Mouth to Heart Assessment

• torus palatines


  A bony protuberance in the midline of the hard palate
• otoscope with a short wide-tip attachment


  used to view the nasal mucosa, nasal septum, the inferior and middle turbinates, and the nasal passage
• epistaxis


  bleeding of the nose
• hypoxia


  Pale or cyanotic nails may indicate ___
• Kyphosis


  an increased curve of the thoracic spine that is common in older clients
• Chest expands when takes a deep breath, the examiner’s thumb should move 5 to 10 cm apart symmetrically
• Elicited resonance percussion tone that is elicited over normal lung tissue
• While percussion elicits flat tones over scapula
• bronchial, bronchovesicular, and vesicular


  3 types of normal breath sounds may be auscultated
• crackles


  discrete and discontinuous sounds
• wheezes


  musical continuous sound
• Bronchophony


  –voice transmission of ninety-nine is soft, muffled, and distinct. The sound of voice maybe heard but the actual phrase cannot be distinguished
• Egophony


  voice transmission will be soft and muffled but the letter “E” should be distinguishable
• Whispered Pectoriloquy


  transmission of sound (one –two-three) is very faint and muffled. It maybe inaudible
• Tachypnea


  more that 24 breath/min and shallow
• Bradypnea


  less than 10 breaths/min and regular
• Hyperventilation


  increased rate and increased depth in breathing
• Kussmaul


  rapid, deep, and labored breathing
• Hypoventilation


  decreased rate, decreased depth, and irregular breathing pattern
• Cheyne-Stokes respiration


  regular breathing pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea
• Biot's respiration


  irregular breathing pattern characterized by varying depth and rate of respirations followed by periods of apnea
• Ataxic


  significant disorganization with irregular and varying depths of respiration
• Air trapping


  increasing difficulty in getting breath out
• Bronchial 


  (normal breath sounds) high pitch, harsh and hollow quality, low amplitude, short during inspiration long in expiration, located in trachea and thorax
• Brochovesicular


  (normal breathing sound) moderate pitch, mixed quality, moderate amplitude, same during inspiration and expiration, located over major bronchi-posterior between the scapulae; anterior: around the upper sternum in the first and second intercostal spaces
• Vesicular


  (normal breath sounds) low pitch, breezy quality, soft amplitude, long in inspiration, short in expiration, located on peripheral and lung fields
• Pectus excavatum


  is markedly sunken sternum and adjacent cartilages or funnel chest
• Pectus carinatum


  is a forward protrusion of the sternum causing adjacent ribs to slope
• Barrel chest


  configuration result in more horizontal position of the ribs and costal angle
• The breasts are then palpated while the client assumes supine position.
• Gynecomastia


  a smooth, firm, movable disc of glandular tissue maybe seen in one breast in males during puberty.
• Weak or bounding pulse may indicate hypovolemia, shock, or decreased cardiac output
• A delayed upstroke may indicate aortic stenosis.
• Loss of elasticity may indicate arteriosclerosis.
• Bradycardia


  (less than 60 beats/min)
• tachycardia


  (more than 100 beats/min)
• pulse deficit


  (difference between the apical and peripheral/radial pulses)
• S1


  the "lub" or first heart sound, corresponds with each carotid pulsation and is loudest at the apex of the heart.
• S2


  the "dub" or the second heart sound, immediately follows after S1 and is the loudest at the base of the heart.
• Pathologic S3


  (ventricular gallop) may be heard with ischemic heart disease.