Kettering TMC workbook (patient assessment)

List 4 critical life functions

Ventilation Oxygenation Circulation Perfusion

What life function is first priority?

Ventilation

What assessments would determine how well a patient is ventilating?

-RR

-Vt

-Chest Movement

-Breath Sounds

-PaCo2

-EtCO2

How would the therapist determine if a patient has a problem with oxygenation?

-HR

-Color

-Sensorium

-PaO2/SpO2

What information would help the therapist determine if a patient's circulation is adequate?

-HR and Strength

-CO

What changes may indicate if a patient doesn't have adequate perfusion?

-HR

-BP

-Sensorium

-Temperature

-Urine Output

-Hemodynamics

Signs are

objective information - things you can see and measure

-color

-pulse

-edema

-vital signs

symptoms are

subjective information - things patient tells you

-dyspnea

-pain level

-nausea

-muscle weakness

5 items that are important to review in a patients medical record

1. Allergies

2. Signs/Symptoms

3. History

4. Advanced directives

5. HPI

advanced directive

set of instructions documenting what Tx a patient wants if they were unable to make medical decisions

what are 4 types of advanced directives

1. living will - Tx patient wants if became terminally ill; doesn't appoint someone else to make medical decisions

2. DNI order - do not intubate (can ventilate)

3. DNR order - do not resuscitate

4. durable power of attorney - health care proxy; only in affect when patient can't make healthcare decisions

A properly written order for respiratory care should include what 4 factors?

1. type of treatment

2. frequency

3. medication/dosage

4. physician signature

The respiratory therapist has just finished administering an aerosol treatment with albuterol to a child with asthma. What should be included in documentation of the treatment?

date, time, reactions, etc.

respiratory notes

What is the normal value for urine output

40mL/hour (approx. 1 liter/day)

What findings might indicate a patients fluid intake has exceeded his urine output?

weight gain

electrolyte imbalance

increased hemodynamic pressures

decreased lung compliance

Changes in what value can indicate hypovolemia?

CVP - less than 2

need fluid (IV) therapy

Describe medication reconciliation

ensuring patients medication list is accurate and up to date as possible. Must be done within first 24 hours of admission

Semicomatose

responds to only painful stimuli

lethargic/somnolent

sleepy

consider sleep apnea, excessive O2 therapy with COPD patients

Obtunded

drowsy

decreased cough/gag reflex

risk of aspiration

when assessing a patients orientation to time place and person, what are some of the factors that could affect the patients ability to cooperate?

language difficulties

influence of medication

hearing loss

fear/apprehension depression

define activities of daily living

basic tasks of everyday life

6 criteria for ADL are based on

bathing

eating

dressing

toileting

transferring

urine/bowel continence

ADL are evaluated using the - system

katz

orthopnea

difficulty breathing lying down

think CHF

general malaise

feeling unwell

electrolyte imbalance

dyspnea

short of breath

dysphagia

trouble swallowing

what are 4 factors to consider when conducting a patient interview

ask open ended questions

use simple language

use pictures or diagrams

identify patients with major problems

Eupnea

normal breathing

tachypnea

fast RR

conditions: fever, hypoxia, pain, CNS problems

bradypnea

slow RR

conditions: sleep (normal), drugs, alcohol, metabolic alkalosis

Gradually increase then decreasing rate and depth in a cycle lasting from 30-180 seconds fast slow period of apnea

condition: increased IC pressure, brainstem injury, drug overdose

cheyne stokes

increased respiratory rate and depth with irregular periods of apnea. Each breath has the same depth fast irregular w/ apnea

Cause: CNS problem

biots breathing

gasping, labored breathing, also called air hunger

condition: hypoxemia, metabolic acidosis, renal failure, diabetic ketoacidosis

Kussmaul breathing

hypertrophy

increased [muscle] size

think COPD

atrophy

decreased [muscle] size

think paralysis

tList 4 changes to a patient's upper airway that complicates airway patency

#1

tracheal shift deviation

List 4 changes to a patient's upper airway that complicates airway patency

#2

bull neck

List 4 changes to a patient's upper airway that complicates airway patency

#3

large tongue (macroglossia)

List 4 changes to a patient's upper airway that complicates airway patency

#4

short mandible

class 1

mallampati Class -

soft palate, uvula, fauces, pillars visible

class 2

mallampati class -

soft palate, uvula, fauces visible

class 3

mallampati class -

soft palate, base of uvula visible

class 4

mallampati class -

hard palate only visible

mallampati class - and - are considered difficult airways and require the use of a fiberoptic bronchoscope or a video assist device*

class 3 and 4

normal range for HR/adult

60-100

indications for tachycardia

hypoxemia anxiety stress - need o2 therapy

indications for bradycardia

heart failure shock code/emergency - atropine

adverse reaction/when to stop tx

HR change of 20 bpm

indications of paradoxical pulses/pulsus paradoxus

sever air trapping, Pneumo, status asthmaticus, cardiac tamponade

(pulse/BP varies with respiration)

Trachea pulled toward affected side

atelectasis pneumonectomy diaphragmatic paralysis

Trachea pushed away from affected side

pleural effusion tension pneumothorax tumor (neck or thyroid) mediastinal mass

vibrations felt on chest wall by hand

Increased in consolidation and pulmonary edema

decreased in COPD, pneumothorax, and pleural effusion

tactile fremitus

skind tender around incisions, chest tubes, bruises, burns, or fractures

tenderness

bubbles of air under skin

crepitus (subcutaneous emphysema)

different than therapeutic chest percussion (chest PT)

diagnostic chest percussion

normal air filled lungs (hollow sound)

resonant

(less air)

normally heard over sternum

areas of atelectasis

flat

(less air)

normally heard over fluid filled organs (heart, liver)

Pleural effusion/pneumonia (thud)

dull

(extra air)

normally heard over air-filled stomach

drum like sound indicating increased volume when heard over lungs

tympanic

(extra air)

booming sound that can be heard on an area of lung were either a pneumothorax or emphysema is present

hyperresonant

normal breath sounds

vesicular

abnormal breath sounds

adventitious

patient instructed to say E and sounds like A (or 99) indicates consolidation of the lung tissue as with a pneumonia like condition

egophony

what breath sounds would be expected in a patient with pulmonary edema

fine crackles (moist crepitant rales)

large airway secretions

rhonchi that clears with cough

suction or have patient cough

coarse crackles

middle airway secretions

bronchial hygiene

medium crackles

moist crepitant rales

alveoli/fluid

associated with CHF and pulmonary edema

o2, IPPB, diuretics, and positive inotropic agents (strengthens the heart)

fine crackles

bronchospasm

unilateral wheeze = obstruction

bronchodilator or bronchoscopy

wheeze

upper airway obstruction

supraglottic swelling (epiglottitis)

subglottic swelling (croup and post extubation)

racemic epi (mild to moderate), suctioning/bronch, intubation (marked or severe)

stridor

noisy during inhalation

low pitch snoring (vibrations for secretions bc tissues relax)

stertor

coarse, raspy, crunching sound

inflamed surface of visceral and parietal pleura rubbing

pleurisy, TB, pneumonia, cancer, pulmonary infarction

*steriods (inflammation) or antibiotics (infection)

pleural friction rub

normal closure of mitral and tricuspid valves lub

S1

normal sound occurring when systole ends, ventricles relax and pulmonic and aortic valves close dub

S2

abnormal heart sound heart failure

S3

abnormal heart sounds hypertension/aortic stenosis

S4

abnormal heart sounds turbulent blood flow/heart valve defects

murmur

abnormal heart sounds made in an artery/vein when blood flow becomes turbulent or flows at abnormal speed/carotid artery

Bruit

what affect would cardiac stress have on blood pressure?

hypertension hypoxemia

what affect would hypoperfusion have on blood pressure (poor perfusion)?

hypotension hypovolemia (chf)

normal Bp

120/80

Normal systolic range

90-140

normal diastolic range

60-90

both hemidiaphragms are rounded

right hemidiaphragm is slightly higher

right hemidiaphragm is at 6th anterior rib

trachea is midline

bilateral radiolucent lungs

sharp costophrenic angles

normal cxr

will show intervertebral disc space through the shadow of the mediastinum

proper exposure/penetration

image doesn't allow visualization of the intervertebral disc through the heart shadow

under penetrated

images will show black lung parenchyma without blood vessels

over penetrated

what condition causes blunting of costophrenic angles?

pleural effusion

in what pathology is the diaphragm flattened?

COPD

what pathology causes crowding of the ribs?

atelectasis

what pathology causes straight or horizontal ribs?

air trapping

posterior to anterior cxr

PA

anterior to posterior cxr

AP

lying on affected side

detects small pleural effusion (liquid moves) if doesn't move then it's pneumonia

lateral decubitus

end of exhalation

detects small pneumothorax

can measure diaphoretic excursion

end expiratory image

below vocal chords

2-6 cm above the carina

at level of aortic knob or arch

position of ETT

what is the FIRST way to determine adequate ventilation following intubation?

inspection and auscultation (followed by CXR)

Inserted in pleural space surrounding the lung

chest tube

positioned in the stomach 2-6 cm below diaphragm

NG or feeding tube