Observation Flashcards
What are you observing during an objective assessment?
General appearance Position Chest Skin colour Abdomen Use of accessory muscles Nasal flaring Lines, drains etc Oxygen therapy Quality of voice
What are you looking for in general appearance?
Eyes
Hands
Mouth
Oedema
What are you looking for when observing the chest?
Shape
Work of breathing
Breathing pattern
What are you observing for skin colour?
Pale
Ruddy
Cyanosed
When observing the eyes in general appearance what type of thing are you looking for?
Pallor
Plethora
Jaundice
Oedema
What causes pallor?
Anaemia
What caused plethora?
High Hb
What causes jaundice?
Liver or blood disorders
What causes oedema?
Fluid retention
What are you looking for when observing the hands?
Flapping tremor Fine tremor Wastage Clubbing Nicotine stains Cyanosis Temperature
What are the causes of clubbing?
Cardiac - congenital heart disease and bacterial endocarditis
Lung disease - infective, fibrotic and malignant
What are you observing for when looking at the mouth?
Dry/dehydrated
Hydrated
Cyanosis
Purse lip breathing
What positions are you observing for?
Slumped
Position of ease
Fixing
What are you observing for when looking at chest shape?
Scoliosis Kyphosis Kyphoscoliosis Funnel chest Pigeon chest Hyperinflated
What are you looking for when observing the chest for work of breathing and shortness of breath?
Needing to pause between sentences Able to talk in full sentences Position Purse lip breathing Accessory muscle use
What are you looking for when observing the chest wall movement?
Symmetrical
Pump handle
Bucket handle
What are you looking for when observing breathing pattern?
Depth
Indrawing/recession of intercostal space
Tracheal tug
Asymmetry
What does pale skin colour mean?
Anaemic
Low BP
What does ruddy skin potentially mean?
Retaining CO2
Increased red blood cells
What does cyanosed skin mean?
Lack of O2
Central
Peripheral
How do you palpate the abdomen?
Recline posture
Apply a flat hand
Gently palpate the abdomen just below the rib cage?
What are the muscles of inspiration?
Diaphragm
External intercostals
What are the accessory muscles of inspiration?
Scalenes Sternocleidomastoid Pectoralis minor and major Serratus anterior Latissimus Dorsi
What are the muscles of expiration?
Passive elastic recoil of lungs
What are the accessory muscles of expiration?
Rectus Abdominis External obliques Internal obliques Transverse Abdominis Longissimus Quadratus Lumborum Serratus posterior inferior Lowest fibres of Iliocostalis
What is nasal flaring?
Dilation of the nostrils
What does nasal flaring do?
Attempt to decrease airway resistance
What do you listen for in someone’s voice?
Volume
Audible sounds
Wet sounding
Talking in full sentences
What can you palpate/notice on palpation?
Abdomen Chest expansion Trachea Body temperature Scars Response to touch Surgical emphysema
What does a distended abdomen limit?
Diaphragmatic movement
How does limited diaphragmatic movement effect breathing?
Restricts lung volume
Increases work of breathing
What is tactile fremitus?
Transmission of crackles felt on the outside of the chest wall?
What does vocal fremitus measure?
Speech vibrations
What is surgical emphysema a sign of?
Pneumothorax
What are the exercise tolerance tests?
6 min walk test Endurance shuttle walk test Stair climbing test Chair-stand test 3 minute SWT
What is on a chart?
Blood pressure Heart rate Temperature Oxygen saturations Oxygen requirements Respiratory rate Weight AVPU Fluid balance Urine output Medications
What are additional things of a critical care chart?
Mode of ventilation FiO2 Heart rhythm Pressure support/volume control Airway pressure Tidal volume PEEP CVP GCS ABG’s Blood chemistry
