Exam 2 Flashcards
(143 cards)
1
Q
What are the 4 classical vital signs(VS)
A
Temp
Pulse
RR
BP
2
Q
What is also included in initial assessment
A
Height
weight
Level of consciousness and responsiveness
General clinical impression
3
Q
When should baseline measurements be taken
A
Upon admission
Beginning of the shift
Prior to Tx or procedure
When there is a change in pt’s condition
4
Q
Define Trending in VS
A
A series of VS measurements over time
5
Q
Define differential diagnosis
A
This is comparison of multiple signs and symptoms to arrive at the pt’s diagnosis
6
Q
What is referred by some clinicians as the “fifth vital sign”
A
Pain
7
Q
The alert pt whose orientation to time,place and person is accurate is said to be ………….. and the sensorium is considered……….
A
oriented *3
Normal
8
Q
True or False
An abnormal sensorium may also occur as a side effect of certain medications and in drug
A
True
9
Q
In a Glasgow scale, the objective evaluation is based on behavioural response in which 3 areas
A
Motor function
Verbal function
Eye-opening response
10
Q
When is body temp usually the lowest and when is it the highest
A
In the morning
In the late afternoon
11
Q
What part of the brain plays an important role in regulating heat loss and can initiate peripheral vasodilation and sweating in an effort to dissipate body heat
A
Hypothalamus
12
Q
An elevation of body temp above normal is known as
A
Hyperthermia
13
Q
True or False
Fever most often results from infection somewhere in the body
A
True
14
Q
What is the term used when the body temp is below normal
A
Hypothermia
15
Q
Describe the breathing of patient with hypothermia
A
Slow and shallow breathing and a reduced pulse rate
16
Q
Name the sites where body temp can be measured
A
Mouth
Ear
Axilla
Rectum
17
Q
What are the common places to measure body temp in both kids and adults
A
Mouth
Tympanic
18
Q
What is the normal pulse rate of an adult
A
60 - 100 bpm
19
Q
A pulse rate exceeding 100 bpm in an adult is termed
A
Tachycardia
20
Q
A pulse rate lower than 60bpm for an adult is termed
A
Bradycardia
21
Q
Which is the most common site for evaluation of the pulse
A
Radial
22
Q
Define Lethargic
A
sleepy, easily aroused and responds appropriately
23
Q
Define Obtunded
A
Difficult to arouse but responds appropriately
24
Q
Define stupor
A
Do not wake up completely,responds to pain and slow respiration
25
Define comatose
Unconscious have loss of reflexes
26
What is the name of the scale that is used to assess pts level of consciousness
Glasgow coma scale
27
If a pt has below an 8 on the Glasgow scale what does it show and what should be done
Shows traumatic head injury
Intubation
28
What are some other common sites available for assessment of the pulse
Branchial
Femoral
Carotid arteries
29
If the strength and rhythm are normal and the pulse is irregular the pulse rate may be counted for 15 secs
False
Only when the pulse, strength and rhythm are normal can you count the rate for 15 secs
30
What are the terms used to describe rhythm
Regular
Regularly
Irregular
Irregularly
31
Describe bigeminy
rhythm coupled in pairs
32
A rhythm grouped as 3 beats and a pause is known as
Trigeminy
33
How long should you wait if a person has taken liquids or smoked before taking their pulse
10 - 15 mins
34
Rate the pulse volume and fullness
0 -4 ...Eg. 0: Absent
1+ : Weak, thready
2+ : Slightly reduced
3+ : Normal
4+ : Bounding
35
What does pulse oximetry measure
HR and O2 saturation
36
Normal RR for an adult
12 - 20
37
True or False: A respiratory rate greater than 60 bpm is considered abnormal for any age and 40bpm is unusual for an adult
True
38
The term used to describe respiratory rates above normal
Tachypnea
39
A fast and deep breathing pattern is known as
Kussmaul breathing
40
A slow RR is referred to as
Bradypnea
41
Define systolic BP
Peak force exerted during contraction of the left ventricle
42
Define diastolic BP
Force occuring when the heart is relaxed
43
Define pulse pressure and what is the normal pulse pressure
It is the difference btn systolic and diastolic pressures
35 - 40 mmHg
44
BP persistently at or above 130/80 mmHg is termed
Hypertension
45
Defined as an arterial BP that is less than 90/60 mmHg in adults
Hypotension
46
The most common technique for measuring arterial BP uses a
Sphygmomanometer
47
Define the korotkoff sounds
Happens when blood flow in the artery resumes
48
When measuring BP what will give you a high pressure reading
Too narrow a cuff
Cuff applied too tight/too loose
Excessive pressure to the cuff or incomplete deflation
49
When measuring BP what will give you a low pressure reading
If the cuff is too wide
50
What effects does the respiratory cycle have on systolic BP during inspiration
It decreases
51
When is low systolic Bp during inspiration present in
Asthma
Cardiac tamponade
52
When does hypotension occur
When the left ventricle of the heart is weak
53
What medications can cause hypotension
Beta blockers
Diuretics
Only affects the systolic
54
Name some identifies to look for when on a pt's face
HINT:Evaluating them
Acute distress
Pain
Alertness, mood and mental capacity
55
What are the 2 signs of respiratory distress
Cyanosis and Nasal flaring
56
If a pt has nasal flaring what does it suggest
Increased WOB is present
57
When is cyanotic more visible
When there is a significant amt of deoxygenated Hb is present
58
What parts of the body can you see central cyanosis
Ears
Neck
Tongue
Lips
Nose
59
Define Acrocyanosis
A persistent, painless blusih discoloration of both hands and less commonly on both feet
60
What kind of pt's use pursed lip breathing
COPD
61
Define mydriasis
Dilated and fixed eyes
62
Define miosis
Pinpoint pupils
63
Define ptosis
Drooping upper lid
64
Define diplopia
Double vision
65
Define nystagmus
Cyclic movement of the eyeballs
66
Define Diaphoresis
Excessive sweating
67
What the Prescence of cyanosis represent
Tissue oxygenation is less than optimum.
68
Inspection and palpation of the neck are of value in determining the:
Tracheal position
Jugular venous pressure(JVP)
Accessory muscle
Tracheal shift
Away from affected side
Tension pneumothorax
Pleural effusion
To the affected side: Atelectasis and lung resection
69
What is the most common cause of JVP
Right heart failure
70
What can cause JVP
Hypervolemia
Obstruction of venous return to the R atrium
71
What's the name that describes enlarged lymph nodes
Lymphademopathy
72
Lymphademopathy is a common finding in patients with
Respiratory infections
73
Tracheal bifurcation at carina is approximately
T4
74
The diaphragm on the right dome gets to
Anterior: 5th rib
Posterior: T9
75
The diaphragm on the left dome gets to
Anterior: 6th rib
Posterior: T10
76
Superiorly on the anterior chest, the lungs extend -------above the medial 3rd of the clavicles.
HINT: in cm
2-4cm
77
Inferiorly, the lung borders extend to the--------midclavicular line and laterally -------
HINT: Ribs
6th rib
8th rib
78
Barrel chest is common in pts with what disease
Emphysema( COPD)
79
Define barrel chest
abnormal increase in AP diameter
80
Define pectus excavatum
Depression of part or all of the sternum
81
Define pectus carinatum
Outward sternal protrusion anteriorly
82
Define kyphosis
Spinal deformity in which the spine has an abnormal anteroposterior curvature
83
Define scoliosis
Spinal deformity in which the spine has a lateral curvature
84
Define kyphoscoliosis
Combination of kyphosis and scoliosis
85
This is the paradoxical motion of the affected rib cage
Flail chest
86
If a pt has flail chest what happens to their chest wall when they inhale or exhale
During inhalation: It sinks in
During expiration: there is an outward protrusion of the chest
87
Define Tachypnea
Rapid rate of breathing
88
Define Apnea
No breathing
89
Define Biot
Irregular breathing with long periods of apnea
90
Irregular type of breathing, breaths increase and decrease in depth and rate with periods of apnea
Cheyne stokes
91
What is defined as deep and fast
Kussmaul
92
Define apneustic
Prolonged inhalation
93
Define Paradoxic
Injured portion of chest wall area moves in the opposite direction to the rest of the chest
94
Define Abdominal paradox
Contraction of accessory muscles to aid inspiratory effort; diaphragm is pulled upwards and abdomen sinks inward during inspiration
95
Define retractions
Inward movement of skin
96
Examples of acute obstruction of intrathoracic airways
Asthma
Prolonged expiratory time
97
Examples of acute upper airway obstruction
Croup
Prolonged inspiratory time
98
Define vocal fremitus
Vibrations created by the vocal cords during talking
99
Define tactile fremitus
When vibrations are heard on the chest wall
100
A reduced tactile fremitus is often present in patients who are
Obese and overly muscular
101
What can cause increased tactile fremitus
Pneumonia
Lung tumor or mass
Atelectasis (with patent bronchiole)
102
What can cause decreased tactile fremitus
Unilateral
Bronchial obstruction w/ mucous plugging or foreign object
Pneumothorax
Pleural effusion
Diffuse
COPD w/ hyperinflation
Muscular or obese chest wall
103
Define Rhonchial fremitus
The passage of air thru airways contaminated with thick secretions may produce palpable variations
104
Vocal fremitus is found in diseases such as
Pneumonia
Atelectasis
105
What causes decreased vocal fremitus
Unilateral
Bronchial obstruction
Pneumothorax
Pleural effusion
Diffuse
COPD w/ hyperinflation
Muscular or obese chest wall
Rhonchial fremitus
Vibrations produced by passage of air thru thick secretions
106
What type of BS does the bell detect
Low frequency sounds( light placement)
107
What type of BS does the diaphragm detect
High frequency ( firm placement)
108
What are the 4 lung sound characteristics
Pitch
Amplitude
Distinctive characteristics
Duration of inspiration vs expiration
109
What's the term for sound heard over the trachea
Tracheal
110
What's the term for sound heard over the parenchyma
Vesicular
111
What's the term for sound that has an expiratory component equal to inspiratory component
Harsh
bronchial
(have the same definition)
112
What's the term for abnormal movement of air in the lungs
Adventitious
113
Digital clubbing is a sign of
Cardiopulmonary disease
114
What makes up the composition of blood
WBC(leukocytes)
RBC(erythrocytes)
Platelets(thrombocytes)
115
Capillary refill helps show
Good cardiac output and digital perfusion
116
Plasma is used to create
Electrolytes
Clotting factors
Immunologic factors
Proteins
Lipids
Hormones
117
All substances used by cells must be transported by
Plasma
118
Define Serum
plasma w/ clotting factors removed
119
What does CBC include
RBC and WBC
120
Primary function of WBC
Help fight infection
121
What makes up WBC
Neutrophils
Eosinophils
Basophils
Lymphocytes
Monocytes
122
What does Granulocytes include
Neutrophils
Eosinophils
Basophils
123
Where are neutrophils produced in and what are they also known as
Bone marrow
Polymorphonuclear leukocytes
124
Immature neutrophils in the circulating blood are known as
Bands
125
What are eosinophils involved in
Immune system regulation
126
It is an important line of defense against foreign microorganisms and cells
Lymphocytes
127
T cells are involved in
Cell-mediated injury
128
B cells are involved in
Humoral immunity
129
What is the main function of Monocytes
Phagocytosis
130
One of body's first response to infection and inflammation
Neutrophilia
131
What is the primary cause of neutropenia
Bone marrow failure
132
Penia means
Decrease
133
Philia and cytosis means
Increase
134
Eosinophilia is elevated in the Prescence of
Parastic infestation
Allergic states
Allergic asthma
135
Associated with myeloproliferative neoplasms(MPNs)
Basophilia
136
What causes lymphocytosis
HIV
Trauma
137
What causes monocytosis
TB
Syphilis
Typhoid fever
Fungal infections
138
RBC's are produced in the
Bone marrow
139
primary function for RBC
Carry O2
140
Life span for RBC
120 days
141
It is the protein that carries O2 to the tissues and carries CO2 from the tissues to the lungs
Hemoglobin (Hgb or Hb)
142
Define Anemia
Reduction in RBC mass of the body
143
What are the causes anemia
Blood loss
Deficiency in cell formation
Abnormal cell formation
Chronic disease and aging
