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78 Cards in this Set
- Front
- Back
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Erythema
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Redness of the skin. Maybe due to inflammation or infection
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Cyanosis
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Blue-gray discoloration of skin and mucous membranes.
Caused by increased amount of reduced hemoglobin. 5gms% of reduced hemoglobin |
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Chest Configuration
Normal |
A-P diameter is less than transverse diameter
A-P diameter increases with age with COPD, barrel Chest |
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Spinal deformities
Pectus Carinatum |
Sternal protusion
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Spinal deformities
Pectus Excavatum |
Sternal depression
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Spinal deformities
Kyphosis |
A-P Curvature
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Spinal deformities
Scolisis |
lateral curvature
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Spinal deformities
Kyphoscoliosis |
both lateral and A-P curvature
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Barrel Chest
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A result of air trapping in the lungs for long periods of time
Increase in A-P diameter |
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General Appearance
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Age, Height, Weight, Sex, Nourishment
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Peripheral Edema
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Presence of excessive fluid in the tissue (pitting edema)
Primarily in arms and ankles CHFand Renal Failure Rated a +1 +2 +3 etc |
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Clubbing of the finger and toes
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Abnormal enlargement of distal phalanges Usually associated with advanced chronic pulmonarey disease
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Venous distention
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Occurs with congestive heart failur Seen with patients with obsturctive lung disease.
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Capillary Refill
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Indication of peripheral circulation.
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Skin Color
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Normal, pink, tan, brown, black.
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Skin Color
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Abnormal decrease in color.
Ashen, pale due to anemia or acute blood loss. |
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Skin Color
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Jaundice; Increase in bilirubin in blood and tissue. Occurs in liver diseases and hemolytic states
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Movement of the Chest/diaphragm
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Normal;Sequence of lung expansion, Abdominal protrusion, Lateral costal expansion, Upper chest expansion Inspiratory muscles. Diaphragm and External Intercostals Expiration is passive
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Unequal Movement
Paradoxical Breathing |
Abdomen retracted during inspiration, usually indicative of fatique of the diaphragm.
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Use of Accessory Muscles of Inspiration
Indicative of increased work of breathing |
Scalenes
Pectoralis major and minor Trapezius Sternocleido mastoid |
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Use of Accessory Muscles of Expiration
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Indicative of increased work of breathing. Used for forced expiration. Muscles of back, thorax, or abdomen. Used to pull thorax down during paradoxical breathing
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Eupnea
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Normal breathing pattern
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Tachypnea
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Abnormal rapid rate of breathing. >20 bpm
Hypermetabolic and hypoxic states |
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Bradypnea
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Abnormal slow rate of breathing <12bpm
Brain Injury Drug overdose |
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Apnea
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No breathing for > 10 or more seconds
Cardiac Arrest Obstructive anatomic blockage |
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Hyperpnea
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Deep, rapid, labored respiration
Exercise, pain,fever, hypoxemia |
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Cheyne-Stokes
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Irregular type of breathing
Breaths increase and decrease in depth and rate with periods of apnea. Siseases of CNS, CHF |
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Biots
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Irregular breathing with long periods of apnea. Increased intracranial pressure
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Kussmal's
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Deep and fast, sighing respirations Diabetic ketoacidosis
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Apneusis
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Prolonged inspiration. Brain damage
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Retractions
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Visible sinking in of the soft tissues of the chest between and around the ribs
Occurs with increased inspiratory effort. |
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Nasal Flaring
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Dilation of the alar nasal on inspiration An early sign of an increase in ventilatory demands and work of breathing;especially in infants
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Breathing Pattern Associated with Restrictive Processes
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Rapid and shallow pattern
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Breathing Pattern Associated with Obstructive Processes
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Slow, deep breaths with long expiration
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Palpation
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Touching the chest wall to evaluate underlying lung structure and function
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Assymmetrical Chest Movement
Assessment of symmetry of chest expansion. |
thumbs should move equally during inspiration.
Bilateral reduction'neuromuscular disease, COPD Unilateral reduction;lovar consolidation,atelectasis, pleural effusin and pneumothorax. |
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Tactile Fremitus
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Vibrations produced by vocal cords during phnation are transmitted down the tracheobronchial tree and through the alveoli to the chest wall Patient says99 assess chsst wall with palm or ulnar aspect of hand
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Incresed fremitus
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Results forem tranmission of the vibration through a more solid medium. Pneumonia , lung turmor, atelectasis
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Decreased fremitus
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Results with ofesity, overly muscular patients and when the pleural space is filled with air of fluid ( blocks transmission from bronchus pneumothorax pleural effusion mucus plug
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Diffuse fremitus
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COPD Muscular or obese chest wall
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Rhonchial fremitus
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Passage of air through airways containing thick secretions Associated with course, low-pitched sound that is audible without a stethoscope May clear with productive cough
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Subcutaneous emphysema
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when air leaks from the lung into the subcutaneous tissue, fine beads of air will produce a crackiling sound and sensation when palpated
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Shift of Trachea Away from affected side
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Pneumothorax and pleural effusion
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Shift of Trachea toward affected side
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atelectasis and consolidation
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Percussion
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Art of tapping on a surface in an effort to evaluate the underlying structureProduces a sound and vibration Place middle finger firmly in chest,parallel to ribs'tip of middle finger of other hand strikes the finger near base of terminal phalanx
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Compare sides of chest
Normal Resonance |
Normal is called normal resonance Heard easily, low in pitch
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Compare sides of chest
Increased Resonance |
Lower in pitch and louder in intensity (tympanic) Hyperinflated lungs. Pneumothorax
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Compare sides of chest
Dull Note |
Sull, flat sound (opposite of resonance) is a high pitched short duration, and not loud Increased density such as consolidation of tissue from pneumonia, atelectasis, pleural fluid
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Diaphragmatic Excursion
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Can be assessed by percussion
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Ascultation
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Listening for sounds, Pitch, intensity, distinctive characteristics, and duration of inspiration vs expiration
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Bronchial
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Heard over trachea loud, tubular, high-pitched, expiratory component equal to inspiratory component
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Bronchovesicular
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Heard around sternum and between scapula not as loud as bronchial, slightly lower in pitch, equal E and I
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Vesicular
heard over lung fields |
heard over lung fields lungs sounds heard over the chest are primarily generated by turbulent flow in the larger aiways, this sound transmitted through lung and chest wall Filtered bronchial sounds muffled because filtered by normal lung tissue soft, muffled, lower in pitch and intensity, heard primarily during inspiration
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Harsh
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Abnormal bronchial sounds may be heard over lung perophery when the lung tissue increases in density as ocurs in atelectasis and pneumonia (filtering effect lost) Increased intensity
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Diminished
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Intensity reduced when breath is shallow or slow
transmission reduced when air or fluid is in the pleural space obesity hyperinflated lungs obstructed airways |
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Wheezes
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High pitched continuous abnormal sounds May also be used for low pitched continuous sounds (Ronchi)Generated by the vibration of the wallof a compressed airway as air passes through at high velocity Reduction in airway due to bronchospasm, mucosal edema foreign objects. Caused by asthma, CHF bronchitis. the tighter the compression the higher the pitch
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Rhonchi (low pitched wheeze)
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Low pitched continuous sounds are usually associated with mucous in the airway. Rapid airflow through obstructed airway caused by excess sputum, bronchospasm Caused by bronchitis asthma
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Crackles
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Siscontinuous lung sounds Also called rales
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Coarse Crackles
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Produced by movement of excessive secretions or fluid in the airways as air passes through;Heard during expiration and inspiration. Many clear with coughing Caused by Bronchitis Respiratory Infections
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Fine Crackles
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Produced when collasped airways pop open during inspiration. Peripheral airway openion heard during end inspiration. Atelectasis fibrosis pneumonia pulmonary edema all related to a decrease in lung volumes.Proximal bronchi opening heard during early inspiration. Larger airways may close during expiration when there is an increase in bronchial compliance COPD
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Pulse Oximetry
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Used to measure the amount of oxygen bound to hemoglobin in the blood
Low blood pressure,nail polish and cold affect reading Normal is>/92% CODP patients88-92% Disfunctional Hemoglobin or carboxyhemoglobin may give inaccurate results |
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Body Temperature
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Measurement of the balance between heat loss and heat produced by the body (muscle movement, digestion of food)
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Conditions that increase body temperature
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Exercise, Digestion of food,Increased environmental temperature, Illness, Infection, excitement anxiety
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Conditions that decrease body temperature
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Sleep, Fasting, exposure to cold, depression decreased muscle acitivity, illness mouth breathing
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Gas Exchange Units
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Terminal Brochole,Pulmonary arteriole,respiratory brochole, alveolar ducts,alveolar sacs, alveoli,alveolar capilary
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Depth of Respiration
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Normal depth is noexaggerated and effortless
Hypoventilation is shallow with minimal chest movement Hypernea is with greater volum/depth |
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Agonal
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End of life /take a deep breath and exhale and then nothing
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Arteries
Capillaries Veins |
Deliver blood to tissues
Actual exchange of gases, nutrients and waste products Reture deoxegenated blood and wasteproducts back to heart |
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Factors that affect heart rate
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Age,time of day,gender(woman higher)body build, exercise, stress and emotions, body temperture(chemical release, infection) blood volume drugs
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Pulse Volume
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pulse strength or amplitude reflects the stroke volume of the heart and the peripheral vascular resistance
Ranges from absent to bounding Reported on a 3 to 4 point scale |
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Palpating a pulse
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Place the pad of your first, second or third finger on the site of the radial pulse
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Pulse sites
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temperal,carcoid,femoral,dorsalic,posterior tibal,popliteal,radial,brachial
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Korotkoff Sounds
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Blood flow through a obstructed artery creates vibrations and sounds between the systole and diastole
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Occulude the artery
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Blood pressure cuff
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Isolation Precautions
Contact |
Private room if possible, gloves, wash hands with antimicrobial agent after glove removal , gown when entering ,removing gown before leaving. limit transport and dedicate single patient to equipement
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Droplet Precautions
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Private room if possible, Mask unpon entering room and limit transport of patient
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Airborne Precautions
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Private room with Hepa filter,(negative pressure) Tuberculosis wear an respiratorN95, when entering room,Measles, Chiclen pox no entry if suceptible or wear respiratorN95.patient wear surgical mask if must move
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Pediatric RSV Precautions
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Private room , Wash hands unpon leaving, Mask and goggles or face shield, gloves when entering, Limit patient transport,Dedicate single care equipment to patient, charts remain outside, clipboards inside room
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