NPTE Full Study Guide

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Normal Value Adult Blood Pressure

<120/80 mmHg

Elevated 121-129/<80

Stage 1 Hypertension: 130-139/80-89

Stage 2 Hypertension >= 140/90

Hypertensive crisis > 180/120

Normal Value Adult Heart Rate

60- 100 bpm

Tachycardia >100bpm

Bradycardia < 60 bpm

Normal Value Adult Respiratory Rate

12-20 breaths/min

Normal Value Adult Oxygen Saturation

> 95%

Normal Value Adult Temperature

98.6 degrees F (37 degrees C)

Normal Value Pediatric Blood Pressure

Newborn: 60–80/40–50 mmHg;

Infant (1–12 mo): 70–100/50–70;

Child (1–10 yr): 90–110/55–75 mmHg

Normal Value Pediatric Heart Rate

Newborn: 120–160 bpm;

Infant: 100–160;

Child (1–10 yr): 70–120 bpm

Normal Value Pediatric Respiratory Rate

Newborn: 30–60 breaths/min;

Infant: 20–40;

Child (1–10 yr): 18–30 breaths/min

Normal Value Cardiac Output

4-8 L/min

Normal Value Ejection Fraction

55-70%

SV/EDV * 100= EF, Quantity of blood ejected during each heart beat.

Normal Value Central Venous Pressure

0-8 mmHg

Normal Value Right Atrial Pressure

2-6 mmHg

Normal Value R Ventricular Pressure

15-30 mmHg (systolic)

Normal Value Pulmonary Artery Pressure

8-20 mmHg

Normal Value Pulmonary Capillary Wedge pressure

4-12 mmHg

Estimates left atrial pressure = estimates how well the left heart is moving. Higher wedge pressure indicative (potentially) of Left heart failure.

Normal Value Maximum Inspiratory Pressure

>80 cmH2O

Max pressure generated during inspiration. Related to strength of the diaphragm and other inspiratory muscles.

Normal Value Maximum Expiratory Pressure

1.5 * MIP ( >120 cmH2O)

Max pressure generated during expiration. Evaluates strength of expiratory muscles.

Normal Value Mean Arterial Pressure

70-110 mmHg

Normal Value Rate Pressure Product

> 20,000 mmHg/min

Rough estimate off myocardial oxygen demand. Higher RPP= higher workload on the heart = at risk for angina or risk of MI. May occur with heart disease or during exercise.

Normal Value Cardiac Index

2.6-4.24 L/min/m²

Cardiac output based on body size. Most accurate assessment of heart’s ability to perfuse based on patient size. Low= poor perfusion. Below 2.0= activity contraindication

Normal Value Electrocardiogram P-R Interval

0.12-0.20 seconds

Normal Value Electrocardiogram QRS Complex

0.08-0.10 seconds

Normal Value Electrocardiogram Intracranial Pressure

< 15 mmHg

Ankle Brachial Index

Values:

>1.4 Calcified arteries

1.0-1.4 Normal

0.8-1.0 Mild PAD - Compression for edema is safe to use

0.5-0.8 Moderate PAD - Intermittent claudication, use modified compression or none if <0.6

<0.5 Severe PAD - Severe ischemia with resting pain, compression is always contraindicated.

Gold standard test for Peripheral Artery Disease (PAD). Formula= Systolic(ankle)/Systolic(brachial).

Electrocardiogram

Evaluates cardiac electrical activity, rhythm, rate, and conduction.

Common indications: Arrhythmias, ischemia, myocardial infarction, electrolyte imbalances.

Key findings:

HR and rhythm (sinus rhythm vs arrhythmias), PR interval (AV conduction), QRS duration (ventricular conduction), ST segment (ischemia/infarction), QT interval (risk of ventricular arrythmias).

Normal Values Diaphragmatic Excursion

3-5 cm

The diaphragmatic excursion test measures the movement of the diaphragm, typically 3–5 cm in healthy adults, by percussing the posterior chest at maximal inhalation and exhalation. Reduced movement (< 3 cm) suggests pathology like COPD, paralysis, or pleural effusion

Obstructive Disorders (5). Name and include structures damaged

A- Asthma: Inflammation/swelling of bronchial lining and bronchoconstriction

B- Bronchiectasis: Permanent dilation and thickening of airways due to chronic infection/inflammation. Heavy mucus retention.

C- Chronic Bronchitis: Chronic inflammation, swelling of the airway lining, and increased mucus production.

C- Cystic Fibrosis- Genetic defect causes production of thick, sticky mucus that clogs the airways. (chronic health issues ex: hypoxemia)

E- Emphysema: Destruction of the alveolar walls and loss of elasticity.

COPD = Chronic bronchitis + Emphysema

MET Levels

One MET is the amount of energy your body uses each minute while resting quietly. This increases with activity.

Light activities <3 MET’s are good for elderly persons and those with physical limitations.

Moderate activities (3-6 Mets) Best for people wanting a moderate exercise program.

Vigorous activities (>6 Mets) Best for those with high fitness level and in good health.

Light activates- (Sitting quietly, Walking, Stretching)

Moderate activities -(Archery, Dance, Surfing)

Vigorous activities - (Backpacking, Hockey, Running 7 min/mile)

How do you determine Obstruction vs Restriction?

Obstruction: Low FEV1 or FVC and FEV1/FVC ratio (<80%). RV is high (>120%).

For reversible: +12% or 200mL change post bronchodilator/spirometer

If DLCO <60% = emphysema, if DLCO high >60% = asthma

Restriction: Low TLC (<80%), normal RV, FEV1 and FVC.

Myocardial ischemia vs infarction. Describe difference and what you see clinically (ECG)

Myocardial infarction: Seen as ST elevation (STEMI) or elevated troponin levels with inverted t-wave/ST depression and pathological Q’s (NSTEMI). Non reversible and treatment must be adjusted/monitored carefully.

STEMI = total arterial blockage, NSTEMI= partial

Myocardial ischemia: Seen as T-wave inversion or ST segment depression. Reversible- ECG readings should return to normal over time. Less contraindications for therapy.

Signs and Symptoms Right Heart Failure

3 Main signs:

Jugular Venous Distention, Ascites/hepatoportal hypertension/liver congestion, and bilateral lower extremity edema

Symptoms: Dyspnea on exertion and decreased exercise tolerance.

Signs and Symptoms Left Heart Failure

Signs and symptoms:

Orthopnea, cardiac arrhythmias, dyspnea on exertion.

Caused by systemic hypertension or CAD.

What is the difference between myocardial ischemia and heart failure?

Myocardial Ischemia- Supply-demand mismatch where reduced blood flow causes O2 shortage in the heart muscle causing pain (angina) and damage.

Heart Failure- Chronic condition where heart can not pump blood efficiently to meet body demands.

Ischemia=cause, HF= result

Postural Drainage Position Apical Segments

Patient positioned in long sitting with two pillows under knees. Percussion/shaking/vibration on apical segment (above clavicle on mid-clavicular line).

Postural Drainage Position Anterior Segments

Patient supine with 2 pillows under knees. Percussion/shaking/vibration (P/S/V) on mid-clavicular line at the level of 1st-4th ribs.

Postural Drainage Position Superior/Inferior Lingual Segments

Patient in supine on wedge feet elevated 12-15” with 1 pillow on left back to induce ¾ rotation elevating the left side and 1 pillow under knees. Percussion on left lateral chest wall slightly anterior to mid-axillary line at 3rd-5th intercostal spaces.

Postural Drainage Position Medial/lateral Segments

Patient in supine with feet elevated 12-15” with 1 pillow behind back and 2 pillow under the knees. Percussion on right lateral chest wall on mid-axillary line at ribs 4-6.

Postural Drainage Position Anterior Basal Segments

Patient in supine positioned with legs elevated to 18” and 2 pillows under the knees. Percussion anterior to mid-axillary line at level of ribs 6-8.

Postural Drainage Position Posterior Basal Segments

Patient in prone with legs elevated to 18” and 2 pillows under the hips. Percussion below inferior border of scapula.

Postural Drainage Position Lateral Basal Segments

Patient in side-lying with feet elevated to 18” and 1 pillow under head and between legs. Percussion on lateral chest wall at 7th to 10th ribs along mid-axillary line.

Postural Drainage Position Superior Segment (LL)

Patient in prone with 2 pillows under hips. Percussion medial to medial border of the scapula.

Postural Drainage Position Right Posterior Segment (UL)

Patient in prone with pillow under right chest elevating right side to ¾ rotation. Percussion above scapula on mid-clavicular line.

Postural Drainage Position Left Posterior Segment (UL)

Patient positioned in prone with table set to 45 degrees with 1 pillow under hips for ¾ rotation on left side. Percussion above scapula along mid-clavicular line.

Patient presents with the following lab values:

PH: 7.37

PaCO2: 47 mmHg

HCO3: 29 mEq/L

Compensated Respiratory Acidosis

Patient presents with the following lab values:

PH: 7.47

PaCO2: 35 mmHg

HCO3: 32 mEq/L

Uncompensated Metabolic Alkalosis

Patient presents with the following lab values:

PH: 7.39

PaCO2: 32 mmHg

HCO3: 20 mEq/L

Compensated Metabolic Acidosis

Patient presents with the following lab values:

PH: 7.46

PaCO2: 30 mmHg

HCO3: 22 mEq/L

Compensated Respiratory Alkalosis

Diaphragmatic Breathing test and purpose

Have patient place one hand on chest and other on stomach. Instruct to take a deep breath and raise just the hand on the stomach. If needing further help instruct to “sniff”.

This test works on diaphragm activation for inhalation.

Paced breathing test and purpose

Instruct patient to in for 3 seconds and out for 3 seconds (range of time varies 2-4 sec).

Helps lower anxiety and has a calming effect.

Pursed-Lip Breathing test and purpose

Place hand on patient abdominals to ensure no contraction takes place. Instruct patient to breathe deeply in through the nose, make a loose “O'“ with their mouth as they exhale slowly.

Creates a back pressure allowing for more effective exhalation for individuals with obstructive disorders.

Segmental breathing with inspiratory hold technique test and purpose.

Place hands over specific bronchopulmonary segment and instruct patient to breathe into it pushing your hand away. At max inhalation have them hold for 3 seconds before exhaling. During exhalation push down on the segment applying a high-velocity low-amplitude PNF stretch at the end.

Promotes diffusion to specific segment.

Stacked Breathing

Instruct patient to take small-moderate breaths without exhaling until hitting maximum inspiration.

For patients with restrictive issue, bad ventilation, or difficulty with deep breathing due to muscular weakness.

Counter-rotation test and purpose

Patient side-lying, place one hand on scapula and other on ASIS. Have patient breathe in as you push with scapular hand and pull with ASIS hand. Instruct them to exhale as you pull with scapular hand and push with ASIS hand. Do not pull spine past neutral and stay off glenohumeral joint.

Mobilizes a tight chest increasing tidal volumes and requires no active participation on the part of the patient.

Active Cycle of Breathing Purpose

Effective for secretion drainage.

Coughing vs Huff techniques for Secretion Clearance

Coughing techniques- Voluntary coughing, prone on elbows, Long-sitting paraplegia butterfly, Wheelchair paraplegia butterfly, hands and knees rocking.

Huff techniques- Long-sitting quadriplegia and wheelchair hook-arm quadriplegia

Techniques involve looking up and breathing in and then looking down and breathing out for 3-5 reps before “throwing” head/arms down and coughing for airway clearance.

Coughing vs Huff activity indications

Huff is ideal for patients with asthma, reactive airways, or lack of muscle control to cough effectively.

Cough works better for everyone else.

Huff technique and Forced Expiratory Technique

Instruct patient to breath out warm air as if fogging a pair of glasses.

FET- medium breath 2 huffs, then small breath two huffs, and repeat.

Splinting technique

Instruct patient to tightly hold pillow over incision cite then take a deep breath in and cough.

Heimlich Maneuver test

For a choking individual, stand behind individual and administer 5 abdominal thrusts under the xiphoid process, then 5 back blows. Repeat until object can be clearly seen and swept from throat.

For pregnant women administer 5 chest thrusts instead.

Patient presents with the following ECG and a troponin value of 0.24 ng/ml. What is the diagnosis?

NSTEMI

Patient presents with the following ECG. What is the diagnosis?

STEMI

What extra test is needed to identify NSTEMI

Troponin Values

List out most common Congenital Heart Defects that are Acyanotic and what their effects/clinical implications are.

Ventricular Septal Defect (Hole in Septum between ventricular heart chambers)

Atrial Septal Defect (Hole in Septum between L and R atria)

Patent Ductus Arteriosus (Vessel btw. pulmonary artery and aorta remains open after birth.)

Left→Right Shunt= Oxygenated blood into right heart= increased workload on right ventricle= hypertrophy and stiffening of R ventricle.

Clinically: Mild to small effects, exercise is generally tolerated well.

List out most common Congenital Heart Defects that are Cyanotic and what their effects/clinical implications are.

Tetralogy of Fallot (Pulmonary Aorta and Aortic Arch are switched)

Transposition of the Great Arteries (Aorta and Pulmonary artery reversed)

Tricuspid Atresia (Tricuspid fails to develop properly)

Right→Left shunt= Unoxygenated blood to left heart= chronic hypoxemia

Clinically Severe limitation in exercise

Cardiac Output Equation

SV * HR = CO

Inverse relationship between SV and HR, Low CO = Hypoxemia/heart failure/shock

Rate Pressure Product Equation

HR * Systolic Blood Pressure

Rough estimate off myocardial oxygen demand. Higher RPP= higher workload on the heart = at risk for angina or risk of MI. May occur with heart disease or during exercise.

Mean Arterial Pressure Equation

Formula: DBP + 1/3(SBP - DBP)

Average pressure in arteries during 1 cardiac cycle. Helps to evaluate tissue perfusion. < 60 mmHg = activity contraindication. 60-70 mmHg minimum to enable perfusion to vital organs. Low MAP = Hypertension or shock.

Equation for Calculation of Oxygen in E cylinder

0.28(Cylinder Pressure-500)/ Flow Rate(L)

Patient is on 4L of O2 with a cylindrical pressure of 1750PSI and a 30 minute walk home. What is the total number of minutes you can work with them?

57 minutes and 30 seconds

What pathology is shown on the ECG? What are the defining characteristics?

Atrial Fibrillation

Irregularly Irregular, no distinguishable P-waves

What pathology is shown on the ECG? What are the defining characteristics?

Atrial Flutter

Jagged “sawtooth” like P-waves.

What pathology is shown on the ECG? What are the defining characteristics?

Ventricular Tachycardia

QRS complex is abnormal with a single ectopic focus (look the same). Can lead to V fib.

What pathology is shown on the ECG? What are the defining characteristics?

1st Degree Heart Block

Prolonged PR Interval

What pathology is shown on the ECG? What are the defining characteristics?

2nd degree heart block Type I (Mobitz I)

PR interval increases in length each beat then a beat is skipped. Longer-longer-drop=Weinkebach

What pathology is shown on the ECG? What are the defining characteristics?

2nd Degree Type II (Mobitz II)

Multiple P-waves before every QRS complex.

What pathology is shown on the ECG? What are the defining characteristics?

3rd Degree Heart Block

Multiple P waves before every QRS. QRS complexes are wide. Bridge is out btw atria and ventricle.

What pathology is shown on the ECG? What are the defining characteristics?

Torsades de Pointes

Undulating waveform. Due to electrolyte imbalance (magnesium)

What pathology is shown on the ECG? What are the defining characteristics?

Significant Q’s

Q> 1 small box, depth of 1/4th the height of following R, abnormally tall QRS complex

Irreversible damage: fingerprint on ECG shows MI happened in the past.

What pathology is shown on the ECG? What are the defining characteristics? What is another way to identify this pathology?

Bundle Branch Block

“Rabbit ears” or abnormally shaped “R” on the QRS complex

What 2 pathologies are shown on the ECG? What is the difference between them?

STEMI = Non reversible, tissue death

Myocardial ischemia = Reversible, impaired blood flow

Blood pressure Response to Exercise Absolute Contraindications to Continue Activity

• SBP drops >/= 10mmHg from baseline with increased workload

• SBP >/= 250mmHg

• DBP >/= 115 mmHg

• Failure of SBP to rise with increased workload.

Blood pressure Response to Exercise Normal SBP and DBP

SBP: Increases about 10mmHg per MET or stage of exercise intensity. Peak at 160-220mmHg in health adults

DBP: Unchanged or decreases slightly (</= 10mmHg drop is normal)

Orthostatic Hypotension- What Vital Signs are seen?

• Drop in Systolic BP >/= 20mmHg or Diastolic BP >/= 10mmHg

• Occurs within 3 min of standing (after supine/sitting for 5 min)

• HR increases (compensatory tachycardia)

• Accompanied by dizziness, lightheadedness, near-syncope

Tracheal Deviation- Chest Exam

• Assessed by palpation in the suprasternal notch (compare space bilaterally)

• Normal: Trachea is midline

Tracheal deviation away from injured site (list pathologies)

• Pleural effusion

• Space Occupying Tumor

• Pneumothorax

Tracheal deviation towards injured site (list pathologies)

Atelectasis

Excursion- Chest Exam: Describe the test and what it measures.

Assesses chest wall and diaphragmatic movement/expansion during deep breathing

Normal thoracic excursion: Symmetric bilateral chest wall expansion ≥3 cm

Abnormal (reduced or asymmetric): Pleural effusion, pneumothorax, atelectasis, pulmonary fibrosis, diaphragmatic paralysis/weakness, or pain/guarding

Fremitus- Chest Exam: Describe the test and what it measures.

• Tactile (vocal) fremitus: Palpate symmetric chest wall (ulnar border or palms) while patient repeats “99” or “blue moon” in a deep voice

• Normal: Symmetric bilaterally; stronger over large airways/upper lobes, decreases toward periphery

• Increased fremitus: Lung consolidation (pneumonia, atelectasis with patent bronchus) – vibrations transmit better through solid tissue

• Decreased or absent fremitus: Pleural effusion, pneumothorax, emphysema/COPD (air trapping), bronchial obstruction, or thick chest wall/obesity

Egophony - Chest exam

Patient says “Eeee” – Normal: muffled “E”; Positive: sounds like nasal “Aaa” (E-to-A change)

• Positive in all three = lung consolidation (pneumonia, atelectasis with patent bronchus)

• All three decreased/absent with pleural effusion, pneumothorax, or emphysema

Bronchophony- Chest Exam

Bronchophony: Patient says “99” – Normal: muffled/indistinct; Positive: words heard louder & clearer

• Positive in all three = lung consolidation (pneumonia, atelectasis with patent bronchus)

• All three decreased/absent with pleural effusion, pneumothorax, or emphysema

Whispered Pectoriloquy- Chest Exam

Patient whispers “1-2-3” or “99” – Normal: faint or inaudible; Positive: whispered words heard clearly & distinctly

• Positive in all three = lung consolidation (pneumonia, atelectasis with patent bronchus)

• All three decreased/absent with pleural effusion, pneumothorax, or emphysema

Mediate Percussion- Chest Exam

Place middle finger of non-dominant hand flat & firm on intercostal space; strike distal interphalangeal joint with tip of dominant middle finger using quick wrist motion

• Normal: Resonant (low-pitched, hollow) sound over air-filled lung tissue; symmetric bilaterally

• Dullness (flat sound): Increased density (pleural effusion, consolidation/pneumonia, atelectasis, tumor, or fibrosis)

• Hyperresonance (boomier/louder): Excess air (pneumothorax, emphysema, asthma, or large bullae)

Heart Sound Auscultation- Name the location of the 4 valves for auscultation

Auscultate in 4 areas (patient supine/sitting):

Aortic (2nd R ICS),

Pulmonic (2nd L ICS),

Tricuspid (4th–5th L ICS),

Mitral/Apex (5th L ICS midclavicular)

Heart Sound S1

“Lub” contracting of ventricles. Semilunar valves open and AV valves closed.

Normal heart sound.

Heart Sound 2

“Dub” relaxing of ventricles. Semilunar valves closed and AV valves opened

Normal heart sound.

Heart Sound S3- Describe the sound, its cause, and the effect.

(ventricular gallop): Low-pitched early diastolic sound (rapid ventricular filling);

normal in children/young adults/pregnant/athletes;

pathologic in adults >40 (heart failure, volume overload)

A sign of Chronic Heart Failure.

Heart Sound S4- Describe the sound, its cause, and the effect.

(atrial gallop) Low-pitched late diastolic sound (atrial contraction into stiff ventricle);

always pathologic (ventricular hypertrophy, ischemia, hypertension, aortic stenosis)

Sign of stiff left ventricle often due to systemic hypertension.

Vesicular Breath Sounds

Soft, low-pitched; inspiration > expiration (3:1 ratio); heard over most peripheral lung fields (normal)

Bronchial Breath Sounds

(Tracheal): Loud, high-pitched; expiration > inspiration; heard over trachea & large airways (Normal)

Abnormal when heard over peripheral lung fields.