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TMC > Patient Assessment > Flashcards

Patient Assessment Flashcards

1
Q

Define life functions?

A

Getting oxygen from the air to all the cells in the body.

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2
Q

List and describe the four critical life functions?

A

1.Ventilation- moving air in and out of the lungs
2.Oxygenation- getting oxygen into the blood.
3.Circularion- moving blood through the body.
4.Perfusion- getting oxygen into the tissue.

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3
Q

How to measure the four critical life functions?

A

1.Ventilation- respiratory rate, tidal volume, chest movement, breath sounds, PaCO2, ETCO2.

2.Oxygenation- heart rate, color, sensorium, PaO2 SPO2.

3.Circulation- heart rate and strength, cardiac output.

4.Perfusion- blood pressure, sensorium, temperature, urine output, hemodynamic

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4
Q

What is the most common problem in an emergency?

A

Oxygenation

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5
Q

List the priority in an emergency?

A
  1. Ventilation
    2.Oxygenation
    3.Circulation
  2. Perusion
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6
Q

Define signs?

A

Objective information, those things that you can see or measure
ex: color, pulse, edema, blood pressure, etc.

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7
Q

Define symptom?

A

Subjective information those things that the patient must tell you.
ex: dyspnea, pain, nausea, muscle weakness.

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8
Q

What is the formula for tobacco use?

A

Pack year= # of packs/day X #of years smoke
ex: 4 packs/day X 10 years= 40 packs years

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9
Q

What is a recommended therapy for tobacco?

A

Nicotine therapy

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10
Q

Define advance directives?

A

A documentation of what treatment a patient would want if he was unable to make a medical decisions.

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11
Q

What is a type of advance directive?

A
  1. DNR- The patient does not wish to have cardiopulmonary.
  2. DNI- The patient does not wish to be intubated.
  3. Living Will- Describe the treatment patient would want if he becomes terminally ill.
  4. Durable power of attorney - Legal document that names a health care proxy responsible.
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12
Q

What are the respiratory care orders?

A

1.Type of treatment
2. Frequency
3. Medication dosage and route of adminstration
4. Physisian signature

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13
Q

List and describe the patient progress notes?

A

1.Respiratory notes- record date, time, reactions, etc.
2. Nursing notes - check patient status.
3. Admission notes- recording of pertinent patient data. (ex: name, address, date of birth, physician or diagnosis).
4. Physician notes- if changes in patient progress, check for corresponding respiratory orders
5. Maternal history or neonatal data.

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14
Q

What is the normal value for urine output?

A

40ml/hr or 1 liter/day

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15
Q

Define sensible water loss?

A

Urine, vomiting

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16
Q

Define insensible water loss?

A

Lungs and skin

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17
Q

What is the result if urine intake exceed urine output?

A

1.Weight gain
2.Electrolyte imbalance
3.Increase hemodynamic pressure
4.Decrease lung compliance

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18
Q

What does central venous pressure (CVP) indicate?

A

Changes in fluid balance

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19
Q

What is the normal CVP?

A

2-6mm Hg

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20
Q

What is the value of decreased CVP?
what is the indication for decreased CVP?
What is the treatment?

A

< 2mm Hg
Indicate hypovolemia
treatment recommends fluid therapy

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21
Q

What is the value of increased CVP?
What is the indication for increased CVP?
What is the treatment?

A

> 6mm Hg
indicate hypervolemia
treatment recommend diuretics

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22
Q

What is medication reconciliation?

how long is it to carry out the process of admission?

A

The process of ensuring that the patient’s medication list is as accurate and up-to-date as possible.

The process should be carried out with 24 hours of admission to the hospital.

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23
Q

List and describe the different level of consciousness?

A

Alert and response- normal.

Lethargic, somnolent, sleepy-consider sleep apnea or excessive O2 therapy in patients with COPD.

Stuporous, confused- respond inappropriately, drug overdose, intoxication.

Semicomatose- responds to only painful
stimuli.

Obtunded- drowsy state, may have decreased cough or gag reflex.

Coma- does not respond to painful stimuli.

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24
Q

How check if a patient is orientated?

A

Time
Place
Person

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25
Q

Define the ADL?

What system is use to evaluate ADL?

A

The basic task of everyday life.

Katz scoring system

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26
Q

Define orthopnea, general malaise, dyspnea, dysphagia?

A

Orthopnea- difficulty breathing except in the upright position (CHF).

General malaise- Run down feeling nausea, weakness, fatigue. headache (electrolyte imbalance)

Dyspnea- a feeling of SOB or difficulty in breathing

Dysphagia- (difficulty swallowing) and hoarseness are also common symptoms

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27
Q

List and describe the grade of dyspnea in relation to the activity of daily living ?

A

Grade I- dyspnea occurs after unusual exertion.

Grade II- breathless after going up the hills or stairs.

Grade III- dyspnea while walking at normal speed.

Grade IV- dyspnea slowly walking a short distance

Grade V- dyspnea at rest, shaving, dressing, etc.

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28
Q

List a few general appearance?

A

Age, height, weight, nourishment, etc.

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29
Q
  1. What is peripheral/ pitting edema?
  2. Where does it primarily occur?
  3. What can cause congestive heart failure?
A

1.Presence of excessive fluid in the tissue.

2.Occurs primarily in arms and ankles

  1. Congestive heart failure (CHF) and renal failure.
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30
Q

1.How is peripheral or pitting edema rated?

  1. What is the recommended treatment for peripheral/ pitting edema?
A
  1. Rated +1, +2,+3, etc. the higher the number the greater the swelling.
  2. Recommend diuretic therapy.
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31
Q

Define ascites and what is it cause by?

A
  1. Accumulation of fluid in the abdomen generally.
  2. caused by liver failure.
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32
Q

1.What is the clubbing of the finger?

  1. What is the causing clubbing of the finger?
A
  1. The thumb and the first finger are affected. The condition is present when the angle of the nail bed and skin increases.

2.Caused by chronic hypoxemia

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33
Q
  1. When does increased venous distention occur?
  2. When is venous distention seen in patients?
A
  1. Occurs with congestive heart failure.
  2. Seen during exhalation in patients with obstructive lung disease and air trapping.
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34
Q

1.What is capillary refill?

2.What is the indication for capillary refill?

  1. How long should the color return after a capillary refill?
A
  1. Blanching the hand and watch for color to return.

2 peripheral circulation

  1. within three seconds
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35
Q

1.What is diaphoresis?

  1. What are the disease related to diaphoresis and the recommended treatment?
A
  1. State of profuse /heavy sweating
  2. Heart failure = treatment diuretics, positive inotropic agent

Fever/infections= antibiotic

Anxiety/nervousness= sedative

Tuberculosis/night sweats= antitubercular drugs

36
Q

1.Describe a decrease in color change?

2.What will a decrease in the color cause?

A

1.Ashen or pallor

  1. Cause with anemia or Vasoconstriction will cause change by reducing blood flow.
37
Q
  1. Define the skin color listed below and the cause for each stated?
    Jaundice
    Erythema and the cause
    cyanosis and cause
A

Jaundice-increase bilirubin level in blood and tissue. This appears mostly in the face and trunk

Erythema- redness of the skin.
cause capillary congestion, inflammation, or infection, flushed

Cyanosis- blue or blue-gray/dusky discoloration of the skin and mucous membrane.
Caused by hypoxia from the increasing amount of reduced hemoglobin (5g of reduce hemoglobin)

38
Q

Describe the normal A-P diameter?

A

Straight spine no alteration in chest size

no leaning forward (kyphosis) and side to side (scoliosis)

39
Q

What is the pectus carinatum?

A

Anterior protrusion of the sternum

40
Q

What is pectus excavatum?

A

Depression of part of or the entire sternum

41
Q

Define kyphosis?

A

Convex curvature of the spine (lean forward)

42
Q

What is scoliosis?

A

lateral curvature of the spine (lean side to side)

43
Q

What is kyphoscolios and what it cause ?

A

Combination of kyphosis and scoliosis.
This causes restrictive pattern or reduce lung volume

44
Q

1.Describe the barrel chest?

  1. What is the cause of barrel chest?
  2. How it is shown in A-P diameter?
A
  1. Barrel chest result in air trapping in the lungs for a long period of time.
  2. Due to chronic obstructive pulmonary disease
  3. Increase in A-P diameter
45
Q

What is symmetrical chest movement?

A

Both sides of the chest move an equal at the same time.

46
Q

What is the movement of the abdomen, diaphragm and thorax during inspiration?

A

The abdomen moves out during inspiration, diaphragm descends and the thorax moves outwards and upward

47
Q

What underlying pathology unequal or asymmetrical indicate?

A
  1. Post lung resection, post pneumonectomy
    2.Atelectasis
    3.Pneumothorax
  2. Flail chest - paradoxical chest movement
  3. Endotracheal tube inserted in right or left mainstem bronchi
48
Q

Describe breathing patterns for Eupnea, tachypnea, bradycardia, and apnea.

What is the normal number for wach?

What is the cause of each breathing pattern?

A

1.Eupnea- normal respiratory rate, depth, and rhythm.
Normal respiratory rate 12-20bpm

48
Q

Describe breathing patterns for Eupnea, tachypnea, bradycardia, and apnea.

What is the normal number for wach?

What is the cause of each breathing pattern?

A

1.Eupnea- normal respiratory rate, depth, and rhythm.
Normal respiratory rate 12-20bpm

  1. Tachypnea- increase respiratory rate.
    >20 bpm
    cause; hypoxia, fever, pain, CNS problem
  2. Bradypnea (Oligopnea)-decrease respiratory rate variable depth and irregular rhythm
    <12 bpm
    cause sleep, drugs, alcohol, metabolic disorder.
  3. Apnea- cessation of breathing
  4. hyperpnea- increase respiratory rate, increase depth regular rhythm
    cause metabolic disorder, CNS disorder
49
Q

Describe breathing patterns for cheyne stoke, biots, kussmauls, apneustic and hypopnea.

What is the normal number for the breathing patterns?

What is the cause of each breathing pattern?

A

1.Cheyne stoke- gradually increasing then decreasing rate and depth in a cycle lasting from 30-180 seconds with periods of apnea lasting up to 60 seconds.
cause increased intracranial pressure, brainstem injury , drug overdose

  1. Biots- increase respiratory rate and depth with irregular periods of apnea. Each breath has the same breath.
    cause CNS problem
  2. Kussmauls- increase respiratory rate, depth, irregular rhythm, breathing sounds labored.
    cause; hypoxemia, metabolic acidosis, renal failure, diabetic ketoacidosis
  3. Apneustic- prolonged gasping inspired followed by extremely short, insufficient expiration.
    cause: prolong with respiratory center, trauma or tumor
  4. Hypopnea - shallow or slow breathing
50
Q

What is the use of accessory muscles?

A

These muscles are to increase ventilation during times of stress, increase airway resistance and decrease compliance

51
Q

List the normal muscles of ventilation?

A

1.Diaphragm
2.external intercostals
3. exhalation ismnormally passive

52
Q

Name the acessory muscle of ventilation?

A
  1. Internal intercostal, scalene, sternocleidomastoid, pectoralis major
  2. Abdominal muscles, (oblique rectus abdominus etc)
53
Q

Describe hypertrophy and atrophy for a muscle condition.

A
  1. Hypertrophy-(increase in muscle size) of accessory muscle occurs with COPD

2.Atrophy- (muscle wasting, cachexia, starvation) loss of muscle tone and occurs in paralysis.

54
Q

Define retraction/intercostal and sternal retraction and what is the cause of it?

A

Occurs when the chest moves inward during inspiratory efforts instead of outward.

it is caused by severe airway obstruction or respiratory distress.

55
Q

Define nasal flaring and the signs of it?

A

Flaring of the nostrils during inspiration
signs of respiratory distress in infants

56
Q

What is the character of cough and what does it indicate?

A

Strong, moderate, weak, productive, and non-productive, frequent or infrequent/loose tight or moist.

a dry or non-productive cough indicates a tumor in the lungs

a productive cough indicates an infection or chronic lung disease

57
Q

What are the signs of changes to upper airway?

A

1.Trachea shift/deviation

2.enlarged thyroid

3.short receding mandible

4.enlarge tongue (macroglossia)

5.Bull neck

  1. Limited range of motion of the neck
58
Q

Describe the classification of mallampati?

A

Class I: soft palate, uvula, fauces, pillars visible

Class II: soft palate, uvula, fauces visible.

Class III: soft palate base of uvula visible

Class IV: hard palate is only visible.

59
Q

What is the complication to ventilate with the existence mallampati?

A

Face mask and manual resuscitation bag.

endotracheal ventilation

60
Q

What are class III and class IV mallampati consider?

A

difficult airways

61
Q

What equipment is needed to utilize for class III and class IV mallampati?

A

Fiberoptic bronchoscope
video assist device

62
Q

What is the normal range for heart rate?

A

60-100 bpm

63
Q

What are the values for tachycardia?

What is the indication?

What is recommended treatment?

A

> 100 bpm

indication are hypoxemia, anxiety,stress

the treatment is oxygen therapy

64
Q

What are the values for bradycardia?

what is the indication?

What is the recommended treatment?

A

<60 bpm

indications are heart failure, shock, code/emergency

The treatment atropine

65
Q

1.What is an adverse reaction to heart rate?

What should the respiratory therapist do?

A

A change heart rate more than 20 bpm

stop therapy, notify nurse and doctor and record the event

66
Q

What are the two different pulse rhythm?

What does a change in pulse rhythm?

A

the two pulse rhythm regular and irregular

a change in rhythm indicate for further monitoring

67
Q

Describe a pulse force?

A

Strong/bonding, or weak and thready

68
Q

Describe paradoxical pulse or pulsus paradoxus?

what does paradoxical pulse or pulsus paradoxus indicate?

A

pulse or bblood presure varies with respiratorion

May indicate airtrapping 9

69
Q

Describe paradoxical pulse or pulsus paradoxus?

what does paradoxical pulse or pulsus paradoxus indicate?

A

pulse or blood pressure varies with respiration

May indicate air trapping

70
Q

Describe how to locate the tracheal deviation?

A

Palpation can be use to determine trachea position.

To determine trachear position, place index finger into the supra-sternal notch.

compare the space between the left clavicle and the left border of the trachea.

71
Q

What are the pulled to abnormal side (toward pathology) cause of trachea deviation?

A

Pulmonary atelectasis
Pneumonectomy
diaphragmatic paralysis

72
Q

What are the pushed to normal side (awayf from pathology) cause of trachea deviation?

A

1.Massive pleural effusion

2.tension pneumothorax

3.neck or thyroid tumors

4.Large mediastinal mass

73
Q

Define tactile fremitus ?

A

Vibration that is felt by the hand on the chest wall

73
Q

Define tactile fremitus ?

A

Vibration that is felt by the hand on the chest wall

74
Q

List and describe the subdivision of the tactile fremitus?

A

vocal fremitus-voice vibration on the chest wall

Pleural rub fremtius- a grating sensatin felt on the chest wall due to roughen pleural surface rubbing together.

Ronchi fremitus (palpable rhonchi)- secretions in the airway

75
Q

What is tenderness?

A

Patient skin may be tender around the incision, chest tube, or bruises. fractured bones and burns

76
Q

What is creptius?

A

Bubbles of air under the skin that can be palpated and indicates the presence of subcutaneous emphysema.

77
Q

Differentiate between symmetrical chest expansion and asymmetrical expansion?

A

Symmetrical chest expansion is both sides of the patient chest moving.

Asymmetrical chest expansion is one side of the patient chest is moving more than the other side

78
Q

What does percussing the patient chest reveal?

Describe the technique use for percussion?

A

Precussing the patient chest reveals changes in the tones that are emitted by the thorax.

Percussion is done by placing the middle finger between two ribs and tapping the middle finger joint using the opposite hand.

79
Q

Descirbe the follwoing emitted sound

A

Resonant- normal air-filled lung. Gives a hollow sound.

Flat-normally heard over the sternum, muscle or areas of atelectasis

Dull - heard over the fluid-filled organs such as heart and liver.

80
Q

How to measure the diaphragmatic excursion?

What is the normal diaphragmatic excursion?

A

Measured by percussing at peak inspiration and the peak exhalation

3 to 5 cm

81
Q

What is normal breath sounds called?

A

Vesicular

82
Q

What is bronchial breath sounds?

What will bronchial breath sound over the lung periphery indicated?

A

Normal sounds heard over the trachea or bronchi.

Breath sounds over the lung periphery indictes lun

82
Q

What is bronchial breath sounds?

What will bronchial breath sound over the lung periphery indicated?

A

Normal sounds heard over the trachea or bronchi.

Breath sounds over the lung periphery indictes lun

TMC (5 decks)

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