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NR-302 IPhysical IAssessmentIStudy IGuide IExam I 3

50 I Questions I – I Multiple I Choice, ISelect IAll IThat IApply, IHOTSPOT, I Multiple I Sequences

Chapter I 15 I – I Respiratory

4 I major I functions

• Supplying I oxygen I for I energy
• Removing I carbon I dioxide
• Acid-base I balance I (homeostasis)
• Maintaining I heat I exchange Control I of I respirations I – I normal I stimulus, I alternative I stimulus I and I what I condition
• Pons I and I medulla
• Normal I stimulus I (Hypercapnia)
• Decrease I in I O2 I in I blood I (Hypoxemia)
• Inspiration I (Active) I expiration I (passive) Lower I – I bronchi, I pleural I membranes, I muscles I of I respiration I (normal, I accessory)
• Bronchi- I right I main I bronchus
• Pleural I membranes- I the I parietal I lines I diaphragm I and I thoracic I wall, I the I visceral I lines I outer I surfaceIof Ilung, Iand Ipleural Ifluid Iacts Ias Ilubricant
• Muscles I of I inspiration- I normal( I intercostal I muscles, I diaphragm), I accessory I ( I neck, I abdomen,Ichest) Anterior I Landmarks I – I sternum I (Angle I of I Louis, I sternal I angle, I 2ICS), I clavicle, I costal I angle I (normal)
• Costal I angle I < I 90 Idegrees Posterior I Landmarks I – I vertebra I prominens, I spinous I processes I (T1 I to I T4), I CVA Itenderness
• Vertebra I prominens- I C7 I (if I 2 I bumps I equally I prominent I C7, IT1)
• Spinous I processes- I aligned I w/ I same I numbered I rib I to I T
• CVA Itenderness- I kidney I problems References I Lines I – I anterior, I posterior, I and I lateral I thorax
• Anterior- I sternal, I midclavicular, I anterior I axillary
• Posterior- I vertebral, I scapular, I posterior I axillary
• Lateral- Ianterior I axillary, I midaxillary, I posterior I axillaryILobes I(3 Ion Iright, I 2 Ion Ileft), Iapex Iversus Ibase
• Right- I upper, I middle, I lower I lobes
• Left- Iupper, I lower Ilobes
• Apex I (highest I point) I anterior I and I 3 - 4 I cm I above I clavicle
• Base I (lower I border) Pediatric I (AP:Transverse I diameter, I abdominal I breathing, I role I of I surfactant)
• AP: I transverse I 1:1 I ratio
• Abdominal I breathing I until I 5 - 7 I yrs Pregnant I (Diaphragmatic I breathing, I SOB, I costal I angle I changes, I lordosis)
• Muscles I and I cartilage I of I the Iribs I relaxes

o Diaphragm I rises I into I chest I to I accommodate I fetus o Diaphragmatic I breathing o Shortness I of I breath I (SOB), I dyspnea, I increase I awareness I of I breathing I in I last I trimester

• Total I oxygen I demand Ican I increase I 20%
• Costal I angle I widens
• Deeper I breathing, I respiratory I rate I unchanged
• Lordosis I or I swayback, I “waddling” I gait

Geriatric I (overall I aging I changes I to I respiratory I rate I and I depth, I vital I capacity, I alveoli); I cough I ability, I kyphosis

• Aging I lung I is I more I rigid, Iharder I to I inflate o Decrease I vital I capacity, I increased I residual I volume o Decreased I number I of I alveoli o Decreased I in I respiratory I depth o Slight I increase I in I respiratory I rate
• Decrease I in I cough I ability o Weakening I of I the I chest I muscles, I decrease I cilia o Compromises I airway I clearance
• Kyphosis I “hunchback”

Subjective Cough I – I differences I between I acute I versus I chronic; I time I of I day; I productive I versus I non- productive;Icolor I of I phlegm I or I sputum; I descriptions I and I meaning; I associated I symptoms; I possible I treatments

• Acute I (lasts I 2 I or I 3 I weeks), I chronic I (over I 2 I months)
• Often? ITime I of I day? o Continuous I – I acute I illness, I respiratory I infection o Afternoon/evening I – I may I irritants I at I work o Night I– Ipostnasal Idrip o Early I morning I – I chronic I bronchial I inflammation, I smokers
• Productive I or I non-productive? I Phlegm I or I sputum? o Hemoptysis I (blood), I frank I blood I versus I streaks I of I blood o White I or I clear I – I colds, I bronchitis, I viral I infections o Yellow I or I green I – I bacterial I infections o Rust I colored I – I TB, I pneumonia o Pink, I frothy I – I pulmonary I edema, I medications
• Describe I your I cough? o Hacking I– Ipneumonia o Dry I – I early I congestive I heart I failure I (CHF) o Barking I– Icroup o Congested I – I colds, I bronchitis, I pneumonia
• Associated? o Activity? I Position I (lying)? I Fever? I Congestion? I Talking? IAnxiety?
• Treatment? o OTC I medications? I Vaporizer? I Rest? I Position I change?

• Brings I on I anything? o Chest I pain? I Ear I pain? ITiring? I Concern?

SOB I – I with I exertion I or I at I rest; I position I – I orthopnea, I PND; I associated I symptoms

• Exertion I or I at I rest? IAmount I of I activity I brings I it Ion? o Number I of I blocks I walked, I number I of I stairs, I talking, I rest
• Position o Orthopnea I (difficult I breathing I when I supine) ▪ One-pillow, I two-pillow I orthopnea
• Specific Itime I of I day I or I night? o Paroxysmal I nocturnal I dyspnea I (PND) ▪ Sudden I onset I of I SOB I at I night; I awaken I from I sleep ▪ CHF I (left-sided)
• Associated I symptoms? o Cough, I diaphoresis, I cyanosis, I wheezing, I allergan I exposure

Chest I pain I – I with I breathing I to I determine I origin; I pleuritis

• Muscle I soreness I with I coughing
• Inflammation I of I pleura I (pleuritis), I pneumonia
• Respiratory, I cardiac, I GI Iorigin

Smoking I history I – I pack/years

• Cigarettes I or I cigars?
• Packs I per I day, I number I of I years I smoked
• Tried I to I quit, I multiple Iattempts

Pneumonia I vaccine; I influenza I immunizationIObjective Techniques I (inspection, I palpation, I percussion, I auscultation) Inspection I (AP:Transverse I diameter I normal I versus I barrel I chest, I spinous I processes, I tripod I withICOPD; Ipectus Iexcavatum; Ipectus Icarinatum; Iscoliosis)

• Thoracic I Cage o Shape I and I configuration I of I chest I wall ▪ Symmetrical ▪ Anteroposterior I diameter I < I transverse I diameter I (1:2 I or I 5:7) o Spinous I processes I straight, I midline o Position ▪ Upright, I relaxed ▪ Tripod I with I COPD I (Chronic I Obstructive I Pulmonary I Disease) o Skin I color I and I condition I (pink, I warm I and I dry) ▪ No I cyanosis, I no I lesions

Palpation I (crepitus; I tactile I fremitus I know I technique I and I normal/abnormal I findings I with I certainIrespiratory Iconditions; Irespiratory Iexpansion)

• Tenderness? I Ribs? I Intercostal I spaces?

• Crepitus? I Coarse, I crackling I sensation?
• Symmetric I chest I expansion
• Tactile Ior Ivocal Ifremitus o “Ninety-nine”; I side-to-side, I over I lung I tissue o Palmar I base I of I fingers I or I ulnar I edge I of I hand o Decreased I with I obstruction ▪ Pneumothorax, I pleural I effusion, I emphysema o Increased I (lobar I pneumonia)

Percussion I (Locations I to I percuss; I Normal I percussion I sound I over I lungs? IAbnormal I sounds I with Icertain I respiratory I conditions; I Know I the I technique I of I diaphragmatic I excursion I and I normal I findings)

• Lungs o Resonance I predominant I note I over I the I lung I fields ▪ Low-pitched, I clear, I hollow I sound o Hyperresonance ▪ Emphysema, I pneumothorax o Dullness ▪ Pneumonia, I pleural I effusion, I atelectasis, I tumor
• Diaphragmatic I excursion o Lung I resonance I to I diaphragm I dullness o Normal I adult I excursion I is I 3 I to I 5 Icm

Auscultation I (Technique, I locations, I and I instructions I to I patient; I Which I side I of I stethoscope; I NormalIbreath I sounds I of I vesicular, I bronchovesicular, I tracheal I – I location, I ratio I of I inspiration I to I expiration; IAdventitious I breath I sounds I (p.378) I – I know I characteristics I of I each I sound I and I possible I respiratoryIconditions; I Voice I sounds I – I perform I if I presence I of I adventitious I breath I sounds; I bronchophony, Iegophony, Iand Iwhispered Ipectoriloquy)

• Sitting, I lean Iforward I slightly, I arms I across I lap
• Instruct I to I breathe I through I mouth, I little Ibit I deeper I than I usual, I but I stop I if I feels I dizzy
• Diaphragm I of I stethoscope, I firmly I on I chest I wall
• Listen I to I one I full I respiratory I cycle I per I location
• Side-to-side I comparison
• Normal I breath I sounds o Bronchial I (tracheal), I bronchovesicular, I vesicular

o I

• Adventitious I sounds I (continuous, I discontinuous) o Rales I or I crackles I (fine, I coarse)

o Rhonchi I (wheezes I - I sibilant I or I sonorous; I stridor, I friction I rub)

• If I adventitious I breath I sounds I present, I then I assess I for I voice I sounds

▪ Bronchophony

• “Ninety-nine” I ; I normal I sound I is I muffled
• Abnormal I clear I “ninety-nine” I with I lung I consolidation

▪ Egophony

• “E”; I normal I sound I is I “eeee”
• Abnormal I “eeee” I changes I to I “aaaa” I with I lung I consolidation

▪ Whispered I pectoriloquy

• Whispered I “one-two-three”; I normal I sound I is I muffled
• Abnormal I clear I “one-two-three” I with I lung I consolidation

Anterior I chest Inspection I (costal I angle, I level I of I consciousness I normal, I abnormal I findings I of I retraction I or I bulging Iintercostal I spaces I and I use I of I accessory I muscles, I respirations I – I know I normal I and I abnormal Irespiratory Irates Iand Ipatterns I– IBiot’s Ior IAtaxic, IObstructive Ibreathing, ICheyne IStokes; Itachypnea,Ibradypnea, Ieupnea, Ihyper Iand Ihypoventilation)

• Shape I and I configuration o Symmetry o Costal I angle I is Iwithin I 90 I degrees
• Facial I expression I (relaxed)
• Level I of I consciousness I (alert)
• Skin I color I and I condition
• Respirations o Retraction I or I bulging I of I intercostal I spaces o Accessory I neck I muscles

o I

o

Palpation I (chest I expansion, I tactile I or I vocal I fremitus, I mobility I and I turgor, I temperature, I moisture)

• Symmetric I chest I expansion
• Tactile Ior Ivocal Ifremitus
• Tenderness o Lumps, I masses o Ribs, I intercostal I spaces
• Skin o Mobility I and I turgor I (under I clavicle) o Temperature I and I moisture

Percussion I (normal I percussive I note I over I lung I fields; I locations I to I percuss)

• Lungs o Resonance I predominant I note I over I the I lung I fields ▪ Low-pitched, I clear, I hollow I sound

Auscultation I (locations, I normal I sounds)

• Sitting, I lean Iforward I slightly, I arms I across I lap
• Instruct I to I breathe I through I mouth, I little Ibit I deeper I than I usual, I but I stop I if I feels I dizzy
• Diaphragm I of I stethoscope, I firmly I on I chest I wall
• Listen I to I one I full I respiratory I cycle I per I location
• Side-to-side I comparison

Respiratory I Disorders I (p I 387-390)

• Asthma I (chronic I hyperreactive I condition)
• Atelectasis I (obstruction I of I airflow)
• Bronchitis I (inflammation I of I tracheobronchial I tree)
• Emphysema I (obstruction I of I the I alveoli)
• Pneumonia I (infection I in I the I alveoli)
• Pleural I effusion I (fluid I in I the I pleural I space)
• Pneumothorax I (collapse I of I the I lung)
• Congestive I heart I failure I (edema I around I the I alveoli)

•

Chapter I 17 I – I Cardiovascular

Basic Ianatomy: I Layers I of I heart, I major I structures I of I heart I (blood I flow I thru I the I heart, I valves, I conduction Isystem), I electrical I components I (P I wave, I QRS I wave, I T I wave), I systole I versus I diastole, I S1 I versus I S2 I due I to Iwhich Icardiac Ivalves, Ilandmarks Iin Iprecordial Iassessment; Iapex Iversus Ibase Iof Ithe Iheart

1. Layers a. Fibrous I pericardium b. Serous I pericardium I (parietal I layer) c. Pericardial I space d. Serous I pericardium I (Visceral I layer) e. Myocardium f. Endocardium
2. Blood Iflow a. Superior I and I inferior I vena I cava b. Right Iatrium c. Tricuspid Ivalve d. Right I ventricle e. Pulmonic I valve f. Pulmonary I artery g. Pulmonary I veins h. Left I atrium i. Mitral I valve j. Left I ventricle k. Aortic I valve l. Aorta m. Body
3. Conduction I system a. SA Inode- I Normal I pacemaker I of I the I heart; I 60 - 100 I BPM b. AV I node- I 40 - 60 IBPM c. Bundle Iof I his d. Right I and I left I bundle I branch e. Purkinje I fibers- I 20 - 40 I BPM
4. Electrical I recordings a. P I wave I (atrial I depolarization) b. PR Iinterval c. QRS I interval I (ventricular I depolarization) d. T I wave I (ventricular I repolarization)
5. Systole I vs. I diastole a. Systole- I contraction I of I ventricles I 1/3 I of I cardiac I cycle b. Diastole- I relaxation I of I ventricles I 2/3 I of I cardiac I cycle c. S1- I Mitral I and I tricuspid I valves I close d. S2- I aortic I and I pulmonic I valves I close
6. Landmarks a. Aortic- IRSB, I 2 nd^ IICS b. Pulmonic- ILSB, I 2 nd^ IICS c. Erb’s I point- ILSB, I 3 rd^ IICS d. Tricuspid- ILSB, I 4 th^ IICS

e. Mitral- ILMCL, I 5 th^ IICS

Characteristics I of I heart I sounds: I S1, I S2, I S3, I S4; I heart I murmurs I – I 10 I distinguishing I characteristics,Iespecially Igrading Imurmurs.

1. Distinguishing I murmurs a. Loudness b. Location I in I cardiac I cycle c. Is I it Icontinuous I in I systole, I diastole, I or I part I of I cycle i. Configuration d. Quality e. Pitch f. Landmarks I heard I best g. Does I it I radiate h. Change I with I respiration i. Associated I with I variations j. Intensity I change I w/ I positionICoronary Iarteries I– Imajor Iones
2. Left a. Left I main b. Left I anterior I descending I (LAD) c. Circumflex

2. Right a. Marginal

Concepts I of I cardiac I function I – I stroke I volume, I cardiac I output, I cardiac I index, I ejection I fraction, I preload,Iafterload

1. Stroke I volume a. Amount I of I blood I ejected I with I each I heartbeat
2. Cardiac I output I (HR I x I SV) a. Amount I of I blood I ejected I from I left Iventricle Iover I 1 I minute b. Normal I 4 - 6 I L/min
3. Cardiac I index a. Measurement I accounting I individual’s I weight b. Normal I 2.6-4.2 I L/min/m^2
4. Ejection IFraction I(LVEF, IRVEF) a. Measurement I of I how I much I blood I (%) I is I being I pumped I out I of I the I left I or I right I ventricle IofIthe Iheart Iwith Ieach Icontraction

Ejection I Fraction I Measurement What Iit I Means

55 - 70% Normal

40 - 55% Below I Normal

Less Ithan I 40% May I confirm I diagnosis I of I heart I failure

<35% Patient I may I be I at I risk I of I life-threatening I irregula

5. Preload a. Length I to I which I the I ventricular I muscle I is I stretched I at I the I end I of I diastole b. Frank-Starling I law i. Greater I the I stretch, I the I stronger I the I heart’s I contraction
6. Afterload a. Pressure I the I ventricle I must I generate I to I pump I its I blood I forward

Pediatric I considerations I – I foramen I ovale, I ductus I arteriosus, I HR I normal, I heart I position, I apex I location

1. Fetus I receives I oxygen I and I nutrients I from I mother
2. Changes I in I newborn’s I cardiovascular I system a. Foramen I ovale I (atrial I septal I defect); I closes I first I few I hours b. Ductus I arteriosus; I (detour I from I pulmonary I artery I to I aorta) I closes I 10 - 15 I hours
3. Infant’s I heart I rate I (70- 170 I BPM; I adult I rate I by I 12)
4. Heart’s I position I more I horizontal I than I adult
5. Apex I is Ihigher a. 4 th^ IICS Iinfant; I 5 th^ IICS Iat I 7 Iyears I of Iage

Pregnant I considerations I – I blood I volume, I CO, I SV, I HR, I BP, I murmurs

1. Heart I is I displaced I to I the I left I and I upward
2. Blood I volume I increases I 30% I to I 40 - 50%
3. Cardiac I output I and I stroke I volume I increase
4. Resting I pulse I may I increase a. 10 - 15 I BPM
5. Blood I pressure I decreases I due I to I vasodilation a. Lowest I 2 nd^ Itrimester, Ithen I rises; I varies I with Iposition
6. Murmurs I may I be I auscultated

Geriatric I considerations I – I BP I (systolic I and I orothostatic I hypotension); I dysrhythmias, I compliance, I thickening

1. Loss I of I ventricular I compliance a. Left I ventricular I wall I thickens
2. Vascular Irigidity a. Systolic I BP Iincreases
3. No Ichange I in I resting I HR I or I CO a. Decreased I maximum I HR I with I exercise
4. Conduction I system a. Dysrhythmias I increases; I most I asymptomatic
5. Orthostatic I hypotension

Subjective I– IAngina I(know Idetails); IDyspnea I(DOE, IPND), IOrthopnea; ICough I– Ihemoptysis, Ipink Ifrothy;IFatigue; I Cyanosis, I pallor, I grey; I Edema I – I pitting, I weight I gain; I Nocturia; I Sudden I cardiac I death, I CAD

1. Chest I pain I or I tightness? IAngina I or I ischemia? a. Squeezing, I pressure, I tightness, I ache, I crushing, I stabbing, I burning, I viselike b. Stable I versus I unstable I angina i. Predictable I amount I of I activity I or I exertion ii. Physical I or I emotional I stress, I sexual I intercourse, I cold I weather c. Location i. Midsternal, I left I mid-clavicular I line ii. Radiates I left I arm, I neck, I teeth, I shoulder d. Associated I symptoms i. Diaphoresis, I cold I sweats, I pallor, I grayness ii. Palpitations, I dyspnea, I nausea, I vomiting, I tachycardia, I fatigue e. Aggravating I factors i. Moving I arms I or I neck, I breathing, I lying I flat ii. Pulmonary, I musculoskeletal, I gastrointestional f. Relieving I factors i. Rest, I nitroglycerin
2. Dyspnea a. At I rest I or I with I exertion I (DOE) b. Activity, Italking, I or I at Irest c. Paroxysmal, I constant I or I intermittent d. Recumbent e. PND I associated I with I Left I CHF
3. Orthopnea a. Need I to I assume I more I upright I position I to I breathe

b. Number I of I pillows?

4. Cough a. Duration? I Dry I or I congested? b. Productive? i. Hemoptysis I – I pulmonary I edema, I mitral I stenosis
5. Fatigue a. Most I common I symptom; I worse I in I evening
6. Cyanosis I or I pallor
7. Edema a. Dependent; I worse I at I night; I bilateral I if I cardiac b. Pitting c. Associated I symptoms i. SOB ii. Weight I gain, I greater I than I 3 I to I 5 I lbs I per I week
8. Nocturia a. Urinating I at I night
9. Past I Cardiac I History a. HTN, I elevated I cholesterol I or I triglycerides, I heart I murmur, I congenital I heart I disease,Irheumatic Ifever, Irecurrent Itonsillitis, Ianemia
10. Family I Cardiac I History a. HTN, I obesity, I diabetes, I coronary I artery I disease I (CAD), I sudden I death I at I younger I age

Cardiac I Risk I Factors I – I non-modifiable I versus I modifiable

1. Non-modifiables Age, I sex, I hereditary
2. Modifiable Obesity, I diabetes, I HTN Smoking, I elevated I cholesterol, I low I activity I level HRT I (hormone I replacement I therapy) Alcohol Stress?

Neck I vessels I – I Carotids I (palpate, I auscultate-bruits); I Jugular I Venous I Pulse I (inspect I and I estimate I JVP I or IJVD) I– Itechnique, Inormal, Iabnormal Ifinding Imeaning ▶ (Carotid I artery) Palpate Medial I to I sternomastoid I muscle Carotid I sinus I higher I in I neck; I vagal I stimulation Palpate I one I carotid I at Ia I time 2+ Iand I equal I bilaterally Auscultate Bell I of I stethoscope; I 3 I positions Take Ia I breath, Iexhale, Iand I hold I it Ibriefly Carotid I bruit I when I 1/3 I to I 2/3 I occlusion I lumen ▶ (Jugular I Venous I Pulse)

Inspect Assess I central I venous I pressure I (CVP) ▶ Judge I heart’s I efficiency I as I pump, I increased I right I CHF ▶ Stand Ion I right I side ▶ Inspect I highest I level I of I external I & I internal I jugular I veins ▶ Supine, I remove I pillow, I HOB I @ I 30 I to I 45 I degree I angle ▶ Turn Ihead Iaway, I tangential Ilight Estimate I Jugular I Venous I Pressure I (JVP) Read I highest I level I of I pulsations Use I angle I of I Louis I (sternal I angle) I reference I point Normal I < I3cm Elevated I with I right-sided I CHF If I elevated, I perform I hepatojugular I reflex I (HJR) Press I on I RUQ, I firm I sustained I pressure I for I 30 I seconds Displace I venous I blood If I CHF I is Ipresent, I JVD I will I elevate I further I and I stay I as I long I as I you I applyIpressure Document: I JVD I 4cm, I negative I HJR Precordium I – I Inspect I (pulsations I – I apical I impulse; I heaves I and I lifts); I Palpate I (apical I impulse, I thrills); IPercussion I (dullness, I chest I x-ray); IAuscultation I (traditional I valve I areas, I Erb’s I point, I Z I pattern, I bell I andIdiaphragm, Ileft I lateral; I apical I pulse I 1 I full I minute; I S1 I louder I at Iapex; I S2 I louder I at I base; I S1=S2 I at I Erb’s Ipoint; Irate; Irhythm I(regular, Iregular-irregular, Iirregular-irregular); IAtrial Ifibrillation ▶ Inspect IAnterior I Chest ◦ Pulsations Apical I impulse I (5th^ I ICS, ILMCL) ◦ Heaves, I lifts Forceful I thrusting I of I ventricle; I hypertrophy Left I ventricular I heave, I apex I or I apical Right I ventricular I heave, I sternal I border ▶ Palpate I Anterior I Chest ◦ Apical I Impulse Location I(5th^ IICS, ILMCL) Ior I 4 th^ IICS Roll I onto I left I lateral I side Palpable I in I about I half I of I adults Used I to I be I called I PMI I (Point I of I Maximal I Impulse) ◦ Thrills Palpable I vibration, I purring I cat Turbulent I blood I flow Palmar I aspect I of I hand Normal I none I occur ▶ Percussion ◦ General I not I performed ◦ Used I to I outline I heart’s I borders ◦ Estimate I heart I enlargement, I hypertrophy

HTN, I CAD, I CHF, I cardiomyopathy ◦ Better I seen I on I chest I x-ray ▶ Auscultation ◦ 4 I traditional I valve I areas, I plus I Erb’s I point Where I valves I heard I best, I not I anatomic I locations Sound I radiates I with I direction I of I blood I flow Aortic Iarea I (2nd^ IICS, I RSB) Pulmonic Iarea I (2nd^ I ICS, ILSB) Erb’s Ipoint I(3rd^ I ICS, ILSB) Tricuspid Iarea I (4th^ Ior I 5 th^ IICS, ILSB) Mitral I or I apical Iarea I (5th^ IICS, I LMCL) ◦ Z I pattern, I intercostal I spaces Diaphragm, I then I bell ▶ Auscultation I Normal I Findings ◦ Aortic I and I Pulmonic I areas I (Base) S2 I is I louder I than I S ◦ Erb’s I point S1 I and I S2 I are I heard I equally ◦ Tricuspid I area, I Mitral I area I (Apex) S1 Iis Ilouder I than I S Auscultate I apical I pulse I 1 I full I minute I for I rate ◦ Rate I and I Rhythm Regular, I regular-irregular, I irregular-irregular If Iirregular, I check I for Ipulse Ideficit ▶ Compare I apical I pulse I to I peripheral I pulse I (radial) ▶ Assess I if I heart I perfusion I of I blood ▶ Premature I beats, I atrial I fibrillation ◦ Heart I Sounds S1 Iand I S Focus I on I systole, I diastole; I then I extras, I murmurs

Disorders I (Myocardial I ischemia I versus I Myocardial I Infarction; I CHF I – I signs I and I symptoms I of I both I right I and Ileft-sided; IVentricular Ihypertrophy; ICardiomyopathy ▶ Myocardial I ischemia ◦ Decrease I myocardial I oxygen I supply I to I demand ◦ Greater I than I 30 - 90 I minutes, I permanent I damage ▶ Myocardial I infarction I (MI) ◦ Necrosis I to I myocardium ◦ Coronary I artery I disease ▶ Congestive I heart I failure I (CHF) ◦ Left-sided I (lung I symptoms) ▶ SOB, I crackles, I cough, I orthopnea, I fatigue, I S3, I anxiety, I confusion ◦ Right-sided I (peripheral I symptoms)

▶ Skin I pale, I gray, I or I cyanotic; I nausea, I vomiting; I pitting I edema, I JVD, I HJR, I ascites,Iweak Ipulse, Icool Imoist Iskin, Idecreased Iurine Ioutput ▶ Ventricular I hypertrophy ◦ Enlargement I of I the I ventricles ◦ Compensatory I mechanism ◦ Cardiomyopathy ◦ Disease I of I myocardium ▶ Dilated I or I congestive I (CHF, I MI, I alcohol, I pregnancy) ▶ Hypertrophic I (inherited) ▶ Restrictive I (connective I tissue I diseases, I cancers) ◦ Symptom I management, I heart I transplant

Other I Findings: I Xantholasma; I Earlobe I creases; I Splinter I Hemorrhage