Advanced Health Assessment NURS 612 Study Guide (2016-17 Essex)

StudyBlue Tue Feb 28 20:39:44 PST 2017

What are some appropriate HPI questions for someone complaining of dyspnea or breathlessness?

When does it occur?

Does it occur with exertion (such as going up and down stairs)? How many flights of stairs?

Is it all the time, even at rest?

Is it constant or intermittent?

What are some appropriate HPI questions for someone presenting with a cough?

Do you cough with change or weather, odors, change in temperature?

Is the cough longer than 4 weeks (which would make it a chronic cough)?

Is it relieved by any measures such as bronchodilators or Guafenisin?

Productive or unproductive cough? (Color, quality, consistency)

When asking about the onset of cough, what 3 factors should you ask about?

Did it start SUDDENLY or GRADUALLY and HOW LONG?

What are important things to ask/assess regarding a nature of a cough?

Dry, moist, wet, hacking, hoarse, barking, whooping, bubbling, productive, nonproductive

What are important things to ask/assess regarding sputum when a patient has a cough?

Duration, frequency, with activity, at certain times of day, amount, color (clear, purulent, blood tinged, mostly blood), foul odor

What associated symptoms should you ask about if a patient presents with a cough?

SOB, CP, tightness with breathing, fever, nasal congestion, noisy respirations, hoarseness, gagging

How do you assess the rate and quality of respirations?

Rate should be 12-20. Ratio of respiration should be approximately 1:4. Note the pattern of respirations and the way in which the

chest moves Expect the patient to breathe easily, regularly, and without apparent distress

What are some things to assess when inspecting the chest and breathing pattern?

What is the rate of breathing? Is effort relaxed? Is the rhythm even? Are they using pursed lip breathing? What is overall chest size?

What is the chest shape?

What should the AP diameter be?

1:2

What happens to the AP diameter with aging?

It increases with age and the AP diameter approaches or equals the lateral diameter (can even be 1:1)

What are the thoracic landmarks?

Midsternal lineR & L Midclavicular linesR & L anterior axillary linesR & L midaxillary linesR & L posterior axillary linesVertebral lineR &

L Scapular Lines

What is the normal rate of respirations?

12 to 12 RPM

When assessing the peripheral areas such as lips and nails, what are abnormal findings? (respiratory system)

Lips and nails with cyanosis, pursing of lips, clubbed fingers, alas nasa flaring

What can pursing of the lips indicate?

Increased expiratory effort

What is clubbing of fingers associated with?