patient assessment competencies

  1. define sensorium
    evaluation of the level of consciousness
  2. describes sensorium rating: confused
    exhibits slight decrease in consciousness, has slow mental responses, decreased or dulled perception, incoherent thoughts
  3. describes sensorium rating: delirious
    easily agitated, irritable, experiences hallucinations
  4. describes sensorium rating: lethargic
    sleepy, arouses easily, responds appropriately when aroused
  5. describes sensorium rating: obtunded
    awakens only with difficulty, responds appropriately when aroused
  6. describes sensorium rating: stuporous
    does not awaken completely, has decreased mental and physical activity, responds to pain and exhibits deep tendon reflexes and responds slowly to verbal stimuli
  7. describes sensorium rating: comatose
    unconscious, does not respond to stimuli or move voluntarily, exhibits possible signs of upper motor neuron dysfunction such as Babinski's reflex or hyperreflexia and loses reflxes with deep or prolonged coma
  8. apnea
    no breathing
  9. biot's respiration
    irregular breathing with long periods of apnea
  10. cheyne-stokes respiration
    irregular type of breathing - breaths increase and decrease in depth and rate with periods of apnea
  11. kussmaul's respiration
    deep and fast respirations
  12. apneustic breathing
    prolonged inhalation
  13. paradoxical respiration
    part or all of the chest wall moves in with inhalation and out with exhalation
  14. what is the physiologic response to hypothermia?
    shivering to generate heat and vasoconstriction to conserve heat
  15. what is the physiologic response to hypoxia?
    vasodilation to increase perfusion
  16. define pulsus paradoxus
    decrease of 15-20mmHg of BP during spontaneous inhalation
  17. define systolic pressure
    peak force exerted in teh arteries during contraction of the left ventricle
  18. define diastolic pressure
    the force remaining in the arteries after relaxation of the left ventricle
  19. define pulse pressure
    difference between systolic and diastolic pressures with a normal range between 35-40 mmHg
  20. what are the 3 physical factors of blood pressure
    interaction of the force of the left ventricle contraction, the systemic vascular resistance, and blood volume
  21. what is the physiologic response to a fever?
    increase of the metabolic rate, thereby increasing both oxygen consumptiong and carbon dioxide production. the increase in metabolic rate must be accompanied by an increase iun both circulation and ventilation to maintain homeostatis (increased heart and respiratory rates)
  22. what causes pulsus paradoxus?
    Indicates a significant drop in intrapleural pressure caused by increase work of breathing due to decreased compliance or increased airway resistance
  23. what are retractions in respect to the lungs?
    intermittent sinking inward of the skin overlying the chest wall during inspiration. Can be intercostal, supraclavicular, subcostal or substernal
  24. what is abdominal paradoxus?
    When the abdomen sinks inward during inspiration due to a fatigued diaphragm
  25. define stridor
    lung sound associated with rapid airflow through obstructed upper airways
  26. what is the physiological response to hypoxemia?
    vasoconstriction to incease blood flow resistance through the pulmonary vasculature which increases pulmonary workload
  27. what is the physiologic process of JVD
    hypoxemia that causes vasoconstriction to increase blood flow resistance which causes increased pulmonary workload which increase right ventricular workload and if persistent, can cause cor pulmonale and JVD
  28. what is bubbling and the lung base?
    crackling resulting from atelectasis, fibrosis, and pulmonary edema
  29. what could cause decreased resonance to precussion?
    pleural spaces filled with fluid, such as blood or water (consolidated alveolus)
  30. what can cause diminished or absent breath sounds?
    air blocking due to inflammation or mucus plugging
  31. when are bronchial sounds abnormal?
    when heard over peripheral lung regions and lung has increased tissue density
  32. what can cause hyperresonance?
    hyperinflation that can result from acute or chronic bronchial obstruction such as asthma or emphysema
  33. what breathing pattern will COPDers adopt?
    shallow breathing
  34. Pursed lip breathing
    A breathing technique used to maintain resistance in the airway during exhalation to enhance oxygenation, used by COPDers
Card Set
patient assessment competencies
chapter 15 competencies concerning patient assessment