Patient Assessment Flashcards
0
Q
Which of these life functions is the first priority?
- Ventilation
- Oxygenation
- Circulation
- Perfusion
A
Ventilation
1
Q
List the four critical life functions?
A
- Ventilation
- Oxygenation
- Circulation
- Perfusion
2
Q
What assessments would determine how well the patient is ventilating?
A
Visual assessment is number one
3
Q
How would the adult critical care specialist determine if the patient has a problem with oxygenation?
A
- Heart rate
- Color
- Sensorium
- SaO2
- PaO2
4
Q
What information would help the adult critical care specialist determine if the patients circulation is adequate?
A
- Pulse/Heart Rate
- Strength
- Cardiac Output
5
Q
What changes would indicate that a patient may not have adequate perfusion?
A
- Blood Pressure
- Sensorium
- Temperature
- Urine Output
- Hemodynamics
6
Q
What is normal urine output?
A
40 to 80 mL/hr (approximately 1 : 2 Liter/day)
7
Q
What are examples of sensible water loss?
A
Is what you can measure:
Urine Output and Vomiting
8
Q
What are examples of insensible water loss?
A
Lungs (Respiration) and Skin (Perspiration)
9
Q
If Fluid intake exceeds output, this could result in:
A
- Weight gain
- Electrolyte imbalance
- Increased hemodynamic pressures
- Decreased lung compliance
10
Q
Changes and CVP can indicate changes in fluid balance.
True or False?
A
True
11
Q
A decreased CVP (< 2 mmHg) can indicate:
A
Hypovolemia
12
Q
A increased CVP ( >6 mm Hg) can indicate:
A
Hypervolemia
13
Q
What is a sign?
A
Objective information, those things that you can SEE our MEASURE
14
Q
What is an example of a sign?
A
- Color
- Pulse
- Edema
- Blood pressure , etc.
15
Q
What is a symptom?
A
Subjective information, those things that the patient must tell you
16
Q
What are examples of symptoms?
A
- Dyspnea
- Pain
- Nausea
- Muscle weakness , etc.
17
Q
List 6 items that are important to examine when reviewing the patient’s chart
A
- Occupation or employment hx
- Allergies or allergic reactions
- Prior surgery, illness or injury
- Vital signs
- Physical examination of the chest
- Smoking history
18
Q
Define an advance directive
A
A set of instructions documenting what treatment the patient would want if was NOT able to make medical decisions
19
Q
What are the four types of advanced directives?
A
- Do Not Resuscitate (DNR)
- Do Not Intubate (DNI)
- Living Will
- Durable power of attorney for healthcare
20
Q
A properly written order for respiratory care should include what four factors?
A
- Type of therapy
- Frequency
- Medication dosage and dilution
- Physician signature
21
Q
What is lethargy and what is it associated with?
A
Somnolent, sleepy. Consider drug overdose or sleep apnea.
22
Q
What is semi-comatose?
A
A state in which the patient responds only to painful stimuli.
23
Q
What is obtunded and what is it associated with?
A
Drowsy state, may have decreased cough for gag reflex.
24
What is the score range for Glasgow coma scale (GCS)?
3 to 15
25
What is a good score for Glasgow coma scale?
10 -15
26
What are the 3 responses when assessing Glasgow coma scale?
1. Eye-opening
2. Verbal
3. Motor
27
Under eye-opening response. what is the point value for spontaneous opening?
4
28
Under eye-opening response. what is the point value for verbal stimuli?
3
29
Under eye-opening response. what is the point value for pain?
2
30
Under eye-opening response. what is the point value for None?
1
31
Under VERBAL response. What is the point value for orientated?
5
32
Under VERBAL response. What is the point value for Confused?
4
33
Under VERBAL response. What is the point value for inappropriate words?
3
34
Under VERBAL response. What is the point value for hey incoherent?
2
35
Under VERBAL response. What is the point value for None?
1
36
Under MOTOR response (arm). What is the point value for Obeys Commands?
6
37
Under MOTOR response (arm). What is the point value for Localizes Pain?
5
38
Under MOTOR response (arm). What is the point value for Withdraws from Pain?
4
39
Under MOTOR response (arm). What is the point value for Flexion to Pain?
3
40
Under MOTOR response (arm). What is the point value for Extension to Pain?
2
41
Under MOTOR response (arm). What is the point value for None?
1
42
When assessing the patient's orientation to time, place and person, what are four factors that could affect the patient's ability to cooperate?
1. Language difficulties
2. Influence of medications
3. Hearing loss
4. Fear, apprehension, depression, etc.
43
Define Orthopnea and what is it associated with?
Difficulty breathing except in the upright position.
1. Heart problems
2. CHF
44
Define GENERAL MALAISE and what is it associated with?
Rundown feeling, nausea, weakness, fatigue, headache
| 1. Electrolyte imbalance
45
Define dyspnea?
A feeling of shortness of breath or difficulty breathing
46
Measuring subjective symptoms, define dysphagia
Difficulty swallowing
47
What is syncope?
A temporary loss of consciousness
48
What is vasovagal syncope?
Calming dizziness and fainting, caused by loss of peripheral venous tone.
49
What is orthostatic hypotension?
Excessive drop in blood pressure when in a standing position.
50
What is carotid sinus syncope?
It is associated with hypertensive carotid sinus. More common in elderly patients.
51
What is a cough syncope?
A loss of consciousness following a severe cough.
52
What criteria is a patient's ability to learn based upon?
1. Cultural and Religious values
2. Emotions barrier
3. Desire and motivation to learn
4. Physical and cognitive limitations
5. Language barrier
6. Age and education level
53
What criteria is the patient's nutritional status based on?
1. Usual food intake.
2. Food likes and dislikes.
3. Recent changes in appetite.
4. Any recent weight loss or gain.
54
List for items that would be important to identify in the patient's past medical history.
1. Heart disease
2. Diabetes
3. Cancer
4. Pulmonary disease
55
What is a normal heart rate?
60 - 100 beats / min.
56
What is a normal respiratory rate?
12 -20 breaths / min.
57
1. What is a normal oral temperature?
2. What is a normal rectal temperature?
3. What is a normal your temperature?
1. 97-99.5 F
2. 98.7-100.5 F
3. 98.7-100.5 F
58
What is a normal blood pressure?
120/80 mmHg
59
Briefly describe Hemiparesis and state one pathology that would be associated with the condition.
Abnormal posturing. Could indicate brain injury
60
Briefly describe Peripheral edema and state one pathology that would be associated with the condition.
Presence of excessive fluid in the tissue. Primarily occurs in the arms and ankles. It is caused by congestive heart failure (CHF), pulmonary hypertension, Venus insufficiency, and renal failure
61
Briefly describe Ascities and state one pathology that would be associated with the condition.
An accumulation of fluid in the abdomen. It is usually caused by liver failure
62
Briefly describe Clubbing and state one pathology that would be associated with the condition.
Caused by chronic hypoxemia. Usually associated with pulmonary disease
63
Briefly describe Venous Distension and state one pathology that would be associated with the condition.
Is increased venous distention. May be observed in jugular vein (JVD). commonly occurs in patients with CHF and obstructive lung disease
64
Briefly describe Capillary refill and state one pathology that would be associated with the condition.
By blanching the hand and watch the blood return. Indicated in peripheral circulation.
65
Briefly describe Diaphoresis and state one pathology that would be associated with the condition.
A state of profuse and or heavy sweating. Usually associated with heart failure, fever infection, anxiety, nervousness, tuberculosis (night sweats)
66
Define ashen/pallor and describe what pathology it would indicate
A decrease in color.
| It is indicated by anemia or acute blood loss.
67
Define Erythema and describe what pathology it would indicate
Redness of the skin.
| Indicated by capillary congestion, inflammation or infection.
68
Define Cyanosis and describe what pathology it would indicate
Blue or blue gray dusky discoloration of the skin and mucous membranes.
Caused by hypoxia and usually resulting in a low hemoglobin.
69
Define Ecchymosis and describe what pathology it would indicate
Subcutaneous purpura, hematoma or bruise.
70
Briefly describe kyphosis
A convex curvature of the spine (lean forward)
71
Briefly describe scoliosis
A lateral curvature of the spine (lean side to side)
72
Briefly describe kyphoscoliosis
A combination of both kyphosis and scoliosis and causes a severe restrictive impairment
73
Describe symmetrical chest movement
It occurs when both sides of the chess move at the same time
74
List for underlining pathologies they can contribute to a patient displaying asymmetrical chest movement
1. Atelectasis
2. Pneumothorax
3. Flail chest also known as paradoxical
4. A patient intubated in one lung
75
Briefly describe eupnea and what condition would be associated with it
A normal respiratory rate, depth, and rhythm
76
Briefly describe Cheyne-Stokes and what condition would be associated with it
A gradually increasing and decreasing rate and depth in a cycle lasting from 30 to 180 seconds, with periods of apnea lasting up to 60 seconds.
Cause: increased intracranial pressure, meningitis, drug overdose.
77
Briefly describe Biot's and what condition would be associated with it
Increased respiratory rate and depth with irregular periods of apnea. Each breath has the same depth.
Cause: CNS problem
78
Briefly describe Kussmaul's and what condition would be associated with it
Increased respiratory rate, usually over 20 breaths a minute, increased depth, irregular rhythm, breathing sounds labored.
Cause: metabolic acidosis, renal failure, diabetic ketoacidosis.
79
Briefly describe Apneustic and what condition would be associated with it
Prolonged gasping inspiration followed by extremely short, insufficient expiration.
Cause: problem with respiratory center, trauma or tumor.
80
List the three normal muscles of ventilation
1. Diaphragm
2. External intercostals
3. Exhalation is normally passive
81
What are the accessory muscles used to increased ventilation?
1. Intercostal, scalene, sternocleidomastoid, pectoralis major.
2. The abdominal muscles are oblique and rectus abdominus
82
What causes hypertrophy of the accessory muscles?
COPD
83
Muscle wasting is also referred to
1. Atrophy and/or CACHECTIC
| Occurs: paralysis
84
List the four face and/or neck pathologies that would present difficult ventilation or intubation.
1. Short receding mandible.
2. Macroglossia (enlarged tongue)
3. Large neck
4. Limited range of motion of the neck
85
What term would be used to describe a heart rate of 100/min? What would this indicate?
Tachycardia , indicating:
1. Hypoxemia
2. Anxiety
3. Stress
86
What is a normal heart rate?
60 - 100 beats/min
87
What term would be used to describe a heart rate less than 60 bpm? What would this indicate?
Bradycardia, indicating:
1. Heart failure
2. Shock
3. Emergency
88
A heart rate change of more than ______ beats/minute is considered an adverse reaction. What do you need to do?
20 beats/min. Stop therapy and notify the nurse and doctor.
89
What does paradoxical pulse or pulses paradoxes mean and indicates? Give 2 examples where you would see this.
When the pulse or blood pressure varies with respiration. This may indicate severe air trapping.
This can be seen in:
1. Status asthmaticus
2. Cardiac Tamponade
90
What are four causes of tracheal deviation when it is pulled to the abnormal side (toward pathology)?
1. Pulmonary atelectasis
2. Pulmonary fibrosis
3. Pneumonectomy
4. Diaphragmatic paralysis
91
What are four causes of tracheal deviation when it is pushed to the normal side (away from pathology)?
1. Massive plural effusion
2. Tension pneumothorax
3. Neck or thyroid tumors
4. Large mediastinal mass
92
What is tactile fremitus?
They are vibrations felt by the hand when placed on the chest
93
What is meant by tenderness?
Tenderness is referred by the patient skin when he or she has sutures, chest tubes, bruises, fractured bones, and burns; avoid areas of tenderness if possible
94
What is crepitus and what is it associated with?
They are bubbles of air under the skin that can lead palpitated. This indicates subcutaneous emphysema.
95
What is chest motion symmetry?
When the examiner places his hands on the patient's chest and during inspiration both hands move the same distance.
96
Describe the following term resonant?
This is air in the lungs it gives a hollow sound
97
Describe the following terms flat?
This is usually hurt over the sternum or muscle. However in the lungs they are areas of atelectasis.
98
Describe the following term dull?
This is over fluid filled organs for example the heart or liver. However the sound heard in the Lungs can indicate pleural effusions or pneumonia.
99
Describe the following terms tympanic?
It is heard over air in the stomach.however in the lungs it indicates increased Vt.
100
Describe the following term hyperresonant?
This is a booming sound. Usually associated with a pneumothorax or patients who have emphysema.
101
Describe the difference between vesicular and adventitious breath sounds.
Vesicular breath sounds are normal breath sounds. Whereas, adventitious breath sounds are abnormal breath sounds. Some examples of abnormal breath sounds are rails a.k.a. crackles, wheezes, stridor, and plural friction rub.
102
Describe how egophony is identified and what it would indicate.
The patient is instructed to say the letter E and it sounds like the letter A. This is indicated by consolidation in the tissue as seen in patients with pneumonia.
103
What causes course rales and how do you treat it?
Large airway secretions. It is treated by sectioning the patient.
104
What causes medium rales and how do you treat it?
Airway secretions in the middle. This is treated with CPT
105
What causes fine rales and how do you treat it?
This is fluid in the alveoli. This is treated with IPPB, drugs, and oxygen
106
What causes wheezes and how do you treat it?
It is caused by bronchospasms.wheezes are treated with bronchodilators. However unilateral wheezes indicate a (FBO) foreign body obstruction.
107
What causes stridor and how do you treat it?
It is caused by upper airway obstruction. For example:
1. supraglottic swelling
2. subglottic swelling
3. foreign body aspiration.
The treatment is:
1. topical the congestion for swelling and edema.
2. Sectioning or bronchoscopy for secretions and foreign body aspiration
3. intubation for marked/severe stridor
108
What causes plural friction rub and how do you treat it?
It is caused by inflammation of the visceral and pleura rubbing together. It is treated with steroids or antibiotics.
109
What are some examples which cause plural friction rub breath sounds.
1. Pleurisy
2. TB
3. Pneumonia
4. Pulmonary infarction
5. Cancer
110
Describe what is happening when you hear the first Heart sound.
It is the closure of the mitral and tricuspid valve at the beginning of ventricular contraction.
111
Describe what is happening when you hear the second Heart sound.
It is the closure of the pulmonic and the aortic valve's which is at the end of SYSTOLE, when the ventricles relax.
112
In an adult, the presence of a third sound is __________ and what does it suggest?
It is abnormal and it suggests that the patient has CHF.
113
In an adult, the presence of a fourth sound is __________ and what does it suggest?
It is abnormal and it suggests a cardiac abnormality such as an MI or cardiomegaly.
114
Describe the abnormal heart sound murmur and what it indicates
They are caused by turbulent blood flow and indicate Valve defects or congenital heart abnormalities
115
Describe the abnormal heart sound bruits.
They are caused by turbulent blood flow in the artery or vein
116
What is a normal adult blood pressure?
120/80mmHg
117
What is an acceptable low blood pressure in an adult?
90/60 mmHg
118
What is an acceptable high blood pressure in an adult?
140/90 mmHg
119
What does hypertension indicate
It indicates cardiac stress resulting in hypoxemia.
120
What does hypotension indicate?
It indicates poor perfusion resulting in hypovolemia or CHF
121
What is the formula to calculate WOB?
Change of pressure multiplied by change volume.
122
What is the normal value for WOB?
0.52 0.7 J/L
123
Be patient with pulmonary disease would be expected to have a ______ WOB.
Increased
124
What does capnometry measure and how is it accomplished?
It measures exhaled carbon dioxide using infrared absorption.
125
how does the PetCO2 compare to the arterial PCO2?
The PetCO2 Will be lower than the PCO2.
126
What is the normal range of end title CO2?
34-36 Torr or mmHg or 3-5%
127
What would an increase in end title CO2 indicate?
It would indicate a decrease in ventilation resulting in respiratory failure.
128
What would a decrease in end title CO2 indicate?
It indicates an increase in ventilation or decreased perfusion, resulting in dead space disease. For example, pulmonary embolism or hypovolemia.
129
Immediately following intubation, the end title CO2 and remains at a low level. How should the adult critical care specialist interpret this information?
The endotracheal tube is in the esophagus.
130
What is another name for an exhaled CO2 detection device?
A color metric detection device.
131
What is anatomic dead space?
It is the amount of air that does not reach the alveoli.
| 1ml per ideal body weight = Vd
132
What is alveolar dead space?
The amount of air in the alveoli that has no blood perfusion. This occurs in patients who have a pulmonary embolus. Resulting in an increase in dead space ventilation
133
What is physiological dead space and how is it estimated?
It is the sum of the anatomic and alveolar dead space. It is estimated by the dead space to tidal volume ratio (Vd/Vt).
134
What is mechanical dead space and what is the formula to calculate it?
It is the amount of circuit between the patient and the Y adapter. The formula is 10 ml/inch of flex tubing
135
What is the formula used to calculate minute ventilation?
Ve = f (Vt)
136
What is the formula used to calculate alveolar minute ventilation?
Va = (Vt-Vd) f
137
What is a normal range for Vd/Vt ratio and for those who are being ventilated?
20-40% and up to 60% for ventilated patients
138
What is the formula used to calculate Vd/Vt ratio?
(PaCO2-PeCO2/PaCO2)100
139
What is the formula used to calculate dead space ventilation?
Vd = Vt * Vd/Vt
140
What are the levels of Dyspnea associated with daily living activities?
1. Occurs AFTER unusual exertion
2. Occurs AFTER going up stairs or hills
3. While walking at Normal speed
4. While Slow walking @ Short distances
5. Rest and simple daily activities
