Fundamentals of Nursing I

Introduction:

Respiration and cardiovascular system are a vital function in our body. An ineffectively functioning of both systems causes disruption throughout the body, just as changes in other body systems have a significant impact on the respiratory and cardiovascular system. On other hand, peripheral-vascular (PV) system is a branching network of vessels that transports oxygenated blood to all body organs and tissues and then returns it to the heart for reoxygenation in the lungs. A disruption in the PV system can cause significant pain, loss of limb, or even death. The lymphatic system helps the heart and peripheral vasculature maintain adequate circulation. Therefore, a thorough, accurate physical assessment will allow you to develop a plan of care that addresses not only treatment measures but also health promotion and disease prevention on your patient. 

Topic Learning Outcome (TLOs):

By the end of this topic, you should be able to:

1. Demonstrate a respiratory physical assessment.
2. Document respiratory findings.
3. Demonstrate a cardiovascular physical assessment
4. Document cardiovascular findings.
5. Demonstrate a peripheral-vascular and lymphatic physical assessment
6. Document peripheral-vascular and lymphatic findings.

Respiratory System

Structures and Functions of the respiratory system

Assessing the thorax and lungs is frequently critical to assessing the client’s oxygenation status. Changes in the respiratory system can occur slowly or quickly. In clients with chronic obstructive pulmonary disease (COPD), such as chronic bronchitis, emphysema, and asthma, changes are frequently gradual.

Chest Landmarks

Before beginning the assessment, the nurse must be familiar with a series of imaginary lines on the chest wall and be able to locate the position of each rib and some spinous processes. These landmarks help the nurse to identify the position of underlying organs (e.g., lobes of the lung) and to record abnormal assessment findings.

The diagram above shows the anterior, lateral, and posterior series of lines. The midsternal line is a vertical line running through the center of the sternum. The midclavicular lines (right and left) are vertical lines from the midpoints of the clavicles. The anterior axillary lines (right and left) are vertical lines from the anterior axillary folds. The posterior axillary line is a vertical line from the posterior axillary fold. The midaxillary line is a vertical line from the apex of the axilla.  The vertebral line is a vertical line along the spinous processes. The scapular lines (right and left) are vertical lines from the inferior angles of the scapulae.

These specific landmarks (i.e., T3 and the fourth, fifth, and sixth ribs) are located as follows. The starting point for locating the ribs anteriorly is the angle of Louis, the junction between the body of the sternum (breastbone) and the manubrium (the handle-like superior part of the sternum that joins with the clavicles). The superior border of the second rib attaches to the sternum at this manubriosternal Junction, as shown in the following diagram.

The nurse can identify the manubrium by first palpating the clavicle and following its course to its attachment at the manubrium. The nurse then palpates and counts distal ribs and intercostal spaces (ICSs) from the second rib. It is important to note that an ICS is numbered according to the number of the rib immediately above the space. When palpating for rib identification, the nurse should palpate along the midclavicular line rather than the sternal border because the rib cartilages are very close at the sternum. Only the first seven ribs attach directly to the sternum.

The counting of ribs is more difficult on the posterior than on the anterior thorax. For identifying underlying lung lobes, the pertinent landmark is T3. The starting point for locating T3 is the spinous process of the seventh cervical vertebra (C7), as in the following diagram.

When the client flexes the neck anteriorly, a prominent process can be observed and palpated. This is the spinous process of the seventh cervical vertebra. If two spinous processes are observed, the superior one is C7, and the inferior one is the spinous process of the first thoracic vertebra (T1). The nurse then palpates and counts the spinous processes from C7 to T3. Each spinous process up to T4 is adjacent to the corresponding rib number; for example, T3 is adjacent to the third rib. After T4, however, the spinous processes project obliquely, causing the spinous process of the vertebra to lie, not over its correspondingly numbered rib, but over the rib below. Thus, the spinous process of T5 lies over the body of T6 and is adjacent to the sixth rib.

Chest Shape and Size

In healthy adults, the thorax is oval. Its anteroposterior diameter is half its transverse diameter as shown in the diagram.

The overall shape of the thorax is elliptical; that is, its transverse diameter is smaller at the top than at the base. In older adults, kyphosis and osteoporosis alter the size of the chest cavity as the ribs move downward and forward.

There are several deformities of the chest as in the above diagram. Pigeon chest (pectus carinatum), a permanent deformity, may be caused by rickets (abnormal bone formation due to lack of dietary calcium). A narrow transverse diameter, an increased anteroposterior diameter, and a protruding sternum characterize pigeon chest. A funnel chest (pectus excavatum), a congenital defect, is the opposite of pigeon chest in that the sternum is depressed, narrowing the anteroposterior diameter. Because the sternum points posteriorly in clients with a funnel chest, abnormal pressure on the heart may result in altered function. A barrel chest, in which the ratio of the anteroposterior to transverse diameter is 1 to 1, is seen in clients with thoracic kyphosis (excessive convex curvature of the thoracic spine) and emphysema (chronic pulmonary condition in which the air sacs, or alveoli, are dilated and distended). Scoliosis is a lateral deviation of the spine.

 

Breath Sounds

Abnormal breath sounds, called adventitious breath sounds, occur when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed. Table below describes normal breath sounds.

Adventitious sounds are often superimposed over normal sounds, as in following table.

Performing the Respiratory System Physical Assessment

Assessment of the lungs and thorax includes all methods of examination: inspection, palpation, percussion, and auscultation. The table below describes how to assess the thorax and lungs.

Documentation

The chest wall is symmetric, without deformity, and is atraumatic in appearance. No tenderness is appreciated upon palpation of the chest wall. The patient does not exhibit signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, rhonchi, or wheezes. Resonance is normal upon percussion of all lung fields. 

 

For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Thorax and Lungs”
Video:

CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEMS

The cardiovascular system consists of the heart and the central blood vessels (primarily the pulmonary, coronary, and neck arteries and veins). The peripheral vascular system includes those arteries and veins distal to the central vessels, extending all the way to the brain and to the extremities.

Heart

Nurses assess the heart through inspection, palpation, and auscultation, in that sequence. Auscultation is more meaningful when other data are obtained first. The heart is usually assessed during an initial physical assessment; periodic reassessments may be necessary for long-term or at-risk clients or those with cardiac problems.

Heart sounds can be heard by auscultation. The normal first two heart sounds are produced by closure of the valves of the heart. The first heart sound, S1, occurs when the atrioventricular (AV) valves close. These valves close when the ventricles have been sufficiently filled. Although the AV valves do not close simultaneously, the closure occurs closely enough to be heard as one sound. S1 is a dull, low pitched sound described as “lub.” After the ventricles empty the blood into the aorta and pulmonary arteries, the semilunar valves close, producing the second heart sound, S2, described as “dub.” S2 has a higher pitch than S1 and is shorter in duration. These two sounds, S1 and S2 (“lub-dub”), occur within 1 second or less, depending on the heart rate.

The two heart sounds are audible anywhere on the precordial area, but they are best heard over the aortic, pulmonic, tricuspid, and mitral areas, as in following diagram.

Each area is associated with the closure of heart valves: the aortic area with the aortic valve (inside the aorta as it arises from the left ventricle); the pulmonic area with the pulmonic valve (inside the pulmonary artery as it arises from the right ventricle); the tricuspid area with the tricuspid valve (between the right atrium and ventricle); and the mitral area (sometimes referred to as the apical area) with the mitral valve (between the left atrium and ventricle).

Associated with these sounds are systole and diastole. Systole is the period in which the ventricles contract. It begins with S1 and ends at S2. Systole is normally shorter than diastole. Diastole is the period in which the ventricles relax. It starts with S2 and ends at the subsequent S1. Normally no sounds are audible during these periods, let look at the following diagram for a better understanding.

The experienced nurse, however, may perceive extra heart sounds (S3 and S4) during diastole. Both sounds are low in pitch and heard best at the apex, with the bell of the stethoscope, and with the client lying on the left side. S3 occurs early in diastole right after S2 and sounds like “lub-dub-ee” (S1, S2, S3) or “Kentuc-ky.” It often disappears when the client sits up. S3 is normal in children and young adults. In older adults, it may indicate heart failure. The S4 sound (ventricular gallop) occurs near the very end of diastole just before S1 and creates the sound of “dee-lub-dub” (S4, S1, S2) or “Ten-nessee.” S4 may be heard in older clients and can be a sign of hypertension. Normal heart sounds are summarized in the below Table.

The nurse may also hear abnormal heart sounds, such as clicks, rubs, and murmurs. These are caused by valve disorders or impaired blood flow within the heart and require advanced training to diagnose.

Central Vessels

The carotid arteries supply oxygenated blood to the head and neck as shown in the following diagram.

Because they are the only source of blood to the brain, prolonged occlusion of these arteries can result in serious brain damage. The carotid pulses correlate with central aortic pressure, thus reflecting cardiac function better than the peripheral pulses. When cardiac output is diminished, the peripheral pulses may be difficult or impossible to feel, but the carotid pulse should be felt easily.

The carotid is also auscultated for a bruit. A bruit (a blowing or swishing sound) is created by turbulence of blood flow due either to a narrowed arterial lumen (a common development in older people) or to a condition, such as anemia or hyperthyroidism, that elevates cardiac output. If a bruit is found, the carotid artery is then palpated for a thrill. A thrill, which frequently accompanies a bruit, is a vibrating sensation like the purring of a cat or water running through a hose. It, too, indicates turbulent blood flow due to arterial obstruction.

The jugular veins drain blood from the head and neck directly into the superior vena cava and right side of the heart. The external jugular veins are superficial and may be visible above the clavicle. The internal jugular veins lie deeper along the carotid artery and may transmit pulsations onto the skin of the neck. Normally, external neck veins are distended and visible when a person lies down; they are flat and not as visible when a person stands up, because gravity encourages venous drainage. By inspecting the jugular veins for pulsations and distention, the nurse can assess the adequacy of function of the right side of the heart and venous pressure. Bilateral jugular venous distention (JVD) may indicate right-sided heart failure.

Performing the Heart and Central Vessels Physical Assessment

The table below describes how to assess the heart and central vessels.

Documentation

Inspection of the Heart

• No pulsation of the apical impulse.
• Chest is symmetrical expansion with respiration, no scars.
• No lift or heaves.

Palpation of the Heart

• No, palpable pulsation over the aortic, pulmonic, and mitral valves.
• Apical pulsation can be felt on palpation.
• No noted abnormal cardiac lift or heaves, and thrills felt over the apex.

Auscultation of the Heart

• PMI noted at fifth intercostal space and midclavicular line.
• Normal S1 & S2 can be heard at all anatomic site.
• No abnormal heart sounds are heard (e.g. Murmurs, S3 & S4).
• Cardiac rate ranges from 60 – 100 bpm, regular.

For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Cardiovascular system”
Video:

Peripheral Vascular System

Assessing the peripheral vascular system includes measuring the blood pressure, palpating peripheral pulses, and inspecting the skin and tissues to determine perfusion (blood supply to an area) to the extremities. Certain aspects of peripheral vascular assessment are often incorporated into other parts of the assessment procedure. For example, blood pressure is usually measured at the beginning of the physical examination.

Performing the Peripheral Vascular System Physical Assessment

The table below describes how to assess the peripheral vascular system.

Documentation

No rashes, swelling, color change, or cyanosis in arms or legs. No clubbing in fingernails. Capillary refill is < 2 sec. Hands and feet pink and warm to touch. No pitting edema in feet.

For better understanding and practice, you may watch the following videoclip on “Physical Examination of the Peripheral Vascular system”
Video: