Patient Assessment Module 1

Vocabulary flashcards covering patient assessment fundamentals, life functions, physical assessment techniques, and common medical terms from Module 1 lecture notes.

Patient Assessment

Mastering techniques to identify major respiratory diseases and set treatment goals, critical for NBRC board prep and real-world practice.

Four Life Functions (Prioritized)

1st: Ventilation, 2nd: Oxygenation, 3rd: Circulation, 4th: Perfusion.

Ventilation

Moving air in and out of the lungs.

Oxygenation

Getting oxygen into the blood.

Circulation

Moving blood through the body.

Perfusion

Getting oxygen into the tissue.

Order of Operations for Assessment

Step 1: Assessment by site and record, Step 2: Assessment by palpation (touch), Step 3: Additional lab testing (if problems can't be quantified).

Assessment General Rule (Severe Problem)

If a severe, life-threatening problem is found, stop and treat immediately; don't proceed with further assessment steps.

Indicators of Ventilation

Respiratory rate, tidal volume, chest movement, breath sounds, PaCO2, EtCO2.

Indicators of Oxygenation

Heart rate, color, sensorium, PaO2, SpO2.

Indicators of Circulation

Heart rate and strength, cardiac output.

Indicators of Perfusion

Blood pressure, sensorium, temperature, urine output, hemodynamics.

Alert and responsive

Normal level of consciousness.

Lethargic, somnolent, sleepy

Level of consciousness that may indicate sleep apneas or excessive O2 in a COPD patient.

Stuporous, confused, or inappropriate response

Level of consciousness suggesting drug overdose/intoxication and possible need for an advanced airway.

Semi comatose

Responds only to painful stimuli, possible indication for an advanced airway.

Obtunded

Drowsy state, may have decreased cough or gag, indication for an advanced airway.

Coma

Does not respond to painful stimuli, indication for an advanced airway.

Orthopnea

Difficulty breathing except in the upright position, possible congestive heart failure (CHF).

General malaise

Run down feeling, nausea, weakness, fatigue, headache, possible electrolyte imbalance.

Dyspnea

Shortness of breath.

Pack years formula

of packs/day x # of years smoked.

Edema

Swelling caused by fluid retention.

Clubbing (digital clubbing)

Enlargement of fingertips and toes, caused by chronic hypoxemia associated with chronic pulmonary disease.

Venous distention (JVD)

Jugular venous distension, occurs with CHF or during exhalation in patients with obstructive lung disease and air trapping.

Capillary refill

Indicates peripheral circulation; color should return in 3 seconds or less.

Diaphoresis

Heavy/profuse sweating, can occur with CHF, fever, anxiety, or night sweats in tuberculosis.

Ashen or pallor

Decrease in skin color, caused by anemia, blood loss, or vasoconstriction.

Jaundice

Yellow skin and eyes, caused by increased bilirubin.

Erythema

Red skin, caused by capillary congestion, inflammation, or infection.

Cyanosis

Blue skin, caused by hypoxia or reduced hemoglobin.

Normal Thoracic Configuration

Transverse diameter of the thorax exceeds the anteroposterior (AP) diameter, with a straight spine.

Barrel Chest

Premature increase of AP diameter of the thorax, commonly seen in COPD patients and associated with emphysema due to air trapping.

Pectus carinatum

Abnormal protrusion of the sternum.

Pectus excavatum

Depression of part or entire sternum, which can produce a restrictive lung defect.

Kyphosis

Spinal deformity with an abnormal anteroposterior curvature.

Scoliosis

Spinal deformity with a lateral curvature.

Kyphoscoliosis

Combination of kyphosis and scoliosis, potentially causing a severe restrictive lung defect due to poor lung expansion.

Symmetrical chest movement

Normal chest movement where both sides move equally with respiration.

Asymmetrical or unequal chest movement

May indicate underlying pathology such as right main stem intubation, atelectasis, pneumothorax, or flail chest.

Flail chest

Paradoxical chest movement where a section of the ribcage sinks in while the rest expands, caused by ribs broken in multiple areas.

Eupnea

Normal respiratory rate, depth, and rhythm (12-20 breaths/min).

Tachypnea

Increased respiratory rate (>20 breaths/min).

Bradypnea (Oligopnea)

Decreased respiratory rate (<12 breaths/min).

Apnea

Cessation of breathing.

Hyperpnea

Increased respiratory rate, increased depth, regular rhythm.

Hypopnea

Shallow or slow breathing.

Cheyne-Stokes breathing

Gradual increase then decrease in depth in a cycle lasting 30-180 seconds with periods of apnea up to 60 seconds.

Biot's breathing

Increased respiratory rate and depth with irregular periods of apnea, where each breath has the same depth.

Kussmaul's breathing

Increased respiratory rate (>20 breaths/min), increased depth, irregular rhythm, deep and labored breathing.

Accessory muscle activity

Use of internal intercostal, scalene, sternocleidomastoid, pectoral, or abdominal muscles, indicating increased work of breathing (WOB).

Retractions

Intercostal or sternal chest movement inward during inspiration, indicating severe airway obstruction or respiratory distress.

Dry or non-productive cough

May indicate a tumor in the lungs or restrictive disease.

Productive cough

May indicate an infection or chronic obstructive lung disease.

Mallampati Class I

Soft palate, uvula, fauces, pillars visible.

Mallampati Class II

Soft palate, uvula, fauces visible.

Mallampati Class III

Soft palate, base of uvula visible.

Mallampati Class IV

Hard palate only visible.

Normal Heart Rate

60 – 100 beats/minute.

Tachycardia

Heart rate >100 beats/minute, indicates hypoxemia, anxiety, stress.

Bradycardia

Heart rate <60 beats/minute, indicates heart failure, shock, or a code/emergency.

Paradoxical pulse/pulsus paradoxus

Condition where pulse pressure varies with respiration, indicating severe air trapping or obstructive shock (status asthmaticus, tension pneumothorax, cardiac tamponade).

Tracheal Deviation (towards side of lesser pressure)

Indicates pulmonary atelectasis, pneumonectomy, or diaphragmatic paralysis.

Tracheal Deviation (away from side of lesser pressure)

Indicates massive pleural effusion, tension pneumothorax, neck or thyroid tumors, or large mediastinal mass.

Tactile fremitus

Chest vibrations that can be felt by hand.

Vocal fremitus

Vibration of the voice on the chest wall.

Pleural rub fremitus

Grating sensation felt on the chest wall due to roughened pleural surfaces rubbing together.

Rhoncal fremitus

Vibration of secretions felt through the chest.

Crepitus

Rice crispy feeling of the skin due to bubbles of air under the skin, indicating subcutaneous emphysema.

Asymmetrical chest rise (palpation)

Indicates the need for further assessment including auscultation, tracheal deviation assessment, and percussion.

Resonant (percussion)

Normal hollow sound heard during diagnostic chest percussion.

Flat (percussion)

Less hollow sound, indicates atelectasis or fluid.

Dull (percussion)

Less hollow sound, indicates atelectasis or fluid.

Tympanic (percussion)

Hollower sound, indicates extra air as seen in pneumothorax.

Hyperresonant (percussion)

Hollower sound, indicates extra air as seen in pneumothorax.

Vesicular breath sounds

Sound of normal breath sounds, bilateral is normal.

Bronchial breath sounds (in periphery)

Heard over the trachea and bronchi, if heard in the lung periphery may indicate lung consolidation.

Diminished breath sounds

Quieter than normal, indicates absence of air movement due to restrictive process, severe obstructive process, or shallow breathing.

Egophony

Patient says 'E' but it sounds like 'A' upon auscultation, occurs with consolidation or pneumonia.

Bronchophony and whispered pectoriloquy

Terms referring to increased intensity or transmission of the spoken voice, indicating consolidation.

Crackles (rales)

Abnormal breath sounds indicating secretions or fluid.

Course crackles

Large airway secretions, patient may need suction or instructed to cough.

Fine crackles (moist crepitant rales)

Alveolar fluid, associated with CHF and pulmonary edema.

End inspiratory crackles (fine)

Associated with atelectasis.

Wheeze

Most commonly caused by bronchospasm; recommend bronchodilator therapy for diffuse/bilateral wheezing.

Unilateral wheeze

Indicates foreign body obstruction; recommend rigid bronchoscopy.

Stridor

High-pitched or crowing inspiratory sound caused by upper airway obstruction.

Marked or Severe Stridor

Requires immediate intubation, as seen in epiglottitis.

Croup or post-extubation stridor (moderate distress)

Treatment includes oxygen, cool mist aerosol, racemic epinephrine, heliox therapy.

Croup or post-extubation stridor (mild distress)

Treatment includes humidity, oxygen, racemic epinephrine PRN.

Pleural friction rub

Sounds like squeaking leather, associated with pleurisy, TB, pneumonia, pulmonary infarction, or cancer.

Normal Blood Pressure (adult)

120/80 mm Hg.

Increased BP (hypertension)

Indicates cardiac stress or hypoxemia.

Decreased BP (hypotension)

Indicates poor perfusion, hypovolemia, or CHF.

Fever

Causes respiratory alkalosis; requires investigation of cause and potential treatment with Tylenol or antibiotics.

Pulse Oximetry (SpO2)

Monitors oxygenation status by measuring redness of blood; normal range 93%-97% (COPD 88%-92%).

CO poisoning (SpO2 contraindication)

Carbon monoxide poisoning gives a false high SpO2 reading due to similar light absorption, making it an absolute contraindication for SpO2 monitoring.