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Advanced clinical practice: examining the complex patient > Week 2 > Flashcards

Week 2 Flashcards

1
Q

What are the measurements taken at the systemic veins?

A
  • Jugular venous distention
  • Venous pulse
  • Central line
    • Central venous pressure
    • PvO2
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2
Q

What are the measurements taken at the systemic arteries?

A
  • Pulse palpation for HR, heart rhythm, patency of blood vessel
  • BP
  • Pulse oxygen or O2 saturation
  • Arterial line: BP, PaO2, cardiac output or index
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3
Q

What are the measurements taken at the R heart?

A
  • ECG
  • Heart rate
  • Heart rhythm
  • Heart sounds
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4
Q

What are the measurements taken at the pulmonary arteries?

A
  • Swan Ganz catheter: pulmonary artery BP, and pulmonary capillary wedge pressure
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5
Q

What are the measurements taken at the lungs using inspired air?

A
  • Breath frequency
  • Tidal volume
  • Lung sounds
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6
Q

What are the results of physiologic measures used to do?

A
  • The need to refer the patient to a physician
  • Establish intervention goals
  • Developing an intervention plan
  • Assess the individual response to intervention
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7
Q

What is body mass index (BMI)?

A

A measure of body composition

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8
Q

What are high BMI values associated with?

A 
• Hypertension	
• Dyslipidemia (abnormalities of	blood lipids)
• Type 2 diabetes
• Coronary heart disease
• Stroke	
• Gallbladder disease	
• Osteoarthritis	
• Sleep apnea and respiratory	problems	
• Cancer	
– Endometria	
– Breast	
– Prostate	
– Colon	cancer
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9
Q

What comorbidities have a high BMI has the primary risk factor?

A
  • Dyslipidemia (abnormalities of blood lipids)
  • Type 2 diabetes
  • Coronary heart disease
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10
Q

What percent of the USA population is overweight or obese?

A

66.3%

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11
Q

When should BMIs be assessed?

A

As part of the initial examination of all patients older than 2 years old, regardless of the reason for the visit

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12
Q

What BMI percent is considered overweight for children?

A

Greater than 85%

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13
Q

What BMI percent is considered obese for children?

A

Greater than 95%

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14
Q

For individuals over 20, what BMI is considered underweight?

A

Less than 18.5

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15
Q

For individuals over 20, what BMI is considered normal?

A

18.5-25

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16
Q

For individuals over 20, what BMI is considered overweight?

A

25-30

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17
Q

For individuals over 20, what BMI is considered obese?

A

30 and above

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18
Q

What are some approaches that have been shown to be effective in reducing BMI?

A
  • Increased physical activity
  • Behavior modification
  • Dietary modification
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19
Q

What is blood pressure?

A

The force driving the blood through vascular system

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20
Q

In what situations is a catheter placement in the artery used to measure BP?

A

In the acute setting with more severely ill patients

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21
Q

When is resting BP measured?

A

At initial evaluation

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22
Q

What are the signs and symptoms of hypotension or hypertension?

A 
– Headache (usually occipital	and present in the morning)	
– Vertigo (dizziness)	
– Flushed face	
– Spontaneous epistaxis (nosebleed)	
– Blurred vision	
– Nocturnal urinary frequency
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23
Q

What is considered an elevated BP?

A

Greater than 200/110 mmHg at rest

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24
Q

When is BP considered a medical emergency?

A

No BP or an extremely low BP

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25
Q

What is the minimum and maximum BP for patients age 3-6?

A

Minimum: 80/50
Maximum: 116/76

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26
Q

What is the minimum and maximum BP for patients age 6-9?

A

Minimum: 84/55
Maximum: 122/78

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27
Q

What is the minimum and maximum BP for patients age 10-13?

A

Minimum: 84/55
Maximum: 126/82

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28
Q

What is the minimum and maximum BP for patients age 14-19?

A

Minimum: 90/60
Maximum: 142/86

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29
Q

What is the minimum and maximum BP for patients age 20-60?

A

Minimum: 90/60
Maximum: 150/90

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30
Q

What is the minimum and maximum BP for patients age ?60?

A

Minimum: 90/60
Maximum: 160/95

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31
Q

What is the optimal BP for adults?

A

<120 and >80

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32
Q

What is the normal BP for adults?

A

120-129 and 80-84

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33
Q

What is the high normal BP for adults?

A

130-139 or 85-89

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34
Q

What is considered stage 1 HTN for adults?

A

140-159 or 90-99

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35
Q

What is considered stage 2 HTN for adults?

A

160-179 or 100-109

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36
Q

What is considered stage 3 HTN for adults?

A

> /=180 or >/= 110

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37
Q

What are the symptoms of orthostatic hypotension?

A
  • Lightheadedness
  • Rubbery legs
  • Feelings of syncope
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38
Q

What are the management methods for orthostatic hypotension?

A
  • Sit or lie down
  • Ankle pumps
  • Notify medical personnel as needed
  • Discontinue standing activities
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39
Q

What are some of the comorbidities that can result from HTN?

A
  • Stroke
  • Myocardial infarction
  • CHF
  • Peripheral vascular disease
  • Renal failure
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40
Q

In R sided CHF, there is elevated R atrial and systemic pressure. What does the elevated pressure lead to, when severe?

A

Engorgement and distention of the jugular veins

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41
Q

What are some of the S/S associated with CHF?

A
  • Increased fluid retention
  • Weight gain
  • Dependent pitting edema
  • Increased fatigue with activity
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42
Q

How can the rate and rhythm of blood pumped during myocardial contraction be sensed?

A

By lightly placing the fingertips over the skin covering peripheral arteries

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43
Q

How is the strength of peripheral pulse determined?

A

By the difference between systolic and diastolic BP or pulse pressure and the elasticity of blood vessels

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44
Q

Heart rate and rhythm at rest are usually ____.

A

Heart rate and rhythm at rest are usually stable.

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45
Q

Heart rate can increase or decrease in response to what?

A

Changes in energy demand

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46
Q

Why does heart rhythm usually remain stable?

A

The synarthrodial node

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47
Q

What are some factors that affect pulse and HR?

A
  • Age: increased in infants and decreased in adults >65 years
  • Gender: male
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48
Q

What is a dysrhythmia?

A

Alterations in rate or rhythm that produce variations in the time of myocardial infarction.

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49
Q

What are the factors that lead to dysrhythmia?

A
  • Ischemia/hypoxia of the myocardium
  • Sympathetic discharge: anxiety and exercise
  • Acidosis
  • Alterations in electrolytes (primary ↓K+ <3.2 mEq/dL)
  • Excessive stretch of the myocardium E.g. CHF
  • Pharmacologic agents
  • Sympathomimetics: caffeine, antiarrhythmic drugs, and digitalis
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50
Q

What are the common sites for pulse palpation in order to measure pulse rate?

A
  • Radial
  • Brachial
  • CaroBd
  • Femoral
  • Temporal
  • Popliteal
  • Posterior tibial artery
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51
Q

What is considered a regular pulse rhythm?

A

Pulse with a similar rate and volume

52
Q

What is considered a regularly irregular pulse rhythm?

A

The periodic nature of the irregularity comes at a specific time (interpulse intervals are unequal, but the pattern is periodic and stable), such as bigeminy (one normal, one abnormal heart contraction) or trigeminy (two normal and one
abnormal heart contraction)

53
Q

What is considered an irregularly irregular pulse rhythm?

A

No specific pattern, and rate and volume vary widely (interpulse intervals are unequal, and the pattern is unstable), such as A-fib or multiple premature ventricular contractions not in a row or sequence

54
Q

When do we assess HR?

A
  • Resting HR
  • HR with activity
  • Emergency situations
  • Initial eval
55
Q

What are the symptoms of cardiac decomposition?

A
  • Angina
  • Palpitation
  • Dyspnea or shortness of breath
  • Fatigue
56
Q

What are the signs of cardiac decomposition?

A
  • Dysrhythmias
  • Syncope
  • Dyspnea or shortness of breath
  • Dependent edema hemoptysis
  • Cyanosis
57
Q

What is HR?

A

An objective, indirect measure of the status and condition of the cardiovascular system

58
Q

What is HR during activity?

A

An objective, indirect measure of work intensity

59
Q

In what fashion does HR change during activity?

A

In a linear fashion

60
Q

How often should HR be measured during activity and why?

A

Every 10 secs, because of the rapidly declining behavior of HR after the cessation of activity

61
Q

How many abnormal beats per min indicates a PVC?

A

More than 6 abnormal beats

62
Q

What is ventilatory rate?

A

The rate and rhythm of air moved during ventilation

63
Q

How can ventilatory rate be sensed?

A

By observing the chest rise and fall in correlation to time

64
Q

What is an apnea breathing pattern?

A

No breathing

65
Q

What is a tachypnea breathing pattern?

A

Rate greater than 20 breaths/min in an adult

66
Q

What is a bradypnea breathing pattern?

A

Rate less than 12 breaths/min in an adult

67
Q

What is a hyperpnea breathing pattern?

A

Normal rate but increased volume

68
Q

What is a hypopnea breathing pattern?

A

Normal rate but decreased volume

69
Q

What is a hyperventilation breathing pattern?

A

Increased rate and volume

70
Q

What is a hypoventilation breathing pattern?

A

Decreased rate and volume

71
Q

What is a cheyne-stokes breathing pattern?

A

Hyperventilation followed by

hypoventilation, then apnea, with the cycle repeating

72
Q

What is orthopnea breathing pattern?

A

Difficulty breathing while horizontal, with easing of breathing with more vertical positioning

73
Q

What is a dyspnea breathing pattern?

A

Labored or difficult breathing

74
Q

How is ventilatory rhythm measured?

A
  • Observe chest rise/fall in relation to time
  • Assess for 30 seconds to 1 minute
  • Compare to expected normal rate for pt’s age
  • Perform further testing as needed.
75
Q

What is an important clinical pearl to keep in mind while assessing a pt’s ventilatory rhythm?

A

Because ventilation is under involuntary and voluntary control, awareness by the patient of the clinician’s observation may cause ventilation to be modified
from the usual resting pattern. A trick that is often used is to appear as though taking a pulse
measurement but actually to observe the rise and fall of the chest.

76
Q

What are the resting breathing values of a neonate?

A

30-40 breaths/min

77
Q

What are the resting breathing values of a 1 y/o?

A

20-40 breaths/min

78
Q

What are the resting breathing values of a 4 y/o?

A

25-32 breaths/min

79
Q

What are the resting breathing values of a 8-10 y/o?

A

23-30 breaths/min

80
Q

What are the resting breathing values of a 12-14 y/o?

A

18-22 breaths/min

81
Q

What are the resting breathing values of a 16 y/o?

A

16-26 breaths/min

82
Q

What are the resting breathing values of a 18 y/o?

A

10-12 breaths/min

83
Q

What are the resting breathing values of an adult?

A

10-20 breaths/min

84
Q

What does a level 0 on the ranchos los amigos dyspnea scale mean?

A

On a single breath

85
Q

What does a level 1 on the ranchos los amigos dyspnea scale mean?

A

Requires 2 breaths

86
Q

What does a level 2 on the ranchos los amigos dyspnea scale mean?

A

Requires 3 breaths

87
Q

What does a level 3 on the ranchos los amigos dyspnea scale mean?

A

Requires 4 breaths

88
Q

What does a level 4 on the ranchos los amigos dyspnea scale mean?

A

Unable to count

89
Q

What are the guidelines of what to do with patients with onset of chest pain or discomfort?

A
  • Stop any activity and place patient in comfortable position (sitting or lying)
  • Monitor vital signs
  • Ask whether patient has been diagnosed with heart disease
90
Q

When a patient that has been diagnosed with heart disease experiences onset of chest pain or discomfort, what should be done?

A
  • Ask whether this symptom is usual or different
  • Ask whether patient has medication (e.g., nitroglycerin)
  • Allow administration of three tablets in a 10-minute period, and if symptoms do not resolve, get patient to emergency department or seek medical attention
91
Q

When a patient that has NOT been diagnosed with heart disease experiences onset of chest pain or discomfort, what should be done?

A
  • Ask patient to describe discomfort
  • Ask what precipitated discomfort
  • Ask whether discomfort is getting worse or better
  • If signs and symptoms improve and do not appear to be musculoskeletal (movement or revealed by palpation) in origin, have patient see his or her physician
  • If signs and symptoms are worsening, get patient to the ED
92
Q

When a patient that has been diagnosed with lung disease experiences onset of chest pain or discomfort, what should be done?

A
  • Ask whether this symptom is usual or different
  • Ask whether patient has medication (inhaler)
  • Allow use of inhaler and see whether symptoms resolve. If symptoms do not resolve and are worsening, get patient to the ED or seek medical attention
93
Q

When a patient that has NOT been diagnosed with lung disease experiences onset of chest pain or discomfort, what should be done?

A
  • Ask patient to describe the discomfort
  • Ask what precipitated the discomfort
  • Ask whether discomfort is getting worse or better
  • If signs and symptoms are improving and do not appear to be musculoskeletal (movement or revealed by palpation) in origin, have patient see his or her physician
  • If signs and symptoms are worsening, get patient to ED
94
Q

What should be done if a pt’s SpO2 is less than 90% in a patient?

A
  • Stop performing any physical activity
  • Check that the device is on properly
  • Retake the measurement with the patient being still
  • Notify medical personnel, if the measurement is valid
  • Continue to monitor the patient
95
Q

What should be done if a pt’s SpO2 is less than 90% in a patient with lung disease?

A

The therapist should stop
activity if:
• Stop activity if SaO2 decreases by ≥5% of resting
value
• ≤88% in patients with right-sided heart failure
• Patients with lung disease with SaO2 <80%

96
Q

Patients with lung disease with SaO2 of ____ use supplemental oxygen

A

Patients with lung disease with SaO2 of <88% use supplemental oxygen

97
Q

During the hand inspection portion of the cardiovascular and pulmonary systems test, what are we looking for?

A
  • Clubbing
  • Peripheral cyanosis
  • Cigarette staining
  • Splinter hemorrhages
98
Q

During the radial pulse portion of the cardiovascular and pulmonary systems test, what are we looking for?

A
  • Examine the rate and rhythm of the pulse

- Allow at least 15 secs to identify the pulse rate

99
Q

By identifying the radial pulse on both hands at the same time, what are we assessing?

A

Possible radial-radial delay

100
Q

What is dermatitis/eczema?

A

Inflammation of the skin caused by allergy/contact, photosensitivity or unknown, genetic/allergic links

101
Q

What are some viral infections of the skin?

A

Herpes, warts

102
Q

What are some bacterial infections of the skin?

A
  • Impetigo – staphylococci/strep
  • Cellulities
  • Abscess
103
Q

What are some fungal infections of the skin?

A

Ringworm, athlete foot

104
Q

What are some parasitic infections of the skin?

A
  • Insect/animal contacts

* Scabies, lice

105
Q

What are the types of cancer that can cause an integumentary disorder?

A
  • Benign/malignant tumors

* Melanoma

106
Q

What are the types of trauma that can cause an integumentary disorder?

A
  • Contusion
  • Ecchymosis
  • Petechiae
  • Abrasion
  • Laceration
107
Q

What are the types of immune disorders that can cause an integumentary disorder?

A
  • Psoriasis
  • Lupus etythematosus
  • Polymiositis
  • Scleroderma
108
Q

Many immune disorders of

the skin also affect ____

A

Many immune disorders of
the skin also affect other
organ systems

109
Q

What is the pneumonic for the symptoms of scleroderma?

A

CREST

110
Q

What do we do in the clinic to screen for integumentary disorders?

A 
• Recent rash, nodule, new
mole, skin changes
• Unusual hair loss or
breakage
• Increased hair growth
• Nail bed changes
• Itching
• Skin turgor
• Current/past medications
111
Q

What are the lab values that we look at for integumentary disorders?

A 
• Nutrition (Pre-albumin, Albumin)
• Total lymphocyte count, WBC
• Coagulation
• Glycosylated hemoglobin
(HbA1c)
112
Q

Changes in skin and nail beds may be the first sign of…?

A
  • Inflammatory response in pulmonary malignancy
  • Impaired circulation, vascular integrity
  • Endocrine, autoimmune disorders
113
Q

What is pruritus?

A

Severe itching of the skin

114
Q

Pruritus is the 1st sign of what?

A 
Dermatologic disease
• Infection
• Hepatic and/or gallbladder
disease/disorder
• Common in aging adults due to
changes contributing to irritated skin
115
Q

What medications can cause

photosensitivity leading to sunburn?

A
  • Antibiotics: ciprofloxacin, oxycycline, sulfanamides and tetracycline
  • Diaretic: Furosemide
  • Cytotoxic: - fluorouracile
  • Hypoglycemics: glipizide and glyburide
  • NSAIDs: Ibuprofen, ketoprofen, naproxen
116
Q

What medications can cause

thinning, weakening of the skin or rash?

A
  • Steroids
  • Glucocorticoids
  • Chemotherapies
  • Any drug allergy
117
Q

What is pre-albumin a marker of?

A

Marker of short-term nutritional

status

118
Q

What is albumin a marker of?

A
  • Marker of longer nutritional status

* Can be inaccurate in short-term

119
Q

What is the function of coagulation labs?

A
  • Ability to achieve hemostasis

* Safe for sharp debridement?

120
Q

What labs are used to assess overall health status?

A
  • WBC, total lymphocyte count

* HbA1c

121
Q

What are the components of the observation portion of the physical examination of the integumentary system?

A
  • Quality
  • Pigmentation
  • Presence of hair
  • Color
  • Edema
122
Q

What are the components of the non- observation portion of the physical examination of the integumentary system?

A
  • Temperature
  • Texture
  • Vascular exam
  • Sensory testing
123
Q

What are the characteristics of the aging integumentary system?

A 
• Epidermal cell production slows
• Epidermal cells larger, more irregular
• Thinner skin
• Decrease in: Immune cells, melanocytes, sebaceous/sweat gland activity, vascular supply
and fat, collagen in underlying tissue
124
Q

What are the things to look at during a melanoma examination?

A
  • Asymmetry
  • Border
  • Color
  • Diameter
  • Evolve: moles that have changed over time
125
Q

What are the general skin care recommendations for everyone, but most especially those with a skin disorder?

A 
• Frequent inspections
• Promote cleaning
• Maintenance of dry, clean skin
• Use of topical agents
• Use of protective
• dressings
• Avoid activities and
procedures that intensify risk

Advanced clinical practice: examining the complex patient (7 decks)

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