respiratory care + assessments Flashcards
What are clinical markers of failing respiration?
Important symptoms: rapid and significant muscle weaknening, facial muscle weakness, bulbar palsy and shallow/rapid breathing with reduced breath sound
Other symptoms: staccato speech, inability to count above 10, a low FVC of 1 litre, dysautonmia, tachycardia, brow sweating, paradoxical breathing, mental clouding or somnolence
What is non-invasive ventilation (NIV)
NIV improves lung volume during expiratory phase and PEP effect
helps patient with severe/end-stage diseases, muscle weakness, hypoxia and dyspnoea
helpful in combination with clearance technqieus for those who struggle with expectorating
what a laboratory markers of failing respiration?
Oxygen saturation less than 92%, pO2 <8kPa, CO2 >6kPa
FVC 30% of FVC from baseline within 24 hours
inconsistent or falling values of FVC at a single test session
A decline in vital capacity by more than 15-20%in the supine position
what is cough assist
provides effective cough flows
prevents pneuomonia and episodes of acute respiratory failure (ARF) and to train patients who have little to no vital capacity
what is secretion managemnt
open and closed circuit and uses aseptic technique with sterile gloves
Why perform ausculation?
- Help better understand patients symptoms
- Check condition of airways
- Where tightness and secretions are
How does auscultation inform assessment?
- Informs which techniques may be needed
- Whether simple positioning
- ACBT – which huff do more off
- Acapella
Whether secretions need moving or further medication to help open airways
What are the points that need auscultating?
Anterior:
Apices (next to collar bone)
Superior lobes
Middle lobe / lingula - no middle lobe L side due to heart
Inferior lobes
Posterior:
Apices
Superior lobes
Inferior lobes
Lung bases
How should auscultation be performed?
- Patient in sitting is preferable
- Instruct patient to breathe a little deeper than normal through mouth
- Stethoscope on chest wall
- Should be systematic
What are possible sounds that may be heard?
Wheezing
Crackling / rales / crepitations
Ronchi
Pleural friction rub
Stridor
What is wheezing?
A sound caused by vibrations of narrowed walls of small airways
What is crackling / rales / crepitations?
Sounds like crackling or clicking when someone is breathing
Crackling is due to air bubbles passing through fluid
Mucus
Normally heard in the bases
Coughing occurs as a reaction to clear this fluid
What are the types of crackles and what do they indicate?
Coarse crackles are prolonged, low pitched sounds
- Indicators of build up of secretions
Fine crackles are higher pitched sounds
- Fine crackles are indicators of fibrosis and sound like velcro
Biphasic crackles are a combination of both types
What is ronchi?
Low pitched continuous gurgling or bubbling when someone inhales or exhales
Build up of secretions in airways
Described like snoring sound
Normally can clear with strong cough
What is pleural friction rub?
Quick explosive sound when breathing in or out
Sign of interruption of movement of pleural membranes
What is stridor?
Similar to wheezing but louder
Indicate upper airway blockage or narrowing
Breathing in indicates blockage/narrowing above larynx
When out means narrowing in trachea
Inspiratory, expiratory or biphasic
What abnormal sounds may be heard in COPD?
Wheezing
Stridor
Crackling
More commonly coarse crackles in COPD
Ronchi
Pleural friction rub
Due to inflammation
What sounds may you hear in asthma?
Wheezing
Stridor
If infection may have ronchi
May here crackles
Pneumonia, pulmonary fibrosis, acute bronchitis, bronchiectasis
Diminished lung sounds
May occur in asthma flare-up
Silent chest
May occur in severe asthma attack
What lung sounds might you expect to hear in pneumonia?
Wheezing
Crackling
Pleural rub
What lung sounds might you expect to hear in CF?
Wheezing
General lung sounds of infection
What lung sounds might be sound in bronchiectasis?
Crepitations on inspiration and expiration due to sharp opening and closure of airways
Ronchi from secretion movement
High pitch inspiratory squeeks
What sounds might be heard post surgery?
Signs of infection such as crackles and wheezing.
What are precautions for auscultation?
Patient being able to maintain sitting or being comfortable sitting.
Perform in side lying if unable.
Be careful around any incisions.
What is type 1 respiratory failure?
Reduced oxygen without normal CO2
What is type 2 respiratory failure?
Reduced oxygen with increased CO2
What is the normal range for pH?
7.35-7.45
What is the normal range for CO2 (kPa and mmHg)?
4.7-6.0 kPa / 35.2-45 mmHg
What is the normal range of O2 (kPa/mmHg)?
11-13 kPA / 82.5-97.5 mmHg
What is the normal range for bicarbonate?
22-26 mEq/L
What is the range for base excess (BE)?
-2 to 2+ mmol/L
What pH is acidotic and what is alkalosis in the body?
below 7.35 is acidotic, above 7.45 is alkalosis
What occurs in respiratory acidosis?
Co2 increases to pH decreases
↑CO2 pH↓
What occurs in respiratory alkalosis?
Decreased CO2 leading to increased pH as not enough hydrogen ions
↓CO2 pH↑
What occurs in metabolic acidosis?
decreased bicarbonate so there is a drop in pH
↓HCO3- ↓pH
What occurs in metabolic alkalosis?
Increased bicarbonate leads to increase in pH
↑ HCO3-↑pH
What are causes of respiratory failure?
Increased work of breathing
Hypoxia
Increased secretion load
Ineffective airway clearance
Reduced lung volume
What are treatments for hypoxia?
Increasing O2
How can increased secretion load and ineffective airway clearance be treated?
Manual percussions
Vibrations
ACBT
Acapella
Airobika
Suction
How can increased work of breathing be improved?
Increased oxygen
Nebuliser
Positioning
Diaphragmatic breathing
Why analyse ABGs?
Gives picture of patient condition
What treatments are best for the patient e.g. if need oxygen therapy
- Idea of type of respiratory failure patient in if at all
What are the components of an A-E assessment?
Airway
Breathing
Circulation
Disability
Exposure
What is involved in airway of A-E?
Oral/nasal airways
Tracheostomy
Endotracheal intubation
Key elements to know:
- Patent/ obstructed airway?
- Self-ventilating
- Coughing
Strength
- Position of patient
- How talking / able
Why check airway?
a critically unwell patient may need support to maintain their airway
Why check breathing?
may need support with their breathing and ventilation to maintain oxygenation and gas exchange
What are components of breathing in an A-E assessment?
May be using
- invasive controlled modes
- invasive spontaneous modes
- non-invasive ventilation
Key areas to find out:
- type of breathing
- if increased WOB / chest expansion
- breathing stats
- auscultation
- chest x-ray
- Palpable fremitus
- Cough strength
- ABGs
What might breathing look at in terms of WOB?
Use of accessory muscles
Splinting of abdomen
Rib recession
Tracheal tug in children
What are areas for breathing stats?
Respiratory rate
SpO2
FiO2
What is a normal respiratory rate?
12-15/12-18 breaths per min
What is normal SpO2?
Normal 94-100
In COPD 88-92
What is normal FiO2?
Normally 21% in normal atmospheric conditions
What notation might be used for auscultation?
BSTO = breath sounds throughout
Reduced BS = reduced breath sounds
E.g. crackles
Right LL = right lower lobe
Bilat UL = bilateral upper lobes
Why is circulation assessed?
may need support to maintain adequate circulation and cardiac function to optimise perfusion if vital organs
What elements may be added from monitoring circulation?
Continuous monitoring via ECG and arterial lines
Delivery of intravenous medication via central lines e.g. inotropes/vasopressors
What are key components that should be included in circulation?
Heart rate
BP normal between 90/60 – 120/80
CRT >2s = capillary refill time
CRP and WCC
possibly ABGs
What aspects may be included in disability?
Induced low arousal by sedative or anaesthetic medication
Consequence of critical illness e.g. respiratory, kidney or liver failure, metabolic derangement or brain injury
Critically ill patients are at high risk of delirium, which may present as fluctuating arousal an cognitive disturbance
AVPU = alert, voice, pain, unresponsive
GCA
Bloods
- CRP
- WCC
- HB and platelets
- Drugs that patient on
Pain
Blood glucose
Possibly position here
Bowel movement?
What may be included in exposure?
All other bodily symptoms
e.g. May require kidney support with dialysis or nutritional/gastrointestinal support with feeding tubes or infusions
E.g.
Stiff rib cage
Barrel chest
Abdominal splinting
Accessory muscle use
Lower limb oedema
Frailty
Temperature
Attachments e.g. catheter, NG tube, arterial line, PCA
Details e.g. stoma
Why should an A-E assessment be carried out?
- Methodical way of assessing
- Looks at wider picture of patient as well as specific measurable factors
- Takes into account both labs and immediate checks done at bed side.
