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1. What is the order of assessment during physical assessment of there respiratory
system?
- ANSWER - inspection
- palpation
- percussion
- auscultation
2. The trachea is normally midline, however a tracheal deviation is associated with
what?
- ANSWER tension pneumothorax
3. What are the signs of acute respiratory distress during the inspection
assessment? (7)
- ANSWER - labored respirations
- irregular breathing pattern
- assessors muscle use
- asymmetrical chest movements
- chest abdominal asynchrony
- spend mouth breathing
- gasping for a breath
4. What are the "red flag" signs during the inspection assessment? (3)
,- ANSWER - flail chest
- retractions
- tracheal deviation
5. What is subcutaneous emphysema or subcutaneous crepitus? which
assessment phase does it go with? - ANSWER the chest wall should not be
tender to palpation, subcutaneous crepitus is the presence of air beneath the skin
surface that has escaped the airway or the lungs. it is PALPATED with the fingertips
and feels like crunching rice cereal under the skin.
6. When percussing the chest, it should be hollow. T/F
- ANSWER True
7. What is a red flag for breath sounds?
- ANSWER absent breath sounds
8. What is a common psychological effect that being in the ICU or ventilated has
on patients?
- ANSWER PTSD and anxiety (up to 59%)
9. Why is it important to use pain scales instead of abnormal vital signs?
- ANSWER abnormal vital signs do not necessarily mean pain, so we have to
use certain tools and scales to justify reasoning.
10. What is the BPS scale and what is it used for?
- ANSWER Behavioral Pain Scale for intubated patients. This scale scores
- facial expression
- the movement of upper limbs
- compliance with ventilation for intubated patients OR vocalization for non-
intubated patients.
Each indicator is rated from 1-4 with a total BPS score ranging from 3-12. 3 being
nonbehavioral pain and 12 being max behavioral pain signs.
,11. What is the CPOT scale and what is it used for?
- ANSWER Critical-Care Observation Tool for pain in intubated/extubated
patients that include 4 behavioral categories...
- facial expression
- body movements
- muscle tension in upper extremities
- compliance with ventilator OR vocalization for extubated patients.
Items in each category are scored from 0-2, with a total CPOT score ranging from 0
to 8. 0 being no pain obersvation and 8 being max pain observation
12. what is the RASS scale?
what are the scores for...
- ANSWER - combative
- very agitated
- agitated
- restless
- alert and calm
- drowsy
- light sedation
- moderate sedation
- deep sedation
- unarousable
13. Richmond Agitation Sedation Scale is used to evaluate a patient's changes in
sedation status using a 10-point scale through 3 steps for 30 to 60 seconds.
+4
+3
+2
+1
0
-1
-2
, -3
-4
-5
what is light sedation defined as on the RASS scale?
- ANSWER -2 to +1
14. What is the SAS scale?
- ANSWER Sedation Agitation Scale that describes patients behaviors seem in
the continuum of sedation to agitation. Scores range from 1 (unarousable) to 7
(dangerously agitated)
15. What are the psychological responses to pain and anxiety? - ANSWER (13)
- constipation
- cool extremities
- diaphoresis
- hypertension
- increased CO
- increased glucose production
- mydriasis (pupil dilation)
- nausea
- pallor or flushing
- sleep disturbances
- tachycardia
- tachypnea
- urinary retention
16. What are some non-pharmacologic tools for the management of pain and
anxiety? (4)
- ANSWER Environmental Manipulation
- explain alarms
- putting up pictures of loved ones or family members
- family participate in family care