pt eval a4-

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pt eval a4-
2011-03-23 01:17:41
pt eval a4 a20

pt eval a4-a20
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  1. 4 critical life functions
    • ventilation
    • oxy
    • circulation
    • perfusion
  2. increase hr is a early sign of
  3. perfusion=
    blood pressure
  4. hemodynamic =
    • circulation
    • perfusion
  5. signs are things that you can
    • see
    • measure
  6. symptoms are things that pt must
    tell you
  7. pack years =
    # of packs/day X # of years smoked
  8. normal urine output is
    40 ml/hr
  9. what do you give to a pt if they have a decrease urine output
  10. obtunded
    drowsy state, may have decreased cough or gag reflex
  11. obtunded risk for
    aspiration--must protect the airway
  12. orthopnea
    difficulty breathing except in the upright position (heart problem, CHF)
  13. general malaise
    • run down feeling
    • nausea
    • weakness
    • fatigue
    • headache
    • decrease in potassium level
  14. dysphagia
    • difficulty in swallowing
    • hoarseness

    risk for aspiration, must protect airway
  15. physical exam: what do you inspect with general appearance
    • age
    • height
    • weight
    • sex
    • nourishment
  16. peripheral edema is a presence of
    excessive fluid in the tissue known as pitting edema
  17. peripheral edema occurs in
    • arms
    • ankles
  18. peripheral edema is caused by
    • CHF
  19. ascites is an accumulation of
    fluid in the abdomen
  20. ascites is caused by
    renal failure
  21. what to give pt to treat edema
  22. clubbing of fingers is caused by
    chronic hypoxemia
  23. clubbing of fingers is usually seen with pt that has
  24. venous distention occurs with
  25. capillary refill indication of
    peripheral circulation
  26. diaphoresis is a a state of
    profuse/heavy sweating
  27. diaphoresis is usually seen in pt with
    • heart failure
    • fever, infection
    • anxiety, nervousness
    • tb (night sweats)
  28. jaundice
    • increase in bilirubin in blood and tissue
    • yellow
  29. jaundice comes from
    liver problem
  30. jaundice appears mostly in the
    face and trunk
  31. erythema
    redness of the skin
  32. erythema may be due to
    capillary congestion, inflammation or infection
  33. cyanosis
    blue or blue-gray discoloration of skin and mucous membranes
  34. cyanosis is caused by
    hypoxia from increased amt of reduced hemoglobin
  35. kyphosis
    lean forward= a decrease of vt
  36. scoliosis
    spine leads side to side
  37. kyphoscoliosis
    combo of kyphosis and scoliosis
  38. barrel chest is a result of
    air trapping in the lungs for a long time
  39. symmetrical chest movement occurs when
    both sides of the chest move at the same time
  40. asymmetrical movement may indicate underlying patho:
    • atelectasis- collapse lung, no chest rise, no air
    • pneumothorax- lung collapse
    • intubated pt with ETT in one lung
  41. eupnea
    normal rr, depth and rhythm
  42. tachypnea
    inc rr over 20 bpm
  43. bradypnea
    dec rr less than 12 bpm
  44. apnea
    cessation of breathing
  45. hypercapnea
    • inc rr
    • inc depth
    • regular rhythm
  46. cheyne stokes
    inc then dec rate and depth in a cycle lasting from 30-180 sec w/ periods of apnea lasting up to 60 sec
  47. kussmauls
    • inc rr
    • inc depth
    • breathing sounds labored
  48. what causes kussmauls to happen
    • metabolic acidosis
    • renal failure
    • diabetic ketoacidosis
  49. hypertrophy
    increase in muscle size (neck)
  50. hypertrophy occurs with pt that has
  51. atrophy is a loss of
    muscle tone
  52. atrophy occurs in
  53. atrophy may be referred to as
  54. look externally for evidence of face or neck patho with evidence of difficult airway
    • short receding mandible
    • enlarged tounge (macroglossia)
    • bull neck
    • limited range of motion of the neck
  55. normal hr
    60-100 bpm
  56. tachycardia
  57. tachycardia indicates
  58. bradycardia
  59. bradycardia indicates
    heart failure
  60. an increase hr is an adverse reaction, so what should you do
    • stop therapy
    • notify nurse and doctor
  61. tracheal deviation- palpation may be used to determine
    tracheal position (midline)
  62. if the trachea is pulled TOWARDS the AFFECTED side
    • atelectasis
    • fibrosis
  63. if the trachea is PUSED to NORMAL side
    • pl effusion
    • pneumothorax
  64. assess by percussion -- resonant
    normal air filled lung (gives a hallow sound)
  65. assess by percussion -- flat is heard over the
    sternum, muscle or areas of atelectasis
  66. assess by percussion -- dull is heard over
    fluid filled organs such as the heart or liver

    pl effusion or pneumonia will give this thudding sound
  67. assess by percussion -- tympanic is heard over
    air filled stomach
  68. assess by percussion -- hyperresonant is found in areas of the
    lung where pneumothorax or emphysema is present
  69. normal breath sounds are also called
  70. bilateral vesicular sounds =
    normal sounds in both lungs
  71. abnormal breath sounds are also called
  72. rales are also called
  73. coarse rales (rhonchi) means
    large airway secretions
  74. wheeze is due to
    • bronchospasm
    • imp aereation
  75. stridor is due to
    upper airway obstruction

    subglottic swelling (epiglottitis)
  76. pleural friction rub is a
    coarse grating or crunching sound (inflammation rub)
  77. what may you give to a pt with a pl friction rub
    • steroids
    • antibiotics
  78. normal heart sounds are called
    • S1
    • S2
  79. abnormal heart sounds are called
    • S3
    • S4
  80. what would you recommend for a pt with a abnormal heart sound
  81. what do you use to measure BP
    sphygmomanometer to measure cuff pressures
  82. adult normal BP
    120/80 mmHg
  83. acceptable range of BP
    90/60 to 140/90