Patient Assessment

Question 1

What are the normal ranges for vitals of Neonates, Infants, Toddlers, Preschool Aged, School Aged, and Adolescent children?

Answer 1

Neonate: HR- 100-200, RR- 30-60, BP- 70/35-80/50.
Infant: HR- 100-180, RR- 30-55, BP- 70/40-100/60.
Toddler: HR- 100-140, RR- 20-40, BP- 85/40- 100/60.
Preschool: HR- 80-120, RR- 20-30, BP- 90/45-112/70.
School: HR- 75-120, RR- 18-25, BP- 100/60-120/80.
Adolescent: HR- 60-100, RR- 12-20, BP- 110/60-130/80.

Question 2

What are Ataxic or Biot respirations?

Answer 2

An irregular breathing pattern/rate/depth of resps with intermittent periods of apnea. Commonly associated with ICP.

Question 3

What are Cheyne-Stokes respirations?

Answer 3

A gradual increase in resp rate and depth followed by a gradual decrease with intermittent periods of apnea. Associated with brainstem injuries.

Question 4

What are Kussmaul respirations?

Answer 4

Deep, gasping respirations. Associated with DKA.

Question 5

What are Apneustic reps?

Answer 5

Fish breathing, long inhales followed by breath holding and quick exhales. Associated with damage to the pneumotaxic centre of the brain.

Question 6

What are Beau Lines?

Answer 6

Depressions transversely across the nail bed that can indicate systemic illness, severe infection or nail injury.

Question 7

What is clubbing in relation to nails?

Answer 7

An increase in the angle between the nail and the nail bed to upwards of 180 degrees. Can indicate chronic respiratory disease.

Question 8

What is psoriasis?

Answer 8

Pitting, discolouration, and thickening of the nail that can indicate autoimmune disease.

Question 9

What are splinter hemorrhages?

Answer 9

Linear red or brown streaks that run through the nail that can indicate bacterial endocarditis or trichinosis.

Question 10

What are Terry nails?

Answer 10

White bands that run transversely across the nail that are indicative of cirrhosis.

Question 11

What is anisocoria?

Answer 11

Asymmetrical pupils that can be normal or indicate brain injury.

Question 12

What are Korotkoff sounds?

Answer 12

sounds related to blood pressure that can be heard through the stethoscope.

Question 13

What are bruit sounds?

Answer 13

Whooshing sound heard while listening to heart sounds that indicates turbulent blood flow.

Question 14

What is ascites?

Answer 14

Fluid build up in the peritoneal cavity that is common in liver disease.

Question 15

What can guarding of the abdomen indicate?

Answer 15

Trauma, appendicitis, cholecystitis, hollow organ perforation, pancreatitis, and diverticulitis.

Question 16

What are Lordosis, Kyphosis, and Scoliosis?

Answer 16

Lordosis= inward curve of the lumbar spine,
Kyphosis= outward curve of the thoracic spine creating a hunchback,
Scoliosis= curve of the spine.

Question 17

How do you assess all cranial nerves?

Answer 17

Ask pt to count how many fingers you’re holding up at different distances, follow your finger in a “Z”, smile, stick out their tongue, and shrug their shoulders checking for symmetry.

Question 18

What is aphasia?

Answer 18

Difficulty speaking.

Question 19

What does each skin colour indicate: Red, Pallor (white), Cyanosis, Mottled, and Jaundice?

Answer 19

Red= fever, hypertension, burns, allergic reactions, alcohol, CO poisoning. Pallor= excess blood loss, anaphylaxis, hypoglycemia, anxiety. Cyanosis= Hypoxemia, O2 desaturation. Mottled= cardiovascular dysfunction, intravascular coagulopathy. Jaundice= liver dysfunction.

Question 20

What are the H’s & T’s?

Answer 20

Hypothermia,
Hypoxia,
Hyperkalemia,
Hypovolemia
Tension Pneumo,
Tamponade,
Toxins,
Thrombosis