Exam In Acute Care Flashcards
Look: Warning Signs
Distress: Grimace, apprehension, frequent position changes, Nasal flaring, using of accessory muscles
Hypoxemia: Cyanosis
Jugular Venous Distention: Suggests increased venous pressure
Look: Environment
Monitoring: Pulse oximeter, ECG, invasive lines
Support: Oxygen, ventilators, circulatory support
Room layout
Look: Observation
Posture, Thorax, Respiration
Listen: Responses
Current Status
Prior Functional Status
Home Environment
Social Support
Goals
Cognition
Evaluating Dyspnea
When?
At rest RED FLAG
Position changes?
Orthopnea- supine
Platypnea- upright
Chest pain associated? RED FLAG
Borg scale and breathlessness scale
Evaluating Chest Pain (Angina)
Described as: Squeezing, tightness, crushing at substernal, mid-chest, left arm, and shoulder
Worst with activity, relieved with rest or nitroglycerin
Unlikely to be angina if changes occur with:
Deep breathing, joint movement or palpation, and position changes
Evaluating Cough
Is it effective?
Is it productive?
- Note amount and consistency
- Color? Clear, white, yellow, brown, green (from less sick to more sick)
- Is there an odor? Hemoptysis suggests infection, inflammation, cancer
Lung Auscultation
The volume and quality of those sounds
indicate:
- Adequacy of airflow into a segment of the lung
- The patency of the airways
- The presence of retained secretions or fluid accumulation
Normal Breath Sounds
Vesicular: Normally heard in periphery (Soft, low pitch, gentle rustling)
Bronchovesicular: Normally heard at first and
second intercostal space, between scapulae (Medium pitch)
Bronchial: Normally heard over sternum (Loud, high pitch, hollow tube)
Adventitious Breath Sounds
Crackles
Wheezes
Rhonchi
Crackles: Sound, Description and Causes
Short, explosive, nonmusical
Sometimes described as:
Fine—high frequency, short duration, like pulling Velcro apart
Coarse—lower pitch, longer duration secretions
Caused by:
Snapping open of atelectatic airways
Fluid in airways (edema vs. retained)
Wheezes: Sound Description and Causes
Continuous, musical sounds with single or multiple notes
Caused by: Airway constriction due to occlusion, bronchoconstriction, or collapse of airways
Rhonchi:Sound Description and Causes
Low pitched, gurgling, snoring, or moaning
Caused by: Retained secretions in larger airways
Evaluating breath sounds
Quality
Are there adventitious sounds?
Volume
- Decreased air flow due to atelectasis, obstruction, hyperinflation, hypoventilation
- Increased distance/obstruction between lung and stethoscope, due to obese/muscular chest wall, effusion, pneumothorax
Lung Density and Transmission
Hyper inflated - poor sound transmission
Consolidated lung - better sound transmission
Normal Heart Sounds
S1: ― ”lub”
- Beginning of systole
- Closure of mitral and tricuspid valves
S2: ― “dub”
- Beginning of diastole
- Closure of aortic and pulmonic valves
Abnormal Heart Sounds
Murmurs
- Turbulent blood flow through incompetent valves
- Systolic vs. diastolic
- Graded I–IV
Gallops (loudest at apex)
- S3: ventricular gallop (Suggests onset of heart failure)
- S4: atrial gallop (Suggests diastolic dysfunction)
Blood Pressure Values
Feel: Pulse
Rate
Rhythm
Amplitude:
0—absent
1+—thready
2+—weak
3+—normal
4+—bounding
Feel: Breathing Pattern
Diaphragmatic: Normal
Paradoxical: (Upper chest collapsing/Diaphragm contracting — Abdomen collapsing/Diaphragm contracting)
Feel: Chest Wall Motion
Qualitatively: with hands (amount and symmetry)
Quantitatively: measured
Feel: Everything Else!
Edema (Location—unilateral vs. bilateral, Pitting vs. non-pitting)
Range of motion
Strength/manual muscle testing
Sensation as needed
Move: Assess!
Respirations
Perceived exertion
Dyspnea rating
Blood pressure
Pulse
Quantify Dose
Reps/time/distance covered in activity
Standardized outcome measures
Assistance (AM-PAC “6 clicks)
Ensign the Session
Ensure patient comfort
Reflect and plan
