skills exam 3 Flashcards
What does AVPU mean?
It is a LOC scale Awake and Alert responds to Verbal stimuli responds to Painful stimuli Unconscious
What does the Glasgow coma scale evaluate?
Eye opening response Verbal response Motor response Evaluates on a scale from 1 to 5, 15 is the best "less than 8, intubate"
What are the four parts of orientation?
Person, place, time, situation
What does PERLLA mean?
Pupils Equal Round Reactive to Light with Accommodation present (and consensual response)
What is aphasia?
Inability to communicate
What is EENT?
Inspect in order, Ears Eyes Nose and then Throat
What is tachypnea?
Respirations >20
What is bradypnea?
Respirations <12
What do coarse crackles sound like and what are they caused by?
Moist bubbling sound, heard on inspiration or expiration, caused by fluid in airways
What do fine crackles sound like and what are they caused by?
Velcro being torn apart, heard at the end of inspiration, caused by alveoli popping open on the end of inspiration
What does stridor sound like and what is it caused by?
Loud crowing noise/dinosaurs heard without stethoscope, caused by airway obstruction
What do wheezes sound like and what are they caused by?
Find high pitched violins mostly on expiration, caused by narrowed airways
What are diminished lung sounds and what are they caused by?
They are faint lung sounds caused by decreased air movement
What do rhonchi sound like and what are they caused by?
Low pitched rattling sound, similar to snoring, caused by lung obstruction or secretions
What is hemoptysis?
Blood in sputum
What are S1 and S2?
Heart sounds. Lub and then dub
When do you listen to apical pulse?
If heart rate or rhythm are outside normal finding expectations
How do you find the apical pulse?
- Have the patient lay donw
- Find the sternal notch (in between the clavicles)
- Find the angle of louis below the sternal notch (chest midline)
- Move your hand slightly to their left side and start to count intercostal spaces (begin at space #2)
- Once you find the fifth intercostal space, place the hand so that it is midclavicle
- Place your stethoscope there and listen for 60 seconds
How do you determine pulse deficit?
Measure apical and radial pulse simultaneously
What are normoactive bowl sounds?
Clicks and gurgles that occur 5 to 34 per minute
What are hypoactive bowel sounds?
Bowels sounds 3 to 5 times per minute
What are hyperactive bowel sounds?
Greater than 34 times per minute
When are absent bowel sounds established?
After 5 minutes of listening in one quadrant
If a patient is incontinent, has progressed dementia, dependent, or has an indwelling catheter, how often do you clean the perineal area?
At least once per shift
What are the four pitting edema categories?
Mild: +1, depression disappears rapidly
Moderate: 2+, depression disappears in 10-15 seconds
Moderately Severe: 3+, depression disappears in about a minute
Severe: 4+, depression can last for more than 2 minutes
What are the four different pulse strengths?
0: absent, medical emergency
Weak: 1+, diminished, barely palpable (peripheral vascular disease or decreased cardiac output)
Strong: 2+, normal findings
Bounding: 3+, full, fluid volume overload
Where is the popliteal pulse?
Back of the knee
What is deep rubor?
Purplish/reddish color, indicates peripheral vascular disease
What are the 6 P’s of neurovascular assessment?
- Pain
- Paresthesia (tingling, pins and needles)
- Pallor
- Paralysis
- Pulselessness
- Poikilothermia (a limb that feels cooler than the others, no temperature regulation which is a circulation problem)
What is the difference between active and passive ROM?
Active: patient can move extremities on their own
Passive: patient cannot move extremities on their own
What is the difference between full and partial ROM?
Full: extremities have no limitations on movement
Partial: extremities have limitations on movement, can only move to a particular position and resistance noted
What are 6 ADLs?
- Bathing self
- Dressing self
- Feeding self
- Toileting
- Brushing hair
- Brushing teeth
How often is safety documented?
Every 2 hours
What type of diet should you implement on an immobile patient?
High calorie and high protein
What is atelectasis?
Hardening of lung tissues/collapsed lung
