Final Study Guide Flashcards
1) Cardiac cycle
➔ Systolic and diastolic
◆ Systole - heart (contracts/relaxes), typically in terms of ventricles as they are the primary pump
◆ Diastole - heart (contracts/relaxes), should be LONGER than systole
● Relaxation important because it feeds the myocardium
➔ When valves are open/closed
◆ Beginning of ventricular systole – atrial pressure lower than intraventricular pressure = AV valves (open/close)
● (S1/S2) sound
● Isovolumetric contraction - all valves (open/closed)
◆ Ventricular systole - intraventricular pressure exceeds pressure in the aorta and pulmonary arteries = semilunar (SL) valves (open/closed)
● (Heart/No heart) sounds in healthy valves opening
◆ Isovolumetric diastole - ventricles relax, no change in volume and ventricular pressures decrease = SL valves (open/close)
● (S1/S2) sound
● Isovolumetric relaxation - all valves (open/closed)
◆ Diastole passive filling - pressure increase in atria increases = AV valves (closed/open)
● S4 if decreased ventricular compliance
➔ course of blood through the circulatory system
◆ Inferior or superior vena cava → right atria → right AV (tricuspid) valve → right ventricle → pulmonary SL valve → pulmonary arteries (deoxy blood) → lungs → pulmonary veins (oxy blood) → left atria → left AV (bicuspid, mitral) valve → left ventricle → aortic AL valve → aorta → body
contracts; relaxes; close; S1; closed; open; No heart; close; S2; closed; open
2) ABG
➔ Normal values for Hgb, ph, CO2, PO2, PCo2
◆ Hgb norm - g/dL for women, - g/dL for men
● Critical level is < _ g/dL (consider transfusion)
◆ pH norm -
● Acidosis < _
● Alkalosis > _
◆ Partial Pressure of Carbon Dioxide (pCO2) norm - mmHg
● Acidosis > _
● Alkalosis < _
● PaCo2 - this measures the partial pressure of carbon dioxide in arterial blood.
◆ CO2 norm - mEq/L
◆ pO2 norm - mmHg
◆ SpO2 norm -%
➔ How gas impacts ph, which organs are involved
◆ pH inversely proportional to the number of (carbon/hydrogen) ions in the system
◆ See above for normal values of gasses
◆ Bicarb (HCO3-) - normal - mEq/L
● Acidosis < _
● Alkalosis > _
◆ Kidneys - slow reaction, hours to days
● If pH is low, they (excrete/retain) bicarbonate
● If pH is high, they (excrete/retain) bicarbonate
◆ Lungs - fast reaction, within 1-3 minutes
● Increase either rate or depth of breathing to change CO2 levels
➔ Awareness of metabolic vs. respiratory AND alkalosis v acidosis
◆ Metabolic = kidneys
◆ Respiratory = lungs
◆ Respiratory alkalosis - occurs when low levels of carbon dioxide disrupt the bloods pH balance. Often occurs in individuals who have uncontrolled, rapid breathing.
● pH is (less/greater) than 7.45 with PaCO2 (less/more) than 33 mmHg
● Causes hyperventilation (breathing out a lot of CO2)–breathing too much and too fast when nervous/anxious
● Signs and symptoms:
○ Neurological: light-headedness, numbness & tingling, confusion, inability to concentrate, blurred vision
○ Cardiovascular: dysrhythmias, palpitations, diaphoresis
○ Other: dry mouth, tetanic spasms of the arms and legs
◆ Respiratory acidosis - this occurs when the lungs cannot remove all of the carbon dioxide the body produces; it causes the blood to become more acidic.
● pH is (lower/higher) than what we consider normal (less than 7.35). (Higher/Lower) pressure of CO2 (higher CO2, lower pH)
● Hypoventilation can cause this. Anything that doesn’t allow patient to blow off CO2
● Signs and symptoms:
○ Pulmonary: dyspnea, respiratory distress, shallow respirations
○ Neurological: headache, restlessness, confusion
○ Cardiovascular: tachycardia, dysrhythmia
● Treatment:
○ Try to decrease the hypoventilation–let them breathe→ increase ventilation
○ Correct causes such as pneumothorax, pain, CNS depression related to meds
○ Ventilation may be required until cause resolved
◆ Metabolic alkalosis - A condition in which the bodies pH (decreases/increases), becoming more basic.
● Bicarbonate level (lesser/greater) than 26mEQ/L with a pH (lesser/greater) than 7.45
● Caused by an excess of base or loss of acid
● Excess base can be from ingestion of antacids, excess use of bicarbonate, use of lactate in dialysis
● Loss of acid: vomiting, gastic suction, hypochloremia, excess use of diuretics, high levels of aldosterone
● Signs and symptoms:
○ Pulmonary - respiratory depression
○ Neurological - dizziness, lethargy, disorientation, seizures, coma
○ Musculoskeletal - weakness, muscle twitching, muscle cramps, tetany
○ GI - nausea, vomiting
● Treatment:
○ Difficult to treat
○ Drugs can stimulate bicarbonate excretion trough the kidneys
○ IV of acids
○ Metabolic alkalosis in a patient who is hospitalized usually iatrogenic (meaning its happen due to some treatment for another problem happening while they’re in the hospital)
◆ Metabolic acidosis - A condition in which too much acid accumulates in the body. Causes of metabolic acidosis can include buildup of body toxins, kidney failure, and ingestion of certain drugs or toxins, such as methanol or large doses of aspirin. It can be a rare complication of diabetes. Symptoms include nausea, vomiting, fast breathing, and lethargy. Treatment depends on the cause. Sodium bicarbonate can reduce the acidity of blood.
● Defined as a bicarbonate level of (less/more) than 22 mEq/L (normal 22-26) with a pH (less/more) than 7.35
● Caused by either a deficit of base in the blood or excess of acids other than Co2 (Lack of base and too much acid)
● Causes decreased levels of base: diarrhea, intestinal fistulas
● Causes of increased acids: renal failure, diabetic ketoacidosis, anaerobic metabolism, starvation, salicylate intoxication
● Signs and symptoms:
○ Neurological - headache, confusion, restlessness, lethargy, stupor or coma
○ Cardiovascular - dysrhythmias, warm, flushed skin
○ Pulmonary - kussmaul’s respirations?
○ GI - nausea and vomiting
● Treatment:
○ Sodium bicarbonate
○ Renal failure is a bicarbonate-responsiveness acidosis
○ Use of sodium bicarbonate routinely can cause metabolic alkalosis with hypernatremia (thirst, confusion, muscle twitching, seizures, coma, and death)
➔ pH → is a measurement of the acidity or alkalinity of the blood → acid base balance tells you nothing about oxygenation
◆ pH is inversely proportional to the number of (carbon/hydrogen) ions (H+)
◆ The more H+ present, the lower the pH will be
◆ Fewer H+, the higher the pH will be
◆ The scale from 1 (very acidic) to 14 (very alkalotic)
◆ A pH of 7 is neither acidic or alkalotic (it is neutral)
● The normal blood pH range is 7.35-7.45
● It is maintained in a tight range of control
● pH lower than 7.35 is acidic - too much (HCO3/CO2), too little (CO2/HCO3)
● Body system functions have changes when in acidic state
○ Decrease in the force of cardiac contractions
○ Decrease in vascular response to catecholamines
○ Diminished response to the effects/actions of certain medications
○ Respiratory acidosis → pt is not blowing off enough CO2
○ Metabolic acidosis → can be due to lack of a base in the blood or too much acids (often CO2)
● Blood pH above 7.45 alkalotic - too little (HCO3/CO2), too much (HCO3/CO2)
○ Body system functions have changes when alkalotic
◆ Interferes with tissue oxygenation
◆ Interferes with normal neurological function
◆ Interferes with normal muscular functioning
○ Respiratory alkalosis → may be due to hyperventilation where they are blowing off too much CO2 ( can cause pt to pass out)
● Significant pH changes above 7.8 or below 6.8 → can be deadly
○ Interferes with cellular functioning and can lead to death
◆ Balance of pH is managed b/tw respiratory and renal systems
12-16; 14-17; 8; 7.35-7.45; 7.35; 7.45; 35-45; 45; 35; 23-29; 90-100; 90-100; hydrogen; 22-26; 22; 26; retain; excrete; greater; less; lower; higher; increases; greater; greater; less; less less; hydrogen; CO2; HCO3; CO2; HCO3;
3) What are causes for an increase in work of breathing
➔ Restrictive and obstructive lung disorders lmao
◆ For restrictive - inspiratory work is increased because of decreased lung elasticity/compliance
● Pneumonia, sarcoidosis
◆ For obstructive - work of breathing is increased because of increased airway resistance
● Asthma, COPD, emphysema, cystic fibrosis
➔ Increased transpulmonary pressure (TPP)
4) Interventions for obstructive and restrictive lung disorders
➔ Restrictive
◆ Incentive spirometry
◆ Stacked breathing
◆ Diaphragmatic breathing
➔ Obstructive
◆ Pursed lip breathing
◆ Forced expiratory technique
◆ Acapella
◆ Flutter
◆ percussion/vibration
5) Interventions for airway clearance
➔ Diaphragmatic breathing
◆ Hand on chest and stomach, tell them the hand on the stomach should be moving. Pushes into hand on inhale and away from hand on exhale.
◆ Pts: hyperventilators, people in pain, pre and post surg patients
➔ Lateral segmental breathing
◆ Feet planted on the ground! Usually in sitting
● Can also be done supine or side-lying if patient cannot sit up
◆ Targeting base of the lungs, place your hands on the pts lower rib cage and ask them to push their ribs out into ur hands on the inhale, and when they exhale you push in.
◆ Pts: people with excess fluid (pregnancy, obesity, cystic fibrosis?)
● Avoid: broken ribs, sternal precautions
➔ Pursed lip breathing
◆ In slowly through the nose and out SLOWLY through the mouth, flickering a candle, mouth shaped like you are going to blow a whistle
● Exhale needs to be longer than the inhale
◆ Pts: obstructive disorders! Barrel chested, COPD!
➔ Stacking breaths
◆ Sitting or long sitting, this helps them take larger/deeper inhalations
◆ Inhale, hold, inhale, hold until you cannot tolerate anymore; repeat 2-3 times
● Avoid dizziness and panic
◆ Trying to max diffusion
◆ Pts: restrictive lung disorders! Post-op patients (pain) and hypoventilators
➔ Forced expiratory technique (huff coughing)
◆ Huffing 1-2 times followed by relaxed breathing 5-10 seconds; repeat 1-2 times
● Avoid wheezing! Should be like fogging glasses or mirror
● You can hold a tissue in front of them to make sure they are actually huffing
◆ Pts: obstructive disorders, CF, anything with mucus
➔ Active cycle of breathing
◆ Breathing control (diaphragmatic breathing) + thoracic expansion (lateral segmental breathing) + FET cycles (forced expiratory breathing)
● Thoracic expansion - up to 5x, patient comfort
● FET - until patient exhibits 2-3 dry, non-productive huff cycles in a row
◆ Used for secretion clearance (obstructive disorders)
➔ Autogenic drainage
◆ 3 parts
● Unsticking - slow, shallow inhale and hold for 2 seconds until breathing ALL the air out
○ Continue until mucus feels loosened
● Collecting - breathing into inspiratory reserve volume, exhale continues into expiratory reserve
○ Continue until mucus is heard/felt in larger, more proximal airways
● Evacuation - increasing breathing volumes, secretion should be heard in trachea, expectoration (clearing that shit out) should occur with exhale or a huff
➔ Acapella
◆ Pts: chronic bronchitis, emphysema, mycobacterial disease, bronchiectasis
● Large amounts of mucus, prevent infection
◆ Expiratory
● Should hear flutter through the device during the exhalation
➔ Flutter
◆ Pts: mucus producing respiratory conditions - atelectasis, bronchitis, CF, COPD, asthma
● Contraindicated for pneumothorax or RSHF
◆ Expiratory
● Should hear flutter, if you lose it you’re out of the range of the machine
➔ Incentive spirometer
◆ Inspiratory - teaching them how to take a slow, deep inhale
● Strengthen muscles of inhalation, facilitate lung expansion
◆ Restrictive lung disorders, post-op pain, etc. pretty much anyone
6) Characteristics of ECG
➔ PVC, A-fib, A-flutter, Couplets, NSR
◆ A-flutter
● P waves are “sawtooth”, flutter like
● More than one P wave before every QRS complex
○ QRS normal
● Atrial depolarization rate is 250-350 per minute
6) Characteristics of ECG
◆ A-fib
● P waves are absent, flat or wavy baseline
● R-R interval is irregularly irregular, chaotic
● Narrow QRS
● Rate varies
● Stroke risk, quivering of atrial because loss of atrial kick
6) Characteristics of ECG
◆ PVC
● Absence of P waves in premature beat - wide and bizarre
● QRS duration of early beat is greater than .10 seconds - wide QRS
● T wave is opposite of R wave
● PVC is followed by compensatory pause
● Serious and can be life-threatening
● Easily noticed
○ Wide QRS complex, no P wave, T wave in opposite direction of R wave
6) Characteristics of ECG
◆ Couplets
● Two PVCs in a row together, if there is run of 3 = v-tach (very concerned if you see this)
◆ NSR
● Normal sinus rhythm - normal conduction pathway (normal p wave, interval, qrs, and t wave)
○ Indicates rhythm and there is nothing unusual they are seeing
● Isoelectric line → P wave (atrial depolarization) → isoelectric line (delay from AV node) → QRS complex (signal goes to bundle branches and purkinje fibers - ventricular depolarization) → isoelectric line → T wave (repolarization of ventricles)
● PR interval: - seconds = AV node holds the signal for atrial kick
● QRS complex duration: - seconds
● R-R wave: .6-1.0
➔ Ischemic presentation
◆ Reduced blood flow to myocardium due to occlusion of coronary arteries from vasospasm, atherosclerotic occlusion, thrombus
◆ Demonstrated on 12-Lead ECG with T wave inversion
● If there are changes on EKG then make sure to check equipment, stop what you are doing and get doctor involved
➔ meaning of Inverted T-waves
◆ Problem with repolarization of ventricles - related to ischemia
.12-.2; .06-.10;
7) PFT- pulmonary function testing
Pulmonary function testing provides information about integrity of airways, function of respiratory musculature, and condition of lung tissues. Most common techniques are spirometry, diffusion capacity of the lung for CO, and helium lung volumes.
➔ Volumes and Capacities
➔ What indicates restrictive or obstructive disease
◆ Restrictive lung disease- overall volumes (IRV, VT, ERV, RV) and capacities (TLC, VC, FRC) are decreased.
● Decreased (TLC/RV) and (FRC/VC) are commonly decreased and used to diagnose restrictive lung disease.
● Normal or (low/high) FEV1/FVC ratio
◆ Obstructive lung disease- (high/low) FEV1/FVC ratio
➔ What does a reversal with bronchodilator indicate → i think it indicates someone has asthma?
TLC; VC; high; low;
7) PFT- pulmonary function testing
Pulmonary function testing provides information about integrity of airways, function of respiratory musculature, and condition of lung tissues. Most common techniques are spirometry, diffusion capacity of the lung for CO, and helium lung volumes.
➔ Volumes and Capacities
➔ What indicates restrictive or obstructive disease
◆ Restrictive lung disease- overall volumes (IRV, VT, ERV, RV) and capacities (TLC, VC, FRC) are decreased.
● Decreased (TLC/RV) and (FRC/VC) are commonly decreased and used to diagnose restrictive lung disease.
● Normal or (low/high) FEV1/FVC ratio
◆ Obstructive lung disease- (high/low) FEV1/FVC ratio
➔ What does a reversal with bronchodilator indicate → i think it indicates someone has asthma?
TLC; VC; high; low;
8) Cardiac Surgery
➔ Definition of on-pump, and off-pump (using google and AHA website)
◆ On-pump CABG- surgery performed when the heart is stopped. A cardiopulmonary bypass machine (“on-pump”) is an artificial circulation machine that acts as the heart/lungs to deliver blood to the rest of the body during the procedure.
◆ Off-pump CABG- surgery is performed while the heart is beating and without the use of a heart-lung machine
● Newer procedure, decreased risk of stroke and organ dysfunction with this procedure
➔ Knowledge of Median sternotomy, lateral thoracotomy
◆ Median sternotomy
● Common approach for cardiac surgeries
● Incision is inferior to suprasternal notch and extends down midline of sternum to below xiphoid
◆ Lateral thoracotomy
● Axillary
○ Shorter length incision for muscle sparing
○ Disadvantage: Poor visibility for surgeon, brachial plexus can be affected
○ Advantages: minimize pulmonary function and mobility impairments, faster recovery
○ For the most frequently minimal invasive cardiac procedures
◆ Epicardial pacemaker placement
9) Lung Surgery
➔ Lung volume reduction surgery- surgical procedure for COPD
◆ Take out a part of your lung
◆ If lungs are hyperinflated - they remove a lobe that can’t exchange oxygen and remove it so that tissue that will be able to exchange oxygen can move into that space
◆ The lung tissue doesn’t have V/Q matching, so have to take it out
➔ Treatments
◆ Because it is an obstructive disorder
● Pursed lip breathing
● Acapella
● Education for deeper exhalation
● Diaphragmatic breathing
● Want to increase exhalation
10) Cardiac Auscultation
➔ S1, S2, S3, S4 and relation to each other in cardiac cycle
◆ S1 - lub, low pitched
● (Opening/Closure) of AV valves
● Best heard over the (base/apex) of the heart
◆ S2 - dub, high pitched
● (Opening/Closure) of SL valves
● Best heart at (apex/base) of heart
◆ S3 - diastolic sound, blood entering non-compliant ventricle (ventricular gallop) - VOLUME OVERLOAD
● Best heard at apex
● Can be normal in children
● Seen with CHF
◆ S4 - diastolic sound produced by atrial kick pushing blood into non-compliant ventricle (atrial gallop) - PRESSURE OVERLOAD
● Heard at L sternal border
● CAD, HTN, stenosis of SL valves, MI, angina
● Can be normal in children
➔ Where you listen for aortic, mitral, pulmonary, tricuspid valves
◆ Aorta - 2nd intercostal space, (left/right) sternal border
◆ Pulmonic - 2nd intercostal space, (left/right) sternal border
◆ Erbs point - 3rd intercostal space, (left/right) sternal border (murmurs)
◆ Tricuspid area - 4th and 5th intercostal space, (L/R) sternal border
◆ Mitral area - 5th intercostal space, (L/R) midclavicular line
● Best heard in L side lying
➔ Where is PMI (point of maximum impulse)
◆ (Apex/Base) of the heart, same as mitral area
➔ Hallmark for CHF - (S3/S4)
Closure; apex; Closure; base; right; left; left; L; L; Apex; S3;
11) Pulmonary Auscultation
➔ Definition of crackles, rales,
◆ crackles/rales - brief/explosive/interruptive sounds
● Like hair rubbing next to ear
● May be wet, dry, course, or fine
○ Fine - high pitched popping (like wood burning)
◆ Best heard at lung (apex/bases)
◆ Chronic bronchitis
◆ Diff dx - CHF, pneumonia, atelectasis
○ Course - low pitched popping (like bubbles)
◆ Chronic bronchitis, bronchiectasis, pneumonia, severe pulmonary edema
◆ Inspiration and expiration, all lung fields
● Represent air passing through fluid in distal airways and reinflation of alveoli – popping open and closing again
◆ Wheezing - musical sound, whistling in narrow tube, snoring in low pitch
● Continuous
● Expiratory may be prolonged
● Represent air passing through constricted airways - COPD or asthma
◆ Rhonchi - snoring, gurgling, rumbling - low pitch
● Continuous, through both inspiratory and expiratory
● Represent air passing through secretions in large airways
● Often cleared with cough (unlike with wheezing)
● Sibilant or sonorous
○ Sibilant - hissing sound
○ Sonorous - similar to snoring or gurgling
● Associated with COPD, cystic fibrosis, bronchiectasis, and pneumonia
◆ Stridor - loud musical sound heard without stethoscope
● Inhalation and exhalation
● Represents obstruction/inflammation of trachea, larynx, airway
● Diff dx - croup, upper airway narrowing after intubation, foreign body obstruction, tumor, peritonsillar abscess, retropharyngeal abscess, allergic response, airway edema
bases;
16) Reasons to terminate an exercise session or test
16) Reasons to terminate an exercise session or test
17) Anatomy
➔ True vs. false ribs
◆ True ribs - attach to the (ribs/sternum) via costal cartilage (vertebrosternal)
● Ribs (1-7/8-10)
● Increase in length from above rib
◆ False ribs - attach to (ribs/sternum) above via costal cartilage (vertebrochondral)
● Ribs (1-7/8-10)
● Decrease in length from above rib
◆ Ribs 11-12 end freely in muscle
➔ Location of sternal angle, suprasternal notch
◆ The suprasternal notch corresponds to a T(2-3/4-5) level, and the sternal angle lies at the T(2-3/4–5) level.
➔ Function of vagus nerve
◆ Vagus nerve controls the parasympathetic nervous system
● Cardioinhibitory - (increases/decreases) HR and BP
● Neurohormone = acetylcholine
◆ Parasympathetic nervous system and pulmonary innervation not sure if this is directly related to the vagus nerve
● Bronchoconstriction - maintain smooth muscle tone
● Increases bronchial mucous production
● Vasodilation of pulmonary artery
sternum; 1-7; ribs; 8-10; 2-3; 4-5; decreases;
