PT Assessment Flashcards
URQ major organs:
ULQ major organs:
LLQ major organs:
LRQ major organs:
= Liver, Gallbladder
= Spleen, Pancreas, Stomach
= Colon
= Appendix
Loss of Peripheral Pulses often indicates:
= decompensating shock.
Bronchophony is:
Indicating:
=PT’s spoken voice sounds louder & clearer than normal when auscultated w/ stethoscope
=often indicating lung consolidation
Finger Clubbing:
Often indicates:
= finger clubs” distal finger rounded & proximal nail feels spongy.
= chronic hypoxia found in cardiopulmonary diseases and lung cancer.
Skin tugor test:
Norm/ skin=
Poor turgor (tenting)=
Decreased mobility=
= pulling skin fold over bony prominence then releasing it.
= immediately returns to its original state.
= results from dehydration
= suggests edema or scleroderma, a progressive skin disease
What is 2nd assessment?
Consists of 3 elements:
= Process which quantifiable/objective info is obtained
from a PT for his/her overall state of health.
= 1. Detailed head-toe exam, 2. complete set of vital signs, 3. History/narrative SAMPLE/ OPQRRST/DCAPBLSTIC
General assessment
intuitive evaluation of your patient. It is also known as your “view from the door.”
1st assess/ A check for:
= AMS, confusion, apprehension, or agitation
Shortness of breath while speaking
=Retractions (supraclavicular/sternal, intercostal)
= Asymmetric chest m-nt
= Accessory M. use (neck, abdominal)
=Cyanosis
=Audible sounds
=Abnormally rapid, slow, or shallow breathing
= Nasal flaring
Cheyenne Stokes B pattern:
Biots B pattern:
Both mean possible:
= series of increasing & decreasing breaths followed w/ period of apnea
= short, gasping, irregular breaths ”random” & “fish out of water”
= brainstem injury or +ICP
Pri/ assess/ C- initial exam:
Furthermore exam pulse:
Furthermore exam CTC:
Skin CTC:
= pulse, skin, & any hemorrhaging
= pulse: rate, regularity, strength, pattern, quality,
= pink, warm, dry
Endotracheal intubation 4 indications: 1.
2. =
3.=
4.=
=1. in or going into Resp/ arrest
=2. Resp/ failure (hypoxic or hypercapnic)
=3. in or going into Cardiac arrest
=4. Airway swelling (anaphylaxis; airway burns)
Oxygenation 3 needs=
intact airway, adequate vent & respiration
Set up for intubation needs:
Adjunct airway, Suctioning, Stylet/Bougee, 1 size below & above size of ETT & Laryngoscope Blade, Capnography, BVM w/ oxy/, Stethoscope, C-Collar
colorimetric changes color after how many breathes:
6 ventalations
Doing surgical Cricothyrotomy steps: Step 1.
Step 2:
= 1. Palpate inferior portion of thyroid & cricoid cartilage then stabilize
= 2. Make 2-4 cm vertical midline skin incision over cricothyroid
= 3. Make 1 to 2 cm horizontal incision cutting through cricothyroid
=4. Use curved hemostat spread incision open to Insert bougie (caudally) & remove scalpel
=5. Insert ETT (6.0 or 7.0) or Shiley trachT (6.0 or 8.0) over bougie & into the opening
=6. Advance tube just until the cuff disappears & Inflate cuff
=7. Attempt to ventilate and confirm placement.
=8. Secure tube, reconfirm placement, evaluate patient.
PA order: 1.
2..
3.
4.
=1. Scene Size up
=2. Primary Asess/ ABCs
=3. 2nd Assess then History
=4. determine to Stay or play
2nd assess/ order:
- Visual, 2. Palpation, 3. Percussion, 4. Auscultation
~SBP site numbers: -Carotid:
Femoral:
Radial:
= 80
= 70
= 60
Shock 5 catagories:
= Hypovolemic, Cardiogenic, Distributive, Obstructive, Respiratory/ metabolic,
Compensated Shock:
Decompensating Shock:
= HR: Elevated or normal BP: Norm or slightly decreased, RR: Increased, Skin: Not warm, pale, possibly sweaty
= HR: lowering, BP: Lowering, RR: none or irregular, Skin: Cool, pale, clammy, or cyanotic
Palpating direct & deep:
Direct & soft:
= ABDMN organs, Pelvis, Head, Peripheral bones,
= ABDMN, pos/ trauma, S-column, Lymph & Sinus sites
Vocal/ Tactile Fremitus:
Decreased Fremitus & indicates:
Increased Fremitus & indicates:
= chest wall changes in intensity of vibrations saying 99 indicating underlying lung pathology
= Softer vibrations: Pneumothorax, Air in plueras,
= Enhanced vibrations: Lung consolidation (EX pneumonia)
equal chest & rise eval:
:Locate 10th rib. (find lowest rib & move up 2 ribs)
Auscultating (heart) sounds sites:
Bruits:
APE To Man
= Carotid
= 2nd ICS-RS, 3rd ICS-LS, 4th ICS-LS, 5th ICS-L-Midclavicular line
Auscultating (lungs) Sounds Sites:
Top to bottom R-side then L-side
TO DOs in A of ABCs
Note:
MENTAL STATUS, Visual inspection & move airways IN, insert airway IN
= Nares, Teeth, Anatomical mouth structures, Cricothyroid
TO DOs in B of ABCs:
Note:
Visual chest rise/fall & symmetry, Give oxy IN, Note smells, Listen for breathing, Auscultate lungs, Intubate IN
= Rate, Pattern, quality, active or passive, lung sounds
TO DOs in C of ABCs:
Note:
= Visual truck & peripheral, Fix LT hemorrhage IN, CTC
= Skin condition/color abnorm/s, Temp, PR: rate rhythm regularity strength equality, peripheral edema
Waddell’s triad consists of:
= Child Head, chest, femur trauma from autoPED
Virchow’s triad is & consists:
= DVT: old age, pregnancy, prolonged immobility, trauma, obesity
Cushings triad:
= increased SBP, decreased HR, irregular RR from SC or brainstem damage
Beck’s Triad=:
= Muffled heart tones (NarrowingHR), JVD, Hypotension> C-Tampenode
APGAR (newborn usually)=
= appearance, pulse, grimace, activity respirations
Kussmaul’s sign:
=+ JVD> pericarditis, restrictive cardiomyopathy, or severe R-sided heart failure.
Stroke Assess:
= FAST Face Arms Speech Time> drooping, drifting/weakness, slurred,
Trousseau’s sign=
Ca binding too much and flexing in in hands “gay hand penguin”
