Patient Medical Record Assessment

Questions and Answers

What is the normal resting respiratory rate for an adult?

12 to 20 breaths/min (correct)

30 to 40 breaths/min

20 to 25 breaths/min

8 to 12 breaths/min

Which of the following conditions is most likely associated with tachypnea?

Opiate narcotics

Hypothermia

Severe myocardial infarction

Anxiety (correct)

What is apnea defined as?

Rapid rate of breathing

Absence of spontaneous ventilation (correct)

Normal rate and depth of breathing

Decreased depth of breathing

What is clinically significant regarding blood pressure?

A sudden drop associated with symptoms Signup and view all the answers

What happens when the cuff pressure exceeds the systolic blood pressure?

Blood flow is occluded Signup and view all the answers

How should the respiratory rate be measured when it is regular?

Count for 30 seconds x 2 Signup and view all the answers

Which of the following errors can lead to erroneously high blood pressure readings?

Applying the cuff too tightly Signup and view all the answers

What does hypertension refer to in terms of blood pressure?

Systolic BP of 140/90 mm Hg or higher Signup and view all the answers

What does shock primarily relate to in terms of organ demands?

Inadequate O2 and nutrient delivery Signup and view all the answers

Which of the following is not a known cause of bradypnea?

Stress and anxiety Signup and view all the answers

What is the normal range for diastolic blood pressure?

60 to 90 mm Hg Signup and view all the answers

What should be considered before acting on SpO2 readings?

Sufficient response time Signup and view all the answers

What is the last sound heard during blood pressure measurement intended to signify?

Diastolic pressure Signup and view all the answers

What is the difference between systolic and diastolic pressure called?

Pulse pressure Signup and view all the answers

In pulse oximetry, what does it reflect?

The patient's clinical condition Signup and view all the answers

Which method is NOT part of the physical examination process?

Evaluation of lab results Signup and view all the answers

What is the primary purpose of reviewing a patient's medical record before providing respiratory care?

To ensure all respiratory procedures are supported by a physician order Signup and view all the answers

Which of the following statements about handwashing is incorrect?

Handwashing is optional if using alcohol-based gels. Signup and view all the answers

Which component is NOT considered a factor affecting communication between the respiratory therapist and the patient?

Patient's online history Signup and view all the answers

When measuring vital signs, which of the following is NOT one of the classic vital signs?

Blood glucose level Signup and view all the answers

Which of the following methods is NOT a way to measure body temperature?

Sublingual Signup and view all the answers

Pulsus paradoxus, a significant decrease in pulse strength during inspiration, is most commonly associated with which condition?

Chronic obstructive pulmonary disease Signup and view all the answers

In interviewing a patient, what is an essential factor in establishing rapport?

Employing neutral questions Signup and view all the answers

What does an irregularly irregular pulse rhythm most likely indicate?

A concerning medical condition Signup and view all the answers

Which of the following is a common sign of fever in a patient?

Increased body temperature exceeding 38.3°C Signup and view all the answers

What does the term 'bedside assessment' typically refer to?

A preliminary assessment at the patient's location Signup and view all the answers

Which of the following vital signs indicates bradycardia?

Heart rate of 55 beats/min Signup and view all the answers

What is the correct function of the Glasgow Coma Scale?

To assess level of consciousness Signup and view all the answers

Which of the following factors can affect the frequency of vital signs measurement?

Presence of chronic disease Signup and view all the answers

In the context of patient assessment, which question type is discouraged?

Leading questions Signup and view all the answers

What characterizes continuous lung sounds, specifically wheezes?

Musical quality produced by constricted airways Signup and view all the answers

What is indicated by monophonic wheezing?

Only one airway is affected Signup and view all the answers

What sound indicates the presence of both S3 and S4 heart sounds?

Gallop rhythm Signup and view all the answers

What can cause diminished breath sounds?

Shallow or slow breathing Signup and view all the answers

Which condition does stridor likely indicate?

Upper airway compromise Signup and view all the answers

What characterizes fine crackles in lung auscultation?

Sudden opening of small airways during deep breathing Signup and view all the answers

What lung sound is typically associated with an enlarged or tender abdomen?

Diminished breath sounds Signup and view all the answers

Which of the following is a sign of right ventricular hypertrophy?

Abnormal pulsation near the sternum Signup and view all the answers

What abnormality would indicate increased voice sounds according to lung assessment?

Increased clarity during vocal fremitus Signup and view all the answers

What can commonly cause coarse crackles during respiratory assessment?

Secretions or fluid in airways Signup and view all the answers

What does the acronym PERRLA stand for in the examination of the eyes?

Pupils equal, round, reactive light, and accommodation Signup and view all the answers

What is the respiratory indication of nasal flaring in infants?

Suggests respiratory distress Signup and view all the answers

Which condition is characterized by a barrel chest?

Emphysema Signup and view all the answers

What is the primary muscle responsible for breathing?

Diaphragm Signup and view all the answers

How is jugular venous distention (JVD) most commonly seen?

In patients with congestive heart failure Signup and view all the answers

Which thoracic configuration abnormality is associated with depression of part or the entire sternum?

Pectus excavatum Signup and view all the answers

What is an immediate sign of respiratory failure indicated by cyanosis of the oral mucosa?

Decreased oxygen levels in the blood Signup and view all the answers

In which type of diseases would you observe a unilateral reduction in chest expansion?

Respiratory diseases affecting one lung Signup and view all the answers

What type of breath sounds are created by turbulent flow and are loud with a prolonged expiratory component?

Tracheal breath sounds Signup and view all the answers

What occurs to the trachea in certain thoracic disorders?

It can shift away from midline Signup and view all the answers

Which abnormal breathing pattern involves the use of muscles other than the diaphragm?

Accessory muscle breathing Signup and view all the answers

What is a common cause of increased tactile fremitus?

Lung consolidation Signup and view all the answers

What does increased AP diameter in thoracic configuration indicate?

Emphysema or barrel chest Signup and view all the answers

What is the expected percussion sound over healthy lung tissue?

Normal resonance Signup and view all the answers

Study Notes

The Medical Record and Medical History

Essential for respiratory therapists (RT) to confirm physician orders for procedures are current and complete.
Chief complaint (CC) and history of present illness (HPI) provide insights into current medical problems.
Past medical history includes smoking history measured in pack-years.
Family and social history may reveal genetic or occupational disease links.
Review of systems (ROS) assesses patient’s overall health.
Advance directive details patient’s medical care preferences.

Handwashing Techniques

Hands should be wet with warm or cold water before applying soap.
Rub hands to create a lather, scrubbing all areas for at least 20 seconds.
Rinse thoroughly and dry with a clean towel.
Alcohol-based gels: Use sufficient amount and rub hands until dry (at least 15 seconds).

Interviewing the Patient

Establish rapport to gather essential diagnosis information.
Monitor changes in symptoms and therapy responses.
Factors affecting communication include sensory, emotional, environmental, and cultural influences.

Structuring an Interview

Introduce yourself at a social distance (~4-12 feet) and move to a personal space (~2-4 feet).
Maintain appropriate eye contact and position at the patient's level.
Utilize neutral questions to avoid leading.

Recording Physical Examination

Components include initial impression, vital signs, and systems: HEENT, neck, thorax, abdomen, extremities.

General Clinical Presentation

Continuous assessment from first sight of the patient.
Indicators: level of consciousness, distress, body hygiene, and positioning.

Level of Consciousness

Assesses oxygenation status and brain health.
Utilized Glasgow Coma Scale for objective assessment of consciousness.

Vital Signs (VS)

Standard vital signs: temperature, pulse, respirations, blood pressure.
Additional observations include pulse oximetry and clinical impression.
Frequency of measurement depends on patient’s condition and treatment.

Understanding Vital Signs Trends

Isolated measurements have limited value; trends over time offer better insight into a patient’s health.

Body Temperature

Normal range is 97 to 99.5 °F (98.6°F average).
Fever indicates an elevation above 38.3°C (101°F), linked to infections or serious illnesses.

Pulse (Heart Rate)

Normal pulse rate: 60-100 beats/min; tachycardia >100, bradycardia <60 bpm.
Rhythm types: regular, irregularly irregular (unfavorable).

Respiratory Rate (RR)

Normal adult RR: 12-20 breaths/min; tachypnea >20, bradypnea <10.
Abnormal rates can indicate respiratory distress, anxiety, or metabolic issues.

Common Breathing Patterns

Apnea: absence of breathing; eupnea: normal breathing; tachypnea: rapid breathing; hypopnea: shallow breathing.

Blood Pressure (BP)

Normal reading: 120/80 mm Hg; hypertension is 140/90 mm Hg or higher, while hypotension is <90/60 mm Hg.
Measurement errors may arise from mismatched cuff size or improper application.

Shock and Blood Pressure

Defined as inadequate delivery of oxygen/nutrients to vital organs.
Various shock types: cardiogenic, hypovolemic, septic, and anaphylactic.

Pulse Oximetry

Noninvasive monitoring of SpO2; should represent patient condition accurately.

Physical Examination Steps

Four steps: Inspection, Palpation, Percussion, Auscultation, essential for ongoing patient assessment.

Examination of Head and Neck

Neurological assessments include pupillary response for neurological condition.
Cyanosis and nasal flaring indicators of respiratory distress.

Lung Topography

Knowledge of lung borders, fissures, and landmarks is crucial for accurate respiratory assessment.

Examination of Thorax and Lungs

Inspect for thoracic configuration, chest expansion, and breathing patterns.
Pectus carinatum and excavatum indicate structural abnormalities.

Breathing Patterns

Observe normal vs. abnormal breathing efforts and use of accessory muscles.

Chest Palpation

Assess vocal and tactile fremitus changes in conditions like pneumonia or pneumothorax.

Percussion and Auscultation of Lungs

Percussion determines resonance (normal, increased, decreased) and auscultation identifies normal and adventitious lung sounds.

Voice Sounds

Evaluated by comparing sounds during speech; changes indicate pathological conditions.

Cardiac Examination

Precordium assessed for pulsations indicating potential heart issues.

Auscultation of Heart Sounds

Four primary heart sounds: S1 (AV closure), S2 (semilunar closure), S3 (abnormal fill), S4 (atria kick).

Abdominal Exam

Inspect and palpate for tenderness or distension; can severely impact respiratory function.
Abdominal compartment syndrome indicated by pressures exceeding 20 mm Hg.

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Description

This quiz focuses on the importance of assessing patient medical records and histories in respiratory care. It emphasizes the crucial steps in ensuring physician orders are up to date and the significance of reviewing current medical problems outlined in the patient's chart.