Cardiopulmonary Assessment Flashcards
What is the normal temperature for a newborn?
37 - 37.7 degrees Celcius
What is the normal PR for a newborn?
120-160 bpm
What is the normal RR = for a newborn?
30-80 breaths/min
What is the normal BP for a newborn?
50-52/25-30
What is the normal temperature for a 3 y/o?
36.9 - 37.5 degrees Celcius
What is the normal PR for a 3 y/o?
80-125 bpm
What is the normal RR for a 3 y/o?
20-30 breaths/min
What is the normal BP for a 3 y/o?
78-114/46-78
What is the normal temperature for a 10 y/o?
36.3 - 37 degrees Celcius
What is the normal PR for a 10 y/o?
70-110 bpm
What is the normal RR for a 10 y/o?
16-22 breaths/min
What is the normal BP for a 10 y/o?
90-132/50-86
What is the normal temperature for a 16 y/o?
36.4 - 37.1 degrees Celcius
What is the normal PR for a 16 y/o?
55-100 bpm
What is the normal RR for a 16 y/o?
15-20 breaths/min
What is the normal BP for a 16 y/o?
104-108/60-92
What is the normal temperature for an adult?
36 - 37.5 degrees Celcius
What is the normal PR for an adult?
60-100 bpm
What is the normal RR for an adult?
12-20 breaths/min
What is the normal BP for an adult?
<120/<80
What is the normal temperature for an older adult?
35.9 - 36.3 degrees Celcius
What is the normal PR for an older adult?
60-100 bpm
What is the normal RR for an older adult?
15-25 breaths/min
What is the normal BP for an older adult?
<120/<80
Normal BP values
<120/<80
Elevated BP values
120-129/<80
Stage 1 HTN values
130-139/80-89
Stage 2 HTN values
> 140/>90
HTN crisis values
> /160/>/120
Grade 0 pulse
Absent
No perceptible pulse even with max. pressure
Grade 1+ pulse
Thready
Barely perceptible; easily obliterated w/ slight pressure; fades in and out
Grade 2+ pulse
Weak
Difficult to palpate; slightly stronger than thready; can be obliterated w/ light pressure
Grade 3+ pulse
Normal
requires moderate pressure to obliterate
Grade 4+ pulse
bounding
Very strong; hyperactive; not easily obliterated w/ moderate pressure
Normal PAO2
80-100 mmHg
Moderate tachycardia
60-80 mmHg
50-60 mmHg
Malaise or nausea
Possible onset of respiratory distress
Restlessness
35-50 mmHg
respsiratory distress
25-35 mmHg
marked respiratory distress
<25 mmHg
Hypoventilation, apnea
Normal respiration
Eupnea
Slow respiration; <10 breaths/min
Bradypnea
Fast respiration; >24 breaths/min
Tachypnea
Normal respirations but abnormally deep and increase in rate
Kussmaul’s respiration
Irregular respirations of variable depth (usually shallow)
Biot’s respirations
Gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea
Cheyne-Stokes respirations
Absence of breathing
Apnea
Body temperature is constantly elevated more than normal throughout the day but does not fluctuate more than 1.8 degrees F
Continuous/Constant/Sustained Fever
Body temperature alternates between periods of fever for some hours of the day with a return to normal for the remaining hours; seen in septicemia and malaria.
Intermittent Fever
Periods of fever are interspersed with normal temperatures; each last at least one day; seen in RA, Crohn’s disease, Malignancy, and Infections caused by ticks and lice
Relapsing/Recurrent/Periodic fever
Elevated body temperature throughout the day and fluctuates more than 3.6 degrees F within 24 hours and never returns to normal; seen in infective endocarditis and typhoid infection
Remittent
Barely perceptible depression
Grade 1+ edema
Easily identified depression; skin rebounds within 15 seconds
Grade 2+ edema
EID; skin rebounds within 30 secs
Grade 3+ edema
EID; skin rebounds > 30 secs
Grade 4+ edema
The volume of gas inhaled and exhaled during normal resting breath
Tidal Volume (500 mL)
The volume of gas that can be exhaled beyond a normal resting tidal exhalation
Expiratory Reserve Volume/ERV (1000 mL)
The volume of gas that can be inhaled beyond a normal resting tidal inhalation
Inspiratory Reserve Volume/IRV (3000 mL)
The volume of gas that remains in the lungs after ERV has been exhaled
Residual Volume/RV (1500mL)
The amount of air that can be inhaled from REEP
Inspiratory Capacity (IC)
The maximum amount of air a person can expel from the lungs after maximum inhalation
Vital Capacity (VC)
Amount of air that resides in the lungs after normal resting tidal inhalation
Functional Residual Capacity
The total amount of air that is contained within the thorax during a maximum inspiratory effect
Total Lung Capacity (TLC)
Angina Scale: 0
No angina
Angina Scale: 1
Light, barely noticeable
Angina Scale: 2
Moderate, bothersome
Angina Scale: 3
Severe, very uncomfortable; pre-infarction pain
Angina Scale: 4
Most painful experience; infarction pain
What are the three walk tests?
6-minute walk test
Incremental Shuttle Walk Test
Gait Speed
Borg CR10 Scale: 0
Nothing at all
No P
Borg CR10 Scale: 0.5
Extremely weak
Just noticeable
Borg CR10 Scale: 1
Very weak
Borg CR10 Scale: 2
Weak
Light
Borg CR10 Scale: 3
Moderate
Borg CR10 Scale: 5
Strong
Heavy
Borg CR10 Scale: 7
Very strong
Borg CR10 Scale: 10
Extremely strong
Max P
Borg CR10 Scale: 12
Absolute maximum
Highest possible
Borg for Breathlessness: 0
Nothing at all
Borg for Breathlessness: 0.5
Very, very slight
Borg for Breathlessness: 1
Very slight
Borg for Breathlessness: 2
Slight
Borg for Breathlessness: 3
Moderate
Borg for Breathlessness: 4
Somewhat severe
Borg for Breathlessness: 5
Severe
Borg for Breathlessness: 7
Very severe
Borg for Breathlessness: 9
Very, very severe
Borg for Breathlessness: 10
Maximal
Tiny red or purple hemorrhagic spots caused by capillary bleeding
Petechiae
The skin takes on a yellow-orange hue due to impaired liver function
Jaundice
Reddened area of the skin caused by hyperemia
Errythema
It is caused by bruising and may be seen anywhere on the body
Ecchymosis
Caused by hypoxia from a blocked airway
Acute cyanosis
Caused by hypoxia with color changes in the nail beds and lips
Peripheral Cyanosis
What are the pulse palpation sites?
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Pedal
Posterior Tibial
Continuous of high or low sounds
Wheezes
Fine discontinued sounds
Crackles
Snoring
Stridor
“99” “Tres tres”
Bronchophony
“Ee” “Aa”
Egophony
There is fluid in air spaces
S1 sound
Lub
Closure of the mitral and tricuspid valve
S2 sound
Dub
Closure of the semi-lunar valves
Resonant percussion
Normal lung tissue
Hyperresonant percussion
Emphysematous or PTX
Dull
Increased tissue density
Where does atrial depolarization occur?
P-wave
Where does the spread of depolarization and slight delay occur?
PR interval
Where does the ventricular depolarization occur?
QRS complex
Where does the period of slight pause occur?
ST segment
Extraordinary magnitude of effort
4
Major magnitude of effort
3
Moderate magnitude of effort
2
Light magnitude of effort
1
No effort
0
Class 1 pt w/ heart disease
4.0-6.0 cal/min
Max: 6.5 METS
Class 2 pt w/ heart disease
3.0-4.0 cal/min
Max: 4.5 METS
Class 3 pt w/ heart disease
2.0-3.0 cal/min
Max: 3.0 METS
Class 4 pt w/ heart disease
1.0-2.0
Max: 1.5 METS
Claudication Discomfort Grade 1
Initial discomfort
Claudication Discomfort Grade 2
moderate discomfort but attention can be diverted to
Claudication Discomfort Grade 3
Intense pain that can’t be diverted
Claudification Discomfort Grade 4
Excruciating and unbearable pain
Bluish gray discoloration of the skin and mucuous membranes
Cyanosis
The skin takes on a lighter tone
Pallor
Reddened area of the skin
erythema
Diffuse redness of the face
Flushing
What is the angle of the head in jugular vein distention
30-45 degrees with cervical spine in neutral position
Ipsilateral mediastinal shift
Atelectasis
Pneumonectomy
Lobectomy
Contralateral mediastinal shift
Edema
Pneumothorax
Abdominal Hernia
Finger clubbing can be assessed using
the schamroth sign/window
Finger clubbing is often associated with
decreased O2 states
Whistling sound due to narrowed airways
Wheezing
Harsh, high pitched crowing due to upper airway obstruction
Stridor
Rattling or bubbling sound due to secretion
Crackles
Indicative of emotional stress
Sigh
Snoring due to obstruction
Stertor
Loud lung sounds location
Tracheal
Bronchial
Soft lung sound location
Bronchovesicular
Vesicular
Where is the tracheal auscultated?
neck
Where is the bronchial auscultated?
jugular notch
Where is the bronchovesicular auscultated?
sternum
Where is the vesicular auscultated?
Periphery
Where to check for the symmetry of the upper chest?
sternal notch
Where to check for the symmetry of the middle ches
xiphoid process
where to check for the symmetry of the lower chest
spinous process
lower thoracic
Clear, thin, and watery
transudate
Clear or tinge of brown/red, thin, and watery
Serosanguineous
Creamy, yellowish with moderate to very thick thickness
Exudate
Yellow, brown with moderate to very thick thickness
Pus
Hues of yellow, blue, and green and is thick
Infected pus
Functional impairment grade 4
Normal
Functional impairment grade 3
Slight impairment
Functional impairment grade 2
moderate impairment
Functional impairment grade 1
Severe impairment
Functional impairment grade 0
Very severe impairment
Distance for 6-minute walk test
25-35 meters
Two cones are set to ID a 10m walking course
Incremental shuffle walk test
Normal distance covered for incremental shuffle walk test
48 meters
Pulmonary disease severity grade 0
Normal lung function
Pulmonary disease severity grade 1
FEV is >/= 80%
Pulmonary disease severity grade 2
FEV is 50-79%
Pulmonary disease severity grade 3
FEV is 30-49%
Pulmonary disease severity grade 4
FEV is <30%
