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RTH 120 Patient Assessment - Chapter 5 (unit 2)

Terms in this set (102)

The core physical examination techniques are:
inspection, palpation, percussion, and auscultation
Physical assessment should include review of the patient's:
- general appearance
- level of consciousness
- and assessment of oxygenation and perfusion.
Chest inspection should include:
- ventilatory pattern
- use of accessory muscles
- chest excursion
- and observation of the right to left chest wall motion and chest-abdominal synchrony
__________ should include noting aeration and any adventitious (i.e., abnormal) breath sounds.
Assessment of breath sounds
Bedside measurement ____________ should be assessed.
of pulse and respirations should be performed and blood pressure
Temperature should be taken to assess for the presence of _________.
hyperthermia or hypothermia
Building a _________ with the patient is important.
trust and rapport
A _________ approach that reduces multiple movement changes is preferred.
systematic
______________ should be taken into consideration when completing a physical exam.
Clinician ergonomics
Before leaving the room, the clinician should ask _____________ .
if the patient has any questions or needs any assistance
Order of the Physical Examination (Head)
- Eyes: Examine the conjunctiva, sclera, cornea, and iris of each eye. Test pupils for irregularity, accommodation, and reaction. Evaluate visual fields and visual acuity (cranial nerve II). Assess extraocular movements (cranial nerves III, IV, VI). Test the corneal reflex (cranial nerve V).
- Ears: Examine the pinnae and periauricular tissues, Test auditory acuity,
- Nose: Connect the nasal speculum to the otoscope and examine the nares, noting the condition of the mucosa, septum and turbinates.
- Mouth: Examine the vermilion border, the oral mucosa, the tongue. Identify the salivary duct papillae. Assess the dentition for decay, repair, condition of bite. View the pharynx. Evaluate the function of cranial nerves IX, X, and XII. If appropriate, evaluate sensory divisions of cranial nerves V, VII.
- Face: Evaluation of symmetry, smile, frown, and jaw movement will provide information about motor divisions of cranial nerves V and VII.
Order of the Physical Examination (Neck)

Palpate the neck with emphasis on the salivary glands, lymph nodes, and thyroid. Look for ___________. Identify the carotid arteries and auscultate for bruits. Note _________________. Certain parts of evaluation of this area, jugular venous filling, may warrant review with the patient reclining. Test shoulder strength of the sternocleidomastoid and trapezius muscles (cranial nerves XI and XII).
tracheal deviation; jugular venous distention
Order of the Physical Examination (With the patient supine)
Thorax: Reexamine the heart, turning the patient to the left lateral decubitus position if appropriate.
Auscultate: Examine the anterior lung structures.
Abdomen: After inspection, auscultate, listening for bowel sounds and bruits. Next inspect, percuss, and palpate the abdomen, taking special notice of hepatic or splenic enlargements.
The vital signs are ____________ .
pulse, respirations, blood pressure, and temperature
Vital Signs
Monitoring trends in vital signs can indicate if the patient is getting better or worse.
Observing changes over time, especially as compared to "baseline" values when the patient is in his or her normal state of health, can be particularly important.
A normal adult resting heart rate (HR) is between:
60 and 100 beats per minute (bpm)
Heart rate tends to ________ with age in adults.
increase
In infants and young children, heart rate __________ with age.
declines
Tachycardia
A rapid heart rate, more than 100 beats/min.
Bradycardia
slow heart rate (less than 60 bpm)
If the pulse is irregular, the heart rate should be counted for __________.
a full minute
With exercise, the predicted maximum HR in adults can be estimated as:
HR max = 220 - Age in years
Factors that elevate or increase heart rate:
- Anxiety and fear
- Body temperature
Tachycardia is associated with many:
pathological conditions
Certain _______ may elevate HR to the point of tachycardia
drugs
Asymptomatic bradycardia requires
prompt evaluation
Symptomatic bradycardia may require
emergent intervention
A healthy full-term newborn may have a respiratory rate of
40 breaths per minute
In adults, a respiratory rate of > 20 breaths per minute is described as
tachypnea
Tachypnea is a normal physiologic response to
hypoxemia
It is important to distinguish between tachynpnea, hyperventilation, and _________.
hypoventilation
__________ is a level of alveolar ventilation that results in a Paco2 < 35 mm Hg.
Hyperventilation
___________ is a level of ventilation that results in a Paco2 > 45 mm Hg.
Hypoventilation
________ and ________ are two different conditions that may or may not occur together.
Tachypnea; hyperventilation
Many patients with _______ exhibit tachypnea and alveolar hypoventilation at the same time.
ventilatory failure
Many patients with acute respiratory failure experience a decline in ____________ due to pulmonary disease.
lung compliance
Lungs become more difficult to inflate and the work of breathing is increased.
This often results in a:
reduction in inspired tidal volume
A normal minute volume ( V E) is respiratory rate (f) multiplied by tidal volume (VT):
V E = f X VT
_________ is the volume of gas in the conducting airways plus any alveoli that are ventilated but not perfused.
Deadspace
_______ is defined as a low respiratory rate of < 12 breaths per minute in adults.
Bradypnea
There are several arterial pressure measurements of interest:
- Systolic arterial pressure
- Diastolic pressure
- Pulse pressure
- Mean arterial pressure (MAP)
Systolic arterial pressure
The peak pressure within the artery during left ventricular contraction (systole).
Diastolic pressure
The lowest pressure within the artery during left ventricular filling (diastole).
Pulse pressure
Systolic pressure minus diastolic pressure.
Mean arterial pressure (MAP)
The mean pressure within the artery.
At the bedside, blood pressure can be measured with _____________ of an artery.
cannulation
In most patients, a __________ is utilized along with a stethoscope or Doppler device.
sphygmomanometer
Systemic hypertension in adults is a sustained systolic pressure of ≥ ___ mm Hg or a sustained diastolic pressure of ≥ ___ mm Hg.
140; 90
Significant number of patients are thought to have "____________" hypertension.
white coat
"white coat" hypertension
Blood pressure is normal at home or work, but is elevated when measured in the clinic setting.
_____________ and hypertensive encephalopathy are life- threatening conditions associated with very high arterial blood pressures, usually ≥ 180/120 mm Hg.
Malignant hypertension
___________ is a sustained arterial blood pressure of less than 90 mm Hg over 60 mm Hg (systolic over diastolic).
Hypotension
Types of shock include:
- Cardiogenic shock
- Hypovolemic shock
Cardiogenic shock
caused by low cardiac output
Hypovolemic shock
caused by inadequate intravascular volume due to blood or fluid loss
_________ is usually measured orally, rectally, or using an infrared sensor for tympanic (ear) measurement.
Temperature
The average oral temperature in healthy individuals is approximately:
37° C or 98.6° F
Rectal temperatures are about 1.0° F (or 0.6° C) higher than ___________, whereas axillary temperature in adults is about 1.0° F (0.5° C) less than __________.
oral temperatures; oral temperature
_______ is an abnormally elevated body temperature due to disease that affects hypothalamic set point.
Fever
A fever typically indicates _________ is present in the body.
infection
FUO
fever of unknown origin
For each ___ degree increase in temperature above 37° C, there is a ___% increase on oxygen consumption, and this may further impair oxygenation in the presence of cardiac or pulmonary disease.
1; 13
Hyperthermia (as opposed to fever) is:
an elevated temperature due to excessive heat production or inadequate heat dissipation.
Heat exhaustion (aka heat prostration) may occur:
following exertion in a hot humid environment resulting in fluid loss and electrolyte disturbances.
Heat exhaustion may lead to:
heat stroke
Body temperature normally ________ at night.
decreases
Cachexia:
Patients with prolonged illnesses may have severe weight loss and muscle wasting.
__________ refers to cyanosis of the oral mucosa or trunk.
Central cyanosis
__________ is observed in the hands, fingertips, and nail beds of the hands and feet.
Peripheral cyanosis
The assessment of a patient's mental status should begin with __________ (the sensory components of the brain and nervous system), level of consciousness (LOC), and orientation.
sensorium
Terms that are often used to describe levels of consciousness:
- Confused
- Delirious
- Lethargic
- Obtunded
- Stuporous
- Semi-coma
- Comatose
Scales and scoring systems to quantify level of consciousness or levels of sedation:
Glasgow Coma Scale
Ramsay Sedation Scale
Richmond Agitation Sedation Scale
Mental Status Examination should include:
- Appearance
- Attitude
- Body Language and Eye Contact
- Level of Consciousness
- Orientation
- Motor Behavior
- Speech and Language
- Mood and Affect
- Thought Process and Content
- Perception
Orientation: four aspects to patient orientation include:
person, place, time, and situation
What does HEENT stand for?
head, eyes, ears, nose, and throat
During a HEENT examination, the patients facial expression can reveal
distress or pain, alertness, mood, and mental status
During a HEENT examination, nasal flaring suggests
an increased work of breathing
Cyanosis is often most apparent in the
lips, gums, and oral mucosa
Mouth breathing may indicate nasal passage:
obstruction or respiratory distress
Pursed-lip breathing during exhalation is sometimes seen in patients with
COPD
During an inspection of the chest, the term barrel chest refers to
the dramatic increase in the AP dimension of the chest in some COPD patients
What is pulsus paradoxus
decrease in force (not rate) (of a pulse), almost to the point of disappearance during inspiration (only).
Why is pulsus paradoxus significant?
it is significant if inspiratory blood pressure (systolic) falls more than 20 mmHg on inspiration
What are some illnesses that have been associated with pulsus paradoxus?
hypvolemic shock, heart failure, increase venous return on inspiration, severe emphysema, and asthma
Tracheal breath sounds
are heard over the trachea and are loud and acoustic high in pitch
Bronchial breath sounds
are loud, coarse sounds normally heard over the large Central airways
Bronchovesicular breath sounds
are a combination of bronchial and vesicular sounds and maybe heard between the scapula and around the sternum over the medium sized airways
Vesicular breath sounds
are heard over the remaining aspects of the chest and are soft in intensity and low in pitch
What does adventitious mean?
abnormal
What are adventitious breath sounds?
are abnormal and may indicate problems in the long parenchyma and/or the airway
Diminished breath sounds
are associated with hypopnea or with an increase in the air-to-tissue ratio in the lung
What are continuous sounds and are associated with narrowing of the airway?
wheezing and stridor
What is stridor a sign of?
upper airway obstruction that is loud and high in pitch
What are crackles?
discontinuous sounds associated with the sudden opening of small airways and alveoli during inspiration.
- are described as fine or coarse
Rhonchi
low pitched gurgling sounds associated with secretions in a larger airway
Pleural friction rub
is thought to be caused by the rubbing together of inflamed pleura as the lung expands and contracts during breathing
Absent breath sounds
indicate an absence of air flow that may occur with atelectasis, pneumothorax, or consolidation
Diminished breath sounds
are often heard over a pleural effusion or with severe COPD
What is PMI?
point of maximum impulse, pulsation that is commonly assessed is the apical impulse
Clubbing
is characterized by a bulbous swelling of the distal phalanges of the fingers and toes caused by proliferation of the connective tissue between the nail matrix and the distal phalanx
Clubbing may or may not be associated with ________ and _________ alone does not lead to clubbing.
cyanosis
COPD
Putting it all together, the respiratory care clinician must be able to correlate what three things to create a differential list and working diagnosis?
- the patient's history
- physical examination
- diagnostic test results
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