Patient Assessment Flashcards
What are the 3 elements of GCS?
- Best eye opening (1-4)
- Best verbal response (1-5)
- Best motor response (1-6)
How do we test central pain response?
- Trapezius squeeze (CN XI Spinal accessory)
2. Supraorbintal pressure (CN V Trigeminal)
Why don’t we use peripheral pain response to test best motor?
May elicit a spinal reflex instead of a pain response
What pupils changes occur with CN III damage?
CN III Occulomotor, damage results in unilaterally dilated non reactive pupil
What do pinpoint pupils indicate?
Brain damage, opioid OD, meds (propofol), PSNS
What do dilated pupils indicate?
Brain damage, SNS meds (atropine), stimulant OD
What is pronator drift?
Sensitive early indicator of corticospinal nerve compression
What CN innervates the corneal reflex?
CN VII Facial
What CN innervates the gag reflex?
CN IX Glossopharyngeal
CN X Vagus
What CN innervates the cough reflex?
CN X Vagus
What are the elements of CPOT?
- Facial expression
- Body movements
- Muscle tension
- Compliance with ventilator or vocalizations
What is the ideal sedation level?
Where pt is calm, relaxed, relatively pain free, and not over-sedated
What are the types of delirum?
- Hypoactive
- Hyperactive
- Mixed
What is delirum?
Disturbance of consciousness with inattention accompanied by changes in cognition or perceptual disturbance
What CN innervates the pupil reaction?
CN III Oculomotor
Which common points to auscultate during lung exam?
- Above clavicles for upper lungs (apex)
- Angle of Louis for bifurcation of trachea
- Posterior chest for middle and lower lobes
How many lobes in each lung?
Left 2 Right 3
Landmark for the RUL?
2 cm above clavicle
4th ICS midclav
5th ICS midax
Landmark for RML?
4th ICS midclav
5th ICS midax
5th ICS midclav
6th ICS midax
Landmark for RLL?
5th ICS midclav
6th ICS midax
6th ICS midclav
8th ICS midax
Landmark for LUL?
2cm above clavicle
6th ICS midclav
5th ICS midax
Landmark for LLL?
6th ICS midclav
5th ICS midax
6th ICS midclav
8th ICS midax
What does barrel chest indicate?
Increased anterior-posterior diameter, common in COPD, emphysema, bronchitis, asthma. Decreases lung compliance
What does kyphosis, lordosis, scoliosis indicate?
Change in thoracic shape, decrease lung compliance
How to check for asymmetrical chest expansion?
Grip pt skin bilaterally and hold as they breathe. Can result from phrenic nerve dmg, atelectasis, lung collapse, rib #
What does cheynes stokes breathing sound like?
Varying periods of deep breathing alternating with apneic periods
What does kussmaul breathing sound like?
Deep labored breathing (is compensatory mechanism for acidosis of any origin)
What does white, foamy, or pink sputum indicate?
Pulmonary edema
How to palpate trachea?
Midsternal line, tracheal deviation results from tension pneumothorax
How to assess for subcutaneous emphysema?
Thoracic tissues may appear edematous, when depressed hear “snap crackle pop”
How/where to auscultate for lung sounds? What do they sound like?
- Bronchial –> Over trachea, high pitch loud. Inspiration softer than expiration
- Bronchovesicular –> Over bronchus, anterior / posterior chest. Medium pitch, inspiration equals expiration
- Vesicular –> Over most of lung fields. Low pitch, soft wispy. Inspiration louder than expipration
What do absent / diminished breath sounds indicate?
Decreased airflow, atelectasis, pneumothorax
What do crackles indicate in breath sounds?
Fluid in small airways or collapsed alveoli popping open during inspiration. If hoarse crackles, should be able to suction out with cough
What do wheezes indicate in breath sounds?
Airflow through narrowed airways
What does pleural friction rub sound like and what does it indicate?
Grating sound through insp and exp on anterolateral chest wall. Indicates inflammation of pleura
What does stridor indicate in breath sounds?
Obstruction or narrowing trachea, musical squeaking sound on insp or exp. Possibly life threatening
How is abdominal ascites related to R sided HF?
Backflow of blood into inferior vena cava, increasing portal vein pressure.
Increase hydrostatic pressure pushes out fluid and albumin leading to ascites
What are S&S of arterial insufficiency?
Legs appear shiny, pale, decreased hair growth throughout.
Pain, pallor, loss of peripheral pulses, paresthesia, paralysis
What are S&S of venous insufficiency?
Edematous, brown patchy skin, ulcers, patchy hair growth
Where is the apical pulse of the heart located?
Mitral area, 5th ICS midclavicular line
Where are cardiac pulses actually palpable on the patient?
Over the apical and epigastric areas
Where is the aortic pulse located?
2nd ICS R Sternal border
Where is the pulmonic pulse located?
2nd ICS L sternal border
Where is Erb’s point located?
3rd ICS L sternal border
Where is the mitral area located?
Apex of heart, 5th ICS midclavicular line
Where is the tricuspid area located?
5th ICS L sternal border
Where is the epigastric space?
Midsternal line below xyphoid process
What do absent / decreased peripheral pulses indicate?
Arterial stenosis, occlusion, loss of perfusion
What do bounding peripheral pulses indicate?
Aneurysm, fever?
What are the heart sounds? Name all
S1 is closure of the tricuspid and mitral valves (AV valves during beginning of systole). Loudest at apex
S2 is the closure of the aortic and pulmonic valves (semilunar valves during beginning of diastole). Loudest at the base
S3 is rapid early filling in diastole with blood rush hitting noncompliant ventricles. Loudest at apex early in diastole “SLOSH-ing-in”
S4 is atrial kick into noncompliant ventricle. Loudest at apex, late in diastole. “a-STIFF-wall”
What does pleural friction rub sound like and where can it be heard?
Grating sound throughout cardiac cycle.
Heard often at Erbs point
What does a bruit sound like and where can it be heard?
Low pitched turbulent blood flow, can be heard over R carotid and femoral arts
What is the process to identify absent bowel sounds?
Must listen >5 mins ideally in RLQ
What is the order of abdo assessment?
1) Inspection
2) Auscultation
3) Palpation
What might rebound tenderness on abdo palpation indicate?
Peritonitis
What is the normal U/O?
0.5ml / kg / hr
