Ch. 3: Assessment of the Cardiopulmonary Patient Flashcards
Ch. 3: Assessment of the cardiopulmonary patient
A patient is experiencing cardiac dysrhythmias and muscle weakness. An arterial blood gas determines that the patient is in metabolic alkalosis. Which is the most appropriate value to assess at this this time?
Potassium
Hypokalemia can cause cardiac dysrhythmias and muscle weakness.
Ch. 3: Assessment of the cardiopulmonary patient
The respiratory therapist is assessing a patient with severe emphysema and observes pedal edema, and jugular venous distention. The therapist and note in the patient’s chart that the signs are most likely the result of:
Right ventricular hypertrophy
Ch. 3: Assessment of the cardiopulmonary patient
What elevated cardiac biomarker is associated with CHF?
BNP (>500pg/mL)
Ch. 3: Assessment of the cardiopulmonary patient
A patient is suspected of suffering acute myocardial infarction. What lab value would you expect to be increased in the patient’s blood?
CK-MB
Ch. 3: Assessment of the cardiopulmonary patient
What is nonproductive coughs caused by? (5)
- Irritation of the airway
- Acute inflammation of the respiratory mucosal membrane
- Presence of a growth
- Pleural irritation
- Irritation of the tympanic membrane
What does green foul smelling sputum indicate?
Psuedomonas infection
Commonly seen with bronchiectasis
What does red sputum indicate?
Contains fresh blood
What does brown sputum indicate?
Old blood
What does yellow purulent sputum indicate?
Infection, contains WBCs
What does white sputum indicate?
Normal mucus
What does pink frothy sputum indicate?
Pulmonary edema
The patient’s complaint of difficult or labored breathing
Dyspnea
Croup or epiglottitis?
Bark-like cough usually indicates ___________.
Croup
What oxygen delivery device is best suited for patients that are mouthbreathers?
Venturi
Causes of dyspnea
- Increased airway resistance
- Upper airway obstruction
- Asthma and other chronic lung diseases
- Decreased lung compliance
- Pulmonary fibrosis
- Pneumothorax
- Pleural effusion
- Abnormal chest wall
- Anxiety state
Define orthopnea.
Dyspnea while laying down
In what type of patients is orthopnea usually seen?
CHF, Emphysema
Usually see in patients with heart failure and is caused by increased congestion of the lungs while lying down.
Define paroxysmal nocturnal dyspnea
Sudden onset of SOB after being in bed for several hours
Where is paroxysmal nocturnal dyspnea typically seen?
Cardiac patients
Massive hemoptysis is defined as _________ mL of blood-tinged sputum in 3 hours or ____________.
Massive hemoptysis is defined as 400 mL of blood-tinged sputum in 3 hours or as more than 600 mL in 24 hours.
What are some causes of hemoptysis?
- Pneumonia
- TB
- Bronchiectasis
- Lung abscess
- Fungal lung infection
- Mitral valve stenosis
- Trauma
- Valvular heart diseases
- Neoplasms
- Pulmonary embolism
Define eupnea.
Normal rate and depth of respirations
Normal respiratory rate ranges
Adults: 12-30 breaths/min
Children: 15-25 breaths/min
Newborn: 35-45 breaths/min
When may bradypnea be seen?
Respiratory center depression, like head trauma or drug overdose
Cstat equation
VT/Pplat-PEEP
What x-ray view is used to identify free fluid in the chest (E.g: plueral effusion or blood)?
Lateral decubitus
Also helpful in determining the presence of a pneumothorax.
Lay patient on the left, if a right pneumothorax is suspected.
True or false.
There will be no tracheal shift if whatever is affecting the lung is bilateral.
True
What is the proper terminology for the following description and where is it commonly found?
Bat wings or or butterfly
Kerley B lines
Found in pulmonary edema (CHF)
What are known drugs for increasing cardiac output?
- Digitalis
- Digoxin
Define hypopnea.
Shallow respirations (about half of normal depth) with slower than normal respiration rate
In what type of patients is hypopnea known to be normal?
Well-conditioned athletes and is accompanied by a slow pulse rate.
Define hyperpnea
Deep, rapid and labored breathing
What is hyperpnea associated with?
Conditions where there is an inadequate O2 supply.
Where is Kussmual respiration usually seen?
Patients with severe metabolic ketoacidosis
Define Kussmual respiration.
Increased rate and depth of breathing
Irregular breathing pattern characterized by short periods of deep, consistent volumes with periods of apnea. Apnea period may last 10-30 seconds
Biots respiration
What is Biot respiration associated with?
Increased ICP and meningitis
Identify the following breathing pattern
Deep, rapid breathing followed by apnea. Breaths begin slowly and shallowly and gradually increase to above normal volume and rate and then gradually diminish in volume and rate followed by apnea. Apnea period may last 10-30 seconds
Cheyne-Stokes respiration
What is Cheyne-Stokes respiration associated with?
- Respiratory center depression caused by stroke or head injury
- PNA in elderly
- Drug overdose
An increased A-P diameter is called barrel chest and is indicative of what?
Chronic lung disease
Describe Mallampati.
1 is the best, you can see everything.
4 would be the most difficult to intubate, nothing can be seen.
What is digital clubbing the result of?
Chronic hypoxemia
The accumulation of fluid in the subcutaneous tissues of the ankles is called ______.
Pedal edema
What is the equation for the following?
Minute Ventilation
VE = RR x VT
What is the equation for the following?
Alveolar minute ventilation
VA = (VT - VD) x f
What is the equation for the following?
Cdyn
Cdyn = VT/(PIP-PEEP)
What is central cyanosis?
It is present when the oral mucosa and trunk are cyanotic.
What is peripheral cyanosis?
Nail beds are cyanotic
Normal capillary refill time is less than ___________.
3 seconds
Backward curvature of the lumbar spine, resulting in a “swayback” appearance.
Lordosis
Also called pigeon breast and results in the forward projection of the xiphoid process and lower sternum.
Pectus carinatum
Also called funnel chest and results in a funnel shaped depression over the lower sternum.
Pectus excavatum
What causes the barrel chest appearance?
Air trapping and subsequent hyperinflation. Loss of lung elasticity causes the lungs to move more outward. Also the increase tone and development of the accessory muscles used during COPD breathing
Muscles normally used for ventilation are the diaphragm and external intercostals, but the diaphragm of COPD patients is flattened, so they use ____________________ during normal ventilation.
Accessory muscles
Vibrations felt on the chest wall as the patient speaks are called ____________________.
Tactile fremitus
When are tactile fremitus vibrations decreased?
- Pleural effusion
- Fluid
- Pneumothorax
- Overly muscular or obese patients
When are tactile fremitus vibrations increased?
- Lung masses
- Atelectasis
- PNA
Palpating over subcutaneous air feelings like crackling under the skin and is referred to as what?
Crepitus
Tapping on the chest directly with one finger or indirectly by placing one finger on a chest area and tapping on that finger over different areas of the chest.
Percussion
A loud low-pitched sound of long duration that is produced over areas that contain greater proportion of air than tissue.
Hyperresonance
What are some examples of when you’d hear hyperresonance?
- Air-filled stomach
- Emphysema
- Pneumothorax
A low-pitched sound of long duration that is produced over areas with equal distribution of air and tissue.
Resonance
Example: Normal lung tissue
A drumlike sound
Tymphany
Example: Tension pneumothorax
Auscultation of breath sounds
If bronchial breath sounds are heard in other areas than the upper lung, what does it indicate?
Atelectasis or consolidation
Adventitious breath sounds
A bubbling or crackling sound that can be heard during inspiration or expiration and that is produced by air flowing through airways containing secretions of fluids.
Crackles
Auscultation of breath sounds
Where are early inspiratory crackles most commonly heard?
Patients with emphysema, chronic bronchitis or asthma
Adventitous breath sounds
When are late inspiratory crackles commonly (4)
- Pulmonary edema
- Atelectasis
- Pneumonia
- Restrictive lung disorders such as pulmonary fibrosis
Adventitous breath sounds
Breath sounds with a musical quality that are produced as air flows through constricted airways
Wheezes
WHEEZING
Airways become constricted as a result of __________. (4)
- Bronchospasm
- Mucosal edema
- Excessive sputum
- Presence of foreign bodies
Adventitous breath sounds
Used to describe low-pitched, continous abnormal lung sounds.
Rhonchi
Continous low-pitched coarse crackles is called rhonchi
Adventitous breath sounds
Most common during inspiration and produced as air passes through a narrowed upper airway structure such as the glottis.
Stridor
A clickling or grating sound caused by friction that is produced as the parietal and visceral pleura rub against each other during the breathing process.
Pleural friction rub
Auscultation of heart sounds
An abnormal sound heard over the heart, arteries, or veins that is caused by turbulent blood flow is called a __________.
Bruit
pg. 38
Chest X-ray Interpretation
Well-defined, solid-appearing lungs that appear light
Consolidation
Chest X-ray Interpretation
What is a common cause of consolidation?
Pneumonia
Chest X-ray Interpretation
White areas that indicate fluids and solids. (Also referred to as opacity)
Radiopaque
Chest X-ray Interpretation
Give an example of what would cause a radiopaque CXR image.
- Pleural effusion
- Pneumonia
Chest X-ray Interpretation
Scattered or patchy white areas
Infiltrates
Caused by inflammatory proccesses that indicate atelectasis or disease
Chest X-ray Interpretation
Dark areas caused by the presence of air
Radiolucency
Hyperlucency = emphysema, asthma or subcutaneous emphysema
Chest radiograph postions
What is the most commonly used x-ray position?
P-A
Back to front!
Chest X-ray Interpretation
This postion is used for portable radiographs in intensive care areas.
A-P
Front to back
The heart is more easily seen in this position.
Chest X-ray Interpretation
The image is obtained from the side with the patient upright while the X-ray passes through the chest laterally
Lateral
Chest X-ray Interpretation
What chest x-ray position allows for visualization of the lung parenchyma behind the heart and the bases of the lungs?
Lateral
Chest X-ray Interpretation
This image is obtained with the patient turned 45 degrees to either the right or left.
Oblique
Chest X-ray Interpretation
Which position is used to help diffrentiate a pulmonary or mediastinal lesion from structures that overlie it?
Oblique
Also used for V/Q scanning
Chest X-ray Interpretation
In an upright position, the patient leans back at a 45-degree angle.
Apical lordotic
Chest X-ray Interpretation
This position moves the shadow of the clavicles out the way for better visualization of the upper lobes of the lungs
Apical lordotic
Chest X-ray Interpretation
This image is obtained with the patient lying on his or her side with the film resting on the posterior surface of the chest.
Lateral decubitus
Chest X-ray Interpretation
Characteristics of an atelectasis X-ray.
- Appears lighter than normal tissue
- Elevated diaphragm
- Mediastinal shift towards affected side
- Decreased volume
- Increased density
Chest X-ray Interpretation
Pneumonia
- Appears white
- Consolidation of the entire lobe or more may cause mediastinal shift toward affected side
Chest X-ray Interpretation
Pneumothorax
- NO VASCULAR MAKINGS
- Very dark
- Tracheal shift AWAY from affected side
Endotracheal tube placement
The tube should rest ____ above the carina.
2-5 cm
Endotracheal tube placement
On an inspiratory film, the carina is located at the level of the ______ rib.
4th
Diaphragm
Appears white on an x-ray film at the level of the ____ during maximal inspiration.
10th
Diaphragm
The dome of the right hemidiaphragm is normally 1-2 cm higher than the lefe because of the space needed for the ___.
Liver
Diaphragm
Elevation of one hemidiaphragm may be the result of ______.
Gas in the stomach or atelectasis
Normal heart rate in an adult
60-100 beats/min
Normal heart rate in a child
80-110 beats/min
What is paradoxical pulse?
A pulse that becomes weaker on inspiration. May be defined as a decrease in systolic pressure of more than 10 mm Hg during inspiration
If seen after chest truma or surgery, suggest cardiac tamponade.
What is pulsus alternans?
An alternating pattern of strong and weak pulses
Where is pulsus alternans commonly seen?
Patients with left ventricular failure and usually indicates PVCs.
The measurement of the pressure within the arterial system
Blood pressure
ADULTS
Normal blood pressure range
<120/80
_ is the pressure measured during ventricular contraction.
Systolic pressure
Diastolic or systolic pressure?
The most critical measurement because it is the lowest pressure that the heart and arterial system experience.
Diastolic
What are some factors that affect blood pressure?
- Blood volume
- Blood viscosity
- Heart’s pumping action
- Elasticity of blood vessels
Slightly higher temperature in children is normal as a result of ______.
Higher metabolic rate
Define afebrile.
Normal body temperature
Define febrile.
Person with a fever
What does the Glasscow Coma Scale help determine?
Neurological impairment
Less than 8, intubate
Serum Electrolytes
Normal sodium (Na+) range
135-145 mEq/L
An elevated BUN level is indicative of ______.
Renal (liver) failure
Apnea Test - Just read.
Blood gas values need to be normalized before the test. The patient is disconnected from vent and placed on 100% oxygen.
Spontaneous breathing, oxygenation and cardiac status are monitored.
MD will end the test when deterioration is observed or no breathing for 8-10 minutes.
APNEA TEST
When is a postive apnea test indicated?
ABG values show that the PaCO2 has increased 20 torr above baseline level or reaches a level of 60 torr.
Serum Electrolytes
Normal potassium (K+) range
3.5 to 5.0 mEq/L
Potassium (K+) is the major intracellular cation.
Serum Electrolytes
Normal Chloride (CI-) range
98 to 107 mEq/L
Chloride (CI-) is the major anion in the body
Serum Electrolytes
What is the normal range for calcium (Ca)?
8.6 to 10.5 mmol/ dL
What are the muscles used for normal ventilation?
Diaphragm and external intercostals
JUST KNOW THAT increased calcium and decreased potassium and sodium can make weaning difficult due to causing muscle weakness!
You’re going to pass :)
What is the normal BUN level?
8-23 mg/dL
When the kidneys fail to remove creatinine from the blood, the level increases, indicating what?
Renal (liver) failure
What is normal creatinine level?
0.7-1.3 mg/dL
Increased BUN and creatinine result in ____________ acidosis.
Metabolic
Normal RBC levels
4 to 6 million/mm3 of blood
Normal Hemoglobin Levels
Males: 14.0-18.0 g/dL
Females: 12-15 g/dL
Normal hematocrit (Hct) levels
Males: 40-54%
Females: 35-49%
Normal level of WBCs
4500-11,500/mm3 of blood
Normal platelet count
150,000-400,000/mm3
They’re the smallest cells in the blood & are essential for clotting
Normal PT (prothrombin time)
11.0-12.5 seconds
Used to determine clotting ability
Normal partial thromboplastin time (PTT)
60-85 seconds
Used to determine clotting ability
What are the cardiac biomarkers? (3)
- CK-MB
- Myoglobin
- Troponin
Normal Urine Output
30 to 40 mL/hour
What Glass Coma Scale numbers indicate moderate coma?
9-12
What Glass Coma Scale numbers does not require ICU admission?
12-15
They higher the number, the BETTER!
What Glass Coma Scale numbers indicate severe coma?
8-9
Important note:
Remember than high FiO2 levels knocks out COPD respiratory drive
LPM should not exceed 4 if its not indicated by a low PaO2/SpO2
Harsh and high-pitched sound heard over the trachea.
Expiration is slightly higher than inspiration
Tracheal breath sound
