Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

CCN > Patient Assessment > Flashcards

Patient Assessment Flashcards

1
Q

What are the 3 elements of GCS?

A
  1. Best eye opening (1-4)
  2. Best verbal response (1-5)
  3. Best motor response (1-6)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How do we test central pain response?

A
  1. Trapezius squeeze (CN XI Spinal accessory)

2. Supraorbintal pressure (CN V Trigeminal)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Why don’t we use peripheral pain response to test best motor?

A

May elicit a spinal reflex instead of a pain response

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What pupils changes occur with CN III damage?

A

CN III Occulomotor, damage results in unilaterally dilated non reactive pupil

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What do pinpoint pupils indicate?

A

Brain damage, opioid OD, meds (propofol), PSNS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What do dilated pupils indicate?

A

Brain damage, SNS meds (atropine), stimulant OD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is pronator drift?

A

Sensitive early indicator of corticospinal nerve compression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What CN innervates the corneal reflex?

A

CN VII Facial

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What CN innervates the gag reflex?

A

CN IX Glossopharyngeal

CN X Vagus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What CN innervates the cough reflex?

A

CN X Vagus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the elements of CPOT?

A
  1. Facial expression
  2. Body movements
  3. Muscle tension
  4. Compliance with ventilator or vocalizations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the ideal sedation level?

A

Where pt is calm, relaxed, relatively pain free, and not over-sedated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the types of delirum?

A
  1. Hypoactive
  2. Hyperactive
  3. Mixed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is delirum?

A

Disturbance of consciousness with inattention accompanied by changes in cognition or perceptual disturbance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What CN innervates the pupil reaction?

A

CN III Oculomotor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Which common points to auscultate during lung exam?

A
  1. Above clavicles for upper lungs (apex)
  2. Angle of Louis for bifurcation of trachea
  3. Posterior chest for middle and lower lobes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How many lobes in each lung?

A

Left 2 Right 3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Landmark for the RUL?

A

2 cm above clavicle

4th ICS midclav
5th ICS midax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Landmark for RML?

A

4th ICS midclav
5th ICS midax

5th ICS midclav
6th ICS midax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Landmark for RLL?

A

5th ICS midclav
6th ICS midax

6th ICS midclav
8th ICS midax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Landmark for LUL?

A

2cm above clavicle

6th ICS midclav
5th ICS midax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Landmark for LLL?

A

6th ICS midclav
5th ICS midax

6th ICS midclav
8th ICS midax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What does barrel chest indicate?

A

Increased anterior-posterior diameter, common in COPD, emphysema, bronchitis, asthma. Decreases lung compliance

24
Q

What does kyphosis, lordosis, scoliosis indicate?

A

Change in thoracic shape, decrease lung compliance

25
Q

How to check for asymmetrical chest expansion?

A

Grip pt skin bilaterally and hold as they breathe. Can result from phrenic nerve dmg, atelectasis, lung collapse, rib #

26
Q

What does cheynes stokes breathing sound like?

A

Varying periods of deep breathing alternating with apneic periods

27
Q

What does kussmaul breathing sound like?

A

Deep labored breathing (is compensatory mechanism for acidosis of any origin)

28
Q

What does white, foamy, or pink sputum indicate?

A

Pulmonary edema

29
Q

How to palpate trachea?

A

Midsternal line, tracheal deviation results from tension pneumothorax

30
Q

How to assess for subcutaneous emphysema?

A

Thoracic tissues may appear edematous, when depressed hear “snap crackle pop”

31
Q

How/where to auscultate for lung sounds? What do they sound like?

A
  1. Bronchial –> Over trachea, high pitch loud. Inspiration softer than expiration
  2. Bronchovesicular –> Over bronchus, anterior / posterior chest. Medium pitch, inspiration equals expiration
  3. Vesicular –> Over most of lung fields. Low pitch, soft wispy. Inspiration louder than expipration
32
Q

What do absent / diminished breath sounds indicate?

A

Decreased airflow, atelectasis, pneumothorax

33
Q

What do crackles indicate in breath sounds?

A

Fluid in small airways or collapsed alveoli popping open during inspiration. If hoarse crackles, should be able to suction out with cough

34
Q

What do wheezes indicate in breath sounds?

A

Airflow through narrowed airways

35
Q

What does pleural friction rub sound like and what does it indicate?

A

Grating sound through insp and exp on anterolateral chest wall. Indicates inflammation of pleura

36
Q

What does stridor indicate in breath sounds?

A

Obstruction or narrowing trachea, musical squeaking sound on insp or exp. Possibly life threatening

37
Q

How is abdominal ascites related to R sided HF?

A

Backflow of blood into inferior vena cava, increasing portal vein pressure.

Increase hydrostatic pressure pushes out fluid and albumin leading to ascites

38
Q

What are S&S of arterial insufficiency?

A

Legs appear shiny, pale, decreased hair growth throughout.

Pain, pallor, loss of peripheral pulses, paresthesia, paralysis

39
Q

What are S&S of venous insufficiency?

A

Edematous, brown patchy skin, ulcers, patchy hair growth

40
Q

Where is the apical pulse of the heart located?

A

Mitral area, 5th ICS midclavicular line

41
Q

Where are cardiac pulses actually palpable on the patient?

A

Over the apical and epigastric areas

42
Q

Where is the aortic pulse located?

A

2nd ICS R Sternal border

43
Q

Where is the pulmonic pulse located?

A

2nd ICS L sternal border

44
Q

Where is Erb’s point located?

A

3rd ICS L sternal border

45
Q

Where is the mitral area located?

A

Apex of heart, 5th ICS midclavicular line

46
Q

Where is the tricuspid area located?

A

5th ICS L sternal border

47
Q

Where is the epigastric space?

A

Midsternal line below xyphoid process

48
Q

What do absent / decreased peripheral pulses indicate?

A

Arterial stenosis, occlusion, loss of perfusion

49
Q

What do bounding peripheral pulses indicate?

A

Aneurysm, fever?

50
Q

What are the heart sounds? Name all

A

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”

51
Q

What does pleural friction rub sound like and where can it be heard?

A

Grating sound throughout cardiac cycle.

Heard often at Erbs point

52
Q

What does a bruit sound like and where can it be heard?

A

Low pitched turbulent blood flow, can be heard over R carotid and femoral arts

53
Q

What is the process to identify absent bowel sounds?

A

Must listen >5 mins ideally in RLQ

54
Q

What is the order of abdo assessment?

A

1) Inspection
2) Auscultation
3) Palpation

55
Q

What might rebound tenderness on abdo palpation indicate?

A

Peritonitis

56
Q

What is the normal U/O?

A

0.5ml / kg / hr

CCN (27 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions