Front to the body / toward the front

Patient next of kin, address, religion, and employer health insurance information

Consent forms signed by the patient (and witness)

Properly signed and witness DNR, do not intubate (DNI)

Past/present family social and medical history

Prescribing provider's orders Doctor (or nurse practitioner/physician assistant's) diagnostic and therapeutic orders, including those pertaining to respiratory care

WBC/RBC counts, ABGs, electrolytes, coagulation studies, and culture results (e.g., sputum, blood, urine)

X-ray, CT, MRI, PET, V/Q scan reports; may also include ultrasound and echocardiography results

Often separate reports for PFTS, sleep, metabolic, and exercise testing

Discipline-specific notes on a patient's progress and treatment plan by physicians and other caregivers

Respiratory therapy charting: may include ABGS, PFTS

Nurses' subjective and objective record of the patient's condition, including vital signs, fluid I/O, and hemodynamic and ICP monitoring trends

is the process of gathering relevant information from a patient, an essential element of which involves establishing rapport.

A. Name of patient B. Address of patient C. Age of patient D. Date and place of birth E. Marital status F. Current occupation G. Religious preference

A. List of patient complaints in the order of severity

Chronological description of each symptom including: A. When it started and what seemed to provoke it B. Severity C. Location on the body D. Aggravating/alleviating factors E. Frequency (how often it occurs)

A. Childhood illnesses and development B. Hospitalizations, surgeries, injuries, and major illnesses C. Allergies/immunizations D. Drugs and medications E. Smoking history and attempts at quitting

A. List of living close relatives and their health conditions B. List of close relatives who are deceased and the causes of death C. Marital history

A. Education level B. Military experience C. Occupational history D. Hobbies and recreation activities E. Current life situation, including stresses from employment and relationship problems F. Recent travel that might have an impact on the patient’s health

• Advance Directives and DNR Orders • Advanced Directives • Specify the healthcare choices patients want if they are unable to make informed decisions • Normally obtained upon admission to the hospital • Legally oblige all healthcare providers to abide by the patient’s choices

What cardiopulmonary symtoms is defined as a shortness of breath?

What color of sputum if there’s an infection?

What medical terminology for a foul-smelling sputum?

What sputum has pus cells

What it is called for a dyspnea that you are felling if your exercising

What kind of dyspnea that you may feel while having panic attack?

It is a chest pain that usually sharp in nature, and cause by lung problem?

How many temperatures you can consider if the patient has fever?

Edema in the lower extremities in the ankle and legs

is a forceful expiratory maneuver that expels mucus and foreign material from the airways.

refers to mucus from the lungs uncontaminated by oral secretions, whereas SPUTUM refers to mucus expectorated from the mouth

production is normal in a healthy being

- Located laterally or posteriorly - Worsens when breathing, coughing, sneezing, or moving the chest wall - It is usually sharp in nature

- located in the center of the anterior chest - radiate to the shoulder, neck, or back

is the force exerted by the heart against the systemic arteries as the blood moves through them

is coughing up blood or blood streaked sputum, usually from pulmonary disease

Expectorant consisting primarily of blood

Medical emergency defined by coughing a variable volume of blood over a defined period of time.

Swelling of the lower extremities is known as

is when finger pressure applied on a swollen extremity leaves an indentation mark on the skin

occurs when tye applied finger pressure causes a small fluid leak

is used to assess the future risk of developing hypertension

is defined a systolic pressure of 140 to 159

hypertension occurs when systolic pressure is 160

is measure through pulse oximeter

Oxygen in tissue

oxygen in blood

I- INSPECTION- observe P- PALPATION- touch P- PERCUSSION- listen by tapping finger A- AUSCULTATION- listening through stethoscope

• Height and weight • Age and sex • Body frame, nutrition

• sensorium is defined as a patient’s cognitive functioning and level of consciousness • asking patients whether they are aware/ oriented to time, place, person and situation

The patient exhibits slight decrease of consciousness and has slow mental responses