Exam 2 Flashcards
What are the 4 classical vital signs(VS)
Temp
Pulse
RR
BP
What is also included in initial assessment
Height
weight
Level of consciousness and responsiveness
General clinical impression
When should baseline measurements be taken
Upon admission
Beginning of the shift
Prior to Tx or procedure
When there is a change in pt’s condition
Define Trending in VS
A series of VS measurements over time
Define differential diagnosis
This is comparison of multiple signs and symptoms to arrive at the pt’s diagnosis
What is referred by some clinicians as the “fifth vital sign”
Pain
The alert pt whose orientation to time,place and person is accurate is said to be ………….. and the sensorium is considered……….
oriented *3
Normal
True or False
An abnormal sensorium may also occur as a side effect of certain medications and in drug
True
In a Glasgow scale, the objective evaluation is based on behavioural response in which 3 areas
Motor function
Verbal function
Eye-opening response
When is body temp usually the lowest and when is it the highest
In the morning
In the late afternoon
What part of the brain plays an important role in regulating heat loss and can initiate peripheral vasodilation and sweating in an effort to dissipate body heat
Hypothalamus
An elevation of body temp above normal is known as
Hyperthermia
True or False
Fever most often results from infection somewhere in the body
True
What is the term used when the body temp is below normal
Hypothermia
Describe the breathing of patient with hypothermia
Slow and shallow breathing and a reduced pulse rate
Name the sites where body temp can be measured
Mouth
Ear
Axilla
Rectum
What are the common places to measure body temp in both kids and adults
Mouth
Tympanic
What is the normal pulse rate of an adult
60 - 100 bpm
A pulse rate exceeding 100 bpm in an adult is termed
Tachycardia
A pulse rate lower than 60bpm for an adult is termed
Bradycardia
Which is the most common site for evaluation of the pulse
Radial
Define Lethargic
sleepy, easily aroused and responds appropriately
Define Obtunded
Difficult to arouse but responds appropriately
Define stupor
Do not wake up completely,responds to pain and slow respiration
Define comatose
Unconscious have loss of reflexes
What is the name of the scale that is used to assess pts level of consciousness
Glasgow coma scale
If a pt has below an 8 on the Glasgow scale what does it show and what should be done
Shows traumatic head injury
Intubation
What are some other common sites available for assessment of the pulse
Branchial
Femoral
Carotid arteries
If the strength and rhythm are normal and the pulse is irregular the pulse rate may be counted for 15 secs
False
Only when the pulse, strength and rhythm are normal can you count the rate for 15 secs
What are the terms used to describe rhythm
Regular
Regularly
Irregular
Irregularly
Describe bigeminy
rhythm coupled in pairs
A rhythm grouped as 3 beats and a pause is known as
Trigeminy
How long should you wait if a person has taken liquids or smoked before taking their pulse
10 - 15 mins
Rate the pulse volume and fullness
0 -4 …Eg. 0: Absent
1+ : Weak, thready
2+ : Slightly reduced
3+ : Normal
4+ : Bounding
What does pulse oximetry measure
HR and O2 saturation
Normal RR for an adult
12 - 20
True or False: A respiratory rate greater than 60 bpm is considered abnormal for any age and 40bpm is unusual for an adult
True
The term used to describe respiratory rates above normal
Tachypnea
A fast and deep breathing pattern is known as
Kussmaul breathing
A slow RR is referred to as
Bradypnea
Define systolic BP
Peak force exerted during contraction of the left ventricle
Define diastolic BP
Force occuring when the heart is relaxed
Define pulse pressure and what is the normal pulse pressure
It is the difference btn systolic and diastolic pressures
35 - 40 mmHg
BP persistently at or above 130/80 mmHg is termed
Hypertension
Defined as an arterial BP that is less than 90/60 mmHg in adults
Hypotension
The most common technique for measuring arterial BP uses a
Sphygmomanometer
Define the korotkoff sounds
Happens when blood flow in the artery resumes
When measuring BP what will give you a high pressure reading
Too narrow a cuff
Cuff applied too tight/too loose
Excessive pressure to the cuff or incomplete deflation
When measuring BP what will give you a low pressure reading
If the cuff is too wide
What effects does the respiratory cycle have on systolic BP during inspiration
It decreases
When is low systolic Bp during inspiration present in
Asthma
Cardiac tamponade
When does hypotension occur
When the left ventricle of the heart is weak
What medications can cause hypotension
Beta blockers
Diuretics
Only affects the systolic
Name some identifies to look for when on a pt’s face
HINT:Evaluating them
Acute distress
Pain
Alertness, mood and mental capacity
What are the 2 signs of respiratory distress
Cyanosis and Nasal flaring
If a pt has nasal flaring what does it suggest
Increased WOB is present
When is cyanotic more visible
When there is a significant amt of deoxygenated Hb is present
What parts of the body can you see central cyanosis
Ears
Neck
Tongue
Lips
Nose
Define Acrocyanosis
A persistent, painless blusih discoloration of both hands and less commonly on both feet
What kind of pt’s use pursed lip breathing
COPD
Define mydriasis
Dilated and fixed eyes
Define miosis
Pinpoint pupils
Define ptosis
Drooping upper lid
Define diplopia
Double vision
Define nystagmus
Cyclic movement of the eyeballs
Define Diaphoresis
Excessive sweating
What the Prescence of cyanosis represent
Tissue oxygenation is less than optimum.
Inspection and palpation of the neck are of value in determining the:
Tracheal position
Jugular venous pressure(JVP)
Accessory muscle
Tracheal shift
Away from affected side
Tension pneumothorax
Pleural effusion
To the affected side: Atelectasis and lung resection
What is the most common cause of JVP
Right heart failure
What can cause JVP
Hypervolemia
Obstruction of venous return to the R atrium
What’s the name that describes enlarged lymph nodes
Lymphademopathy
Lymphademopathy is a common finding in patients with
Respiratory infections
Tracheal bifurcation at carina is approximately
T4
The diaphragm on the right dome gets to
Anterior: 5th rib
Posterior: T9
The diaphragm on the left dome gets to
Anterior: 6th rib
Posterior: T10
Superiorly on the anterior chest, the lungs extend ——-above the medial 3rd of the clavicles.
HINT: in cm
2-4cm
Inferiorly, the lung borders extend to the——–midclavicular line and laterally ——-
HINT: Ribs
6th rib
8th rib
Barrel chest is common in pts with what disease
Emphysema( COPD)
Define barrel chest
abnormal increase in AP diameter
Define pectus excavatum
Depression of part or all of the sternum
Define pectus carinatum
Outward sternal protrusion anteriorly
Define kyphosis
Spinal deformity in which the spine has an abnormal anteroposterior curvature
Define scoliosis
Spinal deformity in which the spine has a lateral curvature
Define kyphoscoliosis
Combination of kyphosis and scoliosis
This is the paradoxical motion of the affected rib cage
Flail chest
If a pt has flail chest what happens to their chest wall when they inhale or exhale
During inhalation: It sinks in
During expiration: there is an outward protrusion of the chest
Define Tachypnea
Rapid rate of breathing
Define Apnea
No breathing
Define Biot
Irregular breathing with long periods of apnea
Irregular type of breathing, breaths increase and decrease in depth and rate with periods of apnea
Cheyne stokes
What is defined as deep and fast
Kussmaul
Define apneustic
Prolonged inhalation
Define Paradoxic
Injured portion of chest wall area moves in the opposite direction to the rest of the chest
Define Abdominal paradox
Contraction of accessory muscles to aid inspiratory effort; diaphragm is pulled upwards and abdomen sinks inward during inspiration
Define retractions
Inward movement of skin
Examples of acute obstruction of intrathoracic airways
Asthma
Prolonged expiratory time
Examples of acute upper airway obstruction
Croup
Prolonged inspiratory time
Define vocal fremitus
Vibrations created by the vocal cords during talking
Define tactile fremitus
When vibrations are heard on the chest wall
A reduced tactile fremitus is often present in patients who are
Obese and overly muscular
What can cause increased tactile fremitus
Pneumonia
Lung tumor or mass
Atelectasis (with patent bronchiole)
What can cause decreased tactile fremitus
Unilateral
Bronchial obstruction w/ mucous plugging or foreign object
Pneumothorax
Pleural effusion
Diffuse
COPD w/ hyperinflation
Muscular or obese chest wall
Define Rhonchial fremitus
The passage of air thru airways contaminated with thick secretions may produce palpable variations
Vocal fremitus is found in diseases such as
Pneumonia
Atelectasis
What causes decreased vocal fremitus
Unilateral
Bronchial obstruction
Pneumothorax
Pleural effusion
Diffuse
COPD w/ hyperinflation
Muscular or obese chest wall
Rhonchial fremitus
Vibrations produced by passage of air thru thick secretions
What type of BS does the bell detect
Low frequency sounds( light placement)
What type of BS does the diaphragm detect
High frequency ( firm placement)
What are the 4 lung sound characteristics
Pitch
Amplitude
Distinctive characteristics
Duration of inspiration vs expiration
What’s the term for sound heard over the trachea
Tracheal
What’s the term for sound heard over the parenchyma
Vesicular
What’s the term for sound that has an expiratory component equal to inspiratory component
Harsh
bronchial
(have the same definition)
What’s the term for abnormal movement of air in the lungs
Adventitious
Digital clubbing is a sign of
Cardiopulmonary disease
What makes up the composition of blood
WBC(leukocytes)
RBC(erythrocytes)
Platelets(thrombocytes)
Capillary refill helps show
Good cardiac output and digital perfusion
Plasma is used to create
Electrolytes
Clotting factors
Immunologic factors
Proteins
Lipids
Hormones
All substances used by cells must be transported by
Plasma
Define Serum
plasma w/ clotting factors removed
What does CBC include
RBC and WBC
Primary function of WBC
Help fight infection
What makes up WBC
Neutrophils
Eosinophils
Basophils
Lymphocytes
Monocytes
What does Granulocytes include
Neutrophils
Eosinophils
Basophils
Where are neutrophils produced in and what are they also known as
Bone marrow
Polymorphonuclear leukocytes
Immature neutrophils in the circulating blood are known as
Bands
What are eosinophils involved in
Immune system regulation
It is an important line of defense against foreign microorganisms and cells
Lymphocytes
T cells are involved in
Cell-mediated injury
B cells are involved in
Humoral immunity
What is the main function of Monocytes
Phagocytosis
One of body’s first response to infection and inflammation
Neutrophilia
What is the primary cause of neutropenia
Bone marrow failure
Penia means
Decrease
Philia and cytosis means
Increase
Eosinophilia is elevated in the Prescence of
Parastic infestation
Allergic states
Allergic asthma
Associated with myeloproliferative neoplasms(MPNs)
Basophilia
What causes lymphocytosis
HIV
Trauma
What causes monocytosis
TB
Syphilis
Typhoid fever
Fungal infections
RBC’s are produced in the
Bone marrow
primary function for RBC
Carry O2
Life span for RBC
120 days
It is the protein that carries O2 to the tissues and carries CO2 from the tissues to the lungs
Hemoglobin (Hgb or Hb)
Define Anemia
Reduction in RBC mass of the body
What are the causes anemia
Blood loss
Deficiency in cell formation
Abnormal cell formation
Chronic disease and aging
