Term
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Definition
general status, baseline, Monitor response, Observe trends, further action |
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Term
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Definition
Temperature, Pulse, Respirations, Blood pressure |
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Term
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Definition
Height, weight, LOC, level and type of pain, general appearance, Pulse oximetry |
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Term
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Definition
On admission, At beginning of each shift, Before procedure, Any time patient’s condition changes |
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Term
Normal Vital Signs for a patient depend on:, |
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Definition
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Term
Change in patient’s condition, |
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Definition
Comparing changes in Vital Signs, signs and symptoms, Establishing differential diagnosis by distinguishing between diseases of similar character by comparing their signs and symptoms |
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Term
Key to expert assessment:, |
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Definition
Constant awareness of change, Look, Listen, Touch, Reassess and analyze, Trend, trend, trend… by recording observations in the patient record (chart) for comparison |
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Term
Hypoxemia General clinical presentation |
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Definition
Impaired coordination or cooperation, Cool extremities, Diaphoresis (profuse sweating) |
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Term
Hypoxemia Sensorium (level of consciousness) |
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Definition
Decreased mental function, Impaired judgment, confusion, Loss of consciousness, Decreased pain perception |
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Term
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Definition
Increased rate and depth of breathing, Difficulty breathing, use of accessory muscles |
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Term
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Definition
Tachycardia , Arrhythmia (irregular heart rate), especially during sleep |
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Term
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Definition
Increased blood pressure initially |
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Term
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Definition
Routinely measured , Scales must be age appropriate and regularly calibrated |
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Term
If hospitalized = admission weight, |
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Definition
Document in kilograms (1 kg = 2.2 lb), every 24 to 48 hours, Fluctuations in weight may mean dehydration/fluid overload, Follow intake/output (I&O) |
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Term
General Clinical Impression, |
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Definition
levels of distress and severity of illness, personality, hygiene, culture, and reaction to illness, May dictate order of care, physical examination |
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Term
Cardiopulmonary distress suggested by:, |
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Definition
Labored, rapid, irregular, or shallow breathing, Coughing, choking, wheezing, chest pain, cyanosis |
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Term
Anxiety may be suggested by:, |
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Definition
Restlessness, fidgeting, tense look, difficulty communicating |
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Term
Pain may be suggested by:, |
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Definition
Drawn features, moaning, shallow breathing, guarding, refusal to take deep breath |
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Term
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Definition
Hearing, smelling, seeing, touching, perception |
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Term
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Definition
Slight development, body linear and delicate with sparse muscular development |
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Term
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Definition
Soft, roundness throughout the body; large trunk and thighs with tapering extremities |
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Term
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Definition
Preponderance of muscle, bone, and connective tissue, with heavy hard physique of rectangular outline (between endomorphic and ectomorphic) |
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Term
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Definition
Average height; well-developed musculature, wide shoulders, flat abdomen; oval face |
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Term
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Definition
Short, stocky, may be obese; shorter, broader chest; thicker abdominal wall; rectangular-shaped face |
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Term
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Definition
Tall, willowy, musculature poorly developed; long, flat chest; abdomen may sag; long neck; triangular face |
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Term
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Definition
Exaggeration of hyposthenic body type |
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Term
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Definition
Profound and marked malnutrition; wasting; ill health |
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Term
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Definition
Weak, feeble, lack of strength (with weakness and loss of energy) |
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Term
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Definition
Physical and developmental delay or retardation in infants and children; seen in children with illness but more often in children with psychosocial or maternal deprivation |
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Term
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Definition
“Fifth vital sign”, Pain level scale 1-10 to quantify subjective measure, facial expressions and verbal description, Find linked symptoms, alleviating/aggravating factors, Patients with chronic lung disease often complain of shortness of breath when experiencing pain |
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Term
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Definition
Measure cerebral oxygenation, Evaluation of time, place, and person (“Oriented × 3”), Deterioration from restlessness to coma, Status of sensorium directs treatment plan, Glasgow Coma Scale |
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Term
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Definition
Normal: 98.6°F (37°C), range (97°-99.5°F), variations (1°-2°F) , Lowest in morning; highest late afternoon, Normal increase from exercise, ovulation, pregnancy, Balance of heat production and loss, Dissipation through sweating, peripheral vasodilation, hyperventilation |
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Term
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Definition
Elevation of temperature, From normal activities (exercise) = hyperthermia, From disease (infection) = fever |
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Term
Newborns, AIDS, Transplant recipients on anti-rejection drugs may not be able to generate…. |
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Definition
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Term
Ratio of fever temperature increase per degree Celsius to O2 and CO2 production |
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Definition
IO2 consumption and CO2 production increase 10% for each 1° C elevation in body temperature , Patients with limited respiratory function may develop respiratory failure in response to fever |
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Term
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Definition
Body temperature below normal, Head injury, cold exposure, Reduced O2 consumption and CO2 production, Slow and shallow breathing |
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Term
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Definition
body core temperature, Rectal in comatose patients, Axillary: safe and accurate in infants and small children, 1°F lower than oral, 2°F lower than rectal |
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Term
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Definition
Evaluate rate, rhythm, and strength, Normal rate: 60-100 beats/min adult, The younger the patient, the faster the rate, Arrhythmia = irregular rhythm |
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Term
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Definition
>100 beats/min, Anxiety, hypoxemia, exercise, fever, anemia |
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Term
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Definition
<60 beats/min, Diseased heart, athletes, medication side effects |
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Term
Measurement of Pulse Rate, |
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Definition
Radial and brachial artery are most common sites, Central pulses (Carotid, femoral) if hypotension present |
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Term
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Definition
a rhythm coupled in pairs |
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Term
Volume of the pulse can be described as |
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Definition
Bounding, Full, Normal, Weak, Thready, Absent |
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Term
Pulse deficit = auscultated – palpated , |
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Definition
A difference in count between heartbeat and peripheral pulse. Pulse is not reaching the periphery. This can occur in irregular heart rhythms, atrial fibrillation, and with pacemakers |
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Term
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Definition
A pulse whose Strength decreases with inspiration |
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Term
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Definition
Alternating strong and weak pulses |
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Term
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Definition
Absence of spontaneous ventilation |
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Term
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Definition
Normal rate and depth of breathing |
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Term
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Definition
Less than normal rate of breathing |
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Term
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Definition
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Term
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Definition
Decreased depth of breathing |
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Term
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Definition
Increased depth of breathing with or without an increased rate |
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Term
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Definition
Normal rate and depth of breathing with periodic deep and audible breaths |
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Term
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Definition
Irregular breathing with periods of apnea |
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Term
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Definition
Force exerted against arterial walls, Systolic: peak force during ventricular contraction, Diastolic: force during ventricular relaxation |
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Term
Pulse pressure Equation = , |
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Definition
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Term
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Definition
Normal: 35-40 mm Hg, <30 mm Hg: poor peripheral perfusion |
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Term
Blood Pressure normal & normal range |
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Definition
Normal: 120/80 mm Hg, Systolic normal range 140-90, Diastolic normal range 90-60 |
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Term
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Definition
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Term
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Definition
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Term
Measurement of Blood Pressure, |
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Definition
Length of the bladder should cover: , 80% distance around arm in an adult, 100% distance around arm in a child, Too wide a bladder: underestimate pressure, Too narrow/short: overestimate pressure |
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Term
Auscultatory Blood Pressure Measurement, |
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Definition
Korotkoff sounds: blood flow in arteries resumes, 1st sound = systolic pressure, Disappearance of sounds = diastolic pressure |
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Term
Effects of the Respiratory Cycle on BP, |
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Definition
Systolic pressure decreases (2-4 mm Hg) with inspiration, If it drops >10 mm Hg: pulsus paradoxus, Asthma, cardiac tamponade are common causes, Pulsus paradoxus in asthma signifies more severe case |
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Term
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Definition
To establish a rapport with patient, To obtain essential diagnostic information, To monitor changes in the patient’s symptoms |
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Term
Common questions to ask for each symptom |
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Definition
When did it start?, How severe is it?, Where on the body is it?, What seems to make it better or worse?, Has it occurred before? |
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Term
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Definition
Occurs when work of breathing is too high and/or when drive to breathe is elevated, Degree evaluated by asking level of exertion at which it occurs. |
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Term
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Definition
dyspnea in the reclining position; associated with CHF |
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Term
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Definition
dyspnea when moved to the upright position |
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Term
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Definition
cough receptors in airways are stimulated by inflammation, mucus, foreign material, or noxious gases |
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Term
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Definition
high Raw, poor lung recoil, weak muscles |
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Term
Patients with airways disease often have |
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Definition
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Term
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Definition
Mucus from lower airways but expectorated through mouth is called “sputum.”, Change in sputum color, viscosity, or quantity may mean infection |
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Term
Sputum that has pus cells in it is said to be |
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Definition
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Term
Sputum that is foul smelling is |
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Definition
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Term
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Definition
Coughing up blood or bloody sputum from the airways, Most often occurs in patients with a history of lung disease, Common causes include bronchitis, lung cancer, tuberculosis, trauma, and pulmonary embolism |
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Term
Vomiting blood from the gastrointestinal tract is known as |
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Definition
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Term
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Definition
Pleuritic chest pain is located laterally or posteriorly, sharp in nature, increases with deep breathing, Nonpleuritic chest pain is located in center of chest and may radiate to shoulder or arm; often caused by coronary artery disease; then called angina |
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Term
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Definition
Defined as an elevation of body temperature due to disease, Most often due to viral infection; also seen with pneumonia, tuberculosis, and some cancers |
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Term
Fever with a cough suggests |
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Definition
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Term
Fever increases the body’s need for |
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Definition
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Term
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Definition
Swelling of the ankles is most often due to heart failure., Patients with chronic hypoxemic lung disease usually develop right heart failure (cor pulmonale) due to pulmonary hypertension, Pedal edema may indicate the need for oxygen therapy. |
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Term
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Definition
Level of consciousness and orientation to time, place, and person , Vital Signs = RR, HR, BT, BP |
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Term
Nasal flaring is often seen in |
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Definition
Infants with respiratory distress and an increase in the WOB |
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Term
Pursed-lip breathing is seen in patients with |
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Definition
COPD who have obstruction of the small airways |
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Term
The trachea may shift left or right with |
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Definition
upper lobe abnormalities or mediastinal tumors |
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Term
Jugular venous distention is seen in patients with |
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Definition
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Term
Enlarged lymph nodes in the neck may occur with |
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Definition
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Term
A barrel chest is seen with |
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Definition
emphysema, indicates poor lung recoil |
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Term
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Definition
abnormal protrusion of the sternum |
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Term
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Definition
abnormal depression of the sternum |
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Term
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Definition
abnormal curvature of the spine; often causes severe restrictive lung disease |
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Term
Rapid/shallow breathing is consistent with |
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Definition
Restrictive lung diseases |
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Term
A prolonged expiratory time is consistent with |
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Definition
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Term
Upper airway obstruction often causes a |
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Definition
prolonged inspiratory time |
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Term
Deep and fast breathing is consistent with |
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Definition
Kussmaul breathing (ketoacidosis) |
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Term
Tactile (or vocal) Fremitus is a |
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Definition
vibration felt on the patient's chest during low frequency vocalization |
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Term
Tactile fremitus is increased with |
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Definition
pneumonia and atelectasis |
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Term
Tactile fremitus is reduced with |
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Definition
emphysema, pneumothorax, and pleural effusion |
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Term
A unilateral reduction in chest expansion is consistent with |
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Definition
pneumonia or pneumothorax |
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Term
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Definition
Resonance of the chest is evaluated with percussion, place middle finger of one hand firmly against patient's chest, With end of the opposite middle finger, strike first finger, Categorize what you hear as normal, dull, or hyperresonant |
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Term
Lung sounds come in two varieties: |
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Definition
breath sounds and adventitious lung sounds |
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Term
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Definition
the abnormal sounds superimposed on the breath sounds (crackles and wheezes) |
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Term
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Definition
pneumonia or pleural effusion |
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Term
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Definition
emphysema or pneumothorax |
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Term
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Definition
heard directly over the trachea and created by turbulent flow; loud and high-pitched |
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Term
Increased breath sounds are often called |
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Definition
“bronchial” breath sounds |
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Term
Bronchovesicular breath sounds = |
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Definition
heard around the sternum; softer and slightly lower in pitch |
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Term
Vesicular breath sounds = |
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Definition
heard over lung parenchyma; represent attenuated turbulent flow sounds from the larger airways; very soft and low-pitched |
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Term
Breath sounds reduced with |
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Definition
shallow breathing and when attenuation is increased (when the lung is hyperinflated as in emphysema) |
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Term
Breath sounds Increased when |
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Definition
attenuation is reduced and the turbulent flow sounds pass through the lung faster (pneumonia) |
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Term
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Definition
Come in two varieties: continuous “wheezes” and discontinuous “crackles”, A continuous ALS heard over the upper airway is called “stridor.” |
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Term
Wheezes are consistent with |
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Definition
airways obstruction; monophonic wheezing indicates one airway is affected, and polyphonic wheezing indicates many airways are involved |
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Term
Fine crackles are produced by |
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Definition
the sudden opening of small airways in the lung with deep breathing; they are heard with pulmonary fibrosis and atelectasis |
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Term
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Definition
abdomen is inspected and palpated for distention and tenderness |
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Term
enlarged liver (hepatomegaly) is consistent with |
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Definition
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Term
Abdominal paradox is present when |
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Definition
abdomen sinks inward during inspiration; this is sign of diaphragm fatigue |
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Term
Examination of the Extremities |
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Definition
Digital clubbing is not common but seen in large variety of chronic conditions: congenital heart disease, bronchiectasis, various cancers, interstitial lung diseases |
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