General PA Review Set 1 Flashcards
Semester 1 General
In the Primary Assessment: what is the acronym “OPQRST”?
- Onset
- Provoke
- Quality
- Region/Radiation
- Severity
- Time
Inspection: Elements to look for above the collarbone?
- Cyanosis
- Trauma
- Sweating
- SOB
- Purse lips
- ptosis (drooping of the upper eyelid)
- Nasal flaring
- JVD
Why do we look for JVD?
Sign of right sided heart failure
- > 3-4cm = Normal
Inspection: What elements are evaluated regarding the thorax
- Accessory muscle use
- Retractions
- Barrel chest
- Scoliosis/kyphosis
Inspection: What elements are evaluated for regarding the extremities
- Clubbing
- Pedal edema
- Where is Stridor Heard?
- what does it sound like?
- Heard over trachea usually during inspiration
- Load, high pitched, and continuous.
What does stridor indicate?
- Anaphylaxis
- Tumor
- Croup
- Edema
Auscultation: fine crackles vs course crackles?
- Fine crackles = high pitched, discontinues,
USUALLY DONT CLEAR WITH COUGH - Course crackles = low pitched, continuous,
MAY CLEAR WITH COUGH
What do fine crackles indicate?
Secretions or leaky air, so the following pathologies would be expected:
- Atelectasis
- Interstitial fibrosis
- Pulmonary edema
what do course crackles indicate?
Fluid/secretions in lungs
- COPD
- CF
- bronchiectasis
- pulmonary edema
Auscultation: What do wheezes indicate?
sign of lower airway obstruction
- edema
- obstruction
- bronchospasm (Asthma or Bronchiolitis)
Auscultation: what does pleural friction sound like?
creaking or grating
Interview questions: aside from the OPQRST. what informed does the secondary assessment seek?
(6)
- Chief complaint (symptoms)
- History of present illness
- Past med. history
- tobacco use
- family history
- occupational history
X-ray analysis: What are we looking for in PPP?
- Person
- Place
- Position
x-ray analysis: what does the abbreviation in “ABCDEFGHI” categorize?
- Airway
- Bones
- Cardiac shadows/costophrenic angles
- Diaphragm
- Edges of heart/effusions
- Field of lung/fissure
- Gastric bubble
- Hila
- Instruments
Expiratory Accessory muscles (4)
- Rectus abdominis
- External oblique
- Internal oblique
- Transversus abdominis
Inspiratory Accessory muscles (4)
- Scalenes
- sternocleidomastoids
- Chest muscles
- Trapezius
Does hyperventilation cause an acidosis or alkalosis?
Respiratory alkalosis (over-breathing)
When you breathe faster, reduction in carbon dioxide level in your blood can lead to respiratory alkalosis (hypocapnia).
Does hypoventilation cause acidosis?
Yes, there is more CO2 in the blood as a result of it not being expelled out in breaths (hypercapnia).
Auscultation: what do wheezes indicate
Indicate obstruction or narrowing of the airways.
- Usually associated with lower airway pathologies like asthma, bronchitis, and COPD
- Could indicate (unlikley) movement of excessive secretions or fluid, more often this is with crackles though.
- Heard during inspiration and expiration
what is a bronchospasm?
When the muscles that line your bronchi tighten and cause your airways to narrow
Auscultation: Diminish breath sounds indicate
- hyper/hypoinflation
- pleural effusion
- Flail chest
What do retractions indicate?
(substernal, supraclavicular, intercostal etc.)
Soft tissue are being pulled in bc of high negative intrapleural pressure during inspiration.
AKA CAUSED BY RESTRICTIVE LUNG DISORDERS
Restrictive vs obstructive lung disorders
Obstructive = hinder ability to exhale out of lungs
Restrictive = difficulty expanding their lungs.
CXR: what are air bronchograms
Air filled bronchi (white blotches)
- sign of alveolar disease or CONSOLIDATION.
CXR: What are Kerley b lines?
Horizontal lines in the lung periphery that extend to the pleural surface.
CXR: what do Kerley b lines indicate?
Pulmonary edema
- Often with chronic heart failure patients
CXR: subcutaneous emphysema
When air gets into tissue under the skin.
CXR: Meniscus signs
Rounded mass in the lung capped by a crescent shaped collection of air (consolidation)
Indicate either a pleural effusion or pneumothorax
CXR: Hemidiaphragm tenting
found in upper lobe collapse or where there is loss of volume.
CXR: Hemidiaphragm tenting
found in upper lobe collapse or where there is loss of volume.
CXR: Pulmonary Edema
Batwings on cxr and Kerley B lines
CXR: Pulmonary Edema
Transport: When would you transfer to a venturi mask or a NRB mask?
hint what are they on/physician orders.
If on HFCN (misty ox) put them on non-breather.
-why?
Because venturi cannot guarantee 60% FiO2
O2 therapy: why would you want to increase flow rather than FiO2 on a optiflow device?
If you want to improve the volume of patients breath
OR
Wash out their CO2 more
Remember: you can control 100% of their inspiration as long as they are breathing through the cannula
What are blebs?
Pulmonary blebs are small subpleural thin walled air containing spaces.
No bigger than 1 or 2 cms in diameter.
What is the most common identifiers for COPD on a CxR?
Elongated heart shadow
“Dark” lung fields
What is the most common identifiers for COPD on a CxR?
Elongated heart shadow
“Dark” lung fields
Atelectasis is described as a loss of air in a portion of lung tissue.
What are 2 typical factors that cause atelectasis?
Obstruction (absorption)
Change in transpulmonary distending pressures (compression)
Atelectasis: what is absorption atelectasis?
Occurs when alveolar gas is absorbed into the bloodstream faster than it can be replaced.
- Common with high oxygen concentrations (FiO₂ ≥ 60%), as nitrogen is washed out, oxygen is rapidly absorbed, leading to alveolar collapse.
- Can happen with mucus plugging or airway obstruction, preventing fresh gas from reaching the alveoli.
- Problem w/poorly ventilated alveoli: as o2 replaces nitrogen it is more readily absorbed into the blood via capillaries. Alveoli in turn shrink and alveolar pressure drops
Atelectasis: what is compression atelectasis associated with?
Pleural effusion, pneumothorax, hemothorax, or space occupying lesion.
Types of Atrial Fibrillation
Ventricular tachycardia vs Fibrillation?
V.fib is completely chaotic with no identifiable waves or complexes
V.Tach = usually regular with qrs and fate rate.
Third degree heart block
no relation between p waves and qrs
Reg: reg, but different.
Rate: Ventricular rate is 40-60bpm if paced by junction, 20-40 if by ventricles
P-wave: upright and uniform, more P waves than QRS
PR Interval: P waves are unrelated to QRS; no PRI
QRS: <0.12 if by junction focus, greater = focus is ventricular
Second degree heart block (TYPE II) (mobitz) Heart block
Fixed PR interval + dropped beat
Regularity: Reg R-R interval in conduction is consistent
Rate: Ventricular rate is below normal
P wave: upright and uniform, more p waves than qrs
PR Interval: may be longer than normal, constant.
QRS: <0.12
Second degree TYPE 1 (Wenkebach) Heart block
Progressive PR intervals lengths + dropped beat
Regularity: regularly irregular
Rate: ventricular rate is lower bc some beats aren’t conducted
P waves: more Ps than QRS
PR interval: gets progressivly longer until it doesn’t follow QRS
First degree heart block
Prolonged PR intervals + dropped beat
Delay at AV node
Each impulse is eventually conducted
Heart blocks describe 3 degrees (4 tyes) of AV blocks.
Describe each block mech.
usually result in delay in impulses before ventricles (extended PRI’s > 0.2 -1st) or none at at all (3rd)
not uncommon to see wide qrs
Junctional Tachycardia characteristics
Regularity: Regular
Rate: 100 - 180 bpm
P Waves: Will be inverted, can occur before, during or after the QRS
PR Interval: If measurable < 0.12 s
QRS Complex: < 0.12 s
Main point: P waves are inverted or invisible (in qrs)
Atrial Fibrillation
Regularity: R-R are irregular
Rate: immeasurable
P waves: can’t discern because is quivering/fibrillating
PR intervals: not measurable
QRS: < 0.12 (normal)
Atrial flutter
Main point:
P waves = sawtooth pattern.
Wandering pacmaker
irregular rhythm
What do deep ST segment and Inverted T waves indicate
Ischemia (Reduced/blocked blood flow)
What is the difference between right-sided heart failure and left-sided heart failure?
left-sided heart failure: left side of heart is weakened and results in reduced ability for the heart to pump blood into the body.
right-sided heart failure: right side of heart is weakened and results in fluid in your veins, causing swelling in the legs, ankles, and liver.
General causes of Hemoptysis
(blood with sputum)
Broad Causes:
Bronchopulmonary, cardiovascular, hematologic, and other systematic disorders
Specific Causes:
Tobacco use, trauma, foreign body aspiration, anticoagulants, chemotherapy, tuberculosis, pulmonary edema, bronchogenic cancer, pulmonary infection, tumor, granuloma, crack cocaine use
Barking/Harsh/Dry/Stridor coughs indicate what?
Laryngeal disorder
Wheezy cough indicate?
Bronchial disorder
Obstruction
Acute productive coughs indicate?
Bacterial, allergic asthma, viral
Pleuritic chest pain (pleurisy) characteristics
Pain diminishes during splinting
Sudden and sharp
intense during deep inspiration or cough.
position change can relieve pain
Characteristics of:
Pneumonia, Pleural Effusion, Pneumothorax, Pulmonary Infarction, Lung Cancer, Pneumoconiosis, Fungal Disease, Tuberculosis
Pleuritic chest pain (pleurisy) characteristics
Pain diminishes during splinting
Sudden and sharp
intense during deep inspiration or cough.
position change can relieve pain
Characteristics of:
Pneumonia, Pleural Effusion, Pneumothorax, Pulmonary Infarction, Lung Cancer, Pneumoconiosis, Fungal Disease, Tuberculosis
Central chemoreceptors vs Peripheral chemoreceptors
They stimulate ventilation:
Central responses to CO2 and pH via modulation of respiration.
Peripheral response to O2 in arterial/aortic bodies -> increase MV.
Neutrophils function (general scope)
Infection response (phagocytic chemotaxis)
-destroy foreign material and dead cells
-inflammatory response
-Destroys bacteria
Lymphocyte function (general scope)
Fight infection, promote immunity.
(t-cell,b-cell, and natural killer cells)
-destroys virally infected cells
Eosinophil function (general scope)
Immune system response, parasitic infections, allergic reactions (problems = hypersensitive)
Atopic Asthma - allergic
Basophil function (general scope)
immune system regulation, infections, allergic reactions
Note: allergic reactions with basophils = inflammatory response
General definition for Polycythemia
Increase in RBC, Hgb, Hct
2 types: primary and secondary.
There is also a “not fully true type” = spurious
Why is polycythemia bad?
Increase in O2 carrying capacity = thick blood = increase in workload on heart
Primary polycythemia?
Rare; uncontrolled proliferation of RBC/HgB/Hct
Caused by abnormality of cells in marrow that form RBC
Secondary polycythemia?
Chronic Hypoxemia-stimulates erythropoietin-increased production of RBC’s
Occurs outside of the bone marrow
COPD
Spurious “polycythemia (not really)*
relative increase in RBC due to decrease in plasma
dehydration
What is Thrombocytopenia and why is a problem?
What is Thrombocytopenia and why is it a problem?
decrease in platelet count = hemorrhaging
What is Thrombocytosis and why is it a problem
increase in platelet count
Reactive process after hemorrhage (stress, inflammation, or surgery)
Increased risk for thrombosis (clot)
Thrombolytic agents?
Prevent/bust existing clots
(clot buster)
Why are anti-coagulants different from thrombolytic agents?
Thrombolytics are to treat already existing clots such as in strokes.
Anti-coagulants prevent the risk of development for clots (i.e warfarin or heparin)
What is D-Dimer?
measures protein fragment when clot dissolves
regular = 0.5 mg/L
Thrombus vs Embolus?
Thrombus: blood clot that forms inside a blood vessel
Embolus: a dislodged thrombus that is in circulation.
What does it mean when an anion gap is too high or low?
High: too acidic
Low: too basic
Normal Potassium Value?
Where is it typically located?
3.3-5.0 mmol/L
Major cation in ICF
Why is potassium important
Important in intracellular fluid osmotic pressure
Important in regulation of cardiac muscle function
Hyperkaliemia is caused by?
-Rhabdomylosis (or any cell rupture/crush injuries)
-Kidney disease (decreased excretion)
-Hypoxia (more K+stays in plasma)
-Metabolic Acidosis (more K+ stays in plasma)
-Poorly controlled diabetic ketoacidosis
-Other: intake/supplements
Hypokalemia is caused by
Increase loss (caused by):
-Severe vomiting (or nasogastric sxning)
-Diuretics (Lasix***)
-Diarrhea
-chronic renal disease
AND
High dose beta agonist therapy
What is high dose beta agonist therapy?
Lower K+ via administration of Ventolin
Signs of Hyperkalemia
Mental confusion
Weakness
Numbness
Respiratory muscle weakness
Bradycardia
Cardiac arrest
Signs of Hypokalemia
Muscle weakness
Irritability
Tachycardia
Supraventricular Tachyarrhythmias
Torsades de Pointes
Life threatening ventricular arrythmias
Normal Chloride levels
and location?
98-111 mmol/L
Major anion in ECF
Chloride function
maintain osmotic pressure and anion-cation balance
Buffers the blood when O2 is released from HgB into tissues
What is the fastest buffer system in the body?
Carbonic acid-bicarbonate buffer system
What is the most powerful buffer system in the body?
Protein buffers (plasma proteins and intracellular)
What is the main buffer system of the human body?
Bicarbonate buffer
manages IF surrounding cells and tissue
Which systems use the bicarbonate buffer system the most effectively
Renal and Respiratory system
What is a major end product of the carbohydrate metabolism?
Glucose; it requires insulin to be used by cells.
Normal value = 50-120 umol/L
What is a non-protein waste product generated during metabolism?
Creatinine; levels are constant with normal muscle function but increase with injury and hypoxia
Normal range - 50-120 umol/L
What is used as a indicator of kidney function?
Creatinine; we compare its filtration via glomerular filtration rate (GFR)
High creatinine indicates renal failure
Blood Urea Nitorgen (BUN) has 2 types.
What are they and what is their function?
Urea; waste product of the breakdown amino acids.
-Indicative of over all renal function: eg. decreased filtration due to low cardiac output (CO)
Ammonia; Waste product
Liver normally turns urea into ammonia to be excreted in urine
-High ammonia can indicate liver or renal failure
Add slide 60 from lab data.
Lactate (lactic acid) is a by-product of what?
anaerobic metabolism
Normal value = less 1.7 - 2.0 mmol/L
What does Lactate indicate?
Perfusion.
High levels indicate poor perfusion and/or tissue hypoxia
Lactate Mortality ranges (past 2 mmol)
Mortality of 67% when > 3.8 mmol/L
Mortality of > 90% when > 8 mmol/L
What do liver disease and kidney failure have in common?
Decrease or loss of proteins.
liver failure = decreased protein manufacturing
Kidney failure = loss of proteins
Albumin function
Major factor in maintaining blood osmotic (oncotic) pressure
C reactive protein (CRP)
Produced by liver
levels increase in the presence of inflammation
Myoglobin is used as in indicator for what?
O2 storage in muscle tissue.
Abnormally high in cardiac cell death, as it gets released.
Troponin I is used as in indicator for what?
Diagnostic marker for cardiac muscle injury
serum levels rise 4 to 8 hours after MI
Creatinine kinase MB (CK-MB)
is used as in indicator for what?
Muscle damage
Lipids are indicative of cholesterol:
Is LDL better than HDL?
Normal value is less than 200 mg/dL
LDL (low density lipoprotein)
The bad kind
HDL (high density lipoprotein)
The good kind
what can Urinalysis indicate?
the presence of agents, glucose, proteins, blood, bacteria, virii
Cloudy or clear
Specific gravity
RBCs, WBCs
Casts, crystal material etc.
Define shunt
Perfusion > Vent.
Example:
-Atelectasis (alveoli collapsed)
-Consolidation (alveoli filled with fluid)
-Pulmonary edema
What is generally associated with:
Consolidation and Pulmonary edema?
Consolidation: pneumonia
Pulmonary edema: CHF
Define deadspace
Ventilation > Perfusion
Any disruption in blood flow via pulmonary capillaries:
-Pulmonary embolism (clots)
-COPD (air obstructed)
https://www.youtube.com/watch?v=z42ZGcc0jAw&ab_channel=RespiratoryCoach
What factors increase V/Q Ratio?
COPD and Pulmonary embolism
What factors decrease V/Q ratio?
Pulmonary edema
Does PPV increase or decrease venous return?
Decrease
If Venous return decreases, how is cardiac output affected?
Decrease
What is the main difference between decorticate and decerebrate posturing?
- which is worse?
Decerebrate is more severe
- Decorticate = elbows bend and fold arms in
- Decerebrate = all limbs extend away
What is the most common abnormal breathing pattern sweet in a pt. with a neurological disorder?
Cheyne Stokes
What are 3 components of cushing triad?
hint think ICP
- Increase systolic BP w/widening pulse pressure
- Bradycardia
- Bradypnea
What does the PEERLA acronym mean?
“pupils are equal, round and reactive to light and accommodation.”
- eye test to check for normal function
How does the GCS modify its level when a Pt. is intubated?
Verbal response will be 1 and score is marked with a “T”
How could the respiratory system be affected by a spine fracture @anything between the C3, C4, or C5?
- Could result in Diaphragm paralysis
- Could cause paradoxical breathing pattern due to loss of lateral and A/P chest expansion
- Absent cough
- VC 0-5% of normal
What is considered a mid-low spine injury?
Anything affecting C3,C4,C5
Describe how motor strength can be assessed in a unconscious pt.
Apply noxious stimuli and access response
Define delirium
Acute brain dysfunction with reduced ability to sustain attention
- usually fluctuates throughout the day
What could delirium indicate?
- Infection
- hypoxemia
- sepsis
- non functioning hear aids or glass
- lab/electrolyte imbalances
What are methods to reduce ICP?
- Therapeutic hyperventilation
- Extra ventricular drain
- Mannitol (drug therapy)
How does therapeutic hyperventilation help decrease ICP?
Inducing Hyperventilation lowers PaCO2 causing cerebral vasoconstriction
- Vasoconsrition decreases blood in the brain
How do you keep secretions thin?
- why do you want secretions thin?
- which group would benefit most from this?
Use a HME or provide humidification to keep airways moist
- thing secretions are easy to cough
- adult tracheostomy pts
Does intrathoracic pressure increase during inspiration or expiration?
- During inspiration, intrathoracic pressure decreases (becomes more negative)
- During expiration, intrathoracic pressure increases (becomes more positive).
List the elements assessed when evaluating the bronchopulmonary hygiene of a patient.
COCA
- Color
- Odor
- Consistency
- Amount
What assessment and maintenance is typically required of an ETT during a routine ICU assessment?
- Size/ type
- Depth, chest x-ray to confirm
- Position at the teeth
- Cuff pressure
- Inspection of tube and site or sign of skin necrosis or irritation/ oral care
and repositioning of the tube/ suction
What assessment and maintenance is typically required of an trach during a routine ICU assessment?
- size/ type
- CXR position
- cuff/ Cuff pressure (is cuff up or down?)
- stoma site inspection for discharge, dryness, bleeding, signs of infection
- Tracheostomy care with suction if indicated
- weaning considerations
How does PPV impact V/Q mismatching?
Can increase V/Q mismatch.
- can lower perfusion to the lungs
- v/q have a inverse relationship.
How does PPV impact venous return and CO?
PPV decreases venous return which causes decreased CO
- venous return decreases because a increase in intrathoracic PPV
In PC-adapative, what is the control variable and what is the delta variable?
- Volume in the control variable
- Pressure is the delta
Which arrhythmias would you use defibrillation for?
- Pulseless ventricular tachycardia
- Pulseless electrical activity (PEA)
- Asystole
Which arrhythmias would you use Cardioversion for?
- Atrial Fibrillation
- Atrial Flutter
- Ventricular Tachycardia
Which arrhythmias would you use Pacemakers for?
- Bradycardia
- Heart Blocks
Epinephrine stimulates which receptors?
A1, B1, and B2
Norepinephrine stimulates which receptors?
Just B1
Dopamine stimulates which receptors?
A1 and B1
Phenylephrine stimulates which receptors
A1, and minimally stimulates B1 and B2 receptors
Which 3 drugs are used to treat hypotension due to a distributive shock?
Epinephrine, Norepinephrine, and Dopamine.
list non-adrenergic drugs that increase SVR
Vasopressin
What’s the difference between anti-coagulants and thrombolytics?
Anti-coagulants prevent clots from forming. Thrombolytics destroy clots that have already formed.
Normal respiratory rate is checked by counting breaths in 1 min. How do you check RR in 15 seconds?
Count the number of breaths in 15 seconds (RR as one inhalation and exhalation) multiplied by 4.
- how about 10 seconds? 30 seconds?
what is Eclampsia and preeclampsia?
- Onset of seizures (convulsions) in a pregnant women.
- Preeclampsia is developed during the 20th week of pregnancy and is characterized by (high BP hypertension ) and damage to the liver and kidneys
why is preeclampsia a fetal risk or problem?
Maternal hypertension as a result of eclampsia causes insufficient blood flow to the placenta. (also causes damage to the mothers liver and other organs)
What is hemolytic anemia?
A disorder in which red blood cells are destroyed faster than they can be made.
- The destruction of red blood cells is called hemolysis.
What is Hemolysis?
The destruction of red blood cells
How do reversal agents work?
They block anticholinesterase so that the muscle receptor remains full/blocked and unable to twitch
What enzyme breaks down acetylcholine?
Anticholinesterase
