pt assessment (test 2)

Created by Kholloway1119 

Upgrade to
remove ads

4 ways to obtain temperature

oral, rectum, axillary, aural

heat produced

metabolism of food, muscle and gland activity

heat lost

perspiration, respiration, excretion of feces and urine

normal body temp

97-100 (98.6)

variations in body temp

lower in the morning, higher in the evening, eating or drinking anything hot or cold, smoking a cigarette or exercising 15 minutes prior to taking temp

oral temp is taken in _____

mouth

when taking oral temp the thermometer is left in for __ - __ minutes

3-5

______ temp is the most common, convenient, comfortable way to take temp

oral

before taking _____ temp check for eating, drinking anything hot/cold, exercising or smoking 15 minutes prior

oral

when taking rectal temp the thermometer is left in for __-__ minutes

3-5

_____ temp is the most accurate

rectal

to take _____ temp, insert 1-1.5 inches, hold in place and screen patient for privacy

rectal

when taking the axillary/groin temp the thermometer is left in for __-__ minutes

8-10

_____ temp is the least accurate

axillary/groin

to take _____ temp dry armpit/groin, place in center and hold in place

axillary/groin

______ temp measures the thermal infrared energy radiating from the blood vessels in the eardrum

aural (tympanic)

_____ and _____ can affect the aural temp readings

position and earwax

normal oral temp

98.6 F (37 C)

normal rectal temp

99.3 F (37.4 C)

normal axillary temp

97.6 F (36.4 C)

normal tympanic temp

98.6 F (37 C)

factors that increase temp

illness, infection, exercise, excitement, high temps in the environment

factors that decrease temp

starvation/fasting, sleep, decreased muscle activity, mouth breathing, exposure to cold temp, certain diseases

body temp >104 F

hyperthermia

body temp >106 F will cause _____ and _____

convulsions and death

temp > 101 F

fever

fever is due to _____ or ____

illness or injury

body temp <96 F

hypothermia

hypothermia is due to

exposure to cold temperatures

hypothermia depends on

core temperature, age, and length of exposure

generated through the vascular system with each ventricular contraction of the heart (systole)

pulse

9 common pulse sites

temporal, carotid, apical, brachial, radial, femoral, popliteal, pedal (dorsalis pedis), posterior tibial

use the first, second, or third finger and apply light pressure to any of the pulse sites to detect a pulse with a strong pulsation

palpation

count number of pulsations for 15, 30, or 60 seconds and then multiply appropriately to determine ______ ____

pulse rate

in patients with irregular, abnormally slow, or fast cardiac rhythms, count pulse rate for __ minute(s)

1

normal pulse rate for newborn

100-180

normal pulse rate for toddler

80-130

normal pulse rate for child

65-100

normal pulse rate for adult

60-100

seen in patients with hypothermia and physically fit athletes; also with head injury patients, vomiting, and while asleep

bradycardia

pulse >100

tachycardia

_______ occurs as a result of hypoxemia, anemia, fever, anxiety, stress, fear, hemorrhage, dehydration, shock, and exercise

tachycardia

tachycardia is a common side effect with some medications such as _____

albuterol

normal left ventricular contraction combined with an adequate blood volume will generate a

strong throbbing pulse

a weak ventricular contraction combined with an inadequate blood volume will result in a

weak, thready pulse

an increased heart rate combined with a large blood volume will generate a

full, bounding pulse

strength of pulse varies while rhythm remains regular

pulsus alternans

pulse decreases markedly in strength during inspiration and increases back to normal during exhalation

pulsus paradoxus

absent or no pulse detected

0

weak, thready, easily obliterated with pressure; difficult to feel

1+

pulse difficult to palpate; may be obliterated by strong pressure

2+

normal pulse

3+

bounding, easily palpated and difficult to obliterate

4+

______is the primary muscle of ventilation

diaphragm

normal RR for newborn

30-60

normal RR for toddler

25-40

normal RR for child

20-25

normal RR for adult

12-20

commonly seen in patients with fever, acidosis, hypoxemia, pain

tachypnea

occurs in hypothermia, head injuries, and drug overdose

bradycardia

decreased rate and depth, decreasing alveolar ventilation and leads to an increased Paco2

hypoventilation

increased rate and depth, which increases alveolar ventilation and leads to a decreased Paco2

hyperventilation

respirations that progressively become faster and deeper, followed by respirations that progressively become slower and shallower and ending with a period of apnea

cheyne-stokes

increased rate and depth of breathing. usually associated with diabetic ketoacidosis as a compensatory mechanism to eliminate carbon dioxide, by buffering the metabolic acidosis

kussmaul

fast, deep respirations with abrupt pauses

biot's

measured during ventricular contraction

systolic pressure

measured during ventricular relaxation

diastolic pressure

normal BP for newborn

80/40

normal BP for toddler

90/65

normal BP for child

105/65

normal BP for adult

120/80

the numeric difference between the systolic and diastolic blood pressure

pulse pressure

blood pressure = 120/80; pulse pressure = ___

40

considered a dangerous disease and is associated with increased risk of morbidity

hypertension

factors associated with hypertension

arterial disease, obesity, pregnancy, OSA (obstructive sleep apnea), family history

hypertension is _______ in men than women

higher

hypertension is _____ as common in blacks as in whites

twice

when a patients blood pressure falls below 90/60

hypotension

factors associated with hypotension

peripheral vasodilation, decreased vascular resistance, hypovolemia, left ventricular heart failure, medications, burns, diarrhea, vomiting

used to establish baseline Sp02; often considered the 5th vital sign

pulse oximetry

normal Sp02 in adult

95-99

mild hypoxemia in adult

90-95

moderate hypoxemia in adult

85-90

severe hypoxemia in adult

<85

normal Sp02 in newborn

91-96

mild hypoxemia in newborn

88-90

moderate hypoxemia in newborn

85-89

severe hypoxemia in newborn

<85

the most common sequence of a physical examination

inspection, palpation, percussion, auscultation

located in the middle of the sternum, equally divides the anterior of the chest into left and right

midsternal line

start at the middle of either the right of left clavicle, run parallel to the sternum

midclavicular lines

originates at the anterior axillary folds and runs down the anterolateral aspect of the chest

anterior axillary line

divides the lateral chest into equal halves

midaxillary line

runs parallel to the midaxillary line

posterior axillary line

an ongoing observational process that begins with the history and continues through the interview, vital signs, and physical exam

inspection

pursed lip breathing, nasal flaring, abnormal extremity findings, digital clubbing, pedal edema, distending neck veins, cough

signs of distress

process of touching the patients chest to evaluate the symmetry of chest expansion, position of the trachea, skin temperature, muscle tone, areas of tenderness, lumps, depression, and tactile and vocal fremitus

palpation

when palpating the chest, the examiner uses the

heel of the hand, palms, and fingertips

both the _____ and _____ chest should be palpated from side to side in an orderly fashion

anterior and posterior

to examine to trachea, the examiner places an index finger over the _____ _____ and gently moves it side to side

sternal notch

trachea should be ______

midline

abnormal pulmonary conditions that cause the trachea to deviate side to side

tension pneumothorax, pleural effusion, tumor or mass may push the trachea to the unaffected side, atelectasis and fibrosis may push the trachea to the affected side

symmetry of chest expansion us evaluated by lightly placing each hand over the patient's posterolateral chest so that the thumbs meet at the midline

chest excursion

pulmonary disorders that can alter chest excursion

asthma, bronchitis, emphysema, pneumonia

bilaterally decreased chest expansion may be caused by both _______ and _______ lung disorders

obstructive and restrictive

an unequal chest expansion may be caused by ______ ______

alveolar consolidation

vibrations that can be felt by palpation over the chest

tactile fremitus

this condition is commonly caused by gas flowing through thick secretions that are partially obstructing the large airway

tactile fremitus

vibrations that can be palpated or auscultated over the chest during phonation

vocal fremitus

sounds that are produced by the vocal cords are transmitted down the ________ _____

tracheobronchial tree

vocal fremitus can often by done by having the patient repeat the phrase "_____ _____" or "_____ _____". These produce strong vibrations

blue moon or ninety nine

fremitus is most prominent between the ______ and around the _______

scapulae / sternum

tactile and vocal fremitus _______ when anything obstructs the transmission of vibration

decrease

conditions that decrease fremitus

COPD, tumors or thickening of the pleural cavity, pleural effusion, pneumothorax, muscular obese chest wall

conditions that increase fremitus (bigger vibrations and sounds)

alveolar consolidation, atelectasis, pulmonary edema, lung tumors, pulmonary fibrosis, thin chest walls

a coarse crackling sensation that may be palpable over the skin surface

crepitus

crepitus occurs when air escapes the _____ and enter sub-q tissue

thorax

______ can happen after tracheostomy, mechanical ventilation, or thoracic surgery

crepitus

done over the chest wall to determine the size, borders, and consistency of air, liquid, or solid material

percussion

in the _____ lung, sound created by percussion throughout the air-filled lung is loud, low in pitch, and long in duration (like thumping a watermelon)

normal

described as a flat, high pitched sound

dull percussion note

pleural thickening, pleural effusion, atelectasis, and consolidation can cause a

dull percussion note

______ note is very loud, low pitched, and long in duration. heard in patients with COPD or pneumothorax

hyper-resonant

this procedure is performed at maximal inhalation and maximal exhalation

diaphragmatic excursion

severe hyperinflation can cause the diaphragm to be ____ and ____ with minimal excursion

flat and low

lung collapse on one lung will cause the diaphragm to pull ____ on the affected side and reduce excursion

up

provides information about the heart, blood vessels, and air flowing in and out of the alveoli

auscultation

a _______ is used to evaluate frequency, intensity, duration, and quality of the sound

stethoscope

during auscultation the patient should ideally be in the _______ position and instructed to breathe slowly and deeply through the mouth

upright

anterior and posterior chest should be auscultated in an orderly fashion from _____ to ____

apex to base

three different normal breath sounds

bronchial, bronchovesicular, vesicular

heard over the trachea, they are loud and high in pitch

bronchial

heard directly over the mainstem bronchi, they are softer and lower in pitch

bronchovesicular

heard over most lung fields, both anteriorly and posteriorly. they are soft and low in pitch

vesicular

additional or different sounds that are not normally heard over a particular area of the thorax

adventitious breath sounds

found in respiratory disorders that lead to hypoventilation, and also found in disorders such as flail chest, pleural effusion and pneumothorax

diminished breath sounds

moist, wet, dry, crackling, coarse, or fine

crackles or rhonchi

when _____ ______ is present in a respiratory disorder, some crackles and rhonchi are always present

fluid accumulation

are usually fine or medium, crackling, wet sounds that are typically heard on inspiration

crackles

usually have a coarse, bubbly quality and are typically heard during expiration

rhonchi

rhonchi often disappear after a _____ _____

strong cough

produced by airway obstruction (mucus, inflammation), cardinal finding of asthma, high pitched and whistling that last through expiratory phase

wheezing

caused when pleurisy accompanies a respiratory disorder; the sound is reminiscent of that made by a creaking shoe and is usually heard in the area where patient complains

pleural friction rub

abnormal high-pitched sound caused by an obstruction in the trachea or larynx; usually loud enough to hear without a stethoscope

stridor

stridor is heard on _______

inspiration

term used to describe the unusually clear transmission of the whispered voice of a patient as heard through the stethoscope

whispering pectoriloquy

whispering sounds travel down the tracheobronchial tree, they remain unchanged, but as the sounds disperses throughout the large surface area of the _____, it diminishes sharply

alveoli

when a person who has _____ or _____ the sounds whispered are prevented from spreading out over the tree

atelectasis or consolidation (fluid, tumor, mucus plug)

_______ compliance = increased elasticity (tachypnea, pursed lip breathing, nasal flaring)

decreased

See More

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set