lab 12 Flashcards
how to examine respiratory rate?
observe the rise and fall of the patients chest and count the breaths in 30 seconds and multiply by 2
what is the normal respiratory rate?
12-20 breaths per minute
Describe normal respiration
average chest wall motion with at least 1 inch expansion in the outward direction, no use of accessory muscles of the chest, neck, or abdomen
describe shallow respiration
only slight chest or abdominal wall expansion during inhalation
describe labored respiration
patient is working hard to breathe, which can be indicated by abnormal breathing sounds; gasping, nasal flaring use of accessory muscles of chest, neck or abdomen
describe noisy respiration
involves abnormal breathing sounds such as snoring and stridor which can be heard without a stethoscope or wheezing, rales, and ronchi
What are the 2 factors you should observe during respiratory rate exam?
- Mental status
- Speech pattern
Patient Position during HR exam
Sitting or lying down
How to calculate HR during HR exam
Count number of beats on radial pulse in 30 seconds and times by 2
Tachycardia and Bradycardia
- Tachycardia - Above 100 bpm
- Bradycardia - Below 60 bpm
Pulse Quality (5)
- Strong Pulse: Bounding and abnormally strong (3+)
- Regular Pulse: Normal pulse at normal intervals (2+)
- Weak Pulse: Difficult to palpate and rapid (1+)
- No Pulse: 0
- Irregular Pulse: Can be irregularly irregular or regularly irregular
Normal Skin Color Assessment
Nail beds, oral mucosa, conjuctiva and palms of hands and soles of feet (dark skin patients) should be pink
Abnormal Skin Color Assessment (5)
- Paleness
- Cyanosis
- Red color/flushing (vasodilation/CO poisoning)
- Jaundice
- Gray/Blue Mottling (shock patients)
Temperature Skin Assessment Normal/Abnormal Exam
- Normal: 98.6 degrees give or take 0.5 - 1 degree F
- Abnormal: Above 99.6 degrees F
Skin Condition Skin Assessment Normal Exam (1)
- Skin is dry and warm
Skin Condition Skin Assessment Abnormal Exam and Causes (4)
- Wet/moist skin - can indicate shock
- Cool and moist skin - Clammy skin
- Profuse sweating- Diaphoresis
- Extremely dry skin - Spinal injury or severe dehydration
Normal Capillary Refill Exam in Infants/Children, Male Adults, Female Adults, and Elderly
- Infants/Children: 2 seconds
- Male Adults: 2 seconds
- Female Adults: 3 seconds
- Elderly: 4 seconds
What can a longer capillary refill indicate?
Shock
Blood O2 Sat. unit of measurement
% SpO2
Normal/Abnormal Blood O2 Sat. Levels
- Normal: 97-100 % SpO2
- Abnormal: Below 90% (Hypoxia)
What condition can Blood O2 Sat. Not Detect?
Carbon Monoxide poisoning
What does AVPU stand for in a LOC exam?
Alert, Verbal Stimulus, Painful Stimulus, and Unresponsive
What are the 3 painful stimuli used for a LOC exam?
- Trapezius pinch
- Sternal rub
- Thumb-Index finger pinch
Define Decorticate Posturing
Patient arches back and flexes arm inwards toward the chest
Define Decerebrate Posturing
Patient arches back and extends the arms straight out parallel to body - sign of serious head injury
How do you document Level of Distress
None, Mild, Moderate, or Severe Distress
What 4 questions do you ask to determine Orientation?
- What is your first and last name?
- Where are you?
- What is the current date and time?
- What just happened to you?
How do you determine Airway, Breathing, Circulation (ABCs)?
- Airway is clear and open with no obstruction or noisy breathing
- Determine rate and quality of breathing
- Determine circulation by measuring pulse rate, pulse quality, skin color, and temperature
How do you perform an Eye Exam?
. Check pupils for PERLA (Pupils Equal, Responsive to Light, and Accommodating) using the 3 tests of the light pen
What are the 4 signs of abnormal pupils and possible causes?
- Dilated Pupils: Might indicate cardiac arrest or use of stimulants
- Constricted Pupils: Might indicate CNS disorder or use of narcotics
- Unequal Pupils: Might indicate stroke, eye trauma, or head injury
- Nonreactive Pupils: Might indicated cardiac arrest. brain injury, or drug overdose
Neck Exam (2)
- Is the trachea midline?
- Does the patient have JVD?
Chest Exam (2)
- Does the patient show good rise of chest and symmetrical breathing?
- Does the patient have abnormal lung sounds?
Abdomen Exam and Markle Test (2)
- Is the abdomen soft and supple?
- Markle test is where patient stands on balls of feet and drops to heals and watch for any grimace or pain
Pelvis Exam (1)
- Does the patient have incontinence?
Back Exam (1)
Exam back for PTA (Pain, trauma, or anything abnormal)
Lower Extremities Exam
- Circulator, Motor, and Sensory (CMS)
- Range of motion
- Signs of pedal edema?
- Babinski reflex to see if big toe moves upward and other toes flare out
Upper Extremities Exam
- Circulator, Motor, and Sensory (CMS)
- Range of motion
- Check for pronator arm drift for stroke signs
- Check for AV Fistula
5 General Considerations during Patient Exam
- Medic Alert Jewlery?
- Implanted Medical Devices?
- Transdermal Medical Patches?
- Surgical Scars?
- IV Drug Abuse Scars?
Patient History: Diet Assessment (4)
- Typical diet consumption of patient
- Do they consume alcohol? How many glasses/week?
- What % of diet is processed food?
- Do they smoke? How many cigarettes/week?
Patient History: Physical Activity (4)
- What types of physical activity does the patient engage in?
- How many times/week the patient exercises
- What intensity does the patient exercise
- How long do they exercise for
Patient History: Medical History
- Ask about medical history
- Ask for list of current medications
- Ask if patient has any allergies
- Ask about patient’s family medical history
Pain Assessment Questions
- Acute or chronic pain?
- Severity of the pain?
- Where is the location of the pain?
- When did the pain start and what were they doing?
- What are the characteristics of the pain?
- Does anything make the pain worse or better?
