Assessment & Exam Flashcards
What information should you focus on in the chart review? (7)
Primary & Secondary Dx Date of Treatment Cardiac Ischemic Symptoms Pulmonary Symptoms Changes in Symptoms PMH/Social Hx Risk Factors
Cardiac Ischemic Symptoms (5)
Chest pain Tightness SOB Palpitations Burning
Pulmonary Symptoms (5)
SOB Dyspnea on exertion Cough Increased work of breathing Sputum production
List Cardiac Risk Factors (7)
HTN Smoking Family Hx Older age Diabetes Obesity Sedentary lifestyle
Lab Data Needed (6)
Cardiac Enzymes Blood Lipids CBC ABGs Coagulation studies Electrolytes/Glucose tolerance test
Key things to look for in chest radiographs? (3)
Changes in lung space
Presence of fluids
Heart size
Oxygen Therapy: Low PO2 but not less than 60 mmHg on room air
Supplemental O2 w/exercise
Oxygen Therapy: Resting PO2 less than 60 mmHg
Supplemental O2
Oxygen Therapy: O2 sat less than 90
Supplemental O2
T/F: O2 can be administer w/o Rx.
False. Must have Rx to administer O2.
*Titration should be noted in the chart. If it isn’t and an adverse event occurs when you administer it, you may be held liable.
Components of Physical Exam
Inspection Palpation Percussion Auscultation Activity Eval
List Important Notes of Inspection
General Appearance/Facial Expression/Body position
Breathing: Effort, nose/mouth, accessory muscles, etc
Neck: Swelling, lumps, etc
Chest: Excavatum, Carinatum, Scoliosis, Barrel chest, RR
Ears: Hearing Aids
Nose: Drainage
Eyes: Color, Dilation, Glasses
What would you expect from a pt w/scoliosis?
Limited vital capacity
Decreased exercise tolerance
What is echymosis?
Bruising
If a pt is cyanotic or confused, what might they need?
Oxygen supplement
If you see that your pt has thickened, yellow toenails, what might be the problem?
They may have poor circulation.
What are facial signs of distress?
Nasal flaring
Sweating
Paleness
