S1 L1.2 Objective Examination Flashcards by Mind Med

CARDIOPULMONARY ASSESSMENT

T/F

Peripheral pulses can be written either under cardiopulmonary assessment or palpation

True

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CARDIOPULMONARY ASSESSMENT

What are the four (4) main characteristics that the PT should watch-out for when it comes to the patient’s breathing patter?

● Character
● Rate
● Rhythm
● Amplitude

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding eupnea:

CPM:
PATTERN:
DEPTH:
Inspiration - Expiration Ratio:

CPM: 12 - 20 cpm
PATTERN: Regular
DEPTH: Normal
Inspiration - Expiration Ratio: 1:1.5 or 2

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding apnea:

Rate:
Depth:
Rhythm:

Rate: -
Depth: -
Rhythm: -

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding bradypnea:

Rate:
Depth:
Rhythm:

Rate: Dec
Depth: (N)/S
Rhythm: R

Depth: S is shallow, D is deep, V is variable
Rhythm: R is regular, I is irregular

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding tachypnea:

Rate:
Depth:
Rhythm:

Rate: Inc
Depth: S
Rhythm: R

Depth: S is shallow, D is deep, V is variable
Rhythm: R is regular, I is irregular

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding hyperventilation (kussmaul):

Rate:
Depth:
Rhythm:

Note: This is also associated with metabolic acidosis

Rate: Inc
Depth: D
Rhythm: R

Depth: S is shallow, D is deep, V is variable
Rhythm: R is regular, I is irregular

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding hyperpnea:

Rate: N
Depth: D
Rhythm: R

Rate:
Depth:
Rhythm:

Depth: S is shallow, D is deep, V is variable
Rhythm: R is regular, I is irregular

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding apneusis:

Rate:
Depth:
Rhythm:

Rate: Dec
Depth: D
Rhythm: I

Depth: S is shallow, D is deep, V is variable
Rhythm: R is regular, I is irregular

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding biot’s:

Rate:
Depth:
Rhythm:

Biot’s is also associated with meningitis

Rate:Dec
Depth: S
Rhythm: I

Depth: S is shallow, D is deep, V is variable
Rhythm: R is regular, I is irregular

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding cheyne-stokes:

Rate:
Depth:
Rhythm:

Note: Cheyne-stokes is periodic and is associated with critically-ill patients

Rate: V
Depth: V
Rhythm: R

Depth: S is shallow, D is deep, V is variable
Rhythm: R is regular, I is irregular

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding Doorstop:

Rate:
Depth:
Rhythm:

Dootstop is associated with Post-operative
patients - inspiration stops due to restriction
(pain)

Rate: N
Depth: (-)
Rhythm: N

Depth: S is shallow, D is deep, V is variable
Rhythm: R is regular, I is irregular

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CARDIOPULMONARY ASSESSMENT

Fishmouth is ____ with concomitant mouth ____ & _____

Fishmouth (buntong hininga) is apnea with concomitant mouth opening & closing.

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CARDIOPULMONARY ASSESSMENT

Identify the following regarding dyspnea:

Rate:
Depth:
Rhythm:

Rate: N
Depth: S
Rhythm: R

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CARDIOPULMONARY ASSESSMENT

T/F: Dyspnea is associated with accessory muscle activity

True

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CARDIOPULMONARY ASSESSMENT

T/F: Dyspnea wherein slow and prolonged expiration with slow inspiration yet has slowed rate, depth, and rhythm is associated with COPD

False. Dyspnea wherein slow and prolonged expiration with FAST inspiration yet has NORMAL rate, depth, and rhythm is associated with COPD

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CARDIOPULMONARY ASSESSMENT

Psychogenic Dyspnea has ___ rate, ____ intervals of sighing and is associated with ____

normal rate, regular intervals of sighing, and is associated with anxiety

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CARDIOPULMONARY ASSESSMENT

Art of listening to sounds produced by the body, especially on chest

Auscultation

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CARDIOPULMONARY ASSESSMENT

Match the following items:
1. Normal, abnormal, adventitious
2. Normal, abnormal
3. Egophony, bronchophony, whispered
pectoriloquy
4. Pleural or friction rubs

A. Breath Sounds
B. Extrapulmonary Sounds
C. Voice Sounds
D. Heart Sounds

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CARDIOPULMONARY ASSESSMENT

Auscultation

What is the smaller portion of the stethoscope called? And what is it for?

Bell; for low-pitched sound

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CARDIOPULMONARY ASSESSMENT

Auscultation

What is the side that is used for high-pitched sounds called in a stethoscope?

Diaphragm

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CARDIOPULMONARY ASSESSMENT

Match the following items:
1. Listening to breath sounds through the pt
gown or clothing
2. Place bell/diaphragm directly against the chest wall
3. Tube rubbing against bed rails or other objects

A. Correct Technique in Auscultation
B. Common Errors in Auscultation

1.B
2.A
3. B

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CARDIOPULMONARY ASSESSMENT

1.Keep tubing free from contact from any objects
2. Eliminate noise from the environment
3. Auscultation in noisy room

A. Correct Technique in Auscultation
B. Common Errors in Auscultation

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CARDIOPULMONARY ASSESSMENT

Access only on convenient areas
Eliminate noise from the environment
Wet the chest hair if thick
Ask pt to sit, if possible; or roll comatose pt to one side
Interpreting chest hairs as adventitious sounds

A. Correct Technique in Auscultation
B. Common Errors in Auscultation

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CARDIOPULMONARY ASSESSMENT What is the auscultatory landmark of the Aortic Valve?

R 2nd ICS (Sternal Border)

CARDIOPULMONARY ASSESSMENT What is the auscultatory landmark of the Cardiac Apex (Point of Maximal Impulse, Apical Pulse, Apical Point)?

L 5th ICS (Midclavicular Line) *Where LV contraction is most pronounced

CARDIOPULMONARY ASSESSMENT What is the auscultatory landmark of the Mitral Valve?

L 5th ICS (Midclavicular Line)

CARDIOPULMONARY ASSESSMENT What is the auscultatory landmark of the Pulmonic Valve?

L 2nd ICS (Sternal Border)

CARDIOPULMONARY ASSESSMENT What is the auscultatory landmark of the Erb's Point?

L 3rd ICS (Sternal Border)

PULSE STRENGTH/ AMPLITUDE GRADING Absent, not palpable

CARDIOPULMONARY ASSESSMENT What is the auscultatory landmark of the Tricuspid Valve?

L 4th ICS (Sternal Border)

CARDIOPULMONARY ASSESSMENT Normal Heart Sounds Characterized by the closing of AV valves; onset of ventricular systole with a duration of 0.10 seconds

First Heart Sound (S1)

CARDIOPULMONARY ASSESSMENT Normal Heart Sounds What is the duration of the first heart sound?

0.10 seconds

CARDIOPULMONARY ASSESSMENT Normal Heart Sounds Characterized by the closing of semilunar valves; start of ventricular diastole

Second Heart Sound (S2)

CARDIOPULMONARY ASSESSMENT Normal Heart Sounds What is the duration of the second heart sound?

<30 milliseconds

CARDIOPULMONARY ASSESSMENT Normal Heart Sounds Modified T/F: During inspiration, splitting of S2 is audible (physiologic split). It is caused by the closing of the pulmonic valve first then the aortic, which usually closes simultaneously A. TF B. FT C. TT D. FF

A. TF Physiologic Split is caused by the closing of the AORTIC valve first then the PULMONIC, which usually closes simultaneously. (Still normal)

CARDIOPULMONARY ASSESSMENT Normal Heart Sounds T/F: S1 and S2 are best heard when bell of the stethoscope is used

False. S1 and S2 are best heard when DIAPHRAGM of the stethoscope is used

CARDIOPULMONARY ASSESSMENT Abnormal Heart Sounds 1. Faint, low-frequency 2. Heard at late diastole just before S1 3. Signifies rapid ventricular filling that occurs after atrial contraction 4. Reflects early diastolic ventricular filling after AV valves open 5. Possible CHF indicative of ventricular dysfunction A. Ventricular, Gallop (S3) B. Atrial Gallop (S4)

1. A 2. B 3. B 4. A 5. A

CARDIOPULMONARY ASSESSMENT Abnormal Heart Sounds T/F: S3 and S4 are best heard when bell of the stethoscope is used, and at the mitral valve

False. S3 and S4 are best heard when bell of the stethoscope is used, and at the APEX of the heart

CARDIOPULMONARY ASSESSMENT Vibrations resulting from turbulent blood flow

Murmurs

CARDIOPULMONARY ASSESSMENT Murmurs are described based on what factors? There are three

- Position in cardiac cycle: systole or diastole - Duration - Loudness - based on velocity of blood flow

CARDIOPULMONARY ASSESSMENT Modified T/F: Systolic murmurs are between S1 & S2. Diastolic murmurs are between S2 & S1. A. TF B. FT C. TT D. FF

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS T/F: Tracheal is the same as the bronchial sound

True

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS T/F: Bronchial sounds similar to tracheal, they are loud, low pitched, and have equal expiration and inspiration.

False. Bronchial sounds similar to tracheal, they are loud, HIGH pitched, and have equal expiration and inspiration.

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS What is the difference of bronchial and bronchovesicular?

Difference of bronchial and bronchovesicular is that there is a pause in bronchial during expiration and inspiration sound while in bronchovesicular there is no pause

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS T/F: Bronchovesicular is also high pitched and is best heard over the 2nd and 3rd intercostal space or between the scapula

False. Bronchovesicular is also high pitched and is best heard over the 1ST and 2ND intercostal space or between the scapula

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS is longer and expiration can be heard only on the first 1⁄3 of expiration

Vesicular Inspiration

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS T/F: Vesicular Inspiration are usually soft intensity and low pitched

True

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS 1. Place stethoscope over the trachea 2. At the jugular notch 3. Just below the jugular nothc 4. Over the lungs A. Tracheal B. Bronchial C. Bronchovesicular D. Vesicular

1. A 2. B 3. C 4. D

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS What are the auscultatory landmarks that are not specific to lung segments?

■ T2, T6, T10 (following 2 & S pattern) - Anterior “2” - Posterior “S” ■ Axilla, Nipple, Subcostal

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS What are the three segments in the upper lobe?

Apical, Anterior, Posterior

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS Match the following items regarding the landmarks in the upper lobe and its segments: 1. Above/Below the clavicle (ant); lateral and below 2. Between the clavicle and nipple 3. Root of the spine of right scapula 4. None A. Apical Segment (Right Side) B. Apical Segment (Left Side) C. Apical Segment (Right and Left Side) D. Anterior Segment (Right Side) E. Anterior Segment (Left Side) F. Anterior Segment (Right and Left Side) G. Posterior Segment (Right Side) H. Posterior Segment (Left Side) I. Posterior Segment (Right and Left Side)

1. C 2. F 3. G 4. H

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS What are the two segments in the middle lobe?

Lateral and Medial

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS Match the following items regarding the landmarks in the middle lobe and its segments: 1. Lateral to right nipple 2. Inf: below the left nipple 3. Medial to right nipple 4. Sup: above the left nipple A. Lateral Segment (Right Side) B. Lateral Segment (Left Side) C. Lateral Segment (Right and Left Side) D. Medial Segment (Right Side) E. Medial Segment (Left Side) F. Medial Segment (Right and Left Side)

1. A 2. E 3. D 4. B

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS What are the five segments in the lower lobe?

Superior Basal, Anterior Basal, Posterior Basal, Lateral Basal, Medial Basal

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS T/F: The right and left side of the lung's lower lobe have the same landmarks when it comes to auscultation

True

CARDIOPULMONARY ASSESSMENT AUSCULTATION: BREATH SOUNDS Match the following items regarding the landmarks in the lower lobe and its segments: 1.Medial and below the inferior angle of scapula 2. Midaxillary line, level just below the inferior angle of scapula 3. Cannot be auscultated 4. Lateral and below the nipples; above the subcostal margin 5. Medial to scapula, between the root of the scapular spine & inferior angle A. Superior Basal B. Anterior Basal C. Posterior Basal D. Lateral Basal E. Medial Basal

1. C 2. D 3. E 4. B 5. A Note: The medial basal CANNOT BE AUSCULTATED because it is too deep from the thoracic wall

CARDIOPULMONARY ASSESSMENT T/F: Counterpart of middle lobe to the left lung is the lingula, which is part of the lower lobe

True

CARDIOPULMONARY ASSESSMENT What are the three (3) abnormal breath sounds?

○ Bronchial - tubular breath sounds on peripheral lung tissues ○ Decreased - diminished sound ○ Absent - abolished sound

CARDIOPULMONARY ASSESSMENT AUSCULTATION: ABNORMAL BREATH SOUNDS T/F: Decreased and absent *may be d/t hyperinflation caused by emphysema, chest deformities, pain on chest wall, chest tumors, neuromuscular weakness

True

VITAL SIGNS T/F: Heart rate is INDIRECT while pulse rate is DIRECT

False Heart rate is the direct performance of the heart, while pulse rate is indirect, only observing the peripheral arteries.

VITAL SIGNS T/F: In CPR pts, there are discrepancies between the HR and the PR.

True

VITAL SIGNS What are the normal values for HR AND PR?

Normal: 60-100 bpm (resting value for adults), HR should be equal to PR

VITAL SIGNS What are the HR values indicating tachycardia?

>100 bpm

VITAL SIGNS What are the HR values indicating bradyycardia?

<60 bpm (except for athletes/very active individuals)

VITAL SIGNS T/F: Athletes have higher HRs

False. Athletes have lower HRs.

VITAL SIGNS What instruments are used to measure the heart rate?

Use of stethoscope & ECG recording - ECG leads are placed over the chest to get electrical activity of the heart

VITAL SIGNS What instruments are used to measure the pulse rate?

Palpation of pulse, pulse oximeter/pulse meter - Pulse meters: Mobile phones can detect PR through sensors - Pulse oximeter - placed in finger

PULSE STRENGTH/ AMPLITUDE GRADING Pulse diminished, barely palpable; weak, thready

PULSE STRENGTH/ AMPLITUDE GRADING Easily palpable, normal

PULSE STRENGTH/ AMPLITUDE GRADING Full pulse, increased strength

PULSE STRENGTH/ AMPLITUDE GRADING Bounding, too strong to obliterate

In getting the PR, what must one assess for?

Strength, rate, rhythm, equality

VITAL SIGNS T/F: To get the pulse, you must apply hard pressure on the area

False. Apply gentle pressure only (except for popliteal pulses). - The less pressure you apply, the more you will be able to feel it - If too hard = will obliterate the flow (push hard, feel less)

VITAL SIGNS Modified T/F: Bell of the stethoscope is for listening to high-pitch sounds, while the Diaphragm is for low-pitch sounds

FF Bell of the stethoscope - for low pitch sounds Diaphragm - high pitch sounds

VITAL SIGNS T/F: If pulses are diminished, use the bell of the stethoscope

True

VITAL SIGNS T/F: Full 60-second count is recommended for cardiopulmonary patients vs 30-sec multiplied by 2

TRUE

VITAL SIGNS What pulse site is being described? ~3.5 inches to the left of mid-sternum, in the 5th ICS, within an inch of the midclavicular line drawn parallel to sternum

Apical pulse

VITAL SIGNS Apical > Radial pulse indicates?

Blood pumped from left ventricle doesn’t reach the peripheral site or too weak

VITAL SIGNS How do you get the apical radial pulse?

- 2 Examiners: 1 for apical (stethoscope), 1 for radial (palpation) - Count the pulse for 60 seconds - Should be done simultaneously - Compare results

VITAL SIGNS Identify according to JNC 8 1. ≥160 OR ≥100 2. <120 AND <80 3. 120-129 AND <80 4. 130-139 OR 80-89 5. 140-159 OR 90-99

1. Stage 2 Htn 2. Normal BP 3. Prehypertension 4. Prehypertension 5. Stage 1 Htn

VITAL SIGNS Blood pressure Conditions for Htn Urgency

>180/>110; no acute end-organ damage

VITAL SIGNS Blood pressure Conditions for Htn Emergency

>180/>110; c acute end-organ damage

VITAL SIGNS Blood pressure -BP cuff is attached to pts throughout the day -Usually seen in in-pts / ICU

24 Hour Ambulatory BP Monitoring

VITAL SIGNS Blood pressure Usual monitoring system we have; we get BP as necessary

Home BP Monitoring

VITAL SIGNS Suggested ACSM Guidelines for getting BP

- Well-calibrated machine (sphygmomanometer at zero) - Pt should be seated quietly for 5 min - Refrain from smoking or ingesting caffeine 30 min prior - Bladder (rubber in the cuff) should encircle at least 80% of upper arm (1-2 inches above the antecubital fossa) - Earpieces of stethoscope should be tilted forward; placed above the brachial artery - Tilted forward to be aligned to eustachian tube - Quickly inflate to >20 mmHg above the 1st Korotkoff sound - If it's the first time to meet pt or not sure of the baseline of pt, must palpate and locate pulse first and identify on what pressure does it disappear (more accurate than asking pt for baseline BP) - Slowly release pressure (2-3 mmHg/sec) - At least 2 measurements (minimum of 1-2 min apart), then take the average

VITAL SIGNS Condition for Postural Orthostatic Hypotension/ Postural Hypotension T/F: Sudden drop in SBP of at least 10 mmHg or drop in DBP of at least 10 mmHg and 10-20% increase in pulse rate

False. Sudden drop in SBP of at least 20 mmHg or drop in DBP of at least 10 mmHg and 10-20% increase in pulse rate

VITAL SIGNS Condition for Postural Orthostatic Hypotension/ Postural Hypotension T/F: Occurs within 5 min of upright/standing after being supine for 3 minutes or at 60% angle on a tilt table

False. Occurs within 3 min of upright/standing after being supine for 5 minutes or at 60% angle on a tilt table

VITAL SIGNS Normal respiratory rate values

12-20 cpm

VITAL SIGNS Tachypnea rate values

>20 cpm (fast)

VITAL SIGNS Bradypnea rate values

<12 cpm (slow)

VITAL SIGNS Represents the balance between the heat produced or acquired by the body and the amount lost

Body temperature

VITAL SIGNS T/F: Normothermic: 36.6-37.50C / 97.2-99.50F

False. 36.0-37.50C / 96.8-99.50F

VITAL SIGNS T/F: Hypothermia: <35.0C / 95 F

True

What are the thermometer types?

hand-held electronic oral, hand-held electronic external ear, clinical glass, thermal scanners

VITAL SIGNS T/F: Placing the pulse oximeter on the 1st or 2nd fingers has been shown to produce more accurate readings than the index finger

False. Placing the pulse oximeter on the 3rd or 4th fingers has been shown to produce more accurate readings than the index finger

OXYGEN SATURATION Identify % of oxygen saturation 1. Mild hypoxemia; below average; may proceed with PT management with caution; monitor closely the patient 2. Observable cyanosis; acute danger to life 3. Severe hypoxemia / Low blood 02 levels that affects the brain; administer supplemental 02, immediately 4. Moderate hypoxemia / Low blood 02 levels; initiate supplemental 02, as prescribed

1. 91-94% 2. 70% 3. 80-85% 4. 85-90/88%

OI Modified T/F: A. Bed fast: can still get out of the bed but stays there due to doctor’s order B. Bed-ridden: can’t get out of the bed due to severity of condition (ie comatose, some post-surgical precautions)

OI> BODY TYPE Body type of pts c emphysema (pink puffer)

Ectomorph

OI> BODY TYPE Body type of pts c chronic bronchitis (blue bloater)

Endomorph

OI> HEAD NECK OBSERVATION 1. Unusual heavy perspiration; different from pts who are “pawisin” (might assume incorrectly); ask them if they sweat a lot 2. For infants (usually manifest with crying), tells us if they have breathing problems; respiratory distress 3. Sign of hypoxia (longer by 3 mins = may cause brain damage) 4. Chest pain; difficulty breathing

1. Diaphoresis 2. Nasal flaring 3. Pupillary dilatation 4. Apprehension

OI T/F: Cherry red lips indicates carbon monoxide poisoning

True

OI -Redness on face with swelling - Occurs when there is excessive blood supply going up there or excessive disruption of blood flow - Seen in superior vena cava syndrome; polycythemia vera

Facial plethora

OI Modified T/F A. Hypertrophic: elevated; within the boundaries of scar B. Keloid: Beyond boundaries of scar

OI - Stains of fingers of cigarette smokers - Indicative of chronic smoking

Nicotine stain on fingers

OI -Flapping tremor of the fingers -Pulmonary insufficiencies especially with liver failure because of the pulmonary issues

Asterixis

OI What causes digital clubbing?

-Decreased amount of oxygen that's why there’s swelling in the digits -Related cardiopulmonary conditions

OI - Commonly inserted on radial artery or femoral artery as an invasive monitoring of BP - Seen in patients in the ICU and if moved can lead to inaccuracy in the BP monitoring

Arterial Line (A line)

OI - Used for therapeutic purposes such as administration of medications, fluids and/or blood products as well as blood sampling - Usually attached to the dorsal hand

Peripheral Intravenous Catheters (IV Line)

OI Commonly inserted through subclavian or jugular vein; direct monitoring of central venous pressure (CVP) or right atrial pressure (RAP)

Central Line / Central Venous Catheter

OI Describe the route the Pulmonary Artery Balloon Flotation / Swan-Ganz Catheter goes through

Introduced via internal jugular or subclavian vein → vena cava → R atrium → tricuspid valve → R ventricle → pulmonary valve → pulmonary artery

OI Pulmonary Artery Balloon Flotation / Swan-Ganz Catheter permits direct measurement of?

-Right atrial pressure (RAP) - Pulmonary arterial pressure (PAP)

OI Matching type 1. Delivers predetermined level of pressure throughout the entire respiratory cycle 2. Delivers 2 levels of pressure – Inspiratory PAP (IPAP) and Expiratory PAP (EPAP) 3. For emergency, manually pumping A. Bilevel Positive Airway Pressure (BiPAP) B. Continuous Positive Airway Pressure (CPAP) C. Manual Resuscitators (Ambu Bag)

1. B 2. A 3. C

OI Matching type 1. O2 flow between 1-6 L/min for adults & 1/16 L for neonates; if >6 L = high-flow nasal cannula (HFNC) 2. Pt breathing through the mouth thru face piece at flow rates of 5-10 L/min 3. Allows room air through a side port A. Simple Mask B. Venturi Mask C. Nasal Cannula

1. C 2. A 3. B

OI Matching type 1. Mouth to pharynx, just short 2. Nose to pharynx 3. Inserted on the side of the pt A. Oropharyngeal airway/tube B. Nasopharyngeal airway/tube C. Chest Tube Thoracostomy (CTT)

1. A 2. B 3. C

OI - Prominent chest forward - The entire diameter expanded - AP and mediolateral are enlarged

Barrel chest (COPD such as emphysema)

OI - Sternum projects forward - Prominent projection of the sternum

Pectus carinatum / Pigeon chest

OI - Sternum projects backward - depressed sternum

Pectus excavatum / Funnel chest

PALPATION What is pitting edema?

Indentation that will retain

PALPATION Indication or non-pitting edema?

Indication that it's not just fluid, there might be proteins found there

PALPATION Indication or pitting edema?

Extra water inside

PALPATION Edema grading: pain with grimace

PALPATION Edema grading: withdrawal; (+) jump sign

PALPATION Edema grading: tender to palpation; no grimace

PALPATION Edema grading: no tenderness