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Patient Evaluation
Assessment by Ausculation
Question | Answer |
---|---|
Assessment By Auscultation Normal Breath Sounds: Vesicular | normal breath sounds = vesicular |
Assessment By Auscultation Normal Breath Sounds: Bilateral Vesicular | normal sounds in both lungs |
Assessment By Auscultation Normal Breath Sounds: Bronchial | normal sounds heard over the trachea or bronchi. the sounds heard over lung periphery = lung consolidation |
Assessment By Auscultation Changes | changes in the breath sounds will identify where the problem is. |
Assessment By Auscultation Egophony | patient is told to say "E" sounds like "A" = Pneumonia = lung consolidation |
Assessment By Auscultation Bronchophony/Whispered Pectoriloquy | increased intensity of spoke voice = pneumonia and consolidation |
Assessment By Auscultation Increased/Decreased | any increase in the spoken voice indicates pneumonia any decrease obstructed bronchi pneumothorax, emphysema |
Assessment By Auscultation Abnormal Breath Sounds/Adventitious/Rales | rales/ crackles = secretion/ fluid coarse rales (rhonchi) = large airway secretions Tx: patient needs suctioning |
Assessment By Auscultation Abnormal Breath Sounds/Adventitious/ Medium Rales | medium rales = middle airway secretions Tx: patient need chest physical therapy |
Assessment By Auscultation Abnormal Breath Sounds/Adventitious/ Fine Rales | fine rales = (moist crepitant rales) = alveoli, fluid patient has CHF/ pulmonary edema Tx: IPPB, heart drugs, diuretics, and oxygen |
Assessment By Auscultation Abnormal Breath Sounds/Adventitious/ Wheeze | due to bronchospasm Tx: bronchodilator unilateral wheeze = foreign body obstruction Tx: bronchoscope |
Assessment By Auscultation Abnormal Breath Sounds/Adventitious/ Stridor | due to upper airway obstruction supraglottic = (epiglottis) subglottic = (croup, post extubation) foreign body aspiration (solids or fluids) |
Assessment By Auscultation Abnormal Breath Sounds/Adventitious/ Stridor Treatment | topical decongestant (racemic epinephrine) for swelling/edema suction/bronchoscope for secretions/foreign body intubate for SEVERE swelling and epiglottis |
Assessment By Auscultation Abnormal Breath Sounds/Adventitious/ Pleural Friction Rub | coarse or crunching sound caused by inflamed surface of visceral & parietal rubbing Association: TB, pneumonia, pulmonary infarction, cancer Tx: steroids and antibiotics |
Assessment By Auscultation Heart Sounds/Normal/S1 | sounds made by the closure of the heart valves first sound S1= mitral and tricuspid valve at beginning of ventricular contraction |
Assessment By Auscultation Heart Sounds/Normal/S2 | second sound S2 occurs when systole ends. the ventricles relax the pulmonic and aortic valves close. |
Assessment By Auscultation Heart Sounds/Abnormal/S3 | if you hear S3 in adults = abnormal = suggest CHF = myocardial infarction or cardiomegaly |
Assessment By Auscultation Heart Sounds/Abnormal/S3 &S4 | are low pitched may be difficult to discriminate |
Assessment By Auscultation Heart Sounds/Abnormal/Heart Murmurs | caused by turbulent blood flow. heart valve defect |
Assessment By Auscultation Heart Sounds/Abnormal/Heart Murmurs Occurs | murmurs occur when blood is pushed through an abnormal opening such as an atrial septal defect. or patent ductus arteriosus. |
Assessment By Auscultation Heart Sounds/Abnormal/Heart Bruits | are the sounds made in an artery or vein that moves at an abnormal speed. heard over stethoscope over the identified vessel carotid |
Assessment By Auscultation Blood Pressure measured | measure the systolic and diastolic pressures. |
Assessment By Auscultation Blood Pressure | use a sphygmomanometer to measure cuff pressure. |
Assessment By Auscultation Blood Pressure/Normal | Adult: 120/80 acceptable: 90/60 to 140/90 |
Assessment By Auscultation Blood Pressure/Increased | hypertension = indicates stress = hypoxemia |
Assessment By Auscultation Blood Pressure/Decreased | hypotension = indicates poor perfusion = hypovolemia, CHF |