S1_L5_Obj - 2-4 Flashcards
Phase 2 is known as the _
soft swishing sound
phase 3 is known as the _
crisp sound
phase 4 is known as the _
blowing sound
after phase 4, what do u hear?
none, phase 5 is silence
what mmHg do u hear phase 1
120-110
what mmHg do u hear phase 2
110-100
what mmHg do u hear phase 3
100-90
what mmHg do u hear phase 4
90-80
what mmHg do u hear phase 5
<80
the BP cuff should be a _ machine
well-calibrated
the sphygmomanometer should be set at _
0 mmHg
Pt should be seated quietly for _ min before getting the BP
5 mins
what to refrain prior to taking BP
Refrain from smoking or ingesting caffeine 30 min prior
Refrain from smoking or ingesting caffeine _ min prior
30 mins
_ (rubber in the cuff) should encircle at least how many percent of
(lower or upper?) arm
bladder, 80%, upper
bladder should be how many inches above what landmark
1-2 inches above the antecubital fossa
__ of stethoscope should be tilted _; placed
above what artery
earpieces, forward, brachial artery
why does it need to be tilted forward?
Tilted forward to be aligned to eustachian tube
Quickly inflate to how many mmHg above what sound
> 20 mmHg above the 1st Korotkoff sound
If it’s the first time to meet pt or not sure of the baseline of pt, what to do?
palpate and locate pulse first and identify on what pressure does it disappear (more accurate than asking pt for baseline BP)
how many mmHg/second will u release the pressure?
slowly release the pressure, 2-3 mmHg/seconds
how many BP measurements will you take?
At least 2 measurements (minimum of 1-2 min apart), then
take the average
Decreased orthostatic tolerance is called
POSTURAL ORTHOSTATIC HYPOTENSION (OH)
postural OH is the sudden drop in SBP of at least _ or drop in DBP of
at least _ AND what percent increase in pulse rate
Sudden drop in SBP of at least 20 mmHg or drop in DBP of at least 10 mmHg
and 10-20% increase in pulse rate
associated sx of postural OH
diaphoresis,
cyanosis,
sudden LOC
OH requires what vital signs?
BP and HR
postural OH occurs within _ mins of what position after being _ for
how many minutes or at what percent on a tilt table
3, upright/standing, supine, 5, 60% angle
att what time will u take BP for OH pts?
Take BP: 5 min after supine (going to sitting);
1 min & 3 min after standing
Other manifestations of OH
dizziness, lightheadedness, pallor,
diaphoresis (excessive sweating), syncope
Full 60-second count in RR and HR recommended for _
cardioulmonary pts
normal RR
12-20 cpm
tachypnea
> 20 cpm (fast)
bradypnea
<12 cpm (slow)
different respiratory rates
○ Normal: 12-20 cpm
○ Tachypnea: >20 cpm (fast)
○ Bradypnea: <12 cpm (slow)
○ Variable
Depth of respiratory rate:
normal, deep, shallow, variable
Rhythm of RR
regular or irregular
Character
effort or effortless
Body _ represents the balance between the heat produced or acquired
by the body and the amount lost
temperature
Body temperature represents the _ between the heat _ or acquired
by the body and the amount _
balance, produced, lost
Normothermic/Afebrile (adults):
36.0-37.50C / 96.8-99.50F
what part of hand do you use to palpate?
dorsal hand
greater than the normal values of temp
febrile
febrile also called
fever or pyrexia
Hyperpyrexia/Hyperthermia: what temp
> 41.1C/106F
Hypothermia: what temp
<35.0C / 95 F
Location of Measurement for temp
oral, axillary, rectal, tympanic
taking temp orally is recommended t or f
f, Oral is now not recommended since there is mercury
(toxic);
Thermometer types
hand-held electronic oral,
hand-held electronic external ear,
clinical glass,
thermal scanners
OXYGEN SATURATION (2)
● Arterial Blood Oxygen Saturation (SaO2)
● Peripheral Oxygen Saturation (SpO2)
Arterial Blood Oxygen Saturation also called as _
SaO2
Peripheral Oxygen Saturation also called as _
SpO2
assesses O2 saturation of hemoglobin
pulse oximeter
pulse oximeter assesses O2 saturation of _
hemoglobin
Should be complemented by other vital signs and objective findings
Peripheral Oxygen Saturation (SpO2)
_is a relative contraindication for pulse oximetry
Abnormal Hgb
Placing the probe on the _ or _ fingers has been
shown to produce more accurate readings than the _ finger
3rd or 4th, index
If pt has a deformation, what finger will u use?
you can use the thumb or little finger
what can block the sensor light path in pulse oximeter?
Dirt,
fingernail polish,
blood
OXYGEN SATURATION: Normal blood O2 levels;
RBC are well-oxygenated and sufficiently transporting O2
around the body
95-100%
OXYGEN SATURATION: Mild hypoxemia; below average;
may proceed with PT management with caution; monitor
closely the patient
91-94%
OXYGEN SATURATION: Moderate hypoxia / Low blood O2 levels;
initiate supplemental O2 as prescribed
85 to 90%/88%
OXYGEN SATURATION: Severe hypoxia / Low blood
O2 levels that affects the brain; administer supplemental
O2 immediately
80-85%
OXYGEN SATURATION: Severe hypoxia; may require hospitalization
<80%
OXYGEN SATURATION: Observable cyanosis; acute danger to life
70%
While doing FA, oxygen saturation became 88%, if
there’s an initial prescription from MD, what will u put in the pt?
supplemental o2
Severe hypoxemia / low blood O2 levels is a medical emergency t or f
t
OCULAR INSPECTION (11)
manner of arrival
alertness
body type
head and neck observation
wound or scar assessment
check the extremities
attachments: invasive monitoring or medication/fluid administration
attachments: non-invasive life support
attachments: invasive ventilatory devices
attachments: invasive feeding devices
chest deformities/asymmetries
can still get out of the bed but stays there due to doctor’s order
bed-fast
can’t get out of the bed due to severity of condition
(ie comatose, some post-surgical precautions)
bedridden
can get out of the bed but is limited by attachments
(ie IV lines, chest tube drainage bottles, etc)
bed-bound
General status of cognition
○ Cerebral assessments are applicable
○ May use Glasgow Coma Scale (GCS)
chronic bronchitis (blue bloater) body type
endomorph
emphysema (pink puffer) body type
ectomorph
BMI computation:
(kg/m2) or weight/height^2
Provides measurement of actual weight density of an individual
BMI
unusual heavy perspiration; different from
pts who are “pawisin” (might assume incorrectly); ask
them if they sweat a lot
Diaphoresis
chest pain; difficulty breathing, what can be the look on pt’s face
apprehension
for infants (usually manifest with crying),
tells us if they have breathing problems; respiratory
distress
nasal flaring
sign of hypoxia
pupillary dilatation
longer by 3 mins of pupilllary dilatation can cause _
brain damage
Skin Color
cyanosis/paleness
facial plethora
cherry red lips or skin
localized and blue periphery (peripheral or central?)
peripheral
Affected brachial artery, only on that area will
be blue
peripheral: localized and blue periphery
reaches CNS
central
Brain tells system that they have less oxygen =
bluish discoloration of lips, figernals, toenails
central
for central, Compare with oxygen saturation measurements t or f
t
redness on face with swelling is called
facial plethora
Occurs when there is excessive blood supply going up
there or excessive disruption of blood flow
facial plethora
facial plethora is seen in _ and _
superior vena cava syndrome;
polycythemia vera
Beyond normal reddish color in lips
Cherry red lips
cherry red lips indicate _
carbon monoxide poisoning
The jugular vein is evident and may even throb
Jugular Vein Distention
Bulging d/t excessive pressure
Jugular Vein Distention
Blood doesn’t go back to the heart, so the vein
distends in _
Jugular Vein Distention
jugular vein distenion can be a manifestation of _ or _
increased blood pressure, heart failure
Hypertrophied muscles may also result to
_
Thoracic Outlet Syndrome (TOS)-related symptoms
what are some of the respiratory accessory muscles
that are hypertrohpied?
SCM, scalenes
Sometimes the patients with pulmonary issues
will have _ pain to UE and paleness; tingling; paresthesia;
diminished blood flow to the area (diminished pulses)
radiating
what to assess in a wound esp on post op?
color
size
ulceration
types of scars
hypertrophic
keloid
