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Patient Assessment 1
WillWallace Patient Asst 2/08 test 1
| Question | Answer |
|---|---|
| Eupnea | Normal breathing, 10 - 18 bpm |
| Apnea | no spontaneous breathing, usually more than 10 seconds, caused by drug overdose, asphyxia, sleep apnea |
| Platypnea | Can breath better when laying down. |
| Orthopnea | Can breath better when sitting up. |
| Cheyne Stokes | Gradual increase of breathing followed by a gradual decrease in breathing followed by apnea. |
| Kussmal breathing | Deep rapid respiration characteristic of diabetic or other types of acidosis. |
| Biot's breathing | Irregular rate, depth and volume followed by apnea seen in patients with ICP and menningitis |
| Tachypnea | Rapid breathing, usually caused by decreased lung compliance |
| Hyperpnea | Deeper and more rapid than normal breathing at rest. |
| Bradypnea | Slow respiratory frequency, caused by CNS depression |
| Paroxymal Nocturnal Dyspnea | Dyspnea during the night. |
| Exertional Dyspnea | Dyspnea that occurs only during exertion. |
| Kyphoscoliosis | Kyphosis (hunch back) plus Scoliosis (lateral curvature) |
| Kyphosis | Abnormal AP curvature causing a hunch back. |
| Scoliosis | Lateral curvature |
| Barrel Chest | A chest with increased A-P diameter, seen in patients with COPD (air trappers) |
| Pectus Excavatum | Funnel chest (concaved) |
| Pectus Carinatum | Pigeon breast (protruding) |
| Jugular Venous Pressure | Reflects the volume of blood and pressure to the right side of the heart. Right heart failure can increase it. |
| Right heart failure | Corepulmonade |
| Paradoxical Pulse | A reverse of normal pulse, during inspiration pulse is weaker and stronger during exhalation. Seen in Cardiac Tamponade. Less moving air, pulse checked at beat 1 and 2 systolic, if greater than 8 to 10 torr difference= paradoxical. |
| Hypertension | Blood pressure higher than 140/90 |
| Causes of Hypertension | Increased ICP, Corpulmonale, hypervolemia, hypoxemia, and sympathomimetics. |
| Hypotension | Blood pressure lower than 90/60 |
| Causes of Hypotension | Hypovolemia, left ventricular failure, peripheral vasodilation/sepsis, beta blockers, positive pressure ventilation, and PEEP/CPAP. |
| Purulent | Thick, yellow, and sticky bacterial infected white cells. |
| Fetid | Foul smelling |
| Mucoid | Thick and clear, normal for someone who has an airway disease. |
| Muco-purulent | Purulent and Mucoid combined |
| Green | Old infection or infection related to alergies. |
| Green and fetid | Pseudamonas |
| Brown | Old blood |
| Asthmatic Breathing | prolonged exhalation, caused by obstruction to airflow out of lungs |
| capillary refill | press on patients fingernail, note spead of capillary refill, less than 3 seconds=healthy. longer = poor vascular supply and decreased Card output |
| Caugh | Most common sympton of pulmonary disease |
| Dry Non-productive caugh | restrictive disease like chf or pulmonary fibrosis |
| loose productive caugh | inflammatory obstructive disease like bronchitis or asthma |
| chest pain | pleuritic (lateral) nonpleuritic (center chest) |
| pleuritic | lateral or posterior chest pain, worsens with depth of breath, sharp, stabbing. Associated w plural lining, pneumonia, or embolism. |
| nonpleuritic | center chest pain, anterior, radiates to shoulder, not effected by breathing, dull ache angina or coronary artery |
| COPD | Cystic Fibrosis, Bronchitis, Asthma, Bronchiectasis, Emphysema |
| Cor Pulmonale | Right-side Heart failure, caused by chronic left side failure |
| digital clubbing | clubbing of the finger tips and toes, develops over time, caused by cardiopulmonary disease, chronic hypoxemia, low O2 and polycythemia |
| Face Inspection for Resp Patients | Nasal Flaring(resp distress), Cyanosis (resp failure), Pursed lips breathing (copd) |
| Fever | common complaint with infection, height may indicate virulence, fever+cough=respiratory infection. ↑ metabolic rate, ↑O2 consumption,↑CO2 production, increased o2 and co2 may cause tachypnea and resp failure |
| frothy secretions | white= non cardiogenic pulmonary edima. Pink= cardiogenic pulmonary edima |
| Hemoptysis | coughing up blood or blood streaked sputum, massive = more than 300 ml in 24 hours |
| Heart Rate | Radial, coritid, femoral |
| Respiratory Rate | chest, abdomen, back |
| hematemesis | vomiting blood |
| hemoptysis | coughing blood |
| hypopnea | decreased rate and depth of breathing, caused by brain damage or well conditioned atheletes |
| LOC | level of consciousness, confused, delirious, lethargic, obtuded stuporus, comatose |
| Oriented x3 | time, people, place |
| measuring body temp | mouth, azilla, rectum, ear |
| non verbal communication | gestrues, facial expressions, eye movement, contact, voice tone, space, touch |
| past medical history | dhildhood disease, hospitalizations, surguries, injuries, alergies, ilnesses, meds |
| pedel ademia | usaully assiated with right heart failure, leaking venous system causes pooling in feet |
| phlegm | mucus from tracheobronchial tree that has not been contaminated by oral secretions |
| pleural effusion | increased fluid in the pleural cavity-usually due to inflamation or inffection |
| polycythemia | abnormally high increase in rbc's |
| pulse alterans | alternbatly strong and week pulses, suggests left side failure usually not related to resp die=sease |
| regulating body temps | raise with shiver, vasoconstriction, slowing pulse and slowing rr, lower with sweat, peripheral vasodialation, increased rr |
| sputum | mucus that has been contaminated by oral secretions |
| sympathetic vascular resistance | main cause of hypertension |
| trachea exam | trachea midline should be directly below the center of the supra sternal notch. trachea moves toward colapsed lung. moves away from tension pneumothorax or large pleural effusion. |
| Vital signs | pulse 60-100, RR 12-18, Temp 98.6F or 37 C = or - 1, BP 90-140/60 -90` |
Created by:
annabannana
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