4 critical life functions
1. Ventilation
2. Oxygenation
3. Circulation
4. Perfusion
Findings that indicate patient's fluid intake exceeds urine
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1. Weight gain
2. Electrolyte imbalance
3. Increased hemodynamic pressures
4. Decreased lung compliance
Reading that indicates hypovolemia
CVP < 2 mmHg
Reading that indicates hypervolemia
CVP > 6 mmHg
Semicomatose
Responds only to painful stimuli
Lethargy or somnolence
Sleepy
Obtunded
Drowsy state, may have decreased cough or gag reflex
Orthopnea
Difficulty breathing in upright position (heart problem, CHF)
General malaise
Run down feeling, nausea, weakness, fatigue, headache (electrolyte imbalance)
Dyspnea
Feeling of SOB/difficulty breathing
Dysphagia
Difficulty swallowing, hoarseness
Peripheral edema
Pitting edema in arms and ankles
Causes of peripheral edema
Fluid accumulation from CHF and renal failure
Ascites
Accumulation of fluid in the abdomen
Causes ascites
Fluid accumulation from liver failure
Clubbing
Angling of nail bed of thumbs, first finger and toes
Causes of clubbing
Effects of chronic hypoxemia on fingers and toes
Venous distention
Engorged jugular veins during exhalation
Causes of venous distention
Engorged jugular veins from CHF and COPD
Capillary refill
Indicates peripheral circulation
Diaphoresis
Profuse, heavy sweating
Causes of diaphoresis
Heart failure, fever, infection, anxiety, nervousness, TB
Ashen/pallor skin
Skin color caused by anemia or blood loss
Erythema
Redness of skin
Causes of erythema
Skin colore caused by capillary congestion, inflammation, infection
Causes of Cyanosis
Skin color caused by hypoxia from increased amount of reduced hemoglobin
Kyphosis
Convex curvature of spine (lean forward)
Scoliosis
Lateral curvature of spine (side to side)
Eupnea
Normal RR, depth, rhythm
Causes of tachypnea
Hypoxia, fever, pain CNS problems
Cheyne-Stokes
Gradual increase in RR, then gradual decrease in RR and depth
Causes of Cheyne-Stokes
Breathing pattern caused by increased ICP, meningitis, narcotic OD
Kussmaul's
Increased RR, increased depth, irregular rhythm, labored breathing
Causes of Kussmaul's
Breathing pattern caused by metabolic acidosis, renal failure, diabetic ketoacidosis
Normal muscles of ventilation
Diaphragm, external intercostals, passive exhalation
Accessory muscle used to increase ventilation
Intercostal, scalene, sternocleidomastoid, pectoralis major, abdominal muscles (oblique, rectus abdominus)
Disease that causes hypertrophy of the accessory muscles
COPD effects on accessory muscles
Signs of respiratory distress in infants
Retractions, nasal flaring
Pulsus paradoxus
Pulse and blood pressure varies with respirations
Causes of tracheal shift toward pathology
Atelectasis, pulmonary fibrosis, pneumonectomy, diaphragmatic paralysis
Causes of tracheal shift away from pahtology
Massive pleural effusion, tension pneumothorax, neck/thyroid tumors, large mediastinal mass
Tactile fremitus
Vibrations felt by hand on chest wall
Resonant percussion note
Hollow sound, normal
Flat percussion note
Heard over sternum, muscles, or areas of atelectasis
Dull percussion note
Thudding sound heard over fluid filled organs like the heart and liver, pleural effusion, PNA
Tympanic percussion note
Drum-like sound heard over air filled spaces like stomach. Heard over lungs= air trapping
Hyperresonant percussion note
Booming sound indicates pneumothorax or emphysema
Egophony
Patient instructed to say "E", but sound like "A". [Show Less]