Clinical Skills Flashcards
1
Q
Target SaO2 for most people
A
94-98%
2
Q
What clues might exist there is a respiratory complaint?
A
peak flows, inhalers, IV drips
3
Q
Where can tar staining also be seen?
A
around the hair line - yellowing in fringe area
4
Q
Signs of finger clubbing (5)
A
Change in nail bed angle Nail bed feels boggy Sharper angle with cuticle Distal ends of fingers may appear enlarged or bulging Nail curves downward
5
Q
When asthma is considered severe, the PEFR is…
A
33-50%
6
Q
What must you do before assembling and giving nebuliser?
A
the drug
7
Q
polycythemic patients become cyanosed at ______ SaO2 because there is an increase in the level of the RBCs in the blood
A
higher
8
Q
How can JVP be assessed if not visible using conventional method?
A
pressing in the RUQ to circulated more blood from liver
9
Q
What should you ask the patient to do when auscultating?
A
breath deeply but at a rate normal for them, ask them to take deep breaths when they feel the stethoscope move
10
Q
You take the average of PEFR - true or false?
A
False
Take the best of all three as given
11
Q
FiO2 of Reservoir mask
A
60-80%
12
Q
the nasal cannula prevents rebreathing of expired CO2?
A
true
13
Q
Example of low pitched sound
A
bowel sounds
heart murmurs
14
Q
When might a spacer be useful
A
when the patient technique is not great
15
Q
When examining the posterior aspect of the chest for percussion and auscultation, what is best for the patient?
A
ask them to swing their legs round and sit over the side of the bed
16
Q
Normal Pulse
A
60-100bpm
17
Q
What does oedema in the legs potentially indicate?
A
DVT
Pulmonary hypertension/R. Ventricular failure
18
Q
Second step when visiting patient
A
introduce self, check you have the right patient and confirm details, explain plan and gain consent
23
Q
What does palpation involve?
A
feeling for the trachea in the neck - should be in the middle of the notch above the sternum
chest expansion
24
Q
Normal SaO2 range for healthy individuals
A
94-100%
25
Q
Where should you percuss and ascultate?
A
anteriorly, posteriorly and laterally
26
Q
How loud are bronchovesicular breath sounds?
A
intermediate
27
Q
When asthma is considered moderate, the PEFR is….
A
50-75%
28
Q
When asthma is considered life-threatening, the PEFR is
A
<33%
30
Abnormal breath sounds are...
bronchial
31
How loud are bronchial breath sounds?
loud
32
Patients should bite down around the mouthpiece of their inhaler - true or false?
false
| they should form seal with their lips and have the inhaler between their teeth
33
Moving on from hand exam what do you check?
pulse, resp rate, skin
34
bronchial breath sounds are
harsher than vesicular sounds
35
Example of high pitched sound
breath sounds
| normal heart sounds
35
palmar erythema
redness of the thenar and hypothenar eminence
37
Location to palpate trachea
supra-sternal notch
39
What side of the bed should you approach the patient
The patients right
40
When asthma is considered mild, the PEFR is...
>75%
41
Diaphragm of the stethoscope is best for hearing _______ pitched sounds
high
41
How might you assess your patients ability to take part?
breathing ability, use of accessory muscles, NEWS, ability to speak in full sentences
42
vesicular breath sounds normally have a shorter expiration than inspiration - true or false?
true
43
Target SaO2 for people who are at risk of Type II respiratory failure
88-92%
45
How do you perform percussion?
left finger lying parallel to the ribs and in between the ribs - tap using middle right finger
need to press firmly into the chest
46
Tracheal breath sounds are?
very loud
47
What can give inaccurate results in SaO2 measurements? (4)
nail polish, strong ambient light, severe anemia, CO poisoning
50
Less common causes of finger clubbing (6)
```
coeliac
cirrhosis of liver
dysentery
graves disease
overactive thyroid
other cancers
```
51
Peripheral cyanosis can occur in isolation from central cyanosis - true or false?
true
52
situations where bronchial breath sounds might be heard?
collapse
consolidation
fibrosis
53
The reservoir mask can reach 100% oxygen delivery if used with high flow rates - true or false?
false
54
Type I Respiratory Failure
Low level of O2 without an increase in CO2
| Pneumonia, ARDS
56
What should the patient do before taking the inhaler?
big breath out
57
Fine wrist tremor is indicative of...
b-agonist use such as salbutamol
58
Where must you inspect?
the axilla
59
common causes of cyanosis (3, 3;2)
```
lung diseases - COPD, pneumonia, pulmonary embolis
cardiac diseases - R-> L cardiac shunt
abnormal haemoglobin
methaemoglobinaemia
suflhaemoglobinaemia
```
60
How long should a patient extend their hands to indicate a tremor?
at least 10 seconds
61
Oxygen must be prescribed - true/false?
true
62
When might the trachea not be in the expected position?
where there is upper lobe pathology i.e. fibrosis, collapse or occasionally tension pneumothorax
63
How do you place your hands to check for chest expansion?
fingers splayed bringing chest towards midline. Have thumbs around the midline but allow them to move - look for equal movement of both thumbs
64
In anemic patients the SaO2 is higher before cyanosis occurs - true or false?
false
| the SaO2 is lower because there is decreased levels of haemoglobin and thus longer before 5g/dL deoxyhaemoglobin
67
Tar staining is indicative of....
heavy smokers
69
Where would you hear stridor?
Inspiration
70
Pathologies associated with assymetry in chest expansion
Collapse
Consolidation
Pleural Effusion
Fibrosis
71
When asking patient to do peak flow, what should be checked?
whether the patient has done it before, what their previous best score is, whether the pointer is at 0
72
Signs that may indicate DVT?
calf hot, red with greater girth than the other leg
72
Instructions for PEFR to patient
```
Ask if they have done it before
If so, what is their best score
Take a deep breath in (as much as possible)
Seal lips around the tube
Blow out as hard and fast as they can
Repeat twice more
BEST of three
```
73
Steps in taking the inhaler
```
breath out
tight seal around inhaler
start to breath in and release medication
continue breath in slowly
hold breath for 10s
```
74
What sort of pulse might be felt in a patient who has used b2-agonists?
tachycardic which may be thready
75
Where should you start your percussion?
apex around the clavicle
76
Normal respiratory rate
12-18 breaths a minute
77
Indications of FiO2
Type II resp. failure and need for exact FiO2
78
Where might a pneumoectomy take place?
from behind in the lung
79
What sort of pulse and characteristics might be seen in a patient with CO2 retention?
bounding pulse and patient may appear drowsy
80
Simple Face Mask
5-10L/min
81
How should the patient be when listening to inspiration and expiration?
have their mouth open
82
Lymph nodes in the face and neck (8)
```
submental
submandibular
anterior and posterior triangle
pre and post auricle
occipital
supraclavicular
```
83
How should the patient be positioned if possible for PEFR?
standing
84
Where would you hear a wheeze in the respiratory cycle?
expiration
85
Flapping wrist tremor is indicative of...
CO2 retention
86
What does redness in the face and hands indicate in a respiratory setting?
CO2 retention
87
cyanosis is a ________ __________ of the skin due to __________ blood which typically occurs when the amount of deoxyhaemoglobin is (>)5g/dL and SaO2 is
bluish discolouration, deoxygenated blood, >, 85
87
What is sulfhaemoglobinaemia?
abnormal haemoglobin secondary to drugs i.e. sulfonamides
89
Indications of Simple Face Mask
Short term, low oxygen requirements
90
Why should you not worry about giving a COPD patient a reservoir mask in an acute situation?
not all COPD patients retain CO2 and hypoxia will kill before hypercapnia
91
How does a spacer such as an aerochamber help?
slows down rate of breathing in
| can be used to have 2 or 3 normal breaths rather than one big breath
94
Why is it more difficult to examine chest expansion anteriorly on a female?
due to chest tissue - also applies to percussion
95
Indications for Reservoir mask
critical illness
96
Bell of the stethoscope is best for hearing _______ pitched sounds
low
96
What should the patient do when examining the supraclavicular lymph nodes?
tilt their head towards side being examined
97
How much fluid must be leaked before oedema becomes noticeable?
500ml
98
How do you assess JVP?
patient should be lying at 45 degree angle on bed and move their head to opposite side. Should be visible just superior to clavicle
98
FiO2 with simple face mask
variable
99
Nebulising canninster must remain....
upright
102
Ipratropium
medication that opens medium to large airways
104
liquid i.e. pleural effusion, sounds _______ on percussion
stony dull
106
How loud are vesicular sounds?
soft
107
4 aspects of chest examination
inspection
palpation
percussion
auscultation
108
Common causes of peripheral cyanosis in isolation
Reynauds phenomenom
Beta blockers
Reduced cardiac output due to HF or hypovolaemia
Venous obstruction i.e. DVT or obstruction to SVC
109
What do electric nebulisers use?
air
110
How can oedema be assessed?
an imprint may be left if pressed for 5secs - be gentle, as may be painful
111
Abnormal percussion over pneumothorax is...
hyper-resonant
112
Venturi Mask
Controlled oxygen delivery with exact percentage FiO2 delivered as stated on device
113
Upper lobe pathologies leading to tracheal dislocation
fibrosis
collapse
tension pneumothorax
114
How do you prepare a resevoir mask?
allow the bag to fill with air by pressing on the valve, empty the bag and allow to go again
115
plethora
redness in the cheeks
115
FiO2
Fraction of Inspired Oxygen
115
When giving any form of treatment or performing any test, you should...
ask permission
| check for questions
116
Signs in general resp. exam in hands (5)
```
Finger Clubbing
Cyanosis
Palmer Erythema
Tar Staining
Tremor
```
116
Peak Flow is a good clinical assessment of...
Asthma
117
What should be removed before assessing SaO2?
nail polish
117
Type II Respiratory Failure
Causes a change in O2 and CO2 levels as a result of poor alveolar ventilation due to conditions such as COPD, ankylosing spondylitis
117
Indications of Nasal Cannula
Low oxygen requirements
| Patient able to speak and eat freely
117
Typical nebulising drugs?
salbutamol
| ipratropium
119
Where else might cyanosis be seen in the face?
under the tongue
119
oxygen cannot be prescribed retrospectively - true or false?
false - in emergency situations oxygen may be prescribed retrospectively
120
Normal breath sounds are...
vesicular
122
What may be noticeable on the skin and why?
thin or easily bruised skin
| steroid use
123
Oxygen prescription should contain the following details (6)
```
patient name
DOB
Unique ID
Drug Name (oxygen)
Route of administration (inhaled)
the target
```
123
Where should a Peak flow meter tube be discarded?
Orange bin
124
What might a grey and breathless patient have?
anemia - they cannot get enough oxygen as not enough blood to carry oxygen
125
polycythemia
have increased levels of RBCs and a raised haematocrit of >55%
decrease in relative plasma volume or increase in RBC
127
solid material sounds ______ on percussion
dull
128
What should be checked in the face/neck? (5)
```
cyanosis
plethora
pallor of conjunctiva
pursed lip breathing
lymph nodes
```
128
Appropriate nebulising flow rate
6-8L/min
128
After checking PEFR what should you do? (3)
tell patient what you have found, check for questions, wash hands
128
How should you check for chest expansion?
grip both hands firmly around the lower rib cage with thumbs in the middle of the chest. Ask patient to breath in and out.
Ask the patient to take a large deep breath
128
Lung consolidation is when....
lung tissue is filled with liquid
129
Reduced breath sounds are common when?
there is damage to alveoli
130
Why might there be asymmetry in chest expansion?
collapse, consolidation, pleural effusion, fibrosis
131
Most common causes of finger clubbing (4, 3:3)
```
Lung Cancer
Congenital Heart Defects
Chronic Lung Infections
Bronchieotasis
cystic fibrosis
lung abscesses
Infectious endocarditis
```
131
What is methaemoglobinaemia?
abnormal haemoglobin due to genetic disorder or secondary to drugs i.e. quinones, sulfonamides
132
From what side is a physical examination done?
patients right hand side
132
Bronchial breath sounds have a shorter expiration than inspiration - true or false?
false they have longer expiratory sounds
133
When is PEFR normally lower?
in the morning
133
air filled tissue sounds _____ on percurssion i.e. pneumothorax
hyper-resonant
133
A good fit of nebuliser is important to...
ensure the drugs do not irritate the patients eyes
134
First thing to do when visiting a patient
WASH YOUR HANDS
| ya wee dirty
134
FiO2 achieved with nasal cannula
24-50% (variable because of room air and pattern of breathing)
135
Inspection involves
looking around patient area
looking for chest shape and movement
looking for prominent veins
scars from chest drains or surgery
136
Nasal Cannula
2-5L/min - preferably not more than 4
136
Reservoir Mask
Used in critical illness - 15L/min
136
Ascultation is usually done with the bell - true or false?
false
| usually with diaphragm
138
PEFR is a measurement of
how hard and fast a patient can exhale after a maximal inspiration
