Patient Assessment

Front 1

PERRL

Back 1

Pupils Equal Round and Reactive to Light

Front 2

Rectus excavatum

Back 2

Common deformity where sternum is indented

Front 3

Increased anterior-posterior diameter

Back 3

Make a barrel chest. Sign of COPD hyperextended lungs

Front 4

Use of accessory muscles

Back 4

Using accessory muscles are a sign of respiratory distress, sternocleidomastoid muscle

Front 5

Auscultation

Back 5

Listen to

Front 6

Crackle

Back 6

Usually caused by excessive fluid within the airway, could be due to pneumonia / other infection of lung / congestive heart failure

Front 7

Wheezes

Back 7

Expiratory sound from forced air flow through abnormally collapsed airways with vesicular trapping of air, common and asthma, may also be due to swelling, tumor, other obstruction

Front 8

Coarse crackles

Back 8

Ronchi; r load pitch, snore like, heard and inspiration / exploration. Originate and larger Airways then wheezes are a side of bronchitis.

- friction rubs sounds like a dry leathery sound heard an inspiration / expiration as a sign of dryness in pleura

Front 9

What part of the stethoscope facilitates hearing the high pitch sounds of the heart

Back 9

S1 and s2, diaphragm

Front 10

What part of the stethoscope hopes hearing low pitch sounds

Back 10

Bell including s3 and s4

Front 11

Normal bowel sounds sound like?

Back 11

Consisting of clicks and gurgles 5 to 30 a minute

Front 12

Occassional Borburgymus

Back 12

Loud prolonged gurgle, maybe heard outside without a stethoscope

Front 13

Superficial palpitation

Back 13

Warm hands, ask if any pain, press down gently in four quadrants

Front 14

Normal superficial palpitation of stomach

Back 14

Abdomen is soft, rectus muscle is relaxed and no discomfort during palpitation

Front 15

Normal inspection of skin

Back 15

Few molesand areas of the pigmentation can be encountered, fine hair is seen over most of the skin, hair distribution varies based on sex

Front 16

Capillary refill

Back 16

To monitor the quality of blood flow or perfusion to peripheral tissues common normal returning color is less than 3 seconds

Front 17

Dependent edema

Back 17

Observed for it by gently compressing the patient soft tissue with your thumb over both shins for a few seconds, normally no indentation

Front 18

2 pulses to look for in lower extremities

Back 18

Dorsalis pedis, posterior tibial

Front 19

Normal in older adult normal ranges for heart rate

Back 19

Adults range, older adults range 60-100

Front 20

Newborn infant, 1 year old, 5 to 8 year old normal range for heart rate

Back 20

130 (80-180), 120 (80-140), 100 (75-120)

Front 21

Normal respiratory rate for adults

Back 21

12-20 breaths per minute

Front 22

Tachypnea

Back 22

Greater than 24 breaths per minute

Front 23

Bradypnea

Back 23

Less than 12 breaths a minute

Front 24

Hyperpnea

Back 24

Respiratory rate greater than 20 and deep

Front 25

Sighing

Back 25

Normal if occasional, anxiety if frequent

Front 26

Cheyne Stokes

Back 26

Pattern of taking deep breaths and stopping breathing for several seconds, abnormal, observed in dying client, can be caused by drugs or CNS damage

Front 27

Accessory muscles used in respiration

Back 27

Sternocleidomastoid, scalenes, serratus

Front 28

Blood pressure is

Back 28

Systolic over diastolic pressure

Front 29

Korotkoff sounds

Back 29

Sounds heard when listening to BP

Front 30

Phase 1 Korotkoff sounds

Back 30

Sharp tapping, start of systolic BP

Front 31

Phase 2 of Korotkoff sounds

Back 31

Switching or whooshing sound, they disappear entirely (auscalatory gap)

Front 32

Phase 3 of Korotkoff sounds

Back 32

A thump, softer than typing in phase 1

Front 33

Phase 2 of Korotkoff

Back 33

Sounds become muffled

Front 34

Phase 5 of Korotkoff sounds

Back 34

End of sounds - ends at diastolic BP

Front 35

Normal range for BP for Infant

Back 35

60-80/40-50

Front 36

Normal BP in children

Back 36

100/60

Front 37

Normal BP for Adults

Back 37

120/80

Front 38

Orthostatic BP

Back 38

Have pt rest supine x10 min; take pulse and BP; have pt sit or stand and immediately retake pulse and BP; repeat pulse and BP after 3 min; record results from all 3 times; if rise in pulse 15-30 or a drop in BP 20 mmHg indicates hypostatic hypotension

Front 39

SpO2

Back 39

Pulse oximetry; saturation of peripheral oxygenation ; method for estimating arterial oxygen saturation (SaO2) ; can detect hypoxemia before physical symptoms

Front 40

How does SpO2 work

Back 40

Red and infrared light passes through patient's blood and the amount of light received by the detector on the other side indicates the amount of oxygen that is bound to hemoglobin

Front 41

Normal SpO2

Back 41

95-100%

Front 42

WNL

Back 42

Within normal limits

Front 43

BID

Back 43

Twice a day

Front 44

TID

Back 44

Three times a day

Front 45

QID

Back 45

4 times a day

Front 46

QD

Back 46

Everyday

Front 47

Adlib

Back 47

At liberty