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Flashcards in Patient Assessment Deck (56)
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1

What are the 3 elements of GCS?

1. Best eye opening (1-4)
2. Best verbal response (1-5)
3. Best motor response (1-6)

2

How do we test central pain response?

1. Trapezius squeeze (CN XI Spinal accessory)
2. Supraorbintal pressure (CN V Trigeminal)

3

Why don't we use peripheral pain response to test best motor?

May elicit a spinal reflex instead of a pain response

4

What pupils changes occur with CN III damage?

CN III Occulomotor, damage results in unilaterally dilated non reactive pupil

5

What do pinpoint pupils indicate?

Brain damage, opioid OD, meds (propofol), PSNS

6

What do dilated pupils indicate?

Brain damage, SNS meds (atropine), stimulant OD

7

What is pronator drift?

Sensitive early indicator of corticospinal nerve compression

8

What CN innervates the corneal reflex?

CN VII Facial

9

What CN innervates the gag reflex?

CN IX Glossopharyngeal
CN X Vagus

10

What CN innervates the cough reflex?

CN X Vagus

11

What are the elements of CPOT?

1. Facial expression
2. Body movements
3. Muscle tension
4. Compliance with ventilator or vocalizations

12

What is the ideal sedation level?

Where pt is calm, relaxed, relatively pain free, and not over-sedated

13

What are the types of delirum?

1. Hypoactive
2. Hyperactive
3. Mixed

14

What is delirum?

Disturbance of consciousness with inattention accompanied by changes in cognition or perceptual disturbance

15

What CN innervates the pupil reaction?

CN III Oculomotor

16

Which common points to auscultate during lung exam?

1. Above clavicles for upper lungs (apex)
2. Angle of Louis for bifurcation of trachea
3. Posterior chest for middle and lower lobes

17

How many lobes in each lung?

Left 2 Right 3

18

Landmark for the RUL?

2 cm above clavicle

4th ICS midclav
5th ICS midax

19

Landmark for RML?

4th ICS midclav
5th ICS midax

5th ICS midclav
6th ICS midax

20

Landmark for RLL?

5th ICS midclav
6th ICS midax

6th ICS midclav
8th ICS midax

21

Landmark for LUL?

2cm above clavicle

6th ICS midclav
5th ICS midax

22

Landmark for LLL?

6th ICS midclav
5th ICS midax

6th ICS midclav
8th ICS midax

23

What does barrel chest indicate?

Increased anterior-posterior diameter, common in COPD, emphysema, bronchitis, asthma. Decreases lung compliance

24

What does kyphosis, lordosis, scoliosis indicate?

Change in thoracic shape, decrease lung compliance

25

How to check for asymmetrical chest expansion?

Grip pt skin bilaterally and hold as they breathe. Can result from phrenic nerve dmg, atelectasis, lung collapse, rib #

26

What does cheynes stokes breathing sound like?

Varying periods of deep breathing alternating with apneic periods

27

What does kussmaul breathing sound like?

Deep labored breathing (is compensatory mechanism for acidosis of any origin)

28

What does white, foamy, or pink sputum indicate?

Pulmonary edema

29

How to palpate trachea?

Midsternal line, tracheal deviation results from tension pneumothorax

30

How to assess for subcutaneous emphysema?

Thoracic tissues may appear edematous, when depressed hear "snap crackle pop"