Cardiovascular System Assessment

In this article we will learn how to gather the patient's health history concerning the heart and peripheral vascular systems, conduct a physical examination of the heart and peripheral vascular system using appropriate techniques, and record the results of the cardiac and peripheral vascular assessment.

I. Overview of the Cardiovascular System 

The cardiovascular system assessment involves examining the peripheral vascular system by evaluating color, temperature, swelling, capillary refill, and peripheral pulses. It also includes examining the heart through inspection, palpation, and auscultation of specific heart landmarks.

II. Step-by-Step Assessment

• Wash hands thoroughly.
• Assess room for necessary contact precautions.
• Introduce yourself to the patient.
• Verify patient identity using two identifiers (e.g., name and date of birth).
• Explain the assessment procedure to the patient.
• Prepare all required equipment before beginning the examination.
• Conduct the assessment in an orderly and methodical manner.
• Employ effective listening and questioning techniques.
• Attend closely to any cues provided by the patient.
• Respect patient privacy and maintain dignity throughout.
• Adhere to principles of cleanliness (asepsis) and safety.
• Record vital signs.

Steps	Additional Information
1.Conduct a targeted interview regarding cardiovascular and peripheral vascular conditions.	Inquire about symptoms such as chest discomfort, irregular heartbeat (palpitations), difficulty breathing (dyspnea), cough, swelling, fatigue, known cardiac risk factors, leg discomfort, changes in skin condition, limb swelling, past medical history, and diabetes history.
2. Inspect: Face, lips, and ears for cyanosis, pallor Chest for scars, deformities, and visible pulsations Both arms/hands, noting color, temperature, moisture, movement, sensation (CTMMS), edema, nail beds, nail shape, and capillary refill Both legs, noting CTMMS, hair distribution, edema, nail beds, and capillary refill, numbness/tingling Calf size/pain for signs of deep venous thrombosis (DVT)	Cyanosis indicates reduced blood flow and oxygen levels. To assess capillary refill, press on the fingernails or finger pads until they blanch; release and note how quickly the original color returns. Normal capillary refill is within 2 seconds. Evaluate capillary refill on both lower legs. Assess capillary refill bilateral lower legs Changes and discrepancies in color, warmth, movement, and sensation (CWMS) may suggest underlying conditions or injury. When assessing capillary refill, also examine the angle of the nail base. Normally, the angle of the nail base is about 160 degrees. Clubbing of the fingers occurs when this angle increases beyond 160 degrees, often associated with chronic oxygen deprivation (hypoxemia). Clubbing fingers The sudden onset of severe, sharp muscle pain worsened by dorsiflexion of the foot suggests deep vein thrombosis (DVT), along with increased warmth, redness, tenderness, and swelling in the calf. Assess calf for CWMS Note: Immediate referral is necessary for deep vein thrombosis (DVT) due to the potential risk of developing a pulmonary embolism.
3. Auscultate: Aortic/Pulmonic/Erb’s point/Tricuspid/Mitral Auscultate apical pulse for one minute. Note the rate and rhythm.   Source: Heart sounds - wikidoc	Instruct the patient to breathe normally. Use the diaphragm side of the stethoscope to auscultate the five landmark areas: Aortic – 2nd ICS on the right sternal border. Pulmonic – 2nd left ICS ERB’s Point – 3rd left ICS Tricuspid– 4th left ICS (for children 4th or 5th left ICS) Mitral Area – 5th left ICS medial to the MCL Auscultate for rate, rhythm, and pitch (the quality of the sound). Auscultate apical pulse at the fifth intercostal space and midclavicular line. Note the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual findings.
4. Palpate: Inspect and palpate of the heart Bilateral radial, brachial, dorsalis pedis, and posterior tibialis pulses. Skin turgor edema (Tip from CNC on palpating pulses- Pulses are felt best when the artery is pressed against a bone, example radial pulse felt best when pressed against the radial bone, dorsalis pedis artery felt best when you palpate at the roundest curve of the dorsum of the foot, carotid pulse felt best at the angle of the jaw but palpate for only 5 to 10 seconds)	The ball of the hand (at the base of the fingers) is the most sensitive at detecting thrills. Inspect and palpate for: Pulsations- are more visible when patients are thin. Pulsations may indicate increased blood volume or pressure. Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. Thrills- these are the vibrations of loud cardiac murmurs. Thrills occur with turbulent blood flow. The finger pads are more sensitive in detecting pulsations. Use the finger pads of index and middle fingers and apply light pressure on the pulsation site. If pulses cannot be felt, a Doppler to amplify the sounds can be used. While palpating the artery, note the rate (normal 60-100 beats/min), rhythm (normal: regular), amplitude (normal: easily palpable, 2+), and contour (normal: smooth and rounded).  Pulse Amplitude (strength): 0 = absent; 1+ = decreased, barely palpable; 2+ = normal; 3+ = Full volume; 4+ = bounding pulse Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction. To check skin turgor, use the thumb and index fingers to pinch an area of the skin and release it. It should instantly return to place. To check edema, press down the skin and release the pressure, the skin normally will return to place right away. Assessing edema. When the indentation of the thumb or any fingers remain in the skin, it is pitting edema. Source: Pitting Edema Assessment: Physical Exam (ebmconsult.com)    No clinical edema = 0 2-4 mm indentation = 2+ edema 4-6 mm indentation = 3+ edema 6-8 mm indentation = 4+ edema
5. Report and record assessment findings and associated health issues following organizational protocols.	Accurate and timely documentation and reporting promote patient safety.

Health Assessment in Clinical Practice

 In this article we will:

1. Explain the significance of health assessment in making clinical judgments and ensuring high-quality patient care

2. Describe the various types of health assessments

3. Distinguish between objective and subjective data

4. Apply physical assessment techniques

Health assessments are conducted by nurses and other healthcare providers using their knowledge of anatomy, physiology, therapeutic communication, and pathophysiology.

Precise patient assessment is crucial for implementing suitable interventions. This assessment entails identifying relevant cues not only from direct patient evaluation but also from environmental factors, health history, and laboratory results. 

This step is vital for clinical judgment, enabling the nurse to analyze these cues, develop hypotheses about their relationships, and prioritize issues to address. See Prompts for clinical judgement tasks in the table below:

 Types of health assessments include:

• Comprehensive Head-to-Toe Assessments: Performed upon patient admission (nursing admission assessment) and at the start of each shift or as needed based on the patient's condition.
• Brief Physical Assessments: Conducted to identify changes in a patient's status and compare with previous assessments.
• Focused Assessments: Targeted evaluations in response to a specific problem identified by the nurse.
• Emergency Assessments: Modified assessments in urgent situations to gather essential information for immediate care.
• Routine Physical Assessments: Regular evaluations to update a patient’s database, documented per agency policy, with unusual findings reported to the healthcare team.

Ongoing, thorough, and objective assessments ensure continuity in patient care.

Types of Data:

Subjective Data:

• Information reported by the patient or a knowledgeable historian, organized into a health history.
• Health history is taken and updated as needed with each patient encounter, informing patient care.

Objective Data:

• Observable and measurable data obtained through systematic physical assessment, vital signs measurement, and correlation with lab and diagnostic findings.
• Observation: Uses senses to assess (e.g., heart sounds, moisture, wound odor).
• Measurement: Compares assessment values to normal standards (e.g., pain scale, weight, tenderness).

Techniques of Physical Assessment:

The standard physical examination includes:

• Inspection: Observing visual clues, such as appearance, demeanor, and expressions.
• Palpation: Gathering information through touch, noting what the patient feels during palpation.
• Percussion: Listening to and interpreting different percussion sounds related to the patient's condition.
• Auscultation: Using a stethoscope to listen to internal body sounds.

These techniques rely on understanding normal conditions to identify abnormalities and require knowledge of common patterns associated with various conditions. Information from these techniques helps nurses formulate nursing diagnoses and identify functional health problems. 

How to Perform the Techniques of Physical Examination:

The typical sequence for physical assessment techniques is: inspection, palpation, percussion, and auscultation. For abdominal assessments, the sequence changes to: inspection, auscultation, percussion, and palpation to avoid altering bowel sounds.

1. Inspection: Use vision, smell, and hearing to assess each body system, noting color, size, location, movement, texture, symmetry, odors, and sounds.

2. Palpation:

   • Touch the patient with different parts of your hands, applying varying degrees of pressure.
   • Keep fingernails short, hands warm, and wear gloves when palpating mucous membranes or areas in contact with body fluids.
   • Palpate tender areas last.  
   

   
   
   

   Types of Palpation:

• Light Palpation:
• Used to feel surface abnormalities.
• Depress the skin ½ to ¾ inch (about 1 to 2 cm) with finger pads.
• Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.

• Deep Palpation:

• Used to assess internal organs and masses for size, shape, tenderness, symmetry, and mobility.
• Depress the skin 1½ to 2 inches (4 to 5 cm) with firm pressure.
• Use one hand on top of the other for firmer pressure if needed.

3. Percussion

   • Involves tapping fingers or hands against the patient's body to locate organ borders, identify shape and position, and determine if an organ is solid or filled with fluid or gas.   

   Types of Percussion

• Direct Percussion:
• Reveals tenderness, commonly used for assessing adult sinuses.
• Tap directly on the body part with one or two fingers.
• Ask the patient to indicate painful areas and observe their facial expressions

• Indirect Percussion:

• Elicits sounds that provide clues about the underlying tissue composition.
• Here’s how to do it:   Press the distal part of the middle finger of your nondominant hand firmly on the body part. Keep the rest of your hands off the body surface. Flex the wrist of your nondominant hand. Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient’s skin. Listen to the sounds produced.

        4. Auscultation- involves using a stethoscope to listen to lung, heart, and bowel sounds.

                Preparation:

                    Ensure a quiet environment.

                    Expose the area to be auscultated (avoid interference from gowns or bed linens).

                    Warm the stethoscope head in your hand.

                    Close your eyes to focus better.

                 How to Auscultate:

                        Diaphragm: Used for high-pitched sounds (e.g., S1 and S2 heart sounds). Hold it firmly against the skin, applying enough pressure to leave a slight ring.

                        Bell: Used for low-pitched sounds (e.g., S3 and S4 heart sounds). Hold it lightly against the skin to form a seal without pressing too hard, as excessive pressure can eliminate low-pitched sounds.

                Focus on identifying the characteristics of one sound at a time.

References:

 Introduction to Patient Assessment:   https://opentextbc.ca/clinicalskills/chapter/introduction-2/

Shinnick, M.A. and Cabrera-Mino, C. ( 2021). Predictors of nursing clinical judgment in simulation. Nursing Education Perspectives. Vol 42, No 2; pp 107-109.

Learning Clinical ( Free) 2006. Assessing patients effectively: Here’s how to do the basic four techniques

Nursing2006: November-December 2006 – Volume 8 – Issue 2 – p 6

Cholesterol Lowering Drugs

These medications are used for patients with hyperlipidemia, dyslipidemia, and hypercholesterolemia. The first line of treatment for increased cholesterol level is still dietary therapy, lifestyle changes, weight loss, and exercise.

1. Bile acid sequestrants lower LDL cholesterol by binding to bile acids, preventing cholesterol absorption in the small intestine. 

They benefit patients with Type 2 diabetes by reducing blood sugar levels and can quickly lower plasma thyroid hormones, making them useful for refractory thyrotoxicosis. Additionally, they can raise HDL-C levels and are used to manage pruritus in patients with cholestatic disease and incomplete biliary obstruction. 

However, these medications can cause gastrointestinal side effects like nausea, bloating, cramping, and increased liver enzymes. Dyspepsia and bloating can be mitigated if cholestyramine is fully suspended in liquid hours before ingestion. Bile acid sequestrants can also inhibit the absorption of fat-soluble vitamins such as vitamin K, leading to potential clotting issues.

Examples: 

cholestyramine (Questran)

colesevelam (Welchol)

colestipol (Colestid)

2. Fibric Acids- prevent cardiovascular disease in patients with elevated triglycerides and low HDL when diet and lifestyle changes are unsuccessful. Fibrate commonly causes dyspepsia and has also been shown to produce fatigue, vertigo, pancytopenia, and elevation of serum transaminases.

Examples: 

fenofibrate (Tricor)

fenofibric acid (Trilipix)

Gemfibrozil (Lopid)

3. HMG CoA Reductase Inhibitors- inhibit the enzyme in the liver (HMG-CoA reductase) responsible for making cholesterol. 

Examples: 

atorvastatin (Lipitor)

pitavastatin (Livalo)

pravastatin (Pravachol)

osuvastatin (Crestor)

simvastatin (Zocor)

lovastatin (Mevacor)

4. Other

Ezetimibe (Zetia) is a synthetic 2-azetidinone agent that lowers cholesterol by inhibiting its absorption in the intestines, unlike other cholesterol-lowering agents that increase bile acid excretion or inhibit cholesterol synthesis in the liver. It can be taken with meals and safely used with statins or fibrates. When taken with bile acid sequestrants, it should be dosed at least 2 hours before or 4 hours after. Side effects of ezetimibe include fatigue, diarrhea, headache, runny nose, body aches, back pain, chest pain, joint pain, sore throat, and elevated serum transaminases.

ezetimibe & simvastatin (Vytorin)

MORE ON STATINS

Statins, also known as HMG-CoA Reductase Inhibitors, reduce low-density lipoproteins (LDL) or "bad" cholesterol but typically do not affect high-density lipoprotein (HDL) or "good" cholesterol. They work by inhibiting the liver enzyme HMG-CoA reductase, which is responsible for cholesterol production. Statins also stabilize and shrink fatty plaques, prevent their rupture, inhibit clot formation, and reduce inflammation. Statins usually have the suffix "-statin."

When taken correctly, statins can lower the risk of coronary artery disease and the risk and recurrence of stroke. However, they can cause side effects such as nausea, headache, blurred vision, muscle pain, rashes, flushing, and gastrointestinal disturbances. Additionally, some patients may experience elevated liver enzymes, hyperglycemia, and hyperuricemia.

Lab Values to Watch Out for When on Statins

Normal Liver Function Test

ALT 7-55 units per liter (U/L)

AST 8-48 U/L

ALP 45- 115 U/L

Albumin 3.5-5 grams per deciliter (g/dL)

Total protein 6.3-7.9 g/dL

Bilirubin 0.1 to 1 mg/dL

GGT 9-48 U/L

LD 122-222 U/L

PT 9.5-13.8 seconds

Normal random blood glucose: 70-140 mg/dl

BUN 7-20 mg/dL

Nursing Precautions and Recommendations for Statins

1. Advise your client to take this during evening meal. Most cholesterol synthesis occurs at night, reflecting the fasting state. Thus, prompting the statins to be administered at evening or bedtime.

2. Assess and monitor the increase in muscle pain and liver enzyme

3. Annual eye exam should be facilitated so as to monitor for the formation of cataracts

4. Never give to clients with preexisting gallbladder disease

5. Patients should avoid taking grapefruit juice since it may increase drug toxicity and adverse effects

References: 

Bansal AB, Cassagnol M. HMG-CoA Reductase Inhibitors. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542212/

Chhetry M, Jialal I. Lipid-Lowering Drug Therapy. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541128/

Duong H, Bajaj T. Lovastatin. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540994/

Sizar O, Nassereddin A, Talati R. Ezetimibe. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532879/ 

Strategies For Answering Prioritization Questions in NCLEX

The concepts of prioritization, delegation, and assignment are among the most challenging for nursing students and new nurses. Many NCLEX-RN exam questions test your ability to prioritize nursing actions. 

To develop these skills, let's review four basic concepts used to answer priority questions. Key strategic words indicating the need to prioritize include: first, essential, best, next, most important, highest priority, most or least appropriate, and most or least likely, vital, or primary. In these questions, all options might be correct, requiring you to determine the correct order of action.

Four Basic Concepts Used to Prioritize

I. ABCs

A frequently encountered priority question is the “ABC” question. In these scenarios, you must determine the most critical action related to the patient’s airway, breathing, and circulation. For instance, you might be asked what initial steps to take if a patient has difficulty breathing or a compromised airway.  

Airway, breathing, and circulation, often referred to by the mnemonic “ABCs,” are essential for nurses when prioritizing care. Focusing on the ABCs ensures attention to the most vital needs for sustaining life. If a patient lacks a clear airway, cannot breathe, or has poor circulation, other interventions become insignificant. The ABCs align with the fundamental physiological needs in Maslow’s hierarchy and guide critical nursing actions and prompt interventions.

Sample ABCs question:

A 16-year-old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?

A. Perform postural drainage and chest physiotherapy every 4 hours

B. Allow the patient to decide whether she needs aerosolized medications

C. Place the patient in a private room to decrease the risk of further infection

D. Plan activities to allow at least 8 hours of uninterrupted sleep

Correct Answer

A. Perform postural drainage and chest physiotherapy every 4 hours

Explanation

Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents. the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath. it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.

II. Maslow's Hierarchy of Needs

Another typical priority question involves “Maslow’s Hierarchy of Needs.” These questions test your knowledge of basic human needs and require you to prioritize actions accordingly. 

Maslow's hierarchy of needs is commonly depicted as a pyramid, where the base represents essential needs that must be met before advancing to higher levels. At the foundational level of Maslow’s Hierarchy of Needs are physiological needs, which include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second tier consists of safety needs, which encompass factors that protect individuals from harm, such as fall precautions in healthcare settings. The third level addresses emotional needs like love and a sense of belonging, often reflected in relationships with family and friends. The top two levels of the hierarchy involve esteem and self-actualization.

Maslow's Hierarchy of Needs

Sample Question:

The older adult has been admitted with right-sided weakness and a history of falls. Which nursing diagnosis has the highest priority for this patient?

A) Self-Care Deficit

B) Risk for Injury

C) Impaired Physical Mobility

D) Impaired Home Maintenance

Patient safety is a priority next to physiologic needs. The correct answer is B.

III. The Nursing Process

The Nursing Process is a crucial framework for guiding decision-making and actions in nursing. The ADPIE mnemonic helps remember the steps:

1. Assessment
2. Diagnosis/Analysis
3. Planning
4. Implementation
5. Evaluation

These steps should be followed sequentially, with assessment always being the first step. It's important to remember to always conduct an assessment before implementing any interventions.

Sample Question:

Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?

A. Call for help to get the client back in bed.

B. Establish whether the client is responsive.

C. Assist the client back to bed.

D. Ask the client what happened.

Correct Answer

B. Establish whether the client is responsive.

Explanation

Assess first for responsiveness.

IV. Acute Versus Chronic Conditions and Unexpected Versus Expected Conditions

Another concept nurses use to prioritize care is distinguishing whether a condition or symptom is acute or chronic, expected or unexpected.

Acute conditions are characterized by a sudden and severe onset, usually resulting from a sudden illness or injury, and provoke a significant response from the body as it attempts to adapt. 

In contrast, chronic conditions develop slowly and may progressively worsen over time. The main difference between acute and chronic conditions lies in the body's adaptation response. Individuals with chronic conditions often have less severe symptom flare-ups because their bodies have had time to adjust to the ongoing illness or injury.

 Unexpected Versus Expected Conditions

In addition to considering acute versus chronic conditions, it is crucial to determine whether a patient’s signs and symptoms are “expected” or “unexpected” based on their overall condition. 

Unexpected conditions are findings that are not typically seen in the normal progression of an illness, disease, or injury. Conversely, expected conditions are those that are likely or anticipated during the course of an illness, disease, or injury.  

It is important to know what are expected signs and symptoms of the disease so that you can recognize deviations or a "sudden change". Unexpected findings usually necessitate immediate action by the nurse.

Sample Question:

Which client is the priority:

A. Client with asthma with a wheeze receiving a nebulizer.

B. Client with COPD and a pulse ox of 90% complaining of shortness of breath.

C. Client with a cast for a broken leg complaining of persistent pain in their extremity.

D. Client with pneumonia and a fever of 101.

A is an airway issue, but it's a chronic condition and it's already being addressed. B is a chronic condition, and the client is showing expected manifestations. We'll check them out, but a pulse ox of 90% is fine in a COPD patient. D? A fever of 101 isn't unexpected in pneumonia.

The correct answer is C. The other problems are either already being addressed, are expected, or are potential problems. The compartment syndrome patient is about to lose a leg if nothing is done now.

How to Approach Priority Questions During the Exam

To effectively answer priority questions on the NCLEX, it is essential to have a systematic approach. Here are some steps to help you tackle these questions:

1. Read the Question Carefully: Take your time to understand the question fully. Look for keywords or phrases that highlight urgency or importance.

2. Identify the Options: Review the answer choices provided. Focus on options that address immediate needs or potential complications.

3. Prioritize the Options: Determine which option is the most urgent or critical. Consider how each option will impact the patient's well-being.

4. Consider the Nursing Process: Use the principles of the nursing process (assessment, diagnosis, planning, implementation, and evaluation) to guide your decision-making.

5. Eliminate Incorrect Options: Narrow down your choices by eliminating options that are clearly incorrect or do not address the patient’s immediate needs.

6. Choose the Best Option: Select the option that is most appropriate for the situation, considering potential outcomes and the overall goal of nursing care.

By following these steps, you can approach priority questions confidently and improve your chances of selecting the correct answer on the NCLEX exam.

You can watch the video here: Mastering NCLEX Prioritization Secrets

References:

THE BEST NURSING CONCEPTS FOR CLINICAL JUDGMENT & THE NEW NCLEX (atitesting.com)

Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 - Prioritization. Available from: https://www.ncbi.nlm.nih.gov/books/NBK598386/

Physical Assessment: Breath Sounds

 

Evaluating Lung Air Entry and Airway Obstruction

To evaluate air entry into the lungs and detect airway obstructions, follow these steps:

Patient Positioning: Have the patient breathe normally with their mouth open.

Auscultation:

Auscultate the lungs, ensuring you cover the apices, middle, and lower lung fields posteriorly, laterally, and anteriorly.

Alternate and compare both sides.

Technique:

Use the diaphragm of the stethoscope.

Listen to at least one complete respiratory cycle at each site.

Begin by listening during quiet respiration; if breath sounds are inaudible, ask the patient to take deep breaths.

Observations:

Describe the breath sounds first, followed by any adventitious sounds.

Note the intensity of breath sounds and compare them with the opposite side.

Assess the duration of inspiration and expiration, noting the pause between them and the pitch quality of the sounds.

Comparisons:

Compare the intensity of breath sounds between the upper and lower chest while the patient is upright.

In the decubitus position, compare the intensity of breath sounds from the dependent lung to the upper lung.

Adventitious Sounds:

Record the presence or absence of any adventitious sounds.

Normal Findings

There are two types of normal breath sounds: bronchial and vesicular. Bronchial breath sounds are heard over the tracheobronchial tree, while vesicular breath sounds are heard over the lung tissue. Bronchial breath sounds can typically be heard in areas where the tracheobronchial tree is close to the chest wall without lung tissue intervening, such as the trachea, right sternoclavicular joints, and posterior right interscapular space. In all other areas, vesicular breathing is heard due to the presence of lung tissue. 

Tracheobronchial tree

Bronchial breath sounds over the trachea are characterized by a higher pitch, louder sound, equal duration of inspiration and expiration, and a pause between them.

Vesicular breath sounds are heard over the thorax and are lower pitched and softer than bronchial breath sounds. In vesicular breathing, expiration is shorter, and there is no pause between inspiration and expiration. The intensity of these breath sounds is greater at the lung bases in an erect position and in the dependent lung in a decubitus position.

Overall, breath sounds are symmetrical and louder at the bases compared to the apices in an upright position, and no adventitious sounds are present.

Abnormal Findings

Understanding Breath Sound Intensity and Abnormalities

The intensity of breath sounds is generally a reliable indicator of lung ventilation. Increased intensity indicates better ventilation, while decreased intensity suggests reduced ventilation. For instance, breath sounds are significantly diminished in cases of emphysema.

Symmetry in Breath Sounds

Asymmetry in breath sound intensity is abnormal, with the side exhibiting decreased intensity indicating potential issues. Various pleural or pulmonary diseases can lead to reduced breath sound intensity.

Abnormal Bronchial Breathing

Bronchial breathing heard outside the trachea, right clavicle, or right interscapular space is considered abnormal. This abnormal bronchial breathing can indicate several conditions, including:

Consolidation 

Cavitation

Complete alveolar atelectasis with patent airways

Mass interposed between the chest wall and large airways

Tension pneumothorax

Massive pleural effusion with complete lung atelectasis

In these conditions, alveolar ventilation is absent, and the sound heard originates from the bronchi and is transmitted to the chest wall.

Differentiating Conditions Based on Bronchial Breathing Quality

Experienced providers can distinguish between consolidation and cavitation by the quality of bronchial breathing. 

In consolidation, the bronchial breath sounds are low-pitched and sticky, termed tubular bronchial breathing. 

In cavitary disease, the breath sounds are high-pitched and hollow, known as cavernous breathing, similar to the sound produced by blowing over an empty bottle.

 In tension pneumothorax, bronchial breath sounds have a metallic quality, referred to as amphoric breathing.

Adventitious Breath Sounds

Wheeze 

Stridor 

Crackles 

Pleural Rub 

Source: Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015). Auscultation of the respiratory system. Annals of thoracic medicine, 10(3), 158–168. https://doi.org/10.4103/1817-1737.160831

Sample Bow Tie Standalone NGN and Case Study NGN NCLEX Questions with Answers

 

Next Generation NCLEX style standalone clinical judgment question.

The nurse cares for a 65- year- old male with cancer who needs a blood transfusion in the outpatient-clinic.

The nurse assesses the client 15 minutes after the beginning of the transfusion.

From the list of choices drag the 1 condition that the client is most likely experiencing to the box on the right.

Drag 2 actions the nurse should take to address that condition to the box on the right.

Drag 2 parameters the nurse should monitor to assess the client’s progress to the box on the right.

ANSWERS:

 

In this case study, you will answer 6 Next Generation NCLEX style questions. Click the Next arrow at the bottom of the screen to advance to the next question. You must answer each question before advancing to the next question. Backtracking is not allowed.

Case Study Question 1 of 6

A 32-year-old female client with a history of hyperthyroidism is brought to the emergency department by their spouse.

What 4 client findings are most urgent?

Case Study Question 2 of 6

 For each assessment the nurse has made, click to specify whether the finding is helpful or not helpful in determining if the client is experiencing a thyroid problem. Each row must have 1 selection.

Case Study Question 3 of 6

Drag the 1 most appropriate choice from the list of options to fill in the blank of the following sentence.

Case Study Question 4 of 6

The client receives a working diagnosis of a thyroid storm.

 Which of the following orders should the nurse anticipate? Select all that apply.

 

Case Study Question 5 of 6

The nurse reviews the client’s vital signs and provider orders. Click to highlight the 2 orders the nurse should implement first.

Case Study Question 6 of 6

The nurse administered the client’s oral acetaminophen and methimazole and placed the client on oxygen and institutes cooling measures. The nurse reviews the laboratory report and reassesses the client.

For each finding, click to specify if the finding indicates that the client’s status has improved or remains unchanged. Each row must have 1 selection.

ANSWERS:

(Note: If you look at the statement on the next question, it says: "The nurse administered the client’s oral acetaminophen and placed the client on oxygen". This is because it takes time for the po meds Acetaminophen to be absorbed and start working and patient placed on O2 for the dyspnea (B for breathing). These measures are done first so that the patient is already absorbing the meds and receiving O2 while the nurse is still getting the ice packs, cooling blanket, IV fluids and EKGs done)

If you have any questions, comments, suggestions regarding these sample NGN NCLEX questions please write a comment. Thank you.