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4 critical life functions
- ventilation
- oxy
- circulation
- perfusion
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increase hr is a early sign of
hypoxemia
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perfusion=
blood pressure
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signs are things that you can
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symptoms are things that pt must
tell you
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pack years =
# of packs/day X # of years smoked
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normal urine output is
40 ml/hr
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what do you give to a pt if they have a decrease urine output
lasix/diuretics
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obtunded
drowsy state, may have decreased cough or gag reflex
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obtunded risk for
aspiration--must protect the airway
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orthopnea
difficulty breathing except in the upright position (heart problem, CHF)
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general malaise
- run down feeling
- nausea
- weakness
- fatigue
- headache
- decrease in potassium level
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dysphagia
- difficulty in swallowing
- hoarseness
risk for aspiration, must protect airway
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physical exam: what do you inspect with general appearance
- age
- height
- weight
- sex
- nourishment
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peripheral edema is a presence of
excessive fluid in the tissue known as pitting edema
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peripheral edema occurs in
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peripheral edema is caused by
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ascites is an accumulation of
fluid in the abdomen
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ascites is caused by
renal failure
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what to give pt to treat edema
diuretics
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clubbing of fingers is caused by
chronic hypoxemia
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clubbing of fingers is usually seen with pt that has
CF
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venous distention occurs with
CHF
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capillary refill indication of
peripheral circulation
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diaphoresis is a a state of
profuse/heavy sweating
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diaphoresis is usually seen in pt with
- heart failure
- fever, infection
- anxiety, nervousness
- tb (night sweats)
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jaundice
- increase in bilirubin in blood and tissue
- yellow
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jaundice comes from
liver problem
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jaundice appears mostly in the
face and trunk
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erythema
redness of the skin
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erythema may be due to
capillary congestion, inflammation or infection
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cyanosis
blue or blue-gray discoloration of skin and mucous membranes
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cyanosis is caused by
hypoxia from increased amt of reduced hemoglobin
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kyphosis
lean forward= a decrease of vt
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scoliosis
spine leads side to side
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kyphoscoliosis
combo of kyphosis and scoliosis
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barrel chest is a result of
air trapping in the lungs for a long time
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symmetrical chest movement occurs when
both sides of the chest move at the same time
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asymmetrical movement may indicate underlying patho:
- atelectasis- collapse lung, no chest rise, no air
- pneumothorax- lung collapse
- intubated pt with ETT in one lung
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eupnea
normal rr, depth and rhythm
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tachypnea
inc rr over 20 bpm
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bradypnea
dec rr less than 12 bpm
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apnea
cessation of breathing
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hypercapnea
- inc rr
- inc depth
- regular rhythm
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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
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kussmauls
- inc rr
- inc depth
- breathing sounds labored
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what causes kussmauls to happen
- metabolic acidosis
- renal failure
- diabetic ketoacidosis
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hypertrophy
increase in muscle size (neck)
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hypertrophy occurs with pt that has
COPD
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atrophy is a loss of
muscle tone
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atrophy occurs in
paralysis
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atrophy may be referred to as
cachectic
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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
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tachycardia indicates
hypoxemia
-
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bradycardia indicates
heart failure
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an increase hr is an adverse reaction, so what should you do
- stop therapy
- notify nurse and doctor
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tracheal deviation- palpation may be used to determine
tracheal position (midline)
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if the trachea is pulled TOWARDS the AFFECTED side
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if the trachea is PUSED to NORMAL side
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assess by percussion -- resonant
normal air filled lung (gives a hallow sound)
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assess by percussion -- flat is heard over the
sternum, muscle or areas of atelectasis
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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
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assess by percussion -- tympanic is heard over
air filled stomach
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assess by percussion -- hyperresonant is found in areas of the
lung where pneumothorax or emphysema is present
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normal breath sounds are also called
vesicular
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bilateral vesicular sounds =
normal sounds in both lungs
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abnormal breath sounds are also called
adventitious
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rales are also called
crackles
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coarse rales (rhonchi) means
large airway secretions
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wheeze is due to
- bronchospasm
- imp aereation
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stridor is due to
upper airway obstruction
subglottic swelling (epiglottitis)
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pleural friction rub is a
coarse grating or crunching sound (inflammation rub)
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what may you give to a pt with a pl friction rub
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normal heart sounds are called
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abnormal heart sounds are called
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what would you recommend for a pt with a abnormal heart sound
echocardiogram
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what do you use to measure BP
sphygmomanometer to measure cuff pressures
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adult normal BP
120/80 mmHg
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acceptable range of BP
90/60 to 140/90
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