314 Health Assess ment Chapter 3 - HESI What does Assessment entail? - Ans ●Inspection=observation of appearance, behavior, movement ●Palpation=using pad of fingers to feel for elevation, depression, temp, or tenderness ●Percussion= striking the plexor finger to tap the pleximeter finger to make sound/vibration ●Auscultation=use of diaphragm and bell ○Bell -low pitched sounds ○Diaphragm -high pitched sounds ●Wellness exams(breast & testicular) ○Done yearly in a physician's office ○Should be performed once monthly at home ○Only the techniques of inspection and palpation are used to perform these exams ● Basic Care? ○ ADL's (bathing, grooming, dressing, brushing teeth, etc.) Use the Bell when listening for? - Ans *Low* pitched sounds Use the Diaphragm when listening for? - Ans *High* pitched sounds How often should Wellness exams(breast & testicular) be completed? - Ans Annually in a physician's office, and Monthly at home S1 - Ans closure Tricuspid and Mitral valve, signals the beginning of systole S2 - Ans closure Semilunar valves i.e. Aortic and Pulmonic Valve Where is the Aortic point located? - Ans 2nd ICS right sternal border (S2 heard loudest) Where is the Pulmonic point located? - Ans 2nd ICS left sternal border (S2 heard loudest) Where is Erbs point located? - Ans halfway between pulmonic and tricuspid (S1 & S2 equal in intensity) Where is the Tricuspid point located? - Ans 5th ICS left sternal border (S1 heard loudest) Where is the Mitral point located? - Ans 5th ICS left midclavicular (S1 h eard loudest) 3 types of breath sounds - Ans Vesicular, Bronchovesicular, Bronchial Vesicular Breath sounds - Ans Soft, *Low pitch*, heard in peripheral lung fields, -*Longer inspiration than expiration* Broncho -vesicular breath sounds - Ans -Normal b reath sound heard over major bronchi, -Characterized by *moderate pitch*, -*Equal duration of Inspiration and Expiration* Bronchial breath sounds - Ans *Loud, harsh, high pitched*, heard over trachea and anterior manubrium, *shorter inspiration than exp iration* Crackles during lung auscultation - Ans Fine, short, interrupted, caused by air passing through *fluid* or mucous in air passage, most commonly noted in bases of lower lobes, can clear with cough Rhonchi during lung auscultation - Ans Continuous low pitched coarse gurgling, harsh, caused by air passing through narrow airways, result of secretions, swelling, or tumors Friction rub during lung auscultation - Ans Grating or creaking sound, doesn't clear with cough, heard on inspiration, r ubbing together of inflamed pleural surfaces Wheezes during lung auscultation - Ans continuous high -pitched whistling sounds produced during breathing, Best heard on *Expiration*, doesn't clear with cough, caused by air passing through narrow airways, result from secretions, swelling, and tumors Testing for Consolidation in the Lungs - Ans -Whispered pectoriloquy: have pt whisper 1, 2, 3, should be inaudible, -Egophony: have pt say "E", if sounds like "A" consider consolidation, -Bronchophony: have pt say 99 in normal tone, should be inaudible Whispered pectoriloquy - Ans have patient whisper 1, 2, 3, should be inaudible, If audible indicates a consolidation (solid/liquid material) Egophony - Ans have patient say "E", if sounds like "A" consider conso lidation Bronchophony - Ans have pt say 99 in normal tone, should be inaudible
