4 critical life functions - ANSWER 1. Ventilation
2. Oxygenation
3. Circulation
4. Perfusion
Findings that indicate patient's fluid intake exceeds urine output - ANSWER 1. Weight
gain
2. Electrolyte imbalance
3. Increased hemodynamic pressures
4. Decreased lung compliance
Reading that indicates hypovolemia - ANSWER CVP < 2 mmHg
Reading that indicates hypervolemia - ANSWER CVP > 6 mmHg
Semicomatose - ANSWER Responds only to painful stimuli
Lethargy or somnolence - ANSWER Sleepy
Obtunded - ANSWER Drowsy state, may have decreased cough or gag reflex
1
,Orthopnea - ANSWER Difficulty breathing in upright position (heart problem, CHF)
General malaise - ANSWER Run down feeling, nausea, weakness, fatigue, headache
(electrolyte imbalance)
Dyspnea - ANSWER Feeling of SOB/difficulty breathing
Dysphagia - ANSWER Difficulty swallowing, hoarseness
Peripheral edema - ANSWER Pitting edema in arms and ankles
Causes of peripheral edema - ANSWER Fluid accumulation from CHF and renal failure
Ascites - ANSWER Accumulation of fluid in the abdomen
Causes ascites - ANSWER Fluid accumulation from liver failure
Clubbing - ANSWER Angling of nail bed of thumbs, first finger and toes
Causes of clubbing - ANSWER Effects of chronic hypoxemia on fingers and toes
Venous distention - ANSWER Engorged jugular veins during exhalation
Causes of venous distention - ANSWER Engorged jugular veins from CHF and COPD
Capillary refill - ANSWER Indicates peripheral circulation
2
, Diaphoresis - ANSWER Profuse, heavy sweating
Causes of diaphoresis - ANSWER Heart failure, fever, infection, anxiety, nervousness,
TB
Ashen/pallor skin - ANSWER Skin color caused by anemia or blood loss
Erythema - ANSWER Redness of skin
Causes of erythema - ANSWER Skin colore caused by capillary congestion, inflamma-
tion, infection
Causes of Cyanosis - ANSWER Skin color caused by hypoxia from increased amount of
reduced hemoglobin
Kyphosis - ANSWER Convex curvature of spine (lean forward)
Scoliosis - ANSWER Lateral curvature of spine (side to side)
Eupnea - ANSWER Normal RR, depth, rhythm
Causes of tachypnea - ANSWER Hypoxia, fever, pain CNS problems
Cheyne-Stokes - ANSWER Gradual increase in RR, then gradual decrease in RR and
depth
Causes of Cheyne-Stokes - ANSWER Breathing pattern caused by increased ICP, menin-
gitis, narcotic OD
3
2. Oxygenation
3. Circulation
4. Perfusion
Findings that indicate patient's fluid intake exceeds urine output - ANSWER 1. Weight
gain
2. Electrolyte imbalance
3. Increased hemodynamic pressures
4. Decreased lung compliance
Reading that indicates hypovolemia - ANSWER CVP < 2 mmHg
Reading that indicates hypervolemia - ANSWER CVP > 6 mmHg
Semicomatose - ANSWER Responds only to painful stimuli
Lethargy or somnolence - ANSWER Sleepy
Obtunded - ANSWER Drowsy state, may have decreased cough or gag reflex
1
,Orthopnea - ANSWER Difficulty breathing in upright position (heart problem, CHF)
General malaise - ANSWER Run down feeling, nausea, weakness, fatigue, headache
(electrolyte imbalance)
Dyspnea - ANSWER Feeling of SOB/difficulty breathing
Dysphagia - ANSWER Difficulty swallowing, hoarseness
Peripheral edema - ANSWER Pitting edema in arms and ankles
Causes of peripheral edema - ANSWER Fluid accumulation from CHF and renal failure
Ascites - ANSWER Accumulation of fluid in the abdomen
Causes ascites - ANSWER Fluid accumulation from liver failure
Clubbing - ANSWER Angling of nail bed of thumbs, first finger and toes
Causes of clubbing - ANSWER Effects of chronic hypoxemia on fingers and toes
Venous distention - ANSWER Engorged jugular veins during exhalation
Causes of venous distention - ANSWER Engorged jugular veins from CHF and COPD
Capillary refill - ANSWER Indicates peripheral circulation
2
, Diaphoresis - ANSWER Profuse, heavy sweating
Causes of diaphoresis - ANSWER Heart failure, fever, infection, anxiety, nervousness,
TB
Ashen/pallor skin - ANSWER Skin color caused by anemia or blood loss
Erythema - ANSWER Redness of skin
Causes of erythema - ANSWER Skin colore caused by capillary congestion, inflamma-
tion, infection
Causes of Cyanosis - ANSWER Skin color caused by hypoxia from increased amount of
reduced hemoglobin
Kyphosis - ANSWER Convex curvature of spine (lean forward)
Scoliosis - ANSWER Lateral curvature of spine (side to side)
Eupnea - ANSWER Normal RR, depth, rhythm
Causes of tachypnea - ANSWER Hypoxia, fever, pain CNS problems
Cheyne-Stokes - ANSWER Gradual increase in RR, then gradual decrease in RR and
depth
Causes of Cheyne-Stokes - ANSWER Breathing pattern caused by increased ICP, menin-
gitis, narcotic OD
3
