CPT II - Final Flashcards
Precautions for permanent pacemaker (so wires have time to scar into place)
Shoulder sling 24-48 hours
No shoulder elevation > 90 deg (x2 wks)
No lifting or WB (x2 wks)
Where is a pacemaker inserted?
In the infraclavicular fossa, through the subclavian veins
Temporary pacemaker precautions
Consider underlying indication
Don’t pull it out
Be sure of proper function
Watch rhythm
Bed rest after wire removal
What is an ECMO?
Extracorporeal Membranous Oxygen - cardiopulmonary bypass
Blood is oxygenated outside of the body
What are the 3 types of venous access?
Peripheral IV
PICC
Hickmann
What is a PICC line?
Peripherally Inserted Central Catheter
Distal part of the line is inserted in the R atrium
Should we avoid manual techniques to the shoulder in order to protect the IV lines?
No, patient is at risk for frozen shoulder and other pathologies. Just be very careful!!
What is a Portacath?
Version of the Hickman line but completely internal - port in the skin for access on a non-daily basis.
PICC and Hickman lines are used for what?
Prolonged daily access for antibiotics or chemotherapy
General IV precautions
Know what’s going on with your patient
Avoid BP on the involved side
Protect the line
Avoid kinking the line
May interfere with mobility and use of ADs (axillary crutches damage PICC lines)
Insertion into foot or femoral vein may keep patient from ambulating
Make IV pumps mobile
Observe integrity of insertion side (look for infection, phlebitis)
What is infiltration?
Medication enters the interstitial spaces instead of the veins, which damages the surrounding tissues.
What is phlebitis? How does it present?
Inflammation of a vein - red streak following the path of the vein.
What are the 2 types of chest tubes?
Pleural tube
Mediastinal tube
When are chest tubes used?
Hemothorax, pneumothorax, empyema, etc.
What should you do if a chest tube comes out?
Yell for help. Tell patient to breathe in and hold pressure over the wound.
Mobilizing concerns of the chest tube?
“Leash effect” of tubes
Keep device below level of insertion
Kinking, tripping, stepping on tubes
What are 3 types of feeding tubes?
NG tube - nasogastric (temporary)
G tube - stomach (permanent)
J tube - jejunum (permanent)
What are patients at risk for if they have a feeding tube? How can this be avoided?
Aspiration
Wait 30-60 minutes after bolus feeding and keep HOB 45 deg during feeding
What can feeding tubes also be used for?
Suctioning substances from the stomach
What is the difference between a foley catheter and a texas catheter?
Foley - goes into bladder through urethra
Texas - slips on like a condom
Mobilization consideration for urinary tubes?
Leash effect
Keep below bladder
Consider I’s and O’s (how much going in, how much coming out)
Empty if full and tell the nurse
What is longterm urinary tube?
Suprapubic indwelling catheter (surgical implant)
Considerations when treating a patient who had an epidural?
Remember that they can’t feel pain and that motor control might be affected
May experience spinal headaches with increasing severity when sitting upright
Considerations when treating a patient who has a PCA (patient-controlled analgesia pump)
Have patient pre-medicate before treatment
They can’t overdose, but don’t tell them that (placebo)
What are types of post-op drains?
JP or bulb drains (work like turkey basters)
Hemovac drains (suction)
If a patient had abdominal surgery, what should you do before treatment?
See if they are clear for OOB activity
What is used to promote circulation after surgery? Mobilization considerations?
Antithrombolytic boots - compressive boots that inflate/deflate
Boots must come off before mobilizing
What day does the heart of an embryo begin to beat?
Day 17
What day does the lung buds appear in an embryo?
Day 26
When have the 4 chambers of the heart fully developed in an embryo? Implication?
8 weeks
Defects usually occur at this point
When does surfactant begin to be produced in an embryo?
24 weeks
When does surfactant reach full maturity?
36 weeks
How does a fetus get oxygen?
From the placenta (umbilical vein)
What fetal circulation supplies the upper body?
IVC –> R atrium –> Foramen ovale –> L atrium –> L ventricle –> Ascending aorta
What fetal circulation supplies the lower body?
SVC –> R atrium –> R ventricle –> Pulmonary artery –> Ductus arteriosus –> Descending aorta
What are the 2 main points of shunting in embryonic heart?
Foramen ovale
Ductus arteriosus
What is the foramen ovale?
Opening between the atria which allows for right to left-blood flow bypassing the lungs
What closes the foramen ovale?
Before 1st breath, lungs are high pressure
At first breath, lungs expand with air; this decreases pulmonary vascular resistance and increases systemic resistance
Blood returns to the left atrium making pressure higher on the left than the right which causes the foramen ovale to gradually seal shut (within 3 months)
What is the ductus arteriosus?
Connection between the pulmonary artery and descending aorta
What closes the ductus arteriosus
After the 1st breath, lungs become filled with O2 which causes blood O2 to rise
The wall of the ductus arteriosus contracts and closes between 10-15 hours after birth. Anatomical closure by 2-3 weeks
Where do you look for cyanosis?
Nail beds and lips
What is an atrial septal defect?
Hole in septum between the atria (persistent foramen ovale).
Oxygenated blood flows from L to R atria. Can put stress on heart and lead to CHF.
What is a ventricular septal defect?
Opening in septum between L and R ventricle.
Blood flows from L –> R. Heart works harder to pump blood to body
What is a patent ductus arteriosus?
DA doesn’t close.
Oxygen-rich blood from aorta mixes with deoxygenated blood from pulmonary artery. Blood shunts from aorta to right ventricle.
What is coarctation of the aorta?
Narrowing of the aorta just after it branches off to the upper body. Blood flow is obstructed to the lower body.
What is pulmonary stenosis?
Fused, thickened, or missing leaflets of pulmonary valve
What is aortic stenosis?
Fused, thickened, or missing leaflets of aortic valve
What is tetrology of fallot?
Combination of heart defects
- Ventricular septal defect
- Aortic override
- Right ventricular outflow obstruction
- Right ventricular hypertrophy
Accounts for 50% of cyanotic defects
What is transposition of the great arteries
Aorta comes out of right ventricle, pulmonary artery out of left ventricle
What is a balloon atrial septostomy used for?
When transposition of the great arteries requires urgent intervention. Creates an ASD to solve the problem temporarily
What is a complete A-V canal defect?
Hole in center of heart where atria and ventricles meet - develop with one large valve
What is pulmonary atresia?
Abnormally formed pulmonary valve, often associated with VSD
What is tricuspid atresia?
Also Hypoplastic R Heart Syndrome
Tricuspid valve fails to develop. Smaller than normal R ventricle.
ALWAYS have ASD, sometimes VSD
What is hypoplastic L heart syndrome?
Underdeveloped or absent L ventricle
Mitral valve stenosis/atresia or aortic stenosis/atresia.
Aorta is underdeveloped and narrowed
Indications for pediatric heart transplant?
- Congenital defect
- Cardiomyopathy –> heart failure
- Intractable arrythmia
Pediatric diagnoses associated with heart defects
Duchenne's muscular dystrophy Fetal alcohol syndrome Juvenile RA Marfan syndrome Noonan's syndrome Prematurity Trisomy 13, 18, 21 Turner's syndrome Williams syndrome HIV-1 infection
What is the pulmonary system like in infants
Narrow airway, soft trachea
High position of larynx
Low compliance of lungs
Immature alveolar structure/function
Less type I fibers in diaphragm
What is the chest wall like in infants?
1/3 of trunk
Triangular in anterior plane, circular in lateral, Horizontal ribs
Narrow intercostal space (ms not at good length-tension relationship; belly breathing)
Minimal sternal stability
Limited ability to expand in all 3 planes
Diaphragmatic nose breather
Why is there “reaching” in infant (3-6 mos)
UE muscle groups develop
Getting out of physiologic flexion
Why does baby hold head upright and push up in prone (3-6 mos)?
Increased anterior chest and extensor musculature
Getting out of physiologic flexion
When are infants able to fully expand their lungs/chest wall?
When they start to sit (around 6 mos). Before then, often laying against a surface
Independent sitting at 6-12 months causes what developments?
Trunk tone balances between flexion/ext
Head moves independent of trunk
Developing abdominal muscles pull and rotate ribs downward
Elongation of chest wall
What happens when the chest wall elongates at 6-12 months?
Diapragm becomes more dome shaped
Abs increase in strength - secretion clearance, diaphragm/visceral support
Intercostal muscles widen as ribs rotate down - stabilize chest wall, increase 3D dimension during inhalation
What kind of abnormal developments show due to weakness and/or tone imbalance (infants)
Incomplete elongation of rib cage
Rib cage flaring - anterior or lateral
Diaphragm with lower resting position
Kyphotic posture
Pectus excavatum
What is primary ciliary dyskinesia?
Genetic autosomal disorder where ciliary motion is abnormal or absent
What is asthma?
Widespread narrowing of the airways in response to stimuli leading to bronchial smooth muscle spasm, inflammation of mucosa, and overproduction of viscous mucus.
What is the most common chronic lung disease in infants? Cause?
Bronchopulmonary Dysplasia
Mechanical ventilator and oxygen therapy use in premature infants
What is the most common respiratory disorder in premature infants?
Hyaline membrane disease
How do you prevent meconium aspiration syndrome?
Suction airways immediately after delivery
What is a differential diagnosis for transient ischemia of the newborn?
Hyaline membrane disease
What is tracheoesophageal fistula?
Abnormal connection between the esophagus and trachea, often associated with other birth defects.
Typical result of TEF?
tracheomalacia - can cause difficulties in airway clearance
What is most common congenital deformity of the chest wall?
Pectus excavatum
How does pectus excavatum present?
Indentation of lower sternum
Asymmetric chest
Shoulders protracted and IR
Protuberant abdomen
Rib cage moves vertically up, not out and up
Exercise intolerance
2nd most common chest wall abnormality?
Pectus carinatum
Pulmonary hypertension leads to…
R ventricular heart failure
What is bronchiolitis obliterans?
Epithelial injury of lower respiratory tract, characterized by obstruction and destruction of distal airways
What causes CF?
Mutation of gene on chromosome 7 that produces protein called cystic fibrosis transmembrane conductance regulator (CFTR) - autosomal recessive gene
What is CFTR for? If absent?
Regulates how much salt gets across cell membranes.
Absent: less fluid in airways making for dry, sticky mucus that is hard to clear
What is cystic fibrosis
Life-shortening disorder that affects the exocrine glands of the lungs, liver, pancreas, and intestines.
Affects ability of salt and water to move in and out of cells.
Current life expectancy for CF?
37
Lung transplants are assigned to kids based on
Body size
Blood type
Score
Amount of time on list
What is huff cough used for?
Used in combination with all airway clearance techniques to increase effectiveness
What do you do for children under 4 instead of huff cough?
10-12 months: mimic coughing
Activities involve blowing - bubbles, pinwheels, etc.
At what age can you start using the trendelenberg position for postural drainage?
2 years old
When can you start performing postural drainage, percussion, and vibration on kids?
Can initiate in newborns
At what age do patients start using The Vest (High frequency chest wall oscillation - HFCWO)
Greater than 3 years
How does positive expiratory pressure (PEP) work?
Prevents airway collapse to improve efficiency of airway clearance
Collateral ventilation - allows air to get behind mucus and push it out
What are the types of Oscillating Positive Expiratory Pressure devices?
Flutter Acapella Choice (better)
Key components to OPEP devices?
Breath hold after inspiration
Tight cheek musculature during expiration
3 components of Active Cycle Breathing Technique (ACBT)?
Breathing control
Thoracic expansion
Forced expiration technique
What is autogenic drainage?
Breath control technique designed to mobilize mucus at a variety of lung volumes.
Learn breathing at low, mid, and high lung volumes. Expirations are gentle with increasing velocity but avoiding airway compression.
When do you start teaching autogenic drainage?
Around 10 years old
Exercise capacity was an independent predictor of…
life expectancy in CF patients
What is the relationship between exercise and secretion mobilization?
Exercise forces us to do the huffing maneuver
Sternal precautions (pediatrics)
2 weeks: no prone
For 6 weeks: no bilateral UE over head, no pull to sit, no lift from under arms, no forward bend, no lifting > 10 lbs, no driving
Relationship between exercise and CF patients?
Sodium conductance in respiratory epithelium is partially blocked during moderate intensity which increases water content of mucus and enhances airway clearance.
Why is postural re-education important in cardiopulmonary PT?
All trunk muscles are both respiratory and postural muscles
Why should you do scar massage on pediatric patients who had surgery in the trunk?
Scars can limit mobility as the child grows (decrease trunk expansion)
Indications for mechanical ventilation
Airway protection
Respiratory muscle fatigue
Respiratory failure
Allow for sedation
Improve/maintain ventilation and respiration
Ventilator considerations
Route Mode Pressure support Rate Tidal volumes Positive end-expiratory pressure FiO2
Things to remember about patients on a mechanical ventilator
Don’t pull it out
Don’t move it
Patient will be uncomfortable and will cough if they move; let them adjust to new positions
Not a contraindication for mobilization though might change how you go about it (ex: don’t do a sit-pivot transfer)
Types of ventilator routes
Endotracheal tube (ETT)
Tracheostomy / Trach collar
Ventilator circuit
How far down does a ventilator tube go?
Down to the carina
Damage that can be caused by an ETT?
Damage to throat structures
If pushed in too far, can go into the R lung
What is a water trap for on a ventilator circuit?
For condensation buildup - needs to be lower than patient so they do not aspirate
What is the balloon/cuff for on an ETT/trach?
Holds the tube in place and creates a seal to make sure air gets into the lungs
If a patient can speak while on a trach, you should suspect…
a cuff leak
If a patient is on a trach and can speak, but there is no cuff leak, what could that mean?
Trach without a cuff is being used to wean the patient off the ventilator (look for lack of inflation tube)
Fenestrated trach (hole in proximal tube) allows for talking even with a cuff inflated
Cuff just isn’t able to create a seal
PT considerations with Route
Don’t pull it out
Comfort
Inspect airway and note position
Cuff (is patient able to talk?)
Why do you wean a patient off of a ventilator? PT consideration?
To prevent respiratory muscle atrophy.
Weaning requires more energy toward respiration. Activity after this can fatigue them too much.
If a patient has a trach and wants to talk, what can you do?
Deflate the cuff and cover trach hole
ETT vs. trach
ETT - short-term, no surgery
Trach - long-term, aid in weaning, decreased resistance, improves mobility, comfort, speech/eating, pulmonary hygiene, reduced laryngeal injury
Types of breath provided by ventilators?
Mandatory breath
Assisted breath
Spontaneous breath
Modes on the ventilator?
Assist control (AC)
Intermittent Mandatory Ventilation (IMV/SIMV)
Pressure Support Ventilation (PSV)
Continuous Positive Airway Pressure (CPAP)
If patient moves from more to less support during the day, that means…
they are improving (though their exercise might be just the work of breathing)
What is SIMV?
Same thing as AC but lets patient take over if he initiates the breath. Must overcome resistance of trach, though.
What is CPAP?
Keeps a little extra pressure in the airways to keep them from collapsing which allows for more time for oxygenation
Low pressure alarms
Patient disconnection
Circuit leaks
Airway leaks
High pressure alarms
Patient coughing Secretions or mucus Patient biting tube Reduced lung compliance Increased airway resistance Patient fighting ventilator
Mechanics of Normal Respiration
A: Airways
B: Body
C: Control of respiration
Upper airways do what
Warm
Humidify
Prevent infection
Phonation
Lower airways do what
Gas exchange
What controls respiration?
Brainstem - pons, medula
Cortex
Chemoreceptors
Internal factors impacting normal respiration
Neuromuscular
Musculoskeletal
Cardiopulmonary
External factors impacting normal respiration
Gravity
Environment (temp, irritants, humidity)
Oxygen demand
Stress
Strategies to maximize respiratory function in the patient with a neurologic diagnosis
A: Assessment
B: Body positioning
C: Control and clearance
Effective coughing requires
Closing the glottis
Increased intrathoracic pressure
Opening of the glottis
Forced quick exhalation
Manual assistive cough techniques
Costophrenic assist
Heimlich-type assist
Anterior chest compression assist
Massery counterrotation assist
Self-assisted cough techniques
Prone on elbows
Long-sitting
Short sitting
Quadruped self-rocking
Standing self-assisted
Impaired respiration following a neurologic insult
Decreased chest expansion
Decreased recruitment of muscles
Abnormal breathing patterns
Changes in pulmonary function
Decreased airway clearance
Decreased phonation
Decreased mobility and ADL
