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