Vital Signs
Normal range of respirations in an adult
What is 12-20?
Respirations less than 12
What is Bradycardia?
Expected breath sound heard with asthma
What is wheezing?
Head of bed (HOB) is upright
What is Fowler's?
High-pitched, musical whistling sound produced by narrowed or inflamed airways, most commonly heard during exhalation
What is wheezes?
Another name for shortness of breath
What is Dyspnea?
Normal range of heart rate/pulse in an adult
What is 60-100?
Respirations greater then 20
What is Tachypnea?
Expected thoracic finding with COPD
What is barrel chest?
Client is lying on their stomach
What is prone?
Produced by air passing over retained airway secretions. Can be classified as fine-soft, high pitched or coarse-louder, low-pitched
What are crackles?
Shoulders rise when attempting to inhale
What is use of accessory muscles?
Normal oral temperature for an adult
What is 97.5-99.5?
Blood pressure systolic 130-139 or Diastolic 80-89
What is high blood pressure?
Hypertension is 140/90 or higher
Physical finding caused by chronic lack of oxygen
What is clubbed fingers?
Client is lying on their back
What is supine?
Low-pitched, rattling, or snoring-like lung sounds caused by airway obstruction from mucus or fluid in the large airways
What are Rhonchi?
Overrall term for abnormal lung sounds
What is adventitious breath sounds?
Range of Oxygen Saturation
What is 95-100%?
Rapid, abnormally deep, and labored respirations
What is Kussmaul Breathing?
breathing through the nose and exhaling through the mouth. Patient looks like they are whistling.
What is pursed lip breathing?
Head of bed is raised to a 35-45 degree angle
What is semi-fowler's?
High-pitched, musical, or screeching breathing sound caused by a turbulent airflow due to narrowing or blockage in the upper airway
What is stridor?
Skin is blue/dusky
What is cyanosis?
Normal BP range in an adult
What is Systolic less than 120 and diastolic less than 80?
Cycle of respirations that increase in depth, followed by gradual shallow breathing, followed by a period of apnea
What is Cheyne-Stokes Respirations?
Palpable vibrations felt when palpating the chest while client is repeatedly saying ninety-nine.
What is tactile fremitus?
Sitting or standing leaning forward supporting self with hands on knees or leaning on a table
What is the Tripod position?
Small airways that have collapsed or are obstructed by mucus/fluid suddenly snap open upon inspiration, sounding similar to bubbles or hair rubbing together.
What is popping?
Where to assess for cyanosis or pallor in someone with dark skin
What is mucous membranes?
Also nailbeds