What are the four critical life functions?
Ventilation, Oxygenation, Circulation, Perfustion
Which of the 4 life functions is first priority?
Ventilation
What assessments would determine how well a pt is ventilating?
RR, Vt, Chest Movement, Breath Sounds, PaCO2 etc.
How would the therapist determine if there was a problem with oxygenation?
HR, Color, Sensorium, PaO2 etc.
What info would help the RT determine if a pt's circulation is adequate?
Pulse/HR and strength, Cardiac Output
What changes would indicate that a patient may not have adequated perfusion?
BP, Sensorium, Temperature, Urine Output, Hemodynamics.
Explain the difference between signs and symptoms and list examples of each:
Signs - Objective information, those things that you can see or measure (color, pulse, edema, BP, etc.
Symptoms - Subjective information, those things that the patient must tell you (dyspnea, pain, nausea, muscle weakness, etc.
List the 8 things that are important to examine when reviewing a patient's chart:
Admission Notes
Signs and Symptoms
Occupation/Employment
Allergies or Allergic Reactions
Prior surgery, illness or injury
Vital signs
Physical exam of chest
Smoking Hx
Define an advance directive:
Set of instructions documenting what treatment a patient would want if he was unable to make medical decisions.
List and describe the 3 types of advance directives:
1. DNR - accepted in all 50 states
2. Living Will - Describes Tx patient would want if he became terminally ill (6 mod to live); Does not allow pt to appoint someone to make decisions.
3. Durable Power of Attorney - Legal doc that names proxy. Takes effec
A properly written order should include what for factors?
1. Type of tx
2. Frequency
3. Medication dosage and dilution
4. Phys signature
What is the normal value for urine output?
40 mL/Hr or approx 1L/day
What findings might indicate a patients fluid intake has exceeded his urine output?
1. Weight gain
2. Electrolyte imbalance
3. Increased hemodynamic pressures
4. Decreased lung compliance
Changes in what reading can indicate hypovolemia?
Decreased CVP (CVP of < 2 mm Hg)
Define Semi comatose:
Responds only to painful stimuli.
Define Lethargy/Somnolence:
Sleep
Define Obtunded:
Drowsy state
When assessing a patient's orientation to time, place and person, what are some of the factors that could affect the patient's ability to cooperate?
Language difficulty
Medications
Hearing Loss
Fear, apprehension, depression, etc.
Define "Activities of Daily Living" ADL:
The basics of everyday life.
List the six criteria that "Activities of Daily Living" are based upon:
Bathing
Eating
Dressing
Toilet use
Transferring
Urine and bowel continence
Describe what a "KATz ADL" score of 1 indicates:
0 = Pt unable to perform or needs assistance performing activity.
1 = Pt needs no assistance
Measuring subjective symptoms, define the following terms:
Orthopnea - Difficulty breathing except in an upright position (CHF, Heart problem)
General malaise - run down feeling, nausea, weakness, fatigue, headache (electrolyte imbalance)
Dyspnea - a feeling of shortness of breath or difficulty breathing
Dysphagi
Peripheral Edema:
Presence of excessive fluid in the tissue known as pitting edema - occurs primarily in arms and ankles - caused by CHF and renal failure. Rated +1 and up... the higher the number, the greater the swelling.
Ascites
Accumulation of fluid in the abdomen; generally caused by liver failure.
Clubbing of fingers
Caused by chronic hypoxia. Presence of this is suggestive of pulmonary disease.
Venous distension
Occurs with CHF; Seen in patients with obstructive lung disease. Seen during exhalation because of the obstructive component.
Capillary refill
Indication of peripheral circulation; Blanching of one hand and watching the blood return (Modified Allen's Test)
Diaphoresis
State of profuse/heavy sweating; Heart failure; fever; infection; anxiety; nervousness; Tuberculosis (night sweats)
Ashen/pallor
Decrease in color due to anemia or acute blood loss. Can be caused by vasoconstriction too.
Erythema
Redness of the skin - May be due to capillary congestion, inflammation or infection.
Cyanosis
Blue or blue-gray(dusky) discoloration of skin and mucous membranes. Caused by hypoxia from increase amount of reduced hemoglobin (5g of reduced hemoglobin).
Kyphosis
Convex curvature of the spine (rounded leaning forward)
Scoliosis
Lateral curvature of the spine
Barrel chest
Result of air trapping in the lungs for a long period of time
What are the normal muscles of ventilation?
Diaphragm, external intercostals
What are the accessory muscles of ventilation?
Intercostal, scalene, sternocleidomastoid, pectoralis major and abdominal
What causes hypertrophy of the accessory muscles?
Occurs with COPD
Signs of respiratory distress in infants:
Flaring of nostrils and intercostal retractions.
What is the normal range for a patient's heart rate?
60-100 BPM
What term would be used to describe a heart rate of 120 bpm? What would this indicate?
Tachycardia. Indication of hypoxemia, anxiety or stress.
What term would be used to describe a pulse of 47 bpm? What would this indicate?
Bradycardia. Indication of heart failure or shock.
What does pardoxical pulse/pulsus paradoxus indicate?
Pulse/blood pressure varies with respiration. May indicate severe air trapping.
What is tactile fremitus
Vibrations felt by hand on the chest wall
What is meant by crepitus and what condition is it associated with?
Bubbles of air under the skin that can be palpated and indicates the presence of subcutaneous emphysema.
Resonant
Normal air filled lung. Gives hollow sound.
Flat
Heard over the sternum, muscle or areas of atelectasis.
Dull
Heard over fluid-filled organs such as the heart or liver. Pleural effusion or pneumonia will give this thudding sound.
Tympanic
Heard over air-filled stomach. This is a drum like sound and when heard over the lungs indicates increased volume.
Hyperresonant
found in areas of the lung where pneumothorax or emphysema is present. This is a booming sound.
What is the difference between vesicular and adventitious sounds?
Vesicular is normal, adventitious is abnormal
What is egophony and what would it indicate?
Patient instructed to say "E" but it sounds like "A". This would indicate consolodation in the lung like pneumonia.
What breath sounds would be expected in a patient with pneumonia?
Dull
Describe S1 heard sound and when it would occur in the cardiac cycle
Created by the normal closure of the mitral and tricuspid valves at the beginning of ventricular contraction.
Describe S2 heard sound and when it would occur in the cardiac cycle
Normal and occurs when systole ends. The ventricles relax and the pulmonic and aortic valves close.
Describe what the abnormal S3 sound indicates:
May suggest CHF; Low pitched and may be difficult to discriminate from S4
Describe what the abnormal S4 sound indicates:
Indicative of a cardiac abnormality such as myocardial infarction or cardiomegaly.
Describe what a murmur may indicate:
Caused by turbulent blood flow. May be caused by heart valve defects or congenital heart abnormalities and should be investigated.
Describe Bruits:
Sound made in an artery or vein when blood flow becomes turbulent or flows in an abnormal speed.
What effect could cardiac stress have on blood pressure?
Hyoxemia
What effect would hypoperfusion have aon BP?
Hypovolemia, CHF
Describe the normal appearance of the hemidiaphragm on a chest x-ray.
Both are rounded (dome shaped); right is slightly higher than the left; right is at the level of the 6th anterior rib.
Describe the normal appearance of the trachea on a chest x-ray.
Midline, bilateral radiolucency, with sharp costophrenic angles.
Describe the normal appearance of the clavicles on a normal chest x-ray.
Head of clavicles should be level.
List some possible causes for loss of airway latency:
Foreign body obstruction; Edema as seen with croup, epiglottitis or allergic reactions, tracheal spasms, internal or external compression, trauma leading to airleak.
What condition causes obliteration of the costophrenic angles?
Pleural effusion
In what pathology is the diaphragm flattened?
COPD
Describe lateral postion when used for x-ray:
Projection from either the right or left side.
Describe lateral decubitus position when used for x-ray:
Patient lying on the affected side. Valuable for detecting small pleural effusions.
Where should the tip of the endotracheal tube be positioned when viewed on a chest x-ray.
Below the vocal chords approx 2 cm or 1 inch above the carina. Approx the same height as the aortic notch.
What is the quickest way to to determine adequate ventilation following endotracheal intubation?
Auscultation
Where should the chest tube be located when positioned properly?
In the pleural space surrounding the lung.
Where should the nasogastric and feeding tube be located when positioned properly?
2-5 cm below the diaphragm.
Where should the pulmonary artery catheter be located when positioned properly?
In the right lower lung field.
Where should the pacemaker be located when positioned properly?
Should normally be positioned in the right ventricle (SA node...).
Where should the central venous catheter be located when positioned properly?
Right or left subclavian or jugular vein and should rest in the vena cava or right atrium of the heart.
What diagnostic test is appropriate for determining an upper airway obstruction in a child (croup and epiglottitis)?
Lateral neck x-ray.
Describe Croup:
Laryngotracheobronchitis - a viral disorder common in infants and young children. the x-ray of the neck will reveal tracheal narrowing with subglottic swelling in a classic pattern called:
Steeple, picket fence or pencil sign.
Describe Epiglottitis:
A potentially life-threatening inflammation of the supraglottic airway caused by a bacterial infection. A lateral neck x-ray shows supraglottic narrowing with an enlarged and flattened epiglottis and swollen aryepiglottic folds. Seen as a thumb sign.
Radiolucent description and diagnosis:
Dark pattern (Air);
Normal for lungs
Radiodense/opacity
White pattern (Solid, Fluid);
Normal for bones
Infiltrate
Any ill-difined radio density;
Atelectasis
Consolidation
Solid white area;
Pneumonia/pleural effusion
Hyperlucency
Extra pulmonary air;
COPD, asthma attack, pneumothorax
Vascular markings
Lymphatics, vessels, lung tissue;
Increased with CHF
Diffuse
Spread throughout;
Atelectasis
Opaque
Fluid, solid;
Consolidation
Fluffy infiltrates
Diffuse whiteness;
Pulmonary edema
Butterfly/Batwing pattern
Infiltrate in shape of butterfly/bat wing;
Pulmonary edema
Patchy infiltrates
Scattered densities;
Atelectasis
Patelike infiltrates
Thin-layered densities;
Atelectasis
Ground glass appearance
Reticulogranular;
ARDS
Honeycomb pattern
Reticulondodular;
ARDS
Diffuse bilateral radiopacity
ARDS
Air Bronchogram
Pneumonia
Peripheral wedge-shaped infiltrate
Pulmonary embolus
Concave superior interface/border
Pleural effusion
Basilar infiltrates with meniscus
Pleural effusion
Describe a CT scan:
An x-ray through a specific plane of the body part to be examined. Images appear as narrow slices of the organ or body part.
What pathologies would a CT be indicated?
Bronchiectasis
What special type of CT scan is indicated to diagnose a pulmonary embolus?
Ct scan with conrtrast dye.
What is the advantage of using MRI over a conventional x-ray?
No x-rays are used.
What type of ventilators are used with MRI and why?
Fluidic (non-electric, gas powered)
Describe how ventilation/perfusion scan test is performed:
Ventilation -
Radioisotope (xenon gas) is inhaled and the location of the gas is recorded producing a photographic pattern of distribution throughout the lungs.
Perfusion -
Albumin, tagged with radioiactive iodine, is injected into a peripheral vein and w
What is indicated by normal ventilation and abnormal perfusion?
Pulmonary emboli.
What are indications for a barium swallow test?
Suspected esophageal malignancy.
Dysphagia (difficulty swallowing)
Congenital defect in hypopharynx, esophagus.
Gastric reflux
Espohageal varices.
What is the main indication for bronchography?
Bronchiectasis
List two hazards of a bronchography:
Allergic reaction and impairment of ventilation
A PET (positron emission topography) scan would be useful to help diagnose what conditions?
Cancer, brain disorders and heart disease.
An EEG is indicated to assess activit of the?
Brain
Pulmonary (arteriogram) Angiogram test is indicated to diagnose what pathology?
Pulmonary embolism.
Briefly describe what echocardiograpy would be indicated and what can be measured with two different types of procedures:
Indications are valvular disease or dysfunciton; mycocardial disease, abnormalities of cardiac blood flow; Cardiac abnormalites in infant (ASD, VSD, PDA); Abnormal hear sounds.
Two dimensional and MMode can measure Ventricular volume and ejection fraction
What is the normal rance for ICP?
5-110 mmHg
Treatment is recommended when ICP increases above what level?
>20 mmHg
Define cerebral perfusion pressure
The pressure gradient that determines cerebral perfusion
What is the formula to calculate CPP?
MAP - ICP
What is the normal value for CPP?
70-90 mmHg
What is nitric oxide (NIOX) testing used for?
Used to monitor the asthma patient's response to anti-inflammatory (corticosteroid) treatment.
What does a decrease in patient's FENO level suggest?
A decrease in FENO suggests a decrease in airway inflammation.
What does a CBC measure?
All major ingredients of the blood: RBC, Hb, Hct, WBC
Identify what RBC stands for, briefly describe it, give normal value and the significance of low or high values:
Red Blood Cells - contain hemoglobin necessary for oxygen transport. Normal value 4-6mill/mm3; High RBC = Polycythemia which occurs with chronic tissue hypoxemia (COPD); Low RBC = anemia which occurs with blood loss
Identify what Hb stands for, briefly describe it, give normal value and the significance of low or high values:
Hemoglobin - Carries oxygen (1.34 mL per gram of Hb); Normal values are 12-16 gm/100 mL blood; Low Hb = anemia, High Hb = Polycythemia
Identify what Hct stands for, briefly describe it, give normal value and the significance of low or high values:
Hematocrit - measures RBC as a percentage of whole blood. Normal value is 40-40%. Low = Anemia, High = Polycythemia
Identify what WBC stands for, briefly describe it, give normal value and the significance of low or high values:
White Blood Cells -
Neutrophils - Major WBC
* Bands - immature cells; normally 4% of WBC; increased with bacterial infection
* Segs - Mature cells; normally 60% of WBC; decreased with bacterial infection.
* Eosinophils - Associated with asthma; 2% of WBC;
What are electrolytes and what is their function?
Potassium, Sodium, Chloride and Bicarbonate; elements required by the body for normal metabolism. Abnormal electrolytes indicate abnormal body function. Clinical Application of Electrolyte imbalance - Muscle weakness, soreness, nausea and mental changes s
Identify K+; briefly describe it, give the normal value and significance of abnormally low and high values:
Potassium - Major intracellular cation; important for acid-base balance and muscle function including cardiac muscle.
Normal is 4.0 mEq/L (3.5 to 4.5). Low K is Hypokalemia and occurs with metabolic alkalosis, excessive excretion, renal loss and vomiting.
Identify Na+; briefly describe it, give the normal value and significance of abnormally low and high values:
Sodium - Major extracellular cation controlled by kidneys. Normal = 140 (135-145). Hyponatremia = low Na; Fluid loss from: diuretics, vomiting, diarrhea, fluid gain from CHF, IV therapy. Hypernatremia is a result of dehydration.
Na is retained in exchange