Patient Assessment part 1 Flashcards
Where can body temperature be measured?
Oral, rectal, axillary, ear
What regulates body temperature?
Hypothalmus
What does the term febrile mean?
Patient has a fever
What does the term afebrile mean?
Without a fever- patient does not have a fever
Body temperature is an indicator of the patients what?
Patients metabolic rate
What are acceptable sites to measure a patient pulse?
Radial, brachial, femoral, carotid, apical
When evaluating a patient’s pulse what should be noted?
Rhythm, rate, strength, irregularities
What is a normal adult heart rate?
60- 100 beats per minute
What is the first sign of hypoxemia?
Tachycardia
What is hypoxemia?
Decreased oxygen level in the arterial blood
What is diaphoresis?
Sweating
What is syncope?
Fainting
What is a normal adult respiratory rate?
12 -20 breaths per minute
What are the parts of a stethoscope?
chest piece, diaphragm, bell, binaural or ear pieces, tubing
What is the term used to describe listening to breathsounds?
Auscultation
What is the term used to describe normal breathsounds?
Vesicular- clear- normal
What is the normal breath sound heard over the trachea?
Tracheal
What type of breath sound will clear with a cough?
Rhonchi
What breath sound will occur if there is an obstruction in the trachea & larynx?
Stridor
What breath sound(s) will occur if the patient has fluid in the lungs?
Crackles, rales, rhonchi
Are rhonchi a continuous or discontinuous sound?
Continuous
Are rales (crackles) a continuous sound or discontinuous sound?
Discontinuous
What breath sound will occur if there is a constricted bronchial wall?
Wheeze
What type of sound does a pleural rub make and what causes this sound?
Pleural friction rub- caused from inflamed pleural surfaces rubbing together
Posterior
Back
Anterior-
front
Lateral
side
What is Pulsus Paradoxus or paradoxus pulsus?
When pulse and blood pressure vary with respiration- BP and Pulse strength decrease on inspiration
What is the term for an increased body temperature and what can cause it to increase?
Hyperthermia- fever, infection/illness, hormonal imbalance, decreased heat loss, increased environmental temperature, drug interactions
What is the term for a decreased body temperature and what can cause it to decrease?
Hypothermia- exposure to cold, blood loss, hypothalmus injury, diaphoresis, hormonal imbalance
What is the term for an increased heart rate and what could cause this to increase?
Tachycardia – hypoxemia, fever, heart abnormalities, emotional stress, exercise, response to medications, blood loss volume
What is term for a decreased heart rate and what could cause this to decrease?
Bradycardia – hypothermia, syncope, heart abnormalities, depressant drugs, infections, well-conditioned athlete
What is the term for an increased respiratory rate and what could cause this to increase?
Tachypnea—hypoxemia, fever, pain, exercise, metabolic acidosis, fear, anxiety
What is the term for a decreased respiratory rate and what could cause this to decrease?
Bradypnea—hypothermia, head trauma narcotic overdose, sedative overdose
What is the term for an increased blood pressure and what could cause this to increase?
Hypertension—hypoxemia, increased intracranial pressure, right sided CHF- congestive heart failure, fluid overload, stimulant drugs, exercise, emotional stress
What is the term for a decreased blood pressure and what could cause this to decrease?
Hypotension—shock, hormonal imbalance, depressant drugs, fluid loss, left sided CHF, Positive pressure ventilation/PEEP, positioning, peripheral vasodilation
What does systolic pressure measure?
Pressure measure in the arterial system when the ventricles of the heart are contracting
What does diastolic pressure measure?
Pressure measured in the arterial system when the ventricles of the heart are at rest
Which blood pressure measurement is the most critical and why?
Diastolic—it’s the lowest pressure that the arterial system & heart are subjected to
What is normal pulse pressure and how do calculate this?
35-40 mmHg Calculated by: Systolic pressure – Diastolic pressure
What factors affect a patient’s blood pressure?
Pumping action of the heart, resistance in the cardiovascular system, elasticity of the vessels, blood volume, viscosity of the blood
