ch 2

Question 1

what are the 4 primary vital signs and what is considered the fifth

Answer 1

-body temp
-pulse
-RR
-blood pressure
-SpO2 (pulse oximetry)

Question 2

what is the normal core body temp in both *C and *F?

Answer 2

37C
98.6F

Question 3

how does the body respond physiologically to an increase or decrease in temp?

Answer 3

-increase cause vasodilation
-decrease cause vasoconstriction

Question 4

what are the possible causes and clinical signs of hypothermia?

Answer 4

Causes
-excessive heat loss
-inadequate heat production to counteract heat loss
-impaired hypothalamic thermoregulation

Clinical sign
-decreased pulse and RR
-severe shivering
-pale,bluish waxy skin
-hypotension
-disorientation
-drowsiness or unresponsive
-coma

Question 5

what is therapeutic hypothermia and why is it used

Answer 5

induce hypothermia for brain protection
-reduction in brain metabolic rate
-reduction of cerebral blood flow
-reduction of the critical threshold for oxygen delivery

Question 6

identify the 4 commonly used sites for measuring body temp. which are considered core temp sites?

Answer 6

-oral
-rectum (core)
(ear)-tympanic (core)
(armpit)-axilla

Additional
Esophagus- core
Pul.artery-core

Question 7

what is the normal pulse rate for adults

Answer 7

60-100

Question 8

define bradycardia and tachycardia

Answer 8

bradycardia-low HR <60

tachycardia-fast HR >100

Question 9

what aspect of the pulse are evaluated during assessment

Answer 9

-rate
-rhythm-irregular/regular
-strength-strong/weak/thready/bounding

Question 10

how does pulse strength differ from pulse rate

Answer 10

pulse rate-# of heartbeats per minute

pulse strength- strength of pulse

Question 11

what is the normal adult respiratory rate

Answer 11

12-20

Question 12

how does temp and oxygenation status influence respiratory rate

Answer 12

increase temp decrease O2–>increase RR to maintain homeostasis

Question 13

define breathing pattern:
eupnea

Answer 13

noraml rate and rhythm

Question 14

define breathing pattern:
bradypnea

Answer 14

slow breathing <12

Question 15

define breathing pattern:
tachypnea

Answer 15

rapid breathing >20

Question 16

define breathing pattern:
apnea

Answer 16

no respirations- respiratory arrest & death

Question 17

define breathing pattern:
cheyne-stoke

Answer 17

faster and deep–>slow and shallow with apnea

Question 18

define breathing pattern:
biots

Answer 18

fast, deep w abrupt pauses of apnea

Question 19

define breathing pattern:
kussmaul

Answer 19

increase rate and depth-metabolic acidosis-diabetic ketoacidosis

Question 20

define breathing pattern:
hyperventilation

Answer 20

increase rate and depth-respiratory alkalosis

Question 21

define breathing pattern:
hypoventilation

Answer 21

decrease rate and depth- respiratory acidosis

Question 22

what conditions are commonly associated with kussmauls and cheyne-stokes respirations

Answer 22

kussmaual-metabolic acidosis-diabetic ketoacidosis

cheyne-stoke- heart failure, stroke, brain injury

Question 23

what is the normal range for systolic and diastolic blood pressure

Answer 23

systolic- 90-140
diastolic- 60-90

Question 24

define pulsus paradoxus and list a condition where it may be observed

Answer 24

systolic blood pressure drops 10mmHg on inspiration

conditions: status asthmaticus
*decrease BP during inspiration
*increase BP during expiration

Question 25

what does a significant drop in systolic blood pressure during inspiration indicate

Answer 25

*status asthmaticus *severe asthma *COPD

Question 26

what are the normal SpO2 ranges for healthy adults and COPD

Answer 26

normal: 92-99% COPD: 88-92%

Question 27

list early and late signs of inadequate oxygenation from respiratory perspective

Answer 27

*tachypnea (early) *dyspnea on exertion (early) *dyspnea at rest (late) *use of accessory muscles (late) *intercostal retraction (late) *takes breath b/w each word or sentence(late)

Question 28

list early and late signs of inadequate oxygenation from cardiovascular perspective

Answer 28

*tachycardia (early) *mild hypertension (early) *arrhythmia ( early/late) *hypotension (late) *cyanosis (late) *skin is cool or clammy (late)

Question 29

why is pulse oximetry considered the 5th vital sign

Answer 29

Tells immediate oxygenation

Question 30

what are the 4 techniques used during a physical chest exam

Answer 30

-inspection -palpation -percussion -auscultation

Question 31

during palpation, what are you assessing for

Answer 31

-symmetry of chest expansion -position of trachea -skin temp, muscle tone -areas of tenderness, lumps, tactile& vocal fremitus

Question 32

how is chest excursion evaluated

Answer 32

symmetry of chest expansion by lightly placing each hand over pt posterior lateral chest so thumbs meet midline -t8-t10 level

Question 33

what is tactile fremitus and what conditions increase and decrease it

Answer 33

vibration or palpations felt over chest -increase fremitus-lung consolidation-air in lung replaced with:pus,blood,inflammatory exudate -decrease fremitus- excess air in lungs-increase thickness of chest wall *pnemithorax,pleural effusion

Question 34

what percussion sounds are expected with: consolidation, pneumothorax, pleural effusion, COPD

Answer 34

dull percussion: consolidation,pleural effusion Hyperresonant percussion: pneumothorax, COPD

Question 35

what are normal breath sounds

Answer 35

- vesicular- soft/low pitch, continuous on inspiration /expiration

Question 36

what are abnormal breath sounds

Answer 36

-fine crackles -medium crackle or coarse crackle -wheeze -bronchial breath sounds -stidor -pleural friction rub -diminished breath sounds

Question 37

match abnormal breath sounds with conditions it may indicate: fine crackles

Answer 37

pneumonia, heart failure

Question 38

match abnormal breath sounds with conditions it may indicate: coarse crackles

Answer 38

pulmonary edema, chronic bronchitis

Question 39

match abnormal breath sounds with conditions it may indicate: wheeze

Answer 39

asthma, copd

Question 40

match abnormal breath sounds with conditions it may indicate: bronchial breath sounds (alveoli)

Answer 40

lung consolidation

Question 41

match abnormal breath sounds with conditions it may indicate: stridor

Answer 41

upper airway obstrustion

Question 42

match abnormal breath sounds with conditions it may indicate: pleural friction rub

Answer 42

pleura surrounding lungs becomes inflamed & rub together during inspiration and expiration

Question 43

match abnormal breath sounds with conditions it may indicate: diminished breath sounds

Answer 43

conditons: atelectasis, pleural effusion

Question 44

how should you document adventitious lung sounds

Answer 44

-intensity or loudness- faint, soft,mild, moderate loud -part of respiratory cycle

Question 45

what information should always be included when charting abnormal breath sounds

Answer 45

-mention of ALS(adventitious lung sounds) occur during respiratory cycle -magnitude of ALS -precise location over chest where ALS are auscultated

Question 46

what is the clinical significance of fine crackles heard at the bases during inspiration

Question 47

what is pursed lip breathing and why might a patient use it

Answer 47

-exhalation through mouth w/lips pursed together to slow exhalation -stabilizes airway -offsets air trapping -better gas mixing breathing patterns *seen in COPD pts

Question 48

what does it mean if a patient uses accessory muscles or shows intercoastal retractions

Answer 48

Late sign of O2 deprivation

Question 49

what are some common caused of diminished breath sounds

Answer 49

Pneumothorax,pleural effusion, obesity

Question 50

how do you distringuish between abnormal and absent breath sounds

Answer 50

Abnormal: extras sounds that sound abnormal Absent: lack of airflow-no sound over area during auscultations

Question 51

how might breath sounds differ between a patient with pneumonia and one with a pneumothorax?

Answer 51

pneumonia-fine crackles-increase fremitus dull perfusion pneumothorax-hyperresonant decrease breath sounds