Assessing Thorax and Lungs
Assessing Heart
Assessing Peripheral Vascular
100

This is characterized by sucking in of the skin around the neck, sternum and ribs during inhalation. 

What are retractions? 


Usually seen with accessory muscle usage in respiratory distress. 

100

This valve landmark can be found at the left 5th-6th intercostal space mid clavicular line. 

What is the mitral location?

100

Color returning in greater than 2 seconds when pressing on a nail bed is considered...

What is delayed capillary refill?

Should be less than 2 seconds due to decreased circulation/perfusion, vasoconstriction

200

Percussion sound that indicates excess air often found with someone who has emphysema 

Hyperresonance is due to trapped air in the lungs from a pneumothorax or advanced emphysema.

200
This condition can cause vessel enlargement, seen when patient is in a semi-fowlers position and typically indicates fluid overload.

What is jugular venous distention?

200

A nurse assess a 2mm pit in the skin when palpating the lower extremities. 

What is 1+ edema 

Caused by mild fluid in the interstitial spaces typically immediate rebound to regular skin level

300

The AP to T ratio is 1:1 & costal vertebral angle  greater than 90 degrees in this finding on that thorax.

What is barrel chest configuration?

300

This heart sound is heard right before the opening of the AV valves in a patient during late diastole and is due to active filling of the ventricles with blood. 

What is S4?

Abnormal sound due to ventricular non-compliance sometimes referred to as atrial gallop

4 looks more like an a and 3 looks more like a v?

300
Symptoms include unilateral swelling in associated part of the limb without pitting, thickening of the skin, discomfort and heavy sensation/difficulty with ROM.

What is lymphedema?

obstruction of lymph vessels/nodes or other disorders that trap fluid and proteins in an area of the body

400

These breath sounds are heard on the anterior chest lateral to the trachea. 

What are bronchial sounds?

400

This harsh blowing sound can be heard in the heart due to stenosis or regurgitation of blood. 

What is a heart murmur?

bruit=bilateral vessels

murmur=heart only

400

A patient that has thick, reddish/blue color skin in the lower legs with moderate edema, complains of aching and cramping, with 2+ pulses in both feet. 

What is symptoms of venous insufficiency?


Arterial would be claudication, diminished pulses, red/pallor, dry cool shiny skin. 

500

An adventitious lung sound characterized by low pitched bubbling associated with pneumonia. 

What is crackles (fine) 

500

Diabetes, hypertension, smoking, alcohol consumption, dietary intake, stress, genetics and age are all factors in contributing to this disease. 

What is Cardiovascular disease?

500

Findings include enlarged calf vessels, occasional irregular pulse rate, slightly increased systolic pressure, and loss of hair on lower extremities. 

What are older adult/lifespan expected findings?

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