1.
1 cm: Light Palpation = __
2.
1-7
8-10
11-12: Bone Structure for Ribs:
_-_ = attached
_-_ = join
_-_ = free/ floating
3.
2 left; 3 rgt (RML - Axillary line): 5 Lobes total for the lungs: __ left & __ right (...)
4.
2-3 cm above the Carina: the rgt main stem bronchus is about _-_ cm above the ___
5.
3 Liters: only give __ of oxygen for COPD pts
6.
4 cm: Deep Palpation = ___
7.
10: A physical exam should last __ min
8.
160: BP High: treat prn @ __ systolic
9.
ABC: Airway, Breathing, Circulation: pt Prioritization: (3)
10.
Adventisious: __ Lung Sounds = abnml lung sound
11.
Afebre: __ = no fever
12.
Alveoli: __ is the small sac in lungs where gas exchange takes place (Analaxusis)
13.
Analaxusis: gas exchange
14.
Ask pt to take a DEEP breath in (if pain gets worse...it can possibly be respiratory in nature).: How to Differentiate Chest Pain:
15.
Aspiration: aka choking
16.
Assesses & Teaches: (Regarding delegation) The NU best __ & __
17.
Atelectasis: incomplete expansion or collapse of alveoli caused by hyperventilation
Diminished breath sounds
low grade tem
decrease oxygen sat
Improvement of temp with incentive spirometer use (NU intervention)
18.
Atelectasis: __ S&S: Diminished breath sounds
Won't hear much of anything
Low-grade temp (alveoli doesn't expand, so body tries to fight an infection that isn't there.
Decrease oxgen saturation
Coming back from surgery (need to get them breathing) incentive spiromometer
19.
Atelectasis: Incomplete expansion or collapse of alveoli caused by hypoventilation
Pain
Lungs won't fully expand
20.
Auscultation: Listening for sounds produced by the body
21.
AV Fistula/ Shunt: Vein & Artery that are surgically sown together to increase bld flow
22.
Axillary line: RML is aka __ __
23.
Back of hand: ___ is used to feel for temp
24.
Base; Apex (dif from heart): __ = bottom of lung
__ = top of lung
25.
Bell: Part of stethoscope to listen to Low pitched S3, S4, Bruit (heart sounds)
26.
Bronchitis: Inflammation of the bronchial Tubes (UPPER airway infection)
Rhonchi - Upper airway garbage
Wheezes
Cough (may or ay not be productive) (We want them to cough it up)
Fever
can turn into pneumonia
SOB
27.
Bronchus --> Bronchioles --> Alveolar Ducts --> Alveoli: __ --> __ --> __ --> Alveoli
28.
Carina: __ is before the break off & it's where we want the ETT (endo-tracheal tube) placed
29.
CC: _ _ is why the pt came in to get help
30.
CC; HPI; Past medical history; Family history; Personal & Social history (exercise, smoke, living conditions, bobbies, martial status); ROS; & Physical Exam: Interview & Health History: (7)
31.
Chest pain; Chest pressure; (if yes) Radiation; SOB; N/V; Diaphoresis (sweating); & get ALL 5 Heart sounds: MI focus on these Q's/signs: (7)
32.
Cheyne-Stokes: Bradypnea - Slower than 12 breaths/ min - __ __ = Varying periods of increased depth interspersed with apnea (speeds up; slows down; no breathing)
33.
Chief Complaint: CC
34.
Chronic Obstructive Pulmonary disease; Emphysema: COPD = ? = AKA __
35.
close you eyes: A way to help you focus when asculating
36.
COPD: condition seen w/ COPD & Chronic Asthma
37.
COPD/ Emphysema/ Chronic Bronchitis: Irreversible expiratory airflow obstruction
Causes over inflation
Breathing all this in, but not getting it all out
Hyperinflation of Alveoli (barrel chested/transverse measurement)
Can see on Chest Xray
38.
Crackles: Anml lung sound that sounds like hair being rubbed b/t fingers.
Coarse
Can't be cleared with a cough
Found best at lower posterior area
39.
Crepitis: AKA Subcutaneous Emphysema
40.
Crepitus: When air has escaped from the lungs and gotten into the subcutaneous tissue (can get in joints too) (sounds like rice crispies)
41.
Cyanotic: __ = blue color (no oxygen) = result of poor circulation
42.
Diaphragm: Part of stethoscope to listen to High pitched sounds
43.
Diaphragm & intercostals: 2 muscles to help you breathe
44.
Diaphragmatic Excursion: __ __ = measure movement of diaphragm
45.
Diminished breath sounds
Won't hear much of anything
Low-grade temp (alveoli doesn't expand, so body tries to fight an infection that isn't there.
Decrease oxgen saturation
Coming back from surgery (need to get them breathing) incentive spiromometer: S&S of Atelactasis (5)
46.
Diminished breath sounds (bc alveoli are still inflated during inspiration)
SOB or Excertional Dyspnea
A-P diameter exceeds transverse
Clubbed nail beds (shamroth test - put nail beds together and nails don't meet)
Will hear A LOT of wheezing
CO2 levels are always HIGH
Your bodies CO2 level tells your body to breathe
Chest Xray shows hyperinflation
You can kill a pt if you give them to much oxygen!!! (bc your taking away their drive to breathe. Need lower levels of CO2): PA for COPD/Emphysema/ Chronic Bronchitis (9)
47.
Doppler: Used to hear the pulse you may not be able to feel
48.
Dorsal: __ palpations = Temperature
49.
down: When using the otoscope on children, pull ear __ & back
50.
down; expands: Breath = diaphragm goes __; exhale = __
51.
Dullness: (sounds of percussion) Liver (or most organs)
52.
Failure to report pt changes: # 1 reason why NU are sued:
53.
False, nurses do not generally do percussions: T/F Percussions are part of the nurses PA
54.
False, pt determines acceptable level; NOT us: T/F The pt DOESN'T determine acceptable levels of pain, but medical employees DO.
55.
False, Toward: T/F ear pieces tipped AWAY from pt. when asculating
56.
Fever, Sepsis (infection in bld): (Reasons for abnml) Temp. (high): (2)
57.
Flatness: (sounds of percussion) over muscle
58.
Gonimeter: Checks flexion & extension
59.
Heart Block (MI), Overdose, Athlete, Hypoxia, OR beta blockers (bld pressure meds that decrease HR): (Reasons for abnml) Pulse (low): (5)
60.
History of present illness or problem: HPI
61.
HTN or pain: (Reasons for abnml) BP (high): (2)
62.
Hype-resonance: (sounds of percussion) COPD Lung (Chronic Obstructive Pulmonary Disease)
63.
Hyperpnea: AKA Hyperventilation
64.
Hypothermia (low temp): Poor perfusion (sign of death)
65.
Hypoxia, metabolic or resp. Acidosis (Hyperventillation): (Reasons for abnml) Resp. (high): (3)
66.
indirect percussion: __ __ = tap middle finger of your dominant hand on pt
67.
Inspection: Process of observation to gather data
68.
Inspection: __ begins as soon as you see you pt & cont. through out
69.
Inspection, Auscultation, Percussion, Palpation: Exam techniques for the GI system in order: (4)
70.
Inspection, Palpation, Percussion, Auscultation: General Exam technique's in order: (4)
71.
Kussmaul: Tachypnea - Faster than 20 breaths/ min - __ = Rapid, deep, & labored (metabolic Acidosis) (decreased pH is Acidic) (Renal failure: Diabetics)
72.
location, intensity, & characteristics of pain: JACHO standards/ presence of pain: (3)
73.
Media Sternum, Pleural spaces, Scapula (no lung sounds)...: Framework of Thorax (3)
74.
Mediastinum: __ holds heart
75.
Medical, Surgical, CC: Pt History: (3)
76.
Monofilament: used to Tests sensations (important for diabetics)
77.
Narcotic use (CNS depressant/ aka opioids); or Resp. failure: (Reasons for abnml) Resp. (low): (2)
78.
Neumothorax: Lung collapses (need chest tube to expand lung again)
79.
Neurological (A&O x 3)(PERRLA)(EENT)
Upper Resp. (lung sounds)
CV/Apical Pulse (APETM)
GI (inspection, auscultation; palpation)(Q's)
GU (palpate & Q's)
CV upper extremities (skin turger/breakdown/bilateral pulses/ cap refill)
CV Lower extremities (bilateral pulses/edema/cap refill/ skin)
Posterior Resp. (lung sound/Axilliary line for RML)
Skin & Equipment
Pain
CC: List Order for PA: (11)
80.
Nml driven by blowing off CO2,
Changes to low level of oxygen in COPD pt
Nml only give 3L of oxygen for COPD pts: Stimulus to Breathe: (3)
81.
Nml VS Ranges:
96-100 degrees F
60-100
12-20
90-120/60-80 140/90+
92-100
0: Nml VS ranges
Temp:
Pulse:
Resp.:
BP: Report when:
Oxygen Saturation:
Pain:
82.
No, bc they depress the CNS
Rate, Depth, & Regularity: (yes/no) Give Narcotics if less than 12 respirations/min?
83.
OLD CARTS
Onset; Location; Duration
Characteristics; Aggravating/Alleviating Factors; Radiation; Timing; & Severity (1-10): Assessing Pain: (8)
84.
Operator error
Hypothermia: (Reasons for abnml) Temp. (low):
# 1 reason = ... OR __ = poor perfusion (sign of death)
85.
Ophthalmoscope: Used to assess eyes
86.
Otoscope: Look in ears
87.
pain: 5th VS:
88.
Palmar: __ palpations = Masses
89.
Palpation: Use of hands & fingers to gather info through the sense of touch
90.
Percussion: Involve striking objects against another producing vibrations & sound waves
91.
Physical Exam: Complete 1st thing after VS
92.
Pigeon & Barrel chested: two abnml chest conditions:
93.
Pleural Friction Rub: Abnml lung sound: Occurs when inflammation of lung rubs against each other
Heard in the LOWER anterior part
94.
Pleural Space: __ __ surrounds lung
95.
Pneumonia;
Yellow = Staph
Green = Pseudomonas;
Infiltrates: associated w/ pneumonia: Inflammatory response of bronchioles and alveolar spaces (bacterial, fungal, or viral)
Productive Cough Sputum Color: Yellow = __; Green = __.
Hear Crackles
Dyspnea & Tachypnea
Fever: 101.1
Chest wall pain (take deep breath)
Chest xray will show ______.
96.
Pneumothorax: Blunt force
Partial collapse of the pleural cavity. Presence of positive air in the pleural space
SOB
Diminished to absent breath sounds
Cuanosis (bluish color)
Tachycardia
Tracheal deviation to unaffected side
Subcutaneous emphysema AKA Crepitis
97.
Position our pts so they can breath better so they can expand lungs (chair/high fowlers, orthopic)
Make pt take deep breaths and cough (if not they will hypoventilate)
Ambulation - walking around
Splint incision (ie hold pillow when coughing): Prevention for Atelatasis: (4)
98.
Position: Sit upright
Sit in chair
Ambulate
Cough & deep breathe
Incentive Spirometer
Medicate to prevent Hypoventilation: Nursing intervention (6)
99.
pt & feelings (how do you feel this pain is affecting your life?: Therapeutic communication: (2)
100.
Pulses, Pitting Edema, Breath sounds, Abnml girth & Calf measurements: (5) some Places to compare right to left
101.
Pyrexia: __ = Fever
102.
Report: Must get a __ before assessing a pt
103.
Resonance: (sounds of percussion) Lung
104.
Review of Systems: ROS
105.
Rhine Test: (Type of tuning fork test) Bone conduction (hold against base of mastoid process (@ base of ear)
106.
Rhonchi: __ Sound in lungs = UPPER airway garbage;
Loud, Low, & Coarse sounding.
Can be Anterior/Posterior(harder to hear)
Can be moved out by a cough or cleared throat (chart even if clears out)
Ask pt to cough. if it clears, then pt has ___
107.
Right main stem bronchus: Main place for Aspiration
108.
Right Pleural Space (rgt lung)
Left Pleural space (left lung)
Mediastinum (over sternal boarder/ where Heart is): Three major spaces of the chest:
109.
Right; Left: (Right/Left) main stem bronchus is larger & more vertical the the (Right/Left)
110.
Semi-Fowlers: Place pts in ___ position if they have dif. breathing
111.
Shock, Dehydration, or Too much bld pressure meds: (Reasons for abnml) BP (low): (3)
112.
Snell chart: Eye chart to check farsighted; uses Ex, Xs, & Os
113.
Sphygomanometer: BP Cuff is known as a ___
114.
Stress, Activity, or Pyrexia (fever): (Reasons for abnml) Pulse (high): (3)
115.
Symmetry of Chest movement
Flailing Chest = Asymmetrical
Using Accessory Muscles? Common w/ asthema (chest & abdominal)
Children = Retraction (areas of chest sunken in)
Absence or use of accessory muscles
Inspecting Resp. Rate (12-20) count w/ pulse
Chest Wall shape (pigeon or barrel chest)
Color of lips and nail beds = circulation
Increase in anterior-posterior diameter (transverse measurement): Inspection of Chest; Things to remember: 9
116.
Tactile fremitus: Ulnar part of hand on their back and have them repeat 99 over and over again...(want vibrations to be equal); This is done to check and see if there is any fluid in the lungs
117.
Teaching a pt, Assessment of a pt, & Evaluation of a pt: Items that can NOT be delegated: (3)
118.
Temp, Pulse, Resp, bld Pressure, & Pain: Vital sign order (5)
119.
Trachea Placement;
Attention Neumothorax: __ __ = should be midline (tip head back to check)
Deviated to rgt/left if not midline
This is a result from __ ___ = Lung Collapses on its own, so air moves to compensate for other side
120.
Transverse Measurement: True Sign of COPD
121.
Transverse measurement; greater: __ measurement should be larger than anterior --> posterior. Anterior should measure __ in distance than if ou did anterior to posterior.
122.
Trends: __ is highest and lowest of the VS (Range)
123.
True: T/F Anything a NU delegates, they ARE responsible for even though someone else is performing the task.
124.
True: T/F When Auscultating, you should ALWAYS listen on skin surface
125.
True: T/F If pt has had a infection for a while, their temp DECREASES
126.
True: T/F a nurse should NOT hang her stethoscope around her neck
127.
Tympani: (sounds of percussion) Gastric bubble; drum like sounds
128.
Ulnar: __ palpations = Vibrations
129.
ulnar side (pinky side) of hand: ___ (__) is used to feel for vibrations
130.
up: When using the otoscope on adults, pull ear __ & back
131.
wear gloves: Standard precautions: when you think you may come into contact with body fluids, you should ....
132.
Webber test: (Type of tuning fork test) Touch middle of forehead (sound should be the same)
133.
Webber Test & Rhine Test: __ Test & __ Test are two tests used with a tuning fork
134.
Wheezes: High, Musical pitch sounds
Heard during INSPIRATION/EXPIRATION
Air has difficulty getting through (restriction in air flow)
Sometimes you can hear it audibly
Note Location & if it was Inspiration/expiration
It can be heard everywhere
