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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