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185 terms

pt assessment (test 2)

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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