Clinical Skills Flashcards
Target SaO2 for most people
94-98%
What clues might exist there is a respiratory complaint?
peak flows, inhalers, IV drips
Where can tar staining also be seen?
around the hair line - yellowing in fringe area
Signs of finger clubbing (5)
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
When asthma is considered severe, the PEFR is…
33-50%
What must you do before assembling and giving nebuliser?
the drug
polycythemic patients become cyanosed at ______ SaO2 because there is an increase in the level of the RBCs in the blood
higher
How can JVP be assessed if not visible using conventional method?
pressing in the RUQ to circulated more blood from liver
What should you ask the patient to do when auscultating?
breath deeply but at a rate normal for them, ask them to take deep breaths when they feel the stethoscope move
You take the average of PEFR - true or false?
False
Take the best of all three as given
FiO2 of Reservoir mask
60-80%
the nasal cannula prevents rebreathing of expired CO2?
true
Example of low pitched sound
bowel sounds
heart murmurs
When might a spacer be useful
when the patient technique is not great
When examining the posterior aspect of the chest for percussion and auscultation, what is best for the patient?
ask them to swing their legs round and sit over the side of the bed
Normal Pulse
60-100bpm
What does oedema in the legs potentially indicate?
DVT
Pulmonary hypertension/R. Ventricular failure
Second step when visiting patient
introduce self, check you have the right patient and confirm details, explain plan and gain consent
What does palpation involve?
feeling for the trachea in the neck - should be in the middle of the notch above the sternum
chest expansion
Normal SaO2 range for healthy individuals
94-100%
Where should you percuss and ascultate?
anteriorly, posteriorly and laterally
How loud are bronchovesicular breath sounds?
intermediate
When asthma is considered moderate, the PEFR is….
50-75%
When asthma is considered life-threatening, the PEFR is
<33%
Abnormal breath sounds are…
bronchial
How loud are bronchial breath sounds?
loud
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
Moving on from hand exam what do you check?
pulse, resp rate, skin
bronchial breath sounds are
harsher than vesicular sounds
palmar erythema
redness of the thenar and hypothenar eminence
Example of high pitched sound
breath sounds
normal heart sounds
Location to palpate trachea
supra-sternal notch
What side of the bed should you approach the patient
The patients right
When asthma is considered mild, the PEFR is…
> 75%
How might you assess your patients ability to take part?
breathing ability, use of accessory muscles, NEWS, ability to speak in full sentences
vesicular breath sounds normally have a shorter expiration than inspiration - true or false?
true
Target SaO2 for people who are at risk of Type II respiratory failure
88-92%
Diaphragm of the stethoscope is best for hearing _______ pitched sounds
high
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
Tracheal breath sounds are?
very loud
What can give inaccurate results in SaO2 measurements? (4)
nail polish, strong ambient light, severe anemia, CO poisoning
Less common causes of finger clubbing (6)
coeliac cirrhosis of liver dysentery graves disease overactive thyroid other cancers
Peripheral cyanosis can occur in isolation from central cyanosis - true or false?
true
situations where bronchial breath sounds might be heard?
collapse
consolidation
fibrosis
The reservoir mask can reach 100% oxygen delivery if used with high flow rates - true or false?
false
Type I Respiratory Failure
Low level of O2 without an increase in CO2
Pneumonia, ARDS
What should the patient do before taking the inhaler?
big breath out
Fine wrist tremor is indicative of…
b-agonist use such as salbutamol
Where must you inspect?
the axilla
common causes of cyanosis (3, 3;2)
lung diseases - COPD, pneumonia, pulmonary embolis
cardiac diseases - R-> L cardiac shunt
abnormal haemoglobin
methaemoglobinaemia
suflhaemoglobinaemiaHow long should a patient extend their hands to indicate a tremor?
at least 10 seconds
Oxygen must be prescribed - true/false?
true
When might the trachea not be in the expected position?
where there is upper lobe pathology i.e. fibrosis, collapse or occasionally tension pneumothorax
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
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
Tar staining is indicative of….
heavy smokers
Where would you hear stridor?
Inspiration
Pathologies associated with assymetry in chest expansion
Collapse
Consolidation
Pleural Effusion
Fibrosis
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
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
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
What sort of pulse might be felt in a patient who has used b2-agonists?
tachycardic which may be thready
Where should you start your percussion?
apex around the clavicle
Normal respiratory rate
12-18 breaths a minute
Indications of FiO2
Type II resp. failure and need for exact FiO2
Where might a pneumoectomy take place?
from behind in the lung
What sort of pulse and characteristics might be seen in a patient with CO2 retention?
bounding pulse and patient may appear drowsy
Simple Face Mask
5-10L/min
How should the patient be when listening to inspiration and expiration?
have their mouth open
Lymph nodes in the face and neck (8)
submental submandibular anterior and posterior triangle pre and post auricle occipital supraclavicular
How should the patient be positioned if possible for PEFR?
standing
Where would you hear a wheeze in the respiratory cycle?
expiration
Flapping wrist tremor is indicative of…
CO2 retention
What does redness in the face and hands indicate in a respiratory setting?
CO2 retention
What is sulfhaemoglobinaemia?
abnormal haemoglobin secondary to drugs i.e. sulfonamides
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
Indications of Simple Face Mask
Short term, low oxygen requirements
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
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
Signs that may indicate DVT?
calf hot, red with greater girth than the other leg
Why is it more difficult to examine chest expansion anteriorly on a female?
due to chest tissue - also applies to percussion
Indications for Reservoir mask
critical illness
What should the patient do when examining the supraclavicular lymph nodes?
tilt their head towards side being examined
How much fluid must be leaked before oedema becomes noticeable?
500ml
FiO2 with simple face mask
variable
Nebulising canninster must remain….
upright
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
Bell of the stethoscope is best for hearing _______ pitched sounds
low
Ipratropium
medication that opens medium to large airways
liquid i.e. pleural effusion, sounds _______ on percussion
stony dull
How loud are vesicular sounds?
soft
4 aspects of chest examination
inspection
palpation
percussion
auscultation
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
What do electric nebulisers use?
air
How can oedema be assessed?
an imprint may be left if pressed for 5secs - be gentle, as may be painful
Abnormal percussion over pneumothorax is…
hyper-resonant
Venturi Mask
Controlled oxygen delivery with exact percentage FiO2 delivered as stated on device
Upper lobe pathologies leading to tracheal dislocation
fibrosis
collapse
tension pneumothorax
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
When giving any form of treatment or performing any test, you should…
ask permission
check for questions
Peak Flow is a good clinical assessment of…
Asthma
Typical nebulising drugs?
salbutamol
ipratropium
Indications of Nasal Cannula
Low oxygen requirements
Patient able to speak and eat freely
oxygen cannot be prescribed retrospectively - true or false?
false - in emergency situations oxygen may be prescribed retrospectively
Normal breath sounds are…
vesicular
Where else might cyanosis be seen in the face?
under the tongue
What may be noticeable on the skin and why?
thin or easily bruised skin
steroid use
Where should a Peak flow meter tube be discarded?
Orange bin
What might a grey and breathless patient have?
anemia - they cannot get enough oxygen as not enough blood to carry oxygen
polycythemia
have increased levels of RBCs and a raised haematocrit of >55%
decrease in relative plasma volume or increase in RBC
Oxygen prescription should contain the following details (6)
patient name DOB Unique ID Drug Name (oxygen) Route of administration (inhaled) the target
solid material sounds ______ on percussion
dull
Lung consolidation is when….
lung tissue is filled with liquid
Reduced breath sounds are common when?
there is damage to alveoli
Why might there be asymmetry in chest expansion?
collapse, consolidation, pleural effusion, fibrosis
What is methaemoglobinaemia?
abnormal haemoglobin due to genetic disorder or secondary to drugs i.e. quinones, sulfonamides
Bronchial breath sounds have a shorter expiration than inspiration - true or false?
false they have longer expiratory sounds
A good fit of nebuliser is important to…
ensure the drugs do not irritate the patients eyes
FiO2 achieved with nasal cannula
24-50% (variable because of room air and pattern of breathing)
Inspection involves
looking around patient area
looking for chest shape and movement
looking for prominent veins
scars from chest drains or surgery
Ascultation is usually done with the bell - true or false?
false
usually with diaphragm
Reservoir Mask
Used in critical illness - 15L/min
PEFR is a measurement of
how hard and fast a patient can exhale after a maximal inspiration
Nasal Cannula
2-5L/min - preferably not more than 4
First thing to do when visiting a patient
WASH YOUR HANDS
ya wee dirty
air filled tissue sounds _____ on percurssion i.e. pneumothorax
hyper-resonant
When is PEFR normally lower?
in the morning
From what side is a physical examination done?
patients right hand side
Most common causes of finger clubbing (4, 3:3)
Lung Cancer
Congenital Heart Defects
Chronic Lung Infections
Bronchieotasis
cystic fibrosis
lung abscesses
Infectious endocarditisHow 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
After checking PEFR what should you do? (3)
tell patient what you have found, check for questions, wash hands
Appropriate nebulising flow rate
6-8L/min
What should be checked in the face/neck? (5)
cyanosis plethora pallor of conjunctiva pursed lip breathing lymph nodes
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
What should be removed before assessing SaO2?
nail polish
Signs in general resp. exam in hands (5)
Finger Clubbing Cyanosis Palmer Erythema Tar Staining Tremor
FiO2
Fraction of Inspired Oxygen
plethora
redness in the cheeks
