Intro to Resp Med Weeks 1-13 Flashcards
Deontological
Based on Duty. An act isn’t right or wrong based on it’s character but on it’s consequences.
4 Things needed to be ethical
1. Universal
2. Self
3. Means
4. Long Term
Teleological (Utilitarianism)
Looking for the best outcome. (Sacrifice 1 to save many)
5 Bacteria Shapes
- Cocci (Circular)
- Bacilli (Rod Shaped)
- Strep (Chain)
- Staph (Cluster)
- Diplo (Pair or 2)
Bacterial Growth Stages (4)
- Lag Phase (Slow Growth)
- Log Phase (Rapid Growth)
- Stationary Phase (Nutrient Depleted, waste product accumulates, grow rate slows)
- Death Phase (Starts to die off)
What is the Difference between Clean, Disinfect and Steril
Clean= Only removed dirt matter
Disinfect= 3 levels.
1. Low- Removed bacteria, viruses
2. Intermediate- Removed bacteria, viruses, fungi & TB
3. High- Inactivates all microorganisms w/o spores
Steril= Complete destruction of microorganisms including spores
Droplet precautions
Private room, if possible, Surgical Mask, Hand Hygiene, Remove Mask in Room, limit transport
Airborne Precautions
Negative Pressure Room, N95, Hand Hygiene, Remove PPE outside of Room, Limit Transport
Infection prevention
- Decrease host susceptibility
- Immunizations & Chemoprophylaxis
- Limit use of device associated with HAI
- Prevention Bundles
- Eliminate Source of pathogen
Electronic MR vs. Paper Benefits
Improves storage & retrieval of Pt. info
10 Barriers to Health Literacy
- Affordability
- Appropriateness
- Availability
- Adoptability
- Acceptability
- Awareness
- Attitude
- Approachability
- Alternative Practice
- Additional Service
Health Literacy
The ability to find, understand and use health related info to make health related decisions for themselves and others
Healthcare Competence; the vulnerable (8)
- Poor
- Racial & Ethical Minorities
- Un or Under Insured
- Older/Younger
- Homeless
- Substance Abuse
- Low Education
- Mental Illness
Conflict Sourced & How to Resolve
Source= Poor Communication, Structural Issues with Leadership, Personal Behaviors, Role Conflict
Resolution=
Competing (Poor Choice)
Accommodating (Poor Choice)
Avoiding (Poor Choice)
Collaborating (Good Choice)
Compromising (Good Choice)
How to Improve Communication
- Listen & Observe entire message
- Understand Med Term
- Understand Culture norms
- Little Room for error w/ meds
- (Sender) Share info don’t tell it
- (Sender) Seek to Relate
- (Receiver) Practice Silence
- (Receiver) Resist Distractions
- (Receiver) Hear before evaluating
- (Receiver) Control Emotions
Communication Zones (4)
- Intimate= 0-1.5 ft (Physical Exams
- Personal= 1.5-4 ft (Gathering Info)
- Social= 4-12 ft (Initial Greetings, doorway)
- Public= 12-25 ft (Not personal, hallways)
What effects good communication (6 topics)
- Environmental
- Emotion/Sensory
- Verbal expression
- Non-Verbal Expression
- Internal or Interpersonal (Previous experiences)
- Physical Appearance and Status
5 Elements of Communication
- Sender
- Message (Encoding)
- Channel or Route (Decoding)
- Receiver
- Feedback
Conditions: Emphysema
(Identify: Percussion, Fremitus, Breath Sounds, Adventitious)
Percussion= Hyper resonant
Fremitus= Decreased
Breath Sounds= Decreased or Absent
Adventitious= None
Conditions: Pneumothorax
(Identify: Percussion, Fremitus, Breath Sounds, Adventitious)
Percussion= Hyperresonant
Fremitus= Decreased
Breath Sounds= Decreased or Absent
Adventitious= None
Conditions: Atelectasis
(Identify: Percussion, Fremitus, Breath Sounds, Adventitious)
Percussion= Dull
Fremitus= Decreased
Breath Sounds= Decreased or Bronchial
Adventitious= None or Crackles
Bronchial breath Sounds
(Identify: The Cause, Percussion, Fremitus, Adventitious)
Cause= Consolidation, Atelectasis
Percussion= Dull
Fremitus= Consolidation (Increased) Atelectasis (Decreased)
Adventitious= Consolidation (Crackles, Rhonchi, Ego-Phony)
Atelectasis (None or Crackles)
Condition: Consolidation
(Identify: Percussion, Fremitus, Breath Sounds, Adventitious)
Percussion= Dull
Fremitus= Increased
Breath Sounds= Bronchial
Adventitious= Crackles, Rhonchi, Egophony
Condition: Bronchitis
(Identify: Percussion, Fremitus, Breath Sounds, Adventitious)
Percussion= Resonant
Fremitus= Normal or Decreased
Breath Sounds= Prolonged on Exhale
Adventitious= Wheezes, Crackles, Rhonchi
Crackles (Rales)
Sound like?
Heard When?
Conditions?
Sound Like= Fine or Medium Wet sounds
Where= On Inspiration
Conditions= Consolidation, Bronchitis, Atelectasis
Rhonchi
Sound like?
Heard where?
Conditions?
Sound like= Coarse bubbly sounds
Where= During Expiration
Conditions= Consolidation, Bronchitis
Wheezes
Sound like?
Heard where?
Conditions?
Sound like= High Pitched Whistle
Where= On Expiration
Conditions= Bronchitis
Pleural Friction Rubs
Sound like?
Heard where?
Conditions?
Sounds like= Creaking Shoe or rocking chair
Where= Over area pt. complains of
Conditions= Pleural Effusion
Stridor
Sound like?
Heard where?
Conditions?
Sounds like= High Pitched Squeal or a Seal
Where= Obstruction in Trachea or Larynx
Conditions= Acute Epiglottitis, Croup, Post Extubating
Whispering Pectoriloquy
Sound like?
Heard where?
Conditions?
Sounds like= Clear transmission of the whispered voice
Where= Through stethoscope
Conditions= Atelectasis, Consolidation
Minute Ventilation Abbreviation and Equation
VE= The amount of air moving in and out of lunch in Liters per minute
VE= Vt x f
What is Tidal Volume and it’s abbreviations
VT= Amount of air you move in and out of lunch with each breath in mL. Measured with Spirometer.
Conditions: Pleural Effusion
(Identify: Percussion, Fremitus, Breath Sounds, Adventitious)
Percussion= Dull/Flat
Fremitus= Decreased
Breath Sounds= Decreased or Absent
Adventitious= None or Pleural Rub
Egophony vs. Bronchophony
Egophony= Pt. says “eeee” over consolidated lungs, you hear “aaaaa”
Bronchophony= Pt says “99” over consolidated lungs you hear “99” but over healthy lungs you cannot make out the sound
Conditions: Diminished breath sounds
(Identify: Percussion, Fremitus, Breath Sounds, Adventitious)
Percussion= Dull except when Pneumothorax
Fremitus= Decreased
Adventitious= None Except with Pleural Effusion
Conditions= Air trapping, Flail Chest, Pneumothorax, Pleural Effusion, Neuromuscular Diseases such as Guillain Barre and/or Myasthenia Gravis
Vesicular vs. Bronchovesicular Auscultation
Vesicular= Heard of most lung fields, low pitched, soft and short expirations, louder in thin person or child, diminished in overweight or muscles
Bronchovesicular Auscultation= Heard of main bronchus and upper R. Posterior Field. medium pitched, inhale and exhale equal
8 Adventitious Breath Sounds
- Crackles (Rales)
- Rhonchi
- Wheezing
- Stridor
- Pleural Rubs
- Bronchial
- Whispering Pectoriloquy
- Diminished
Abnormal Percussion Notes
Dull: Pleural thickening, Pleural Effusion, Atelectasis, Consolidation
Hyper-resonant: COPD, Pneumothorax, Emphysema
SpO2
What is it?
Normal Ranges?
Oxygen Saturation. Pulse Ox, Non Invasive
Normal= Greater than 95%
Carboxyhemoglobin
What is it?
Normal Ranges?
What is the relation with CO and O2?
Carboxyhemoglobin= Dysfunctional Hemoglobin
Normal Ranges Non-Smoke= Less than 1.5%, Smoker= 3-15%
CO and O2 Relation= Will always bind with CO more than O2 because it is 200-250X the afinity
7 reasons a Pulse ox can be wrong
- Motion/Movement
- Abnormal Hemoglobin
- IV Dyes
- Ambient/Fluorescent Lights
- Low perfusion
- Skin Pigment
- Fake Nails/ Nail Polish
Abnormal Breathing Patterns & What it looks like: Biots
Neurological Issue, Fast, Deep Breaths with abrupt Pauses
Looks Like: (3 Triangles, Space, 3 Triangles)
Abnormal Breathing Patterns & What it looks like: Kussmauls A.K.A. DKA
Increased Rate & Depth, usually associated with Diabetic Ketoacidosis to eliminate excess CO2
Looks like: (Many Triangles in a row)
Hypoventilation vs. Hyperventilation
Hypo= Decreased Rate & Depth with a Increased PaCO2
Hyper= Increased Rate & Depth with a decreased PaCO2
SaO2
What is it?
How is it measured?
Normal ranges?
O2 attached to Hemoglobin.
Measured: ABG
Normal Ranges: 80-100%
PaO2
What is it?
How is it Measured?
Normal Ranges?
Partial Pressure of oxygen dissolved in the Blood
Measured: ABG
Normal Ranges: 75-100mmHg
Abnormal O2 Signs and Symptoms (CNS, Resp, Cardio)
CNS= Apprehension, Restless, Irritable
—->Combative, Coma
Resp= Tachypnea, Dyspnea at exertion/Rest
—> Accessory Muscle Use, Rib Retractions, 1-2 Word Dyspnea
Cardio= Tachycardia, Mild Hypertension, Arrythmias
—>Hypotension, Cyanosis, Cool/Clammy Skin
Peak Expiratory Flow Rate Meaning and Abbreviation?
Normals?
What is the Nomogram?
Meaning: Max flow a person can generate on expiration
Abbreviation: PEFR or PEF
Ranges: Males= 600 L/min, Females 450 L/min
Nomogram= PEF Prediction Charts
MIP vs. MEP
Meaning?
MIP= Max inspiratory pressure
MEP= Max Expiratory pressure
Meaning: Max amount of air a person can breathe into their lungs and out of their lungs in one breath
MIP vs. MEP
Normals?
How is the test performed?
Normals:
MIP Males: -125 cmH2O
MIP Females: -90 cmH2O Inadequate= Less than -20 to -25 cmH2O
MEP Males: 230 cmH2O
MEP Females: 150 cmH2O
Inadequate= Less than 40- Requires ventilation
How it’s performed= MIP and MEP are done 3 times each to obtain the best of the 3 scores.
(Note: must have nose clips on, and it will feel as if the pt cannot breathe into the tube or suck air from the tube)
MIP: Pt blows all the air out of their lungs and takes a deep breath in on the manometer.
MEP: Pt takes a deep breath in and blows all their air out into the manometer
Slow Ventilated Capacity
Abbreviation and reasoning why we do it?
How we do it?
What pt. do we do this on?
SVC, Testing how much air pt. can get out in one breath.
- Deepest breath in
- Blow all the air out until lungs are empty either slowly or quickly (preferably slowly) into Spirometer
Done with pt. who have neuromuscular diseases to monitor lung function
Condition: Apnea
Not breathing, leads to respiratory arrest and Death
Condition: Tachypnea
Fast Breathing: Regular Rhythm with more than 20 breaths/min
Condition: Bradypnea
Slow Breathing: Regular Rhythm with fewer than 12 breaths/min
Normal Respiratory Rate (Adults) and how we measure it?
12-20 Beats/min (can never be an odd number). Measure by counting the full rise/fall of the chest for 30 seconds and multiplying by 2. (Pt. cannot know you are counting RR’s)
Normal Range for Pulse on Adult and how it’s measured
60-100 BPM. Measured by feeling the pulse for 30 seconds and multiplying by 2 (or counted for 15 seconds x 4)
Hypothermia vs. Hyperthermia vs. Fever
Hypo= Temp below 95’F.
Hyper= Temp above 104’F
Fever= Infection
Normal Temperature Ranges (adult)
98.6’F or 37’C (typically lower in AM and Highest in Afternoon)
HIPAA
Abbreviation Meaning and what does it mean?
Health Insurance Portability & Accountability Act
Ensures privacy and protection of patients personal records
Hypotension vs Hypertension vs. Orthostatic Hypotension
Hypo= Low BP below 90/60
Hyper= High BP higher than 120/80
Orthostatic= BP Drops when standing up
6 CO poisoning Signs and Symptoms and how we treat it? What form of measurement is not accurate with CO poisoning?
- Headache
- Weakness
- Dizziness
- Vomiting
- Confusion
- Loss of Consciousness/Death
Treated with LOTS of O2- Flood the system.
Pulse OX (SpO2) will not work accurately. It will appear within normal range because it cannot determine CO from O2
A
I
D
E
T
A: Acknowledge- the pt.
I: Introduce- yourself
D: Duration- time it will take
E: Explain- what your doing
T: Thank- the pt & Family
Hemoptysis vs. Hematemesis
Hemoptysis: Coughing up blood
Hematemesis: Blood from the GI Tract
What is:
Inspection, Palpation, Percussion and Auscultation?
Inspection= Continuous through entire interaction with patient. looking for if they appear healthy, their facial expressions, are they in tripod position, nasal flaring etc.,
Palpation= Touching the pt. chest symmetry, trachea position, skin temp, lumps/bumps, tactile fremitus (pt says “99” we feel on top/middle/low back the vibrations
Percussion= Feeling with side of hand in between ribs for dull or hyper-resonant vibrations
Auscultation= Listening to lung sounds in 10 locations (top R/L Chest, once under each armpit, 6 positions on back)
Lordosis vs. Scoliosis vs. Kyphosis vs. Kyphscoliosis
Lordosis= Inward curve of the lumbar spine
Scoliosis= Lateral curve of the spine “S” shaped
Kyphosis= Curvature of upper spine, Hunchback
Kyphoscoliosis= Both Kyphosis and Scoliosis
Condition: Eupnea
Normal Breathing 12-20 Breaths/min
Hypoxemia and the 3 ranges
Low O2 in the blood
1. Mild
2. Moderate
3. Severe
Blood Pressure Normals (Adult)
What is Top and Bottom #s
Systolic (Top) 110-140
Diastolic (Bottom) 60-90
Systolic= blood pumping out of the heart
Diastolic= Heart relaxing
Pulse Paradoxus
Think: Severe Asthma exacerbation
Pulse is decreased on inhale but normal on exhale
Pulse Alternans
Think: Alternates
Pulse is strong every other beat
Pulse scale (0-4+)
0= Absent
1+=Weak, thready, easy to obliterate
2+= Hard to palpate
3+= Normal
4+= Easily palpated, hard to obliterate
Abnormal Breathing Patterns & What it looks like: Cheyne Stokes
Neurological Issue
Respirations are faster & Deeper and then they are slow and shallow with periods of apnea
Looks like: little triangles, getting bigger then smaller again, pause, repeat
Types of Pt. interview Questions and the meanings (4)
- Open Ended= Encourages Convo
i.e. What brought you in today? - Closed Ended= Specific Info
i.e. When did your cough start? - Indirect= Less Threatening
i.e. Can you tell me about…? - Direct= Leading questions (Avoid these)
i.e. you didn’t cough up blood did you?
Pt Interview questions you should ask (When, Where, What, How, Has)
When did it start?
Where on the body is it?
What makes it better or worse?
How severe is it?
Has it occurred before?
Cough/Sputum Production questions and/or observations
8 weeks or more= chronic
Amount?
Consistency?
Color?
Odor?
Condition: Digital Clubbing
What are the causes?
What does it look like?
Diseases Associated?
Caused by: Chronic Hypoxemia (Low O2)
Looks like: Bulging fingertips
Diseases: Bronchiectasis, cystic fibrosis, CHD, Liver/GI diseases
NOT COPD
Tracheal Shifts
Toward affected side= Pneumectomy, lobectomy, uncomplicated pneumothorax, atelectasis, Fibrosis
Away from affected side= Pleural Effusion, Tension Pneumothorax
Thorax Lines
Anterior:
Midsternal= Middle of Sternum
R or L Midclavicular= Middle of Clavicle Right & Left
Lateral:
Anterior Axillary= Front under armpit
Midaxillary= Middle under armpit
Posterior Axillary= Back under armpit
Posterior:
Vertebral= Middle of Spine
R or L Midscapular= Right or Left Middle of Shoulder Blade
PEFR/PEF Testing
How its performed and why?
For obstruction or bronchoconstriction especially with Asthma Patients
- Twice a day for 2 weeks when feeling well
- Record best value out of 3= Personal Best
- Children to be done every 6 months
Patient takes deepest breath in and blasts out the breath. Patient will have Green/Yellow/Red Zones.
PEFR/PEF Zones and how to calculate predictions
Green= 80-100% continue current therapy
Yellow= 50-79% use quick relief methods
Red= Less than 50% call Dr. or go to ED.
Take either Predicted value based on nomogram or Personal Best from testing and multiply by .8 to get the 80% Green zone. Repeat for .5 to get Yellow zone.
Pleuritic Chest Pain vs. Non-Pleuritic Chest Pain
Feeling/Location, Conditions?
Pleuritic= Sudden, Sharp, Stabbing.
Conditions: Pneumonia, pleural effusion, pneumothorax, pulmonary infection, lung cancer, fungal disease, TB
Non-Pleuritic= Constant, Central to Heart
Conditions: Myocardial Ischemia, Pericardial inflammation, pulmonary hypertension, esophagitis, locale trauma, inflammation of the chest cage, muscle, bones or cartilage
How to perform Palpations and what is normal?
- Butterfly shaped hands on the pt. back
- Pt takes deep breath in, RT looks for expansion of the thumb separation
- Touch pt. Trachea to look for shifting
- Touch skin, lumps/bumps, areas near incision
- Perform Tactile Fremitus: Pt says “99” and RT feels the vibration to see if they are dull or resonant
Normal is 3-5cm separation
2 Breathing Techniques
Pursed lip breathing & Tripod Breathing
Condition: Barrel Chest
Seen with what disease?
What does it indicate?
Rounding of the rib cage. Seen with emphysema. Indicates poor lung recoil
Sternal Deformities: Pectus Carinatum vs. Pectus Excavatum
Carinatum= Congenital. Sternum pokes outward. AKA. Pigeon Chest
Excavatum= Congenital. Sternum pokes inward at Xiphoid process. AKA. Funnel Chest
Intercostal Retractions indicate what?
Increased work of breathing
Low Flow Devices (list)
Nasal Cannula, Nasal Catheter, Transtracheal Catheter
Low Flow Devices do what?
Flow & FIO2% Rates?
Provide a portion of Pt. Total Flow
Flow= 8L or less
FIO2= .22-.80%
What is FIO2 affected by in low flow devices?
Flow rate on inspiration, Flow rate of O2, Tidal Volume, Respiratory Rate
Nasal Cannula
Flow & FIO2 Rate and it’s Rule of 4’s?
What are the requirements and precautions?
Flow= 1-6 L/min
FIO2= 24%-40%
Rules of 4’s= For every 1 liter, FIO2 increases by 4
Nasal cannulas required nasal passage and nares, irritation can occur, foam/gauze are available
High Flow Nasal Cannula (HFNC)
Flow & FIO2 Rate?
What’s the temp to be at?
Why we use it?
Flow= 25-70 L/min
FIO2= 21%-100%
Temp= To pt. Body Temp 37’C
Produces a CPAP effect, meets high flow requirements, provides high humidity, Doesn’t interrupt the Pt.
Air Entrainment Mask (High Flow- Venti Mask)
Flow & FIO2 Rates?
Precautions and Complications?
Flow= 12-15 L/min (Flow and FIO2 coincide together)
FIO2= 24%, 28%, 31%, 35%, 40%, 50%+
Used for pt needing low to moderate FIO2, has highly variable Respiratory patterns, or nasal cannula cannot be used. Can interfere with patient abilities
High Flow Devices
What makes a high flow considered a high flow?
- High Flow Nasal Cannula (HFNC)
- Air Entrainment Mask
- Air Entrainment Nebulizer AKA. Large Volume Neb
Device must reach 60 L/min to be considered high flow
Pt Flow Demand Equation?
VE x 3= Pt Flow Demand
Simple Mask (reservoir device)
Flow & FIO2 rates?
Important Cautionary
Flow= 5-10 L/min
FIO2= 35%-50%
Must always be used at minimum of 5 L/min because CO2 can back up in reservoir
What is deposition?
What affects deposition (3 things)?
Deposition= Only a portion of aerosol and inhaled dose are deposited into the lungs
1. Inertial= Aerosol collides and deposits on surface
2. Sedimentation= aerosol settles and deposited due to gravity
3. Brownian Diffusion= Primary deposition for small particles deep in lungs
How much PSI can an O2 E tank hold
2,000 PSI plus 10%
Cylinder Safety and Storage
Yellow= Air PIN 1-5
Green= O2 PIN 2-5
Stored in O2 storage containers, carts, at pt. bedside or chained to walls,
D
I
S
S
What PSI?
Where are they in facilities?
D= Diameter
I= Index
S= Safety
S= System
For low pressure PSI. Less than 200 PSI connectors, often found in the walls of the facility
P
I
S
S
What size tanks?
Pin Positions for O2 and Air?
P= Pin
I= Index
S= Safety
S= System
Small tanks up to E tanks
Air= 1-5
O2= 2-5
What do Blenders do?
Mix O2 and Air together
Flow vs. FIO2
Flow= The rate O2 is being delivered
FIO2= The % of O2 in the air pt. is breathing
To Give FIO2 or Flow?
Increased Work of Breathing?
Decreased O2?
Increased WOB= Flow
Decreased O2= FIO2
Non-Rebreather (NRB) (reservoir Device)
Flow & FIO2 Rate?
Cuationaries?
Flow= 15 L/min
FIO2= 100%
Ensure the reservoir bag is fully inflated prior to providing therapy to pt.
What is the Bubble Humidifier and what device is it used with?
Simple, unheated humidifier that delivers just enough to make the patient comfortable. Used with a low flow system typically a nasal cannula. It attached directly to the flow meter on the wall.
Aerosol vs. Humidity
Aerosol= Liquid particles suspended in a gas
Humidity= water in a gas phase
What is the blow by technique?
Used when a pt cannot tolerate a mask. Direct the aerosol toward the pt nose and mouth. A few inches away from face
Do we adjust neb dose for infants? Why?
No. Their airways are smaller, they breath faster, they have lower minute ventilation and they breath through their nose so less particles get deposited into their lungs
6 Rights of Medication Administration
- Right Patient
- Right Drug
- Right Dose
- Right Route
- Right time
- Right Documentation (MAR & Military Time)
Mesh Neb AKA. Aerogen What is it and what devices can it be used with?
Has a vibrating mesh.
Can be used with Bipaps and Vents.
What 3 areas in the lungs do particles deposit?
Upper Airways= 5-50 microns
Lower Airways= 2-5 microns
Parenchyma (alveolar)= 1-3 microns
Parenchyma= less than .1 micron
MMAD meaning?
Mass Median Aerodynamic Diameter= Average size of particle and where it deposits (mouth, lungs, etc)
Oxygen Conservation Device AKA. Pulse Flow O2
How does it work? Who can use it?
What is important to remember about the settings?
Patients using Nasal cannulas/catheters can use it. When the patient inhales, the device senses the flow and delivers the FIO2. (only during inspiration- hence pulse)
Settings are not LPM, they are gradually increased per level of setting changed
What does HME stand for? What does it do? When do we use it?
Heat Moisture Exchange
Traps expired heat and moisture for pt. next inhale. Used when airway has been bypassed
Drug: Albuterol
Dosage and Clasification?
2.5mg unit dose diluted with saline
SABA- Short acting Beta agonist
Bronchodilator
Drug: Ipratropium Bromide AKA. Atrovent
Dosage and Clasification?
.5 mg diluted with saline
Anticholinergic Bronchodilator
Drug: Duoneb
Dosage?
2.5 mg Albuterol + .5 mg Atrovent
Drug: Budesonide
Dosage and Classification? What most important to remember and why?
.5 mg or 1 mg unit dose
Pulmicort
Inhaled Corticosteroid
Must rinse mouth after use as it can cause Thrush
8 Roles of an RT
- Assess Pt Responses
- Pt Interviews
- Observation
- Vital Signs
- Auscultation
- Blood Gas Analysis
- Oximetry
- Pt Education
What is a Breath Actuated Neb (BAN)
Aerosol generated on inspiration.
SVN Technique and Delivery method
Slow inspiration flow increases aerosol deposition. Delivered via mask or mouthpiece
Hazards of Medicated Aerosol
Infection
Airway Reactivity
Overhydration
Ineffective airway clearance
Drug reconcentration
Indications for Medicated Aerosol Therapy
Bronchoconstriction
Wheezing
Inflammation of airways
Infection
Excessive Mucus production
SVN stands for? What are the 4 types and the dosage?
Small Volume Neb. 3-5 mL.
1. Continuous Neb with simple mask or with reservoir bag
2. Breath Enhanced Neb (BE)
3. Breath actuated Neb (BAN)
Hazards of O2 Therapy
O2 toxicity
Retinopathy of Prematurity (ROP)
Absorption Atelectasis
Fire Hazard
O2 Toxicity. How does it present? What’s the cycle?
Vasoconstriction, decreased cardiac output and perfusion, tremors, twitching, hyaline membrane, pulmonary fibrosis, inflammation.
O2 toxicity–>Increased shunting—>Low PaO2—>Increased FIO2—>Repeat
4 Reasons for O2 Therapy
- Documented Hypoxemia
- Suspected Hypoxemia
- Trauma
- Short Term
Clinical Signs of Hypoxia (Resp, Cardio, Neuro)
Respiratory= Tachypnea, Dyspnea, Paleness–>Cyanosis
Cardio= Tachycardia, Mild Hypertension, Peripheral vasoconstriction, –>Bradycardia, arrythmia, hypertension, hypotension
Neuro= Restlessness, Disorientation, headaches, No energy—>Confusion, Blurred vision, loss of control, impaired judgement, manic depression, coma
A
S
S
S
What tanks? How does the regulator work?
A= American
S= Standard
S= Safety
S= System
H & K Tanks
Each gas has it’s own R and L handed valves. American Medical Gasses are R Handed with External Threads
Tank Duration Equation and Calculation (with and with out buffer)
E Tank= .28
H Tank= 3.14
PSI x Cylinder=Factor
Factor / Flow = L/min
(With buffer: Subtract 500 from PSI)
To get the minute breakdown, Multiply the decimal by .6
What is Heliox and when do we use it?
Mixture of Helium and Oxygen
Used during airway obstruction as it decreased the work of breathing, has a lower density and makes gas flow more laminer
When do we use Nitric Oxide
Used in the treatment of term and near term infants with Hypoxic Respiratory Failure
What is Absolute Humidity and what is the max at warm/cold temps?
Measurement of water vapor in the air. (Actual fullness amount of water vapor in the air)
at 30’C/86’F= Max is 30g/m3
at 0’C/32’F= Max is 5 g/m3
What is Relative Humidity?
Water vapor in air in relation to the temperature. Often described in weather forecasts as a %
Isothermic Saturation Boundary (ISB)
What is it?
Where is it?
The point when inspired gas becomes fully saturated to 100% relative humidity at body temperature. Takes place 5 cm below the carina
2 Primary Reasons for Humidity and 4 Secondary Reasons
- Humidifying Medical Gas
- Overcoming humidity deficit when upper airway is bypassed
- Thick, bloody secretions
- With expired Tidal Volume less than 70% of the delivered tidal volume
- Body temp below 32’C
- With high spontaneous Minute Ventilation
4 Hazards of Humidity
- Temp= higher Temp the more vapor (vice versa)
- Surface Area= Greater Surface area between water and gas the more evaporation can occur
- Contact Time= The longer gas is in contact with water the more evaporation can occur
- Thermal Mass= the greater the mass of water & the heater, the better to transfer heat
3 Types of Pass Over Humidifiers and how do they work?
- Simple Reservoir (Fisher and Paykel Pot)
- Wick Units (Metal Container on bubble CPaP)
- Membrane Device (Vapotherm)
Why do we use Heated Humidity and what are the risks?
To increase the absolute humidity of a gas
Risks: Increased condensation, increased thermal burns to airways, increased risk of infection
Critical Thinking:
Your Pt. has CDiff. You have taken off your PPE in the correct oder and left the single Pt use equipment in the room. What is also necessary to do as you leave the room to ensure proper Infection Control and why?
Hand Hygiene.
Wash hands thoroughly to ensure proper cleaning and disinfection of hands.
Which of the following Organism is NOT destroyed by disinfection agents?
- Gram Positive
- Gram Negative Cocci
- Bacterial Spores
-Viruses
Bacterial Spores
Standard Precautions consist of the following except?
- Negative pressure rooms
- all of the listed are included
-hand washing
-use of gloves, masks, and eye protection
Negative Pressure Rooms
Name 4 things the AARC Guide to Professionalism lists as expectations of a professional
- High Level of Education
- Continuing Education
- Appearance is represented as professional
- Proper Communication Skills
Community Acquired pneumonia may be contacted
- in the hospital
- in the Dr office
- at daycare
- at the OP lab
At Daycare
All of the following conditions are necessary for the transmission of infections agents except
- A Source
- a gram positive bacillus
- A Mode of Transmission
- A Susceptible Host
A gram positive bacillus
Which of the following components of communication is a method used to transmit messages?
- channel
- feedback
- receiver
- sender
Channel
You have just come out of a pt. room, which of the following would be the best choice to disinfect the diaphragm and head of your stethoscope?
- alcohol
- iodophor
- phenol
- OPA
Alcohol
Test image that is a circle, with mini circles in it is called what? and how does it work?
Culture and Sensitivity
Different antibiotics are presented to the bacteria and depending on how much space surrounding the bacteria is remaining determines how well the antibiotic is working.
What is the National Board for Respiratory Care (NBRC) and what do they do?
The organization that gives the Registered Respiratory Therapist Board Exams
What term is used to describe the complete destruction of all microorganisms, including spores?
Sterilization
Name 4 Barriers to culturally competent health care
Accountability, Approachability, Adaptability, Accessibility, Affordability
Critical Thinking:
When seeing a Pt. for asthma education in the clinic, what level of precautions should be observed by the RT?
Standard Precautions
All of the following are true of Autonomy except
- It is the basis of informed consent
- it gives the pt the right to decide their own course of treatment
- it gives the pt the right to refuse treatment
- it is the idea of doing what is best for the greatest amount of people
It is the idea of doing what is best for the greatest amount of people
Basic purposes of communication include all of the following except
- obtain or relay info
- give instruction to teach
- change others values orientation
- persuade others to take action
Change others values orientation
You walk into a pt room to teach them about their inhaler. You note that the television is on and the volume is high. What category of factors affecting communication is this?
- Non-Verbal Cues
- Environmental
- Emotional
- Physical appearance
Environmental
What ethical principle binds the healthcare provider and the pt to be truthful?
Veracity
True or False:
You do not need to use alcohol based hand gel if you are putting gloves on?
Flase
Tue or False:
Colonization is the process by which microorganisms establish a presence and grow in the human body but do not necessarily produce a pathologic response
True
Critical Thinking:
You are about to treat a Pt with TB on airborne precautions. What type of mask would be available for you to war when entering the room?
- Fabric Mask
- N95
- Surgical Mask
- Q-42 Mask
N95
Which of the following populations is not at risk for having, accessing or obtaining good healthcare?
- Rural
- Elderly
- Middle class
- Homeless
Middle class
What settings can a RT practice in?
Hospital
Pulmonary Clinic
Patient Home
Propper Donning of PPE
Gown
Mask
Goggles
Gloves
Proper Doffing of PPE
Gown
Gloves
Goggles
Mask
Gram staining. If it holds the color (pink or purple) is it Gram Positive or Negative?
Gram positive
Gram staining. if it does not hold the color (pink or purple) is it Gram Positive or Negative?
Gram negative
A Chain of Rod Shapped bacteria would be called?
- Spirochete
- Staphlobacilli
- Streptococci
- Streptobacilli
Streptobacilli
Colonization is what?
Microorganisms establish a presence and grow in the human body but does not produce a pathologic response
Staphylococcus resembles what?
Custers of spheres
Condition: Diaphoresis
Excessive Sweating
Your assessment of a pt in the ED reveals tachycardia. Which of the following is the least likely cause?
- Hypotension
- Hypothermia
- Severe pain
- Fever
Hypothermia
If your pt has atelectasis what would you expet to find over the area where the atelectasis is present?
Crackles, decreased tactile fremitus, dull percussion
During auscultation you hear fine popping near the end of inspiration, you would describe that as what lung sound?
Crackles
all of these are commonly recognized percussion tones, except?
- resonant
- hyper-resonant
- dull
-high-pitched
High Pitched
Critical Thinking:
Your pt. has dull percussion over the RLL and increased tactile fremitus over the RLL. What could cause this?
Consolidation
3 things that create a therapeutic climate for the patient
- Caring demeanor
- competence
- professional image
Subcutaneous emphysema
popping, or crackling feeling underneath the skin. Similar to Rice Krispys
The high-pitched musical breath sound that indicated bronchoconstriction is?
Wheezes
Critical Thinking:
Prior to placing a pulse oximeter on your pt right index finger, you perform a capillary refill test. Blood returns to the nailbed in 4 seconds. What is your next step?
Choose a different site
The breath sound that indicates sputum moving around in the airway is?
Rhonchi
Critical Thinking:
You are the RT covering the ED. EMS has just brought a 40 yr old female pt. that was rescued from a house fire and is believed to have significant smoke inhalation. her HR is 98, RR 20, SpO2 reads 100%. What would you like to do FIRST?
Give 100% O2
Critical Thinking:
A 45 year old, otherwise healthy woman presents to the ED following a Fall. She has persistent RR of more than 20 breaths/min. The pt. states her breathing makes her nervous. With this info, you know the pt. has which of the following.
- concussion
- asthma
- angina
- tachypnea
Tachypnea
Critical Thinking:
Your pt has smoked an average of 1 pack of cigarettes per day for the last 40 years. What is their pack year amount?
40
pack of Cig per day x years
The RT observes the pt breathing patters which is slow and shallow breaths. The RT would best describe this breathing pattern as?
Hypoventilation
What is the anteroposterior-transverse chest diameter ratio in the normal adult?
1:2
Cyanosis
What color is it?
What causes it?
Blueish Skin
Caused by: Hypoxemia, hypothermia
Critical Thinking:
Your pt. has a trachea deviated to the left, hyper resonant sounds on the right and decreased tactile fremitus on the right. What may be the cause of this?
Tension pneumothorax on the right
Critical Thinking:
You see the following waveform on your pulse oximeter (Peaks, gradual decent, peak, gradual decent, repeat). Your pt had an adequate capillary refill time prior to you placing it on their finger. The SpO2 reads 72%. What can you infer about that value?
It is very low and needs to be addressed
The 4 characteristics we look for in sputum
Consistency
Color
Odor
Production/Amount
Name an accessory muscle of inspiration
Sternocleidomastoid, pectoralis, Scalene
Critical Thinking:
Your pt. has a RLL pneumonia. What would be the expected assessment findings that would be evident with pneumonia? (Inspection, palpation, percussion, auscultation)
Inspection: Pt may be in tripod stance with an increased work of breathing and nasal flaring. This would indicate shortness of breath and respiratory distress.
Palpation: Increased tactile fremitus in the posterior RLL
Percussion: Dull percussion
Auscultation: Would hear adventitious breath sounds in the RLL. The Chest symmetry would differ between the two lungs. There would be louder bronchial breath sounds on the RLL. Would hear crackles (rales), Rhonchi, wheezing or pleural friction rub through the stethoscope
Critical Thinking:
Why do some patients have diminished breath sounds? List 3 diseases or disorders that pt. may exhibit diminished breath sounds.
Can be due to trauma to the lung, a disease of the lung tissue or infection present in the lungs.
- Tension Pneumothorax
- Pleural Effusion
- Neuromuscular Diseases such as Guillain Barre or Myasthenia Gavis
Critical Thinking:
Your pt. has atelectasis document on chest x-ray. What would be expected assessment findings if the atelectasis is located in the Left Upper Lobe. (Palpation, Percussion, Auscultation)
Palpation: Decreased fremitus. Symmetry of rise and fall compared to Right Lung would be lesser. Trachea would be shifted toward the left side
Percussion: Dull
Auscultation: Adventitious breath sounds with either no sound or Crackles (Rales). Loud Bronchial breath Sounds
Critical Thinking:
Your pt has a long standing history of COPD. He complains of increasing shortness of breath and a productive cough. During physical exam of the chest, you notice a hyper resonant percussion note with decreased fremitus over most of the lung fields except for the RLL which has a dull percussion note and increased fremitus. Identify a possible explanation for these differences in your findings.
Part 2: Based on your findings, describe what you would expect to hear on auscultation over the RLL.
The patient has hyper resonant percussion with decreased fremitus in majority of the lung fields because of the pt. history with COPD, However, the RLL has dull percussion with increased fremitus which indicates the pt. has consolidation or Pneumonia
Part 2) You would hear crackles, Rhonchi, wheezing as well as abnormalities when performing the Whispering Pectoriloquy, egophony and bronchophony tests
Critical Thinking:
Your pt. A 34 year old man, presents to the ED with left sided chest pain and shortness of breath. It is suspected that he has a left sided pneumothorax. What findings on a physical exam would help establish the diagnosis? (Inspection, Palpation, percussion, Auscultation)
part two) what tests should be performed to confirm the Dx?
Inspection: There would be signs of respiratory distress by either nasal flaring, tripod stance, tachypnea, irregular RR, low O2 rate and may be 1-2-3 word dyspnea. There would be discomfort and pleuratic chest painn in the location of the pneumothorax.
Palpation: Decreased tatile fremitus. The Trachea should be shifted away from the side of pneumothorax.
Percussion: Abnormal percussion sounds would be Hyper Resonant
Auscultation: Diminished breath sounds with no adventitious breath sounds
Part two) A Chest x-ray should be completed to confirm the presence of air in the pleural cavity.
Why is it important to crack a cylinder before use?
To clean debris and dust that may have built up in the valve stem
Critical Thinking:
Your patient needs to go the imaging department for a CT scan. He is currently using oxygen. What will you need to gather to ensure he can continue to use oxygen for the transport?
A Grab and Go oxygen Tank or a smaller portable oxygen tank
Why are the separate pipping zones for gas supply systems in hospitals?
For easier access to cut off supply to a portion of the facility in case of general maintenance or a fire.
What are 5 safety rules when using compressed gas?
- Cylinder Color
- Cylinder Testing Stamp Date is appropriate
- Ensure cylinder is always secured at Pt bedside
- Ensuring O2 tank in use is greater that 500 PSI but no more than max limit for tank size
- Ensuring appropriate safety Index Connector system is in use for the cylinder
Would you want to use a Bourdon Gauge or a Thorpe Tube if the O2 tank you will be using will be laying on its side, secured under the stretcher for transport?
Bourdon Gauge as it’s not gravity dependent like a Thorpe Tube.
Critical Thinking:
A 60 year old female patient with COPD is admitted to the ED via ambulance wearing a NRB mask at 10 LPM. She was alert and awake when the ambulance arrived at her home, she is now extremely lethargic and somnolent. The ED physician order you to change the O2 delivery device to a nasal cannula at 3L. Briefly explain the most likely cause of the Pt. Lethargy.
Part two: The Physican requests that you change the device to a Venti mask at a comparable FIO2 as the nasal cannula was set to. What would the FIO2 be set at on the Venti mask?
There is a possibility that the pt. has depression ventilation due to her COPD. RT would need to determine the CO2 levels to verify if this is the issue as it only affects a small portion of COPD patients.
More than likely; the cause is due to the patient receiving too much Oxygen with the Non-Rebreather mask. This caused the Nitrogen to wash out which caused poor gas exchange and an increased work of breathing.
Part two: FIO2= 35%. Pt was on a 3L nasal cannula. Venti mask offers 31% and 35% options, going a little above the equivalent to the nasal cannula will allow the RT to decrease the FIO2 as the patient progresses
Why is a minimum of 5LPM on a simple mask required?
Because CO2 can back up in the reservoir bag.
Why will an air entrainment mask never deliver 100% O2?
The air entrainment mask mixes with ambient air and O2 by the different FIO2 settings
Explain the difference between a High Flow and a Low Flow O2 delivery system and give an example of each
High Flow: Allows us to meet or exceed the pt flow demand, it mixes O2 and air to create a precise FIO2
- Air Entrainment Mask
Low Flow: Provides a portion of the total patient flow, The low flow system adds to the patient’s own flow, which means it is always diluted with air
- nasal cannula
Critical Thinking:
You observe a pt. wearing a non-rebreather mask and note that the bag completely deflates with each inspiration. What actions, if any, should be taken?
Turn up the flow rate
What oxygen delivery device would you recommend for a pt. who has just been successfully resuscitated and is spontaneously brathing?
Non-Rebreather with as much oxygen as possible as they may have been out of O2 during the resuscitation
List 3 factors that will affect he FIO2 delivered by a low flow oxygen System,
Inspiratory Flow rate, Tidal Volume, Respiratory Rate
