitched. Intensity/loudness: loud or soft. Duration:
very short for heart sounds; silent periods are longer. Timing: systole or diastole
EXAM 3_316
Aging- increase systolic BP (thickening and stiffening of arteries; arteriosclerosis), left
ventricular wall thickens, diastolic BP may decrease later, Electrocardiograph: changes in the
ECG occur as a result of histologic changes in the conduction system. These changes include:
• Prolonged P-R interval (first-degree AV block) and prolonged Q-T interval, but the QRS
interval is unchanged. • Left axis deviation from age-related mild LV hypertrophy and
fibrosis in left bundle branch. • Increased incidence of bundle branch block.
 Hypertension is 2 to 3 times more common among women taking oral contraceptives
 The prevalence of hypertension is 41.4% for African Americans, 25.8% for American Indians
or Alaska natives, 28.1% for Whites, 22.2% for Hispanics, and 18.7% for Asians.1 Compared
with Whites, African Americans develop high BP earlier in life, and their average BPs are
much higher. This results in African Americans having a greater rate of stroke, death from
heart disease, and end-stage kidney disease.
 Cholesterol- 39.9% of Mexican-American men and 30.4% of Mexican-American women;
30.1% of White men and 29.3% of White women; and 33.1% of African-American men and
31.2% of African-American women.
 DM- Approximately 12.6% of African Americans 20 years of age and older, 11.8% of
Hispanics, 8.4% of Asians, and 7.1% of Whites have DM
1. Describe techniques used to assess the cardiovascular and peripheral vascular systems.
 Subjective Data: 1. Chest pain 2. Dyspnea (paroxysmal. constant or intermittent.
recumbent) 3. Orthopnea (how many pillows) 4. Cough (sputum production, mucoid or
purulent. hemoptysis is often a pulmonary disorder but also occurs with mitral stenosis)
5. Fatigue 6. Cyanosis or pallor 7. Edema (common w/heart failure) 8. Nocturia
(Recumbency at night promotes fluid resorption and excretion; this occurs with heart
failure in the person who is ambulatory during the day) 9. Past cardiac history 10. Family
cardiac history 11. Patient-centered care (cardiac risk factors: Collect data regarding
elevated cholesterol, elevated BP, blood sugar levels above 100 mg/dL or known DM,
obesity, cigarette smoking, low activity level, and length of any hormone replacement
therapy for postmenopausal women). 1. Leg pain or cramps (Apply PQRSTU, associated
w/anything?) 2. Skin changes on arms or legs (temp- PAD, Critical link-why ask about
skin changes related to circulation?) 3. Swelling in arms/legs (edema is bilateral when the
cause is generalized (heart failure) or unilateral when it is the result of a local obstruction
or inflammation) 4. Lymph node enlargement (occur with infection, malignancies, and
immunologic diseases) 5. Meds. 6. Smoking history (constricts arteries, increases
coagulability, injures endothelium, and promotes inflammation. strongest risk factor for
PAD; starting smoking at ≤16 years more than doubles future pad risk)
o Aging: 1. Do you have any known heart or lung disease: hypertension, CAD,
chronic emphysema, or bronchitis? 2. Do you take any medications for your
illness such as digitalis? Aware of side effects? Have you recently stopped taking
your medication? Why? 3. Environment: Does your home have any stairs? How
often do you need to climb them? Does this have any effect on ADLs?
 Assess carotid arteries, the person can be sitting up. To assess jugular veins and the
precordium, the person should be supine with the head and chest elevated between 30 and
45 degrees. Stand on the person's right side. The room must be warm—cold makes the
person uncomfortable, and shivering interferes with heart sounds. Take scrupulous care to
ensure quiet; heart sounds are very soft, and any ambient room noise masks them.
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EXAM 3_316
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Neck vessels
o Palpate carotid, auscultate carotid. Note characteristics of its waveform: smooth
rapid upstroke. summit rounded and smooth. downstroke more gradual and has a
dicrotic notch caused by closure of aortic valve
o Carotid sinus hypersensitivity is the condition in which pressure over the carotid
sinus leads to a decreased heart rate, decreased BP, and cerebral ischemia with
syncope. This may occur in older adults with hypertension or occlusion of the
carotid artery.
o Auscultate for a bruit. Ask person to take a breath, exhale, and hold it briefly
while you listen so that tracheal breath sounds do not mask or mimic a carotid
artery bruit. A bruit indicates turbulence from a local vascular cause and is a
marker for atherosclerotic disease. This increases the risk of transient ischemic
attack (TIA) and ischemic stroke. However, a bruit also occurs in 5% of those age
45 to 80 years who have no significant carotid disease. A carotid bruit is audible
when the lumen is occluded by ½ to ⅔. Bruit loudness increases as the
atherosclerosis worsens until the lumen is occluded by ⅔. After that, bruit
loudness decreases. When the lumen is completely occluded, the bruit disappears.
Thus absence of a bruit does not ensure absence of a carotid lesion. A murmur
sounds much the same but is caused by a cardiac disorder. Some aortic valve
murmurs (aortic stenosis) radiate to the neck and must be distinguished from a
local bruit.
o Inspect jugular venous pulse. Look for pulsations of internal jugular veins in area
of suprasternal notch or around origin of sternomastoid muscle around clavicle.
distinguish internal jugular vein pulsation versus carotid artery pulse. It is easy to
confuse them because they lie close together
Anterior chest
o Before you begin, alert person that you always listen to heart in a number of
places on chest, and just because you are listening a long time does not
necessarily mean that something is wrong
o Begin with diaphragm endpiece and use following routine
1. Note rate and rhythm (regular or steady, irregular is abnormal)
2. Identify S1 and S2
3. Assess S1 and S2 separately
4. Listen for extra heart sounds
5. Listen for murmurs
o Apical pulse- heave or lift is a sustained forceful thrusting of the ventricle during
systole. It occurs with ventricular hypertrophy as a result of increased workload. A
right ventricular heave is seen at the sternal border; a left ventricular heave is seen
at the apex
 • Location—The apical impulse should occupy only one interspace, the
4th or 5th, and be at or medial to the midclavicular line • Size—Normally
1 × 2 cm • Amplitude—Normally a short, gentle tap • Duration—Short;
normally occupies only first half of systole
o Heart auscultation Second right interspace—Aortic valve area
 Second left interspace—Pulmonic valve area
EXAM 3_316
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Left lower sternal border—Tricuspid valve area
Fifth interspace at around left midclavicular line—Mitral valve area
Begin with the diaphragm end piece and use the following routine: (1)
note the rate and rhythm, (2) identify S1 and S2, (3) assess S1 and S2
separately, (4) listen for extra heart sounds, and (5) listen for murmurs.
The soft diastolic murmur of aortic regurgitation may be heard only when
the person is leaning forward in the sitting position.
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 described
earlier, inspiration separates the timing of the two valves' closure, and the aortic
valve closes 0.06 second before the pulmonic valve. Instead of one DUP, you hear
a split sound—T-DUP (Fig. 19-26). During expiration, synchrony returns, and the
aortic and pulmonic components fuse together. A split S2 is heard only in the pvalve area (2nd interspace)
 A fixed split is unaffected by respiration; the split is always there. A
paradoxical split is the opposite of what you would expect; the sounds fuse
on inspiration and split on expiration
Palpation- A thrill is a palpable vibration. It feels like the throat of a purring cat.
The thrill signifies turbulent blood flow and directs you to locate the origin of
loud murmurs. However, absence of a thrill does not rule out the presence of a
murmur. Accentuated first and second heart sounds and extra heart sounds also
may cause abnormal pulsations
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Neck
1. Carotid pulse—Observe and palpate
2. Observe jugular venous pulse
3. Estimate jugular venous pressure
Precordium
Inspection and palpation
o 1. Describe location of apical impulse.
o 2. Note any heave (lift) or thrill.
Auscultation
o 1. Identify anatomic areas where you listen.
o 2. Note rate and rhythm of heartbeat.
o 3. Identify S1 and S2 and note any variation.
o 4. Listen in systole and diastole for any extra heart sounds.
o 5. Listen in systole and diastole for any murmurs.
o 6. Repeat sequence with bell.
o 7. Listen at the apex with person in left lateral position
o 8. Listen at the base with person in sitting position.
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EXAM 3_316
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Arms
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flattening of angle and clubbing (diffuse enlargement of terminal phalanges,
Normal nail bed angle is 160 degrees) occur with congenital cyanotic heart
disease and cor pulmonale.
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.
Edema of upper extremities occurs when lymphatic drainage is obstructed after
breast surgery or radiation. Edema of UE  Lymphatic blockage, DVT, infection
Radial & ulnar pulse- 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 PAD
Check the epitrochlear lymph nodes in the depression above and behind the
medial condyle of the humerus. Do this by “shaking hands” with the person and
reaching your other hand under the person's elbow to the groove between the
biceps and triceps muscles, above the medial epicondyle (usually non-palpable)
Legs
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Peripheral arterial disease (PAD) affects noncoronary vessels and refers to arteries
affecting the limbs
Legs have three types of veins
1. Deep veins run alongside deep arteries and conduct most of venous return
from the legs
2. Superficial veins are great and small saphenous vein
3. Perforators are connecting veins that join two sets
Pallor with vasoconstriction; erythema with vasodilation; cyanosis.
Locate femoral arteries just below inguinal ligament halfway between pubis and
anterior superior iliac spines. To help expose femoral area, particularly in obese
people, ask person to bend his or her knees to side in a froglike position. Press
firmly and then slowly release, noting pulse tap under your fingertips. If this pulse
is weak or diminished, auscultate site for a bruit. Posterior tibial pulse curve your
fingers around medial malleolus. Feel the tapping right behind it in groove
between malleolus and Achilles tendon. Dorsalis pedis pulse requires a very light
touch. Normally it is just lateral to and parallel with extensor tendon of big toe.
Do not mistake pulse in your own fingertips for person’s. In adults over 45 years,
occasionally either dorsalis pedis or posterior tibial pulse may be hard to find, but
not both on the same foot
Ask the person to stand so that you can assess venous system: Note any visible,
dilated, and tortuous veins. If present, varicose veins cause pain, swelling, fatigue,
and cramping.
Malnutrition: thin, shiny, atrophic skin; thick-ridged nails; loss of hair; ulcers;
gangrene. Malnutrition, pallor, and coolness occur with arterial insufficiency.
Diffuse bilateral edema occurs with systemic illnesses. Acute, unilateral, painful
swelling and asymmetry of calves of 1 cm or more is abnormal; refer the person to
determine whether DVT is present.
EXAM 3_316
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Skin- Brown discoloration occurs with chronic venous stasis caused by
hemosiderin deposits from red blood cell degradation. Venous ulcers occur
usually at medial malleolus because of bacterial invasion of poorly drained
tissues. With arterial deficit, ulcers occur
A unilateral cool foot or leg or a sudden temperature drop as you move down the
leg occurs with arterial deficit.
Inguinal lymph nodes- abnormal: Nodes that are enlarged, tender, or fixed in area.
The popliteal pulse is a more diffuse pulse and can be difficult to localize. With
the leg extended but relaxed, anchor your thumbs on the knee and curl your
fingers around into the popliteal fossa (Fig. 20-16). Press your fingers forward
hard to compress the artery against the bone (the lower edge of the femur or the
upper edge of the tibia). Often it is just lateral to the medial tendon.
The dorsalis pedis pulse requires a very light touch. Normally it is just lateral to
and parallel with the extensor tendon of the big toe. Do not mistake the pulse in
your own fingertips for that of the person.
Edema- If pitting edema is present, grade it on the following scale: 1+, Mild
pitting, slight indentation, no perceptible swelling of the leg 2+, Moderate pitting,
indentation subsides rapidly 3+, Deep pitting, indentation remains for a short
time, leg looks swollen 4+, Very deep pitting, indentation lasts a long time, leg is
grossly swollen and distorted. Bilateral pitting edema calls for an examination of
the neck veins. If the neck veins are abnormally distended, the peripheral edema
may be related to heart disease or pulmonary hypertension).11 If neck veins are
normal, something else may cause the edema
Color changes- If you suspect an arterial deficit, raise the legs about 12 inches off
the table and ask the person to wag the feet for about 30 seconds to drain off
venous blood. The skin color now reflects only the contribution of arterial blood.
A light-skinned person's feet normally look a little pale but still should be pink. A
dark-skinned person's feet are more difficult to evaluate, but the soles should
reveal extreme color change. Dependent rubor (deep blue-red color) occurs with
severe arterial insufficiency. Chronic hypoxia produces loss of vasomotor tone
and pooling of blood in the veins. Delayed venous filling occurs with arterial
insufficiency. *Doppler- used when can’t find pulse, hear a whooshing sound;
measures low blood pressure or blood pressure in lower extremity
 Skin discoloration, skin ulcers, or gangrene, note size and exact location
 Chronic venous stasis causes brown discoloration and
ulceration/infection
 Chronic arterial deficit causes ulcers on toes
If lower legs look asymmetric: measure leg at widest point, taking care to measure
other leg in exactly same place, same number of centimeters down from patella or
other landmark
Palpate for temperature along legs down to feet, comparing symmetric spots
Or you may sharply dorsiflex foot toward tibia
Pulsus Bigeminus- ectopy, irregular conduction (from somewhere else other than
the SA node)
Pulsus Paradoxus- changes with respiration cycle
EXAM 3_316
2. Identify appropriate cardiovascular and peripheral vascular assessment techniques for clients
based on age, development, and other psychosocial or environmental variables.
 A gradual rise in SBP is common with aging; the DBP stays fairly constant with a
resulting widening of pulse pressure. Some older adults experience orthostatic
hypotension, a sudden drop in BP when rising to sit or stand.
 Left ventricular wall becomes thicker but the overall size of the heart does not change
 Pulse pressure increases
 No change in resting heart rate or cardiac output at rest
 Ability of heart to augment
 Dysrhythmias
 EKG changes
 Use caution in palpating and auscultating the carotid artery. Avoid pressure in the carotid
sinus area, which could cause a reflex slowing of the heart rate. Pressure on the carotid
artery could compromise circulation if already narrowed by atherosclerosis.
 The chest often increases in anteroposterior diameter with aging. This makes it more
difficult to palpate the apical impulse and hear the splitting of S2. The S4 often occurs in
older people with no known cardiac disease. Systolic murmurs are common, occurring in
over 50% of aging people. The S3 is associated with heart failure and is always abnormal
over age 35 years.
 Occasional premature ectopic beats are common and do not necessarily indicate
underlying heart disease. When in doubt, obtain an ECG. However, consider that the
ECG records for only one isolated minute in time and may need to be supplemented by a
test of 24-hour ambulatory heart monitoring.
 Peripheral blood vessels grow more rigid with age- arteriosclerosis= rise in systolic blood
pressure. Do not confuse this process with atherosclerosis, or the deposition of fatty
plaques on the intima of the arteries. Both processes are present with PAD in aging
adults. PAD is underdiagnosed and undertreated, yet it is a large cause of morbidity and
mortality in the United States. It increases dramatically with age and more men have PAD
than women. Aging produces a progressive enlargement of the intramuscular calf veinsprolonged bed rest, prolonged immobilization, and heart failure increase the risk for deep
vein thrombosis (DVT) and subsequent pulmonary embolism. Low-dose anticoagulant
medication reduces the risk for venous thromboembolism. Loss of lymphatic tissue leads
to fewer numbers of lymph nodes in older people and to a decrease in the size of
remaining nodes.
3. Differentiate between normal and abnormal cardiovascular and peripheral vascular assessment
findings that require further evaluation.
 Variation in pulses
o Weak, thread-1+
o Full bounding-3+
o Pulsus Bigeminus-ectopy, irregular conduction
o Pulsus Paradoxus-changes with respiration cycle
 Ateriosclerosis
 Atherosclerosis-PVD, CAD, MI
 Claudication distance
 Unilateral Edema of LE  DVT?
 Inspect arms for color, size, or any lesions
EXAM 3_316
 Palpate pulses UE: radial and brachial
 Inspect legs for color, size, any lesions, or trophic skin changes
 Palpate temperature of feet and legs
 Palpate inguinal nodes
 Palpate pulses LE: femoral, popliteal, posterior tibial, and dorsalis pedis
4. Document health history and results of cardiovascular and peripheral vascular assessments in
the client record utilizing documentation best practices.
Sample Charting
Subjective
 No chest pain, dyspnea, orthopnea, cough, fatigue, or edema. No history of hypertension,
abnormal blood tests, heart murmur, or rheumatic fever in self. Last ECG 2 yrs. PTA,
result normal. No stress ECG or other heart tests.
o Family history: Father with obesity, smoking, and hypertension, treated diuretic
medication. No other family history significant for CV disease.
o Personal habits: Diet balanced in 4 food groups, 2 to 3 c. regular coffee/day; no
smoking; alcohol, 1 to 2 beers occasionally on weekend; exercise, runs 2 miles, 3
to 4 ×/week; no prescription or OTC medications or street drugs.
Objective
 Neck: Carotids' upstrokes are brisk and = bilaterally. No bruit. Internal jugular vein
pulsations present when supine and disappear when elevated to a 45-degree position.
 Precordium: Inspection. No visible pulsations; no heave or lift.
 Palpation: Apical impulse in 5th ICS at left midclavicular line; no thrill.
 Auscultation: Rate 68 bpm, rhythm regular, S1-S2 are crisp, not diminished or
accentuated, no S3, no S4 or other extra sounds, no murmurs.
Assessment
 Neck vessels healthy by inspection and auscultation
 Heart sounds normal, no murmurs
Sample Charting
Subjective
 No leg pain, no skin changes, no swelling or lymph node enlargement. No history of
heart or vascular problems, diabetes, or obesity. Does not smoke. On no medications.
Objective
 Inspection: Extremities have pink-tan color without redness, cyanosis, or any skin
lesions. Extremity size is symmetric without swelling or atrophy.
 Palpation: Temperature is warm and = bilaterally. All pulses present, 2+ and =
bilaterally. No lymphadenopathy.
Assessment
Healthy tissue integrity
Effective tissue perfusion
EXAM 3_316
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Reference lines pinpoint/map findings vertically on chest
o Anterior chest: midsternal line and midclavicular line  bisects center of each
clavicle at a point halfway between palpated sternoclavicular and acromioclavicular
joints.
o Posterior chest wall: vertebral (or midspinal) line and scapular line, extends through
inferior angle of scapula when arms are at sides of body.
o Lateral chest by divided by three lines when arms at 90 degrees: Anterior axillary
line: anterior axillary fold where pectoralis major muscle inserts. Posterior axillary
line: posterior axillary fold where latissimus dorsi muscle inserts. Midaxillary line:
apex of axilla and lies between and parallel to other two
In inspiration increasing the size of the thoracic container creates a slightly negative pressure
in relation to the atmosphere; therefore 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 AP 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.
Four major functions of respiratory system
o Supplying oxygen to the body for energy production
o Removing carbon dioxide as a waste product of energy reactions
o Maintaining homeostasis (acid-base balance/pH) of arterial blood
o Maintaining heat exchange (less important in humans)
Negative pressure for inspiration/positive pressure for expiration
.
Incidence of tuberculosis (TB) has declined in the U.S.
o however, persons who are foreign-born and of racial or ethnic minorities have a
disproportionately large incidence of TB disease
o In 2012 the TB rates were:
EXAM 3_316
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 11.5 times higher in foreign-born than in U.S.-born
 8.7 million new cases of TB worldwide
o Incidence of multi-resistant TB is increasing
Prevalence rate of asthma in the U.S. in 2011 was 8.4%.
o Most common chronic disease in childhood with a prevalence rate of 9.5% in children
ages 0 to 17 years.
o African Americans, Hispanics, and Native Americans experience more asthma-related
problems and medical care than do Caucasians or Asians.
Ch. 18
1. Describe techniques used to assess the respiratory system.
 Subjective Data: 1. Cough (sputum? Blood (hemoptosis)? Acute? Chronic?) 2. Shortness
of breath (dyspnea? related to food, pollen, position, dust, animals, season, or emotion?
paroxysmal nocturnal dyspnea is awakening from sleep with SOB and needing to be
upright to achieve comfort, effect on ADLs) 3. Chest pain with breathing (point to it) 4.
History of respiratory infections 5. Smoking history 6. Environmental exposure (work) 7.
Patient-centered care (vaccines, self-care)
 Thoracic cage
o Note shape and configuration of chest wall.
o Spinous processes should appear in a straight line; thorax is symmetric, in an
elliptical shape, with downward sloping ribs, about 45 degrees relative to spine;
scapulae are placed symmetrically in each hemithorax. Skeletal deformities may
limit thoracic cage excursion: scoliosis, kyphosis
o Anteroposterior diameter should be less than transverse diameter.
o The neck muscles and trapezius muscles should be developed normally for age
and occupation. Neck muscles are hypertrophied in COPD from aiding in forced
respirations across the obstructed airways.
o Position- People with COPD often sit in a tripod position, leaning forward with
arms braced against their knees, chair, or bed. This gives them leverage so the
abdominal, intercostal, and neck muscles all can aid in expiration
o Skin color- cyanosis with tissue hypoxia
 Posterior chest
o Confirm symmetric chest expansion by placing your warmed hands sideways on
the posterolateral chest wall with thumbs pointing together at the level of T9/10.
Slide your hands medially to pinch up a small fold of skin between your thumbs.
o Assess tactile (or vocal) fremitus- Fremitus is a palpable vibration. Sounds
generated from the larynx are transmitted through patent bronchi and the lung
parenchyma to the chest wall, where you feel them as vibrations. “99” Use palmar
base (ball) of fingers or ulnar edge of one hand.
 Decreased fremitus occurs with obstructed bronchus, pleural effusion or
thickening, pneumothorax, or emphysema. Any barrier that comes
between the sound and your palpating hand decreases 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
the consolidation extends to the lung surface. Note that only gross changes
increase fremitus. Small areas of early pneumonia do not significantly
EXAM 3_316
affect it. Rhonchal fremitus is palpable with thick bronchial secretions.
Pleural friction fremitus is palpable with inflammation of the pleura
o Palpate- Crepitus is a coarse, crackling sensation palpable over the skin surface. It
occurs in subcutaneous emphysema when air escapes from the lung and enters the
subcutaneous tissue, as after open thoracic injury or surgery. Note any tenderness,
skin temperature and moisture, detecting any superficial lumps or masses, and
exploring any skin lesions noted on inspection.
Lung fields
o Resonance is the low-pitched, clear, hollow sound that predominates in healthy
lung tissue in the adult. Hyperresonance is a lower-pitched, booming sound found
when too much air is present such as in emphysema or pneumothorax. A dull note
(soft, muffled thud) signals abnormal density in the lungs, as with pneumonia,
pleural effusion, atelectasis, or tumor. Determine diaphragmatic excursion.
Percuss to map out the lower lung border in both expiration and inspiration.
o Auscultate- Evaluate the presence and quality of normal breath sounds. The
person is sitting, leaning forward slightly, with arms resting comfortably across
the lap. Instruct the person to breathe through the mouth, a little bit deeper than
usual, but to stop if he or she begins to feel dizzy. Side-to-side comparison is most
important. Crackles are abnormal. (minimize this by pressing harder or by wetting
the hair with damp cloth). You should expect to hear three types of normal breath
sounds in adult and older child.
 Three breath sounds:
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PITCH
AMPLITUDE
DURATIO
N
QUALITY
NORMAL LOCATION
BRONCHIAL
(TRACHEAL)
High
Loud
Inspiration <
expiratio
n
Harsh, hollow
tubular
Trachea and larynx
BRONCHOVESICULAR
Moderat
e
Moderate
Inspiration =
expiratio
n
Mixed
Over major bronchi where fewer alveoli
are located: posterior, between
scapulae especially on right;
anterior, around upper sternum in
1st and 2nd intercostal spaces
VESICULAR
Low
Soft
Inspiration >
expiratio
n
Rustling, like the
sound of the
wind in the
trees
Over peripheral lung 4elds where air
5ows through smaller bronchioles
and alveoli
EXAM 3_316

PITCH
o
o
o
o
AMPLITUDE
DURATIO
N
QUALITY
NORMAL LOCATION
Decreased or absent breath sounds occur: 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; the
lungs also are already hyperinflated, so the inhaled air does not make as much
noise 3. When anything obstructs transmission of sound between the lung and
your stethoscope such as pleurisy or pleural thickening or air (pneumothorax) or
fluid (pleural effusion) in the pleural space
Increased breath sounds mean that sounds are louder than they should be. 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) or compression (e.g., fluid in the intrapleural
space) yields a dense lung area that enhances the transmission of sound from the
bronchi. When the inspired air reaches the alveoli, it hits solid lung tissue that
conducts sound more efficiently to the surface.
Note the presence of any adventitious sounds (sounds that are abnormal) 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, but crackles (or
rales) and wheeze (or rhonchi) are terms commonly used by most examiners. If
you hear adventitious sounds, describe them as inspiratory versus expiratory,
loudness, pitch, and location on the chest wall. Crackles are discontinuous
popping sounds heard over inspiration; wheezes are continuous musical sounds
heard mainly over expiration. One type of adventitious sound, atelectatic crackles,
is not pathologic. They are short, popping, crackling sounds that last only a few
breaths. When sections of alveoli are not fully aerated (as in sleepers or in older
adults), they deflate slightly and accumulate secretions. Crackles are heard when
these sections are expanded by a few deep breaths. Atelectatic crackles are heard
only in the periphery, usually in dependent portions of the lungs, and disappear
after the first few breaths or after a cough.
Voice: The spoken voice can be auscultated over the chest wall just as it can be
felt in tactile fremitus described earlier. Normal voice transmission is soft,
muffled, and indistinct; you can hear sound through the stethoscope but cannot
distinguish exactly what is being said. Pathology that increases lung density
enhances transmission of voice sounds. testing for the possible presence of
bronchophony, egophony, and whispered pectoriloquy. Eliciting voice sounds
EXAM 3_316
usually not done in routine examination. these are supplemental maneuvers that
are performed if you suspect lung pathology on basis of earlier data.
 Anterior chest
o Ribs are sloping downward with symmetric interspaces.
o Costal angle is within 90 degrees; development of abdominal muscles as expected
for person’s age, weight, and athletic condition. Barrel chest has horizontal ribs
and costal angle >90 degrees. Hypertrophy of abdominal muscles occurs in
chronic emphysema.
o Note person’s facial expression; facial expression should be relaxed, indicating
unconscious effort of breathing. Tense, strained, tired facies and purse-lipped
breathing (the lips in a whistling position) accompany COPD. By exhaling slowly
and against a narrow opening, the pressure in the bronchial tree remains positive,
and fewer airways collapse.
o Assess the level of consciousness; level of consciousness should be alert and
cooperative. Cerebral hypoxia may be reflected by excessive drowsiness or
anxiety, restlessness, and irritability.
o Note skin color and condition; lips and nail beds are free of cyanosis; nails are of
normal configuration. Clubbing of distal phalanx occurs with COPD because of
growth of vascular connective tissue. Cutaneous angiomas (spider nevi)
associated with liver disease or portal hypertension may be evident on the chest.
o Respirations- Noisy breathing occurs with severe asthma or chronic bronchitis.
Unequal chest expansion occurs when part of the lung is obstructed (pneumonia)
or collapsed or when guarding to avoid postoperative or pleurisy pain. Retraction
suggests obstruction of respiratory tract or that increased inspiratory effort is
needed, as with atelectasis. Bulging indicates trapped air as in the forced
expiration associated with emphysema or asthma. Accessory muscles are used in
acute airway obstruction and massive atelectasis. Rectus abdominis and internal
intercostal muscles are used to force expiration in COPD. Tachypnea and
hyperventilation, bradypnea and hypoventilation, periodic breathing
o Symmetrical chest expansion. Abnormally wide costal angle with little inspiratory
variation occurs with emphysema. Assess tactile fremitus. Palpate chest wall.
Percuss- Lungs are hyperinflated with chronic emphysema, which results in
hyperresonance where you would expect cardiac dullness. Dullness behind the
right breast occurs with right middle lobe pneumonia.
 Pulmonary function
o 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. A forced expiration of 6 seconds or more occurs with
obstructive lung disease. Refer this person for more precise pulmonary function
studies. Spirometer & pulse oximeter & 6-min walk test (is a safer, simple,
inexpensive, clinical measure of functional status in aging adults)
2. Identify appropriate respiratory assessment techniques for clients based on age, development,
and other psychosocial or environmental variables.
 The Aging Adult: The costal cartilages become calcified; thus the thorax is less mobile.
Respiratory muscle strength declines after age 50 years and continues to decrease into the
70s. A more significant change is the decrease in elastic properties within the lungs,
EXAM 3_316
making them less distensible and lessening their tendency to collapse and recoil. In all,
the aging lung is a more rigid structure that is harder to inflate. These changes result in an
increase in small airway closure, which yields a decreased vital capacity (the maximum
amount of air that a person can expel from the lungs after first filling the lungs to
maximum) and an increased residual volume (the amount of air remaining in the lungs
even after the most forceful expiration). With aging, histologic changes (i.e., a gradual
loss of intra-alveolar septa and a decreased number of alveoli) also occur; therefore less
surface area is available for gas exchange. In addition, the lung bases become less
ventilated as a result of closing off of a number of airways. This increases the older
person's risk for dyspnea with exertion beyond his or her usual workload. The histologic
changes also increase the older person's risk for postoperative pulmonary complications.
He or she has a greater risk for postoperative atelectasis and infection from a decreased
ability to cough, a loss of protective airway reflexes, and increased secretions. The chest
cage commonly shows an increased AP diameter, giving a round barrel shape and
kyphosis or an outward curvature of the thoracic spine. The person compensates by
holding the head extended and tilted back. You may palpate marked bony prominences
because of decreased subcutaneous fat. Chest expansion may be somewhat decreased
with the older person, although it still should be symmetric. The costal cartilages become
calcified with aging, resulting in a less mobile thorax. The older person may tire easily,
especially during auscultation when deep mouth breathing is required. Take care that this
person does not hyperventilate and become dizzy. Allow brief rest periods or quiet
breathing. If the person does feel faint, holding the breath for a few seconds restores
equilibrium.
 Ill patient: Use of a second examiner to assist the patient in terms of positional changes.
If no one is available, examiner may roll patient from side to side to facilitate change of
position. If rolling technique is used, this may interfere with bilateral assessments of
inspection and percussion.
3. Differentiate between normal and abnormal respiratory assessment findings that require
further evaluation.
 Thorax abnormals
o Barrel chest- Note equal AP-to-transverse diameter and that ribs are horizontal
instead of the normal downward slope. This is associated with normal aging and
also with chronic emphysema and asthma as a result of hyperinflation of lungs.
o Pectus excavatum- caved in chest
o Pectus carinatum- sternum goes out
o Scoliosis- A lateral S-shaped curvature of the thoracic and lumbar spine, usually
with involved vertebrae rotation. Note unequal shoulder and scapular height and
unequal hip levels, rib interspaces flared on convex side
o Kyphosis- An exaggerated posterior curvature of the thoracic spine (humpback)
that causes significant back pain and limited mobility. Severe deformities impair
cardiopulmonary function
 Respiratory patterns
o Sigh- Occasional sighs punctuate the normal breathing pattern and are purposeful
to expand alveoli. Frequent sighs may indicate emotional dysfunction and also
may lead to hyperventilation and dizziness.
EXAM 3_316
Tachypnea- Rapid, shallow breathing. Increased rate, >24 per minute. This is a
normal response to fever, fear, or exercise. Rate also increases with respiratory
insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.
o Bradypnea- Slow breathing. A decreased but regular rate (<10 per minute), as in
drug-induced depression of the respiratory center in the medulla, increased
intracranial pressure, and diabetic coma.
o Hyperventilation- Increase in both rate and depth. Normally occurs with extreme
exertion, fear, or anxiety. Hyperventilation blows off CO2, causing a decreased
level in the blood (alkalosis).
o Hypoventilation- An irregular shallow pattern caused by an overdose of narcotics
or anesthetics. May also occur with prolonged bed rest or conscious splinting of
the chest to avoid respiratory pain.
o Cheyne-Stokes respiration- tachypnea and then long periods of rest (that get
longer), happens at the end of life usually; A cycle in which respirations gradually
wax and wane in a regular pattern, increasing in rate and depth and then
decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20
seconds) alternating the cycle. The most common cause is severe heart failure;
other causes are renal failure, meningitis, drug overdose, and increased
intracranial pressure. Occurs normally in infants and aging persons during sleep.
o Biot’s respiration- groups; Similar to Cheyne-Stokes respiration, except that the
pattern is irregular. A series of normal respirations (three to four) is followed by a
period of apnea. The cycle length is variable, lasting anywhere from 10 seconds to
1 minute. Seen with head trauma, brain abscess, heat stroke, spinal meningitis,
and encephalitis.
o Chronic obstructive breathing- taught pursed lip breathing, CO2 retention usually;
Normal inspiration and prolonged expiration to overcome increased airway
resistance. In a person with chronic obstructive lung disease, any situation calling
for increased heart rate (exercise) may lead to dyspneic episode (air trapping)
because the person does not have enough time for full expiration.
4. Document health history and key components of a respiratory assessment in the client record.
o
Sample Charting

Subjective
o

Objective
o
o
o
o

No cough, shortness of breath, or chest pain with breathing. No history of
respiratory diseases. Has “one or no” colds per year. Has never smoked. Works in
well-ventilated o;ce on a smoke-free campus. Last TB skin test 4 years PTA,
negative. Never had chest x-ray.
Inspection: AP < transverse diameter. Resp 16/min, relaxed and even.
Palpation: Chest expansion symmetric. Tactile fremitus equal bilaterally. No tenderness to palpation.
No lumps or lesions.
Percussion: Resonant to percussion over lung fields. Diaphragmatic excursion 5 cm and = bilaterally.
Auscultation: Vesicular breath sounds clear over lung fields and = bilaterally. No adventitious sounds.
Assessment
o
o
Intact thoracic structures
Lung sounds clear and equal
EXAM 3_316
Discontinuous sounds:
Continuous sounds:
Crackles—fine
Wheeze—sibilant: high pitched
Crackles—course
Wheeze—sonorous rhonchi: lower pitched
Atelectatic crackles- clear after cough
Stridor- upper airway obstruction
Pleural friction rub