pt assessment (test 2)
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Created by:
Kholloway1119 on September 21, 2011
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185 terms
Terms | Definitions |
|---|---|
 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 |
| ________ compliance = decreased elasticity ("old sock"; emphysema, pulmonary fibrosis, COPD) | increased |
| normal compliance | 0.1 L/cm h2o |
| increased resistance | pneumonia, mucus plugs, tumors, bronchoconstriction |
| with resistance ventilatory pattern will be _____ | turbulent (use of accessory muscles, nostril flaring, retractions, splinting, pursed lip breathing) |
| "healthy lungs"; respond to Co2 | central chemoreceptors |
| if you have an increased Co2 the normal body response is to ________ | hyperventilate |
| decreased Co2 the normal body response is to _______ | hypoventilate |
| "non-healthy lungs"; respond to Pao2 | peripheral chemoreceptors |
| pulmonary reflexes | deflation, irritant, j receptors, aortic and carotid receptors |
| accessory muscles of inspiration | scalene, sternocleidomastoid, pectoralis major, trapezius |
| accessory muscle of expiration | rectus abdominis, external oblique, internal oblique, transversus abdominis |
| occurs during advanced stages of COPD | pursed lip breathing |
| during pursed lip breathing the patient exhales through lips that are held in a position similar to ______ | whistling |
| this _______ pressure created by retarding the airflow provides the airway with some stability | positive |
| pursed lip breathing offsets early _______ _____ and ______ _____ during exhalation | airway collapse and air trapping |
| pursed lip breathing has been shown to ______ respiratory rate | slow |
| may be seen in patients with severe restrictive lung disorders such as pneumonia or ARDS | retractions |
| worst retraction | substernal |
| often seen during inspiration in infants experiencing respiratory distress | nasal flaring |
| two types of chest pain | pleuritic and nonpleuritic |
| described as a sudden, sharp, or stabbing pain that usually intensifies during deep breathing or coughing | pleuritic chest pain |
| examples of pleuritic chest pain | pneumonia, pleural effusion, pneumothorax, lung cancer, tuberculosis |
| described as a constant pain that is located centrally but also may radiate | nonpleuritic chest pain |
| examples of nonpleuritic chest pain | myocardial infarction, pericardial inflammation, pulmonary hypertension, esophagitis, trauma |
| brown/dark | old blood |
| bright red (hemoptysis) | fresh blood (bleeding tumor, tuberculosis) |
| clear and translucent | normal |
| copious | large amount |
| frank hemoptysis | massive amount of blood |
| stagnant sputum or gram-negative bacteria | green |
| pseudomonas or anaerobic infection | green and foul smelling |
| asthma, chronic bronchitis | mucoid (white/gray) |
| pulmonary edema | pink, frothy |
| secretions that are sticky or adhesive or otherwise tend to hold together | tenacious |
| thick, viscid, sticky, or glutinous | viscous |
| presence of white blood cells, bacterial infection | yellow or opaque |
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