Health Assessment Exam 1

normal HR for infant/newborn

100-160bpm

normal HR for toddler

98-140bpm

normal HR for school-age

75-118bpm

normal HR for adolescent/adult

60-100bpm

how long should you count for respiratory rate for infants vs adults?

1 minute, 30 seconds and multiply by 2 unless irregular

Normal RR for infant/newborn

30-53bpm

normal RR for toddlers

22-37bpm

normal RR for school-age

18-25bpm

normal RR for adolescent/adult

12-20bpm

normal blood pressure for adults

less than 120, less than 80

elevated blood pressure for adults

120-129, less than 80

stage 1 hypertension for adults

130-139 or 80-89

stage 2 hypertension for adults

140 or higher or 90 or higher

hypertensive crisis for adults

greater than 180 or greater than 120

what does systolic mean

maximum force exerted on the arteries when the ventricles contract

what does diastolic mean

minimum amount of force exerted on the vessels when the ventricles relax

what could cause a false high bp on someone? (where is their arm, what about cuff bladder)

arm is below the level of the heart, cuff bladder is too narrow, cuff is too loose

what could cause a false low bp on someone? (where is their arm, what about the cuff bladder)

arm is above the level of the heart, cuff bladder is too wide, cuff is too snug

how big should the cuff bladder length and width be?

length should be 80-100% of arm circumference, width should be 40% of arm circumference

normal bp for infants

S:72-104

D:37-56

normal bp for toddler

S:86-106

D:42-63

normal bp for school-age

S:97-115

D:57-76

normal bp for adolescent

S:110-131

D:64-83

normal bp for adult

S: less than 120

D:less than 80

what is nociceptive pain

pain arising from somatic structures (bone, joint, muscle)

what is neuropathic pain

nerve pain (nerve damage)

what is referred pain

pain in area not associated with tissue damage

what is phantom pain

pain in area that is no longer there

when can you use the FACES pain assesment

for patients 3 years and up

when can you use FLACC for pain assesment

on nonverbal pediatric patients (2 months to 7 years)

when do you use NVPS for the pain assesment

nonverbal adult patients

where do you palpate to measure a infant’s HR

apex of the heart

what should the costal angle be

90-100 degrees

how to calculate pack years if they smoke a pack

1 times years

how to calculate pack years if they smoke a number of cigs a day

number of cigs times years divided by 20

what should you ask if someone has/is experiencing dyspnea

how day to day activities are affected

what should you check for during labored breathing

retraction of accessory muscles

what does an AP diameter of 1:1 mean, and what happens to the costal angle

barrel chest, increases

how do you assess thoracic expansion anteriorly vs. posteriorly?

Anterior: costal margin and xiphoid process

Posterior: T9 or T10, 10th rib

Ask to take a deep breath and assess symmetry

how to assess fremitus

place hands on anterior/posterior thorax and have patient repeat a phrase

where are bronchovesicular lung sounds heard

over the main stem bronchi

where are vesicular lung sounds heard

over periphery of lungs

where are bronchial lung sounds heard

over the trachea and thorax

what causes fine crackles

collapsed alveoli or air passage, often with fluid

what causes coarse crackles

secretions in larger bronchi, fluid overload

what should you do if you hear adventitious sounds when auscultating the lungs

ask patient to cough and see if you hear it again

when are crackles heard

on inspiration

describe rhonchi, when is it heard, what causes it

low-pitched, snoring or moaning sounds heard on expiration, COPD or airflow obstruction

describe wheezing, when is it heard, what causes it

high-pitched musical sounds heard on expiration, air passes through constricted passage

describe stridor, when is it heard, and what causes it

high pitched crowing or honking sound heard on inspiration and expiration, obstruction of the larynx or trachea

describe pleural friction rub, when it is heard, and what causes it

palpated as coarse, grating sensation heard on inspiration and expiration, inflamed parietal and visceral pleura rub against each other

what causes a pneumothorax

air or gas in the chest wall, causing collapse of the lungs

what is pleural effusion and hemothorax?

fluid or blood accumulating in the pleural cavity, often caused by trauma

what is atelectasis, what does it cause

collapsed alveoli, causes diminished or absent breath sounds