Flashcards in Patient Assessment Deck (82):
Two key sources of patient data are
the medical history and the physical examination.
approximately 4 to 12 feet from the patient is considered.
2 to 4 feet from the patient is considered
The introduction is done in what space
How should you word your questions when you conduct an interview with a patient.
Use Neutral Questions
What kind of questions should you avoid in a patient interview.
is a subjective experience and is a general term describing the sensation of breathing discomfort
is the specific sensation of an unpleasant urge to breathe.
Difficulty breathing in the reclining position
Dyspnea in the upright position
oxygen desaturation on assuming an upright position.
patients with normal cardiopulmonary function complain of intense dyspnea or suffocation is known as
psychogenic hyperventilation syndrome
and is associated with panic disorders
the sensation of tingling and numbness in the extremities that often accompanies respiratory alkalosis
a forceful expiratory maneuver that expels mucus and foreign material from the airways
cough depends on the ability of the individual to
take a deep breath, lung elastic recoil, expiratory muscle strength, and level of airway resistance
Coughing up blood or blood-streaked sputum from the lungs
T/F Hemoptysis is characterized as massive when more than 100 ml of blood is expectorated over 24 hours.
vomiting blood from the gastrointestinal tract
Mucus is gradually moved to the hypopharynx by the
mucus from the tracheobronchial tree that has not been contaminated by oral secretions
Mucus that comes from the lung but passes through the mouth as it is expectorated
Sputum that contains pus cells
Purulent sputum appears
thick, colored, and sticky.
Sputum that is foul-smelling
Sputum that is clear and thick
What type of chest pain usually is located laterally or posteriorly. It worsens when the patient takes a deep breath, and it is described as a sharp, stabbing type of pain
What type of chest pain is located typically in the center of the anterior chest and may radiate to the shoulder or back. It is not affected by breathing, and it is described as a dull ache or pressure type of pain
patient takes a deep breath, and it is described as a sharp, stabbing type of chest pain
dull ache or pressure type of chest pain
Fever that occurs with a cough suggests
Patients with a significant fever have an increases in
increased metabolic rate and an increased oxygen (O2) consumption and carbon dioxide (CO2) production
Swelling of the lower extremities
an indentation mark left on the skin Weeping edema is when a small fluid leak occurs at the point where pressure is applied.
small fluid leak occurs at the point where pressure is applied.
The smoking history is often recorded in
includes resuscitative efforts. DNI, DNR
The physical examination consists of the following four general steps:
(1) inspection (visually examining),
(2) palpation (touching),
(3) percussion (tapping),
(4) auscultation (listening with a stethoscope).
listening with stethoscope
Weakness and emaciation
a patient with severe pulmonary hyperinflation tends to sit upright while bracing his or her elbows on a table. This position helps the accessory muscles gain a mechanical advantage for breathing
can help determine both the duration and the impact of the illness on the patient's daily activities.
personal hygiene indicators
observing patients level of conciousness (alertness)
•Exhibits slight decrease of consciousness
•Has slow mental responses
•Has decreased or dulled perception
•Has incoherent thoughts
•Is easily agitated
•Responds appropriately when aroused
•Awakens only with difficulty
•Does not awaken completely
•Has decreased mental and physical activity
•Responds to pain and exhibits deep tendon reflexes
•Responds slowly to verbal stimuli
•Does not respond to stimuli
•Does not move voluntarily
•Exhibits possible signs of upper motor neuron dysfunction, such as Babinski reflex or hyperreflexia
•Loses reflexes with deep or prolonged coma
Temperature elevation caused by disease is called
Temperature elevation caused by disease is called fever, and the patient is said to be
The average body temperature for adults is approximately
37° C (98.6° F)
A body temperature below normal
The normal adult pulse rate is ____ beats/min, with a regular rhythm.
60 to 100
A condition in which the pulse rate exceeds 100 beats/min
A condition in which the pulse rate is less than 60 beats/min
A significant decrease in pulse strength (>10 mm Hg) during spontaneous inhalation
pulsus paradoxus, or paradoxical pulse
alternating succession of strong and weak pulses.
pressure is the peak force exerted in the major arteries during contraction of the left ventricle.
Generally, the normal range for systolic blood pressure in an adult is
90 to 140 mm Hg
what pressure is the force in the major arteries remaining after relaxation of the ventricles
Diastolic pressure normal
60 to 90 mm Hg
the difference between the systolic and diastolic pressures.
A normal pulse pressure is
30 to 40 mm Hg.
arterial blood pressure persistently greater than 140/90
systolic arterial blood pressure less than 90 mm Hg or a mean arterial pressure less than 65 mm Hg mm Hg
is present when the jugular vein is enlarged and it can be seen more than 3 to 4 cm above the sternal angle.
Jugular venous distention (JVD)
The most common cause of JVD is right heart failure
Patients with diabetic ketoacidosis often breathe with a deep and rapid pattern
caused by extreme negative pressure that pulls the trachea downward during inspiration
Contraction of a flat diaphragm tends to draw in the lateral costal margins instead of expanding them
refers to the vibrations created by the vocal cords during speech
vibrations are felt on the chest wall
What condition causes air leaks from the lung into the subcutaneous tissues, fine air bubbles produce a crackling sound and sensation when palpated.
When air leaks from the lung into the subcutaneous tissues, fine air bubbles produce a crackling sound and sensation when palpated. This condition is referred to as subcutaneous emphysema. The sensation produced on palpation is called
When the percussion note is louder and lower than normal, the sound is said to be increased resonance or hypertympanic
increased resonance or hypertympanic
Percussion may produce a sound with characteristics just the opposite of resonance, referred to as
decreased resonance, dampened, or dull.
passing of fresh blood through the anus.