Ch 16 Bedside Assessment Flashcards
What are the 4 critical life functions?
- Ventilation: open airways and breathe
- Oxygenation: increase fio2
- Circulation: chest compression, difibs drugs
- Perfusion: increase blood pressure
What to do if patient is diaphoretic after given treatment?
Stop and assess
What are the definitions of signs and symptoms
Signs: objective info
Symptoms: the sensation or subjective experience of some aspect of an illness
What are pack years?
of packs per day x the # of years smoked
What is polycythemia?
An excess of hemoglobin characteristics of the COPD patients in response to chronic hypoxemia they have
What is cachexia?
Patients are thin, “wasting away”, have general ill health are malnourished and weak
What is jaundice and what does it indicate
Yellowing of the skin. Indicates liver failure, look at bilirubin lab
What is erythema
Redness of skin
Central cyanosis vs. peripheral cyanosis
Central cyanosis- cyanosis of the oral mucosa or trunk
Peripheral cyanosis- observed in the hands, fingertips and nail beds of hands and feet
What is digital clubbing
Notice and inspect the angulation of your patients nail bed to assess hypoxemia
Rounded fingernails
What is the main cause of hypoxemia
V/Q mismatch
Normal values for SpO2, SaO2, PaO2
SpO2: 93-98%
SaO2: 95-100%
PaO2: 80-100 mmhg
60-79 mild hypoxemia
40-59 moderate
<40 severe
What is ALOC and AMS
ALOC( altered level of consciousness)
AMS( altered mental status)
Both common descriptors to determine level of consciousness
If any adverse reactions to medication, what should you do?
Stop treatment, assess patient and call the doctor with a recommendation for different treatment
Is an interview with the patient considered part of the physical assessment?
No it’s not, it’s used to help determine their level of consciousness
Orthopnea
Difficulty breathing except in upright position
What is the common treatment for CHF
A diuretic like Lasix. You’ll hear fine crackles when auscultating
When a patient is SOB, what should you not do
Assume it’s anxiety, find the cause of it
What is phlegm
Mucus from tracheobronchial tree that is not contaminated by oral secretion
What is sputum
Mucus from lower airways but is expectorated through the mouth
Hemoptysis
Coughing up blood or bloody sputum from the lungs
What are the 3 things in sputum analysis
- Amount of sputum
- Consistency
- Color
Fever( hyperthermia) aka febrile
What is normal urine output
40 ml/hr approximately 1 liter/day
Decreased CVP vs increased CVP
Decreased CVP: <2 mmhg indicates hypovolemia ( lack of fluid)
Increase CVP: >6 mmhg indicates hypervolemia ( excess fluid)
Normal heart rate
60-100 bpm
Tachycardia- increased HR
Bradycardia- decreased HR
Normal respiratory rate
12-20 per min for adults
Apnea- no respirations
Tachypnea- RR greater than 20~ caused by fever, hypoxemia, metabolic acidosis
Bradypnea- RR less than 12~ caused by traumatic brain, hypothermia, and meds
What is orthostatic hypotension
Postural change which causes a quick decrease in blood pressure
Blood pressure
120/80 with range of 140/90 to 90/60
With tension pneumothorax, which way does the trachea shift
Shifts away from affected site
With atelectasis, which way does the trachea shift
Shifts towards affected site
What’s hyper resonant
Found in lungs where pneumothorax or emphysema is present
Pleural effusion can be confirmed with CXR if what is present
Blunting of costophrenic angles
What are the 4 steps in physical assessment
- Inspection
- Palpation
- Percussion
- Auscultation
Increased resonance vs decreased resonance
Increased resonance: any disease process that has excess air
Decreased resonance: any disease that has excess fluid and or lack of air
Fine crackles
Sudden opening of small airways
Treat with IPPB, diuretics and oxygen
Coarse crackles aka rhonchi, rales
Large airways secretions and the patient needs suction
Marked stridor
Upper airway obstruction
Airway emergency, must intubate
What are wheezes
Consistent with bronchospasm( bronchoconstriction)
Diminished breath sounds
Occurs when sound transmission cannot occur due to loss of space where gas exchange occurs
