Ultimate Review Pt. 2 Flashcards
common circulatory pulse locations
carotid, brachial, radial, ulnar, femoral, popliteal, post tib, dorsalis pedis
cardiac lab testing
hematocrit, hemoglobin, partial thromboplastin time, platelet count, prothombin time, white blood cell count
hematocrit
percentage of packed RBC in total blood volume.
hemoglobin
iron containing pigment of RBC. function is to carry oxygen from lungs to tissues. used to assess blood loss, anemia, and bone marrow suppression. low hemoglobin=blood loss, high hemoglobin=hemoconcentration caused by polycythemia or dehydration
partial thromboplastin time
used to monitor oral anticoagulant therapy or to screen for selected bleeding disorders. more sensitive than prothrombin time in detecting minor deficiencies.
platelet count
refers to number of platelets per mL of blood. important for blood coagulation, homeostasis, blood thrombus formation. low platelet counts increase risk of bruising and bleeding. high platelet counts increase the risk of thrombosis
prothrombin time
most commonly used to monitor oral anticoagulant therapy or to screen for selected bleeding disorders. examines extrinsic coagulation factors V, VII, X, prothrombin, and fibrinogen
WBC count
refers to number of white blood cells per milliliter of blood. commonly used to identify presence of infection. increase=after hemorrhage, surgery, coronary occlusion or malignant growth
clinical chemistry values
cholesterol: under 200 (LDL 60-180, HDL 30-80). Oxygen= partial pressure (PaO2): 80-100 mm Hg, saturation: 95-98%. pH: arterial blood: 7.35-7.45
ECG
measures electrical activity of heart
P wave
atrial depolarization
PR interval
time required for conduction from SA node to AV node. time btwn atrial and ventricular depolarization. normal .12 to .2 seconds
QRS complex
ventricular depolarization and atrial repolarization
QT interval
electrical systole that is measured by time elapsed from start of Q wave to end of T wave. normally .32 to .40 secs
ST segment
delay before repolarization of ventricles; useful in assessing myocardial ischemia
T wave
ventricular repolarization
depressed QRS
heart failure, ischemia, pericardial effusion, obesity, COPD
ectopic foci
location where abnormal myocardial depolarization originates
elevated QRS
hypertrophy of myocardium
Q wave
previous MI
ST sgmt elevation
acute MI
A fib
irregular atrial rhythm, no rate, no P waves, F waves absent, quivers noted, ventricular rhythm varies. common causes: hypertension, CHF, CAD, rheumatic heart disease, cor pulmonale, pericarditis, drug use
supraventricular tachycardia
rate varies btwn 160-250 bpm, regular rhythm, originates from a location above AV node, will start and stop w/o cause. common causes: mitral valve prolapse, cor pulmonale, digitalis toxicity, and rheumatic heart disease
premature atrial contractions (PAC)
occurs when ectopic focus in atrium fires and supersedes the SA node. P wave is premature with abnormal configuration, rate normal btwn 60-100 bpm, irregular rhythm can be regularly irregular such as consistently skipping every 3rd beat, can be indicative of ischemia or valve pathology. common causes: caffeine, emotional stress, smoking, and pathologies like CAD, electrolyte imbalance, infection and CHF.
ventricular tachycardia (VT)
rate usually above 100 bpm. rhythm usually regular. no P wave or it appears after QRS complex with retrograde conduction. requires immediate medical attention. common causes: post MI, rheumatic heart disease, CAD and cardiomyopathy
v fib
no regular rate or rhythm, emergency, requires immediate medical attention. causes: long term or severe heart disease, post MI, hypercalcemia, hypokalemia, and hyperkalemia.
multifocal v tachycardia
rate over 150 bpm, irregular rhythm, no P waves, QRS complex is wide, requires immediate medical intervention. causes include: hypokalemia, hypomagnesemia, hypothermia, and drug induced through antiarrhythmic medications.
premature v contractions (PVC)
occur when an ectopic focus in the ventricles or Purkinjue fibers fires and supersedes normal conduction. focal PVCs occur from one ectopic foci and have the same waveform. rate is normal between 60-100 bpm, P wave is absent, ST sgmt is distorted, and QRS complex occurs early. irregular rhythm that can be regularly irregular such as consistently skipping every 3rd beat. common causes: caffeine intake, emotional stress, smoking, CAD, digitalis toxicity, cardiomyopathy, and MI.
complete heart block (3rd degree AV block)
regular rhythm, atrial rate is higher than ventricular rate, requires immediate medical intervention (pacemaker). causes include: infection, electrolyte imbalance, CAD, anteroseptal MI, impairment with the AV conduction system.
asystole
no rhythm, absence of P wave, QRS and T waves, can have abrupt onset, requires immediate medical attention. causes: failure of all pacemakers to initiate, conduction system failure, acute MI and ventricular rupture
systole
(upper number bp reading) contraction of cardiac muscle
diastole
(lower number bp reading) relaxation of cardiac muscle
atrial systole
atrial emptying of blood
atrial diastole
atrial filling of blood
ventricular systole
ventricular contraction that causes a rapid ejection of blood (emptying)
ventricular diastole
ventricular filling in combination with atrial contraction
hypertension
elevated arterial blood pressure both for systole and diastole.
korotkoff’s sounds
5 phases - sounds that are heard sounds over an artery when blood pressure is determined by the auscultatory method
bp prep and procedure
values are usually slightly higher in left UE vs. the right UE. inflate cuff to 20 mm Hg above reading where brachial pulse disappears. 1st sound indicates systolic pressure, last audible sound indicates diastolic pressure.
ABI: ankle-brachial index
test that measures arterial perfusion using a Doppler unit. blood pressures are measured in both UEs and LEs and highest LE systolic pressure is divided by brachial systolic pressure.
ABI scale
Normal=1.0. .5-.9=arterial occlusion, impairment with wound healing. less than .5=severe arterial occlusion.
peripheral pulse assessment grading system
0-3 scale: 0=absent, 3+=full, firm pulse. pulse amplitude classification: 0=absent, 1+=diminished thru to 4+=markedly increased
inspiration
to breathe air into the lungs
expiration
to breathe air out of the lungs
normal RRs:
12-18 per minute for adults, 30-50 per minute for infants
METS
metabolic equivalents: amount of oxygen consumed per kilogram of body weight per minute to perform a given activity. at rest a person consumes 3.5 ml/kg/minute.
MET chart
eating=1, dressing=2, light housework=2-4, dancing=4-5
borg’s rate of perceived exertion scale and the revised 10-grade scale
see page 121
left sided heart failure
affects pulmonary
right sided heart failure
causes swelling in extremities
target heart rate
max heart rate is determined by subtracting patient’s age from 220. normal training intensity ranges from 60-90% of age-adjusted max heart rate.
karvonen’s formula: heart rate reserve method
max heart rate is obtained by an exercise stress test and resting heart rate is subtracted from it. number is termed the heart rate reserve.
cardiac rehab indications
MI, angina (stable), CABG, cardiac surgery, high risk for CAD, hypertension, end stage renal disease, status post pacemaker insertion, cardiomyopathy, heart transplant, high risk for diabetes
contraindications to stop exercising during cardiac rehab
heart rate that increases over 50 bpm with low level activity, increasing bp, any ST segment chgs, severe LE claudication, angina, confusion, extreme fatigue, ventricular gallop
contraindications for cardiac rehab
uncontrolled atrial/ventricular arrhythmias, embolism, thrombophlebitis, orthostatic bp, acute infection, unstable angina, resting ST sgmt deplacement, uncompensated CHF
absolute contraindications for treatment of an unstable cardiac patient
third degree heart block, uncompensated CHF, PVCs of vent tachycardia at rest, multifocal PVCs, chest pain with ST sgmt changes, ECG changes that indicate ischemia, dissecting aortic aneurysm
cardiac rehab program
consists of 4 phases. 1st phase averages 3-5 days, 2nd phase 2-12 weeks, 3rd phase 6-8 weeks, 4th phase lasts throughout pt’s lifetime
phase 1
active ROM, ambulation, self care, in inpatient (hospital)
phase 2
begins after hospitalization, monitored closely. 2-3 visits per week. does not require ECG monitoring.
phase 3
continuation of phase 2. exercise training, phys fitness, endurance and risk factor modifications are goals in this phase. once a week visits
phase 4
lasts throughout patient’s life and is designed to promote optimal health. self monitoring of exercise, stable cardiac status, no contraindications to exercise, and at least a 5 MET capacity for activities
therapist’s role during inpatient cardiac rehab
provides constant monitoring of heart rate, blood pressure, and ECG interpretation before, during and after each session, use of exertion scale to identify intensity of exercise, promote proper technique and breathing patterns during exercise, progress activities based on METs tolerated
therapist’s role during outpatient cardiac rehab
initially close monitoring of ECG, heart rate, and blood pressure throughout session is required, constant measurement of vitals, exercise should be gradual in progression, isometrics are contraindicated
ADULT: CPR flow chart
no mvmt-phone 911-open airway, check breathing-if NO breathing, administer 2 breaths that make chest rise. if NO response, check pulse. if pulse, rescue breathing only at 10-12 breaths per minute. if NO pulse, begin CPR with 30 compressions and 2 breaths. continue to perform CPR until medical assistance arrives
Cardiopulmonary ABCs
Airway-maintain open airway. Breathing-rescue (look, listen, feel). Circulation-compressions: check pulse.
aneurysm
weakening in wall of a vessel that produces a sac like area. 50% increase in normal vessel diameter with weakening of all layers of arterial or venous wall. most common sites include aorta, abdominal aorta, femoral, and popliteal arteries. surgical repair prior to rupture has a good prognosis; ruptured aneurysm is a medical emergency with high mortality rate. symptoms: abnormal heart beat, MI, stroke, renal failure, embolization, intermittent or constant pain
angina pectoris
when coronary arteries are unable to supply the heart with adequate oxygen. sudden onset is common once the myocardial oxygen demand is higher than the supply. CAD accounts for 90% of all angina.
nocturnal angina
angina that will wake someone up from sleep
prinzmetal’s angina
occurs while at rest secondary to CAD or spasm. can be severe and not readily relieved by nitroglycerin
stable angina
angina that usually occurs at predictable level of exertion, exercise or stress and responds to rest or nitro.
unstable angina
occurs at rest or with exertion and has changed intensity, frequency, and/or duration
symptoms of angina
temporary pain, sudden onset, pain may radiate, usually lasts one to five minutes, usually relieved with rest or nitroglycerin
atherosclerosis
condition of progressive accumulation of fatty plaques on inner walls of vessels that ultimately produces stenosis. begins in childhood and usually affects medium sized arteries. over time the plaque that produces stenosis inside the vessel can also block blood flow. heart attack or stroke can result from atherosclerosis
cardiomyopathy
group of conditions that affect the myocardium muscle itself, impairing the ability for the heart to contract and relax. 3 types are dilated, hypertrophic, and restrictive. symptoms: same as heart failure, neck vein distension, fatigue and weakness, possible chest pain, sudden death, exercise intolerance
CHF
congestive heart failure: results usually from coronary artery disease when heart is unable to maintain an adequate cardiac output. characterized by abnormal retention of fluid and results in diminished blood flow to tissue and congestion of the pulmonary and or systemic circulation. symptoms: pulmonary edema, dyspnea, cough (nonproductive), S3 gallop, exertional hypotension, weight gain within hours, increased resting heart rate.
CAD
coronary artery disease: narrowing or blockage of coronary arteries that may produce ischemia and necrosis of the myocardium. inability for vasodilation and as a result the arteries cannot meet the metabolic demands. will produce ischemia and ultimately necrosis. CAD includes thrombus, vasospasms, and atheroscelerosis. results from inheritance, environment, culture, nutrition and smoking. symptoms: appear after significant blockage is present, over 75%. pain in occluded artery’s region. if untreated, MI or death.
heart failure
inability of heart to maintain a proper cardiac output of 4 liters per minute while at rest. chronic hypertension is most common cause
infective endocarditis
inflammation of endothelium that lines heart and cardiac valves. most commonly damages mitral valve, then aortic and tricuspid valves. commonly caused by bacteria that are normally present in the body. can also occur after an invasive medical or dental procedure. symptoms: valvular dysfunction, may affect organ systems, chest pain, CHF, clubbing, meningitis, low back pain, arthralgia, arthritis
MI: myocardial infarction
causes irreversible damage to a segment of heart muscle due to prolonged ischemia. causative factors include narrowing of coronary arteries due to atherosclerotic occlusion, poor coronary perfusion secondary to hemorrhage or occlusion or one of the major coronary arteries.
areas of MI
expected damage: anterior heart-left anterior descending artery, high risk of large infarction, heart failure, sudden death. inferior heart-rt coronary artery, right ventricle damage, AV block, medium infarct possible, lateral heart and/or superior heart-least area of muscle affected, usually least overall damage, minor impairment or complications
myocarditis
uncommon condition of inflammation to myocardium muscle usually due to infection. can be treated with antimicrobial therapy. if left untreated can quickly progress to a dilated cardiomyopathy with heart failure. symptoms: mild, low level chest pain, soreness, fatigue, palpitations
pericarditis
inflammation of the pericardium (outer membrane) of heart. condition may be acute or chronic. can be painful or asymptomatic. can be caused by infection, MI, radiation therapy, post cardiac surgery, aortic dissection. symptoms: auscultation reveals pericardial friction rub, pleuretic chest pain, diffuse ST segment elevation, retrosternal chest pain, cough and hoarseness, fever, fatigue and weakness, joint pain.
rheumatic heart disease
result of damage to heart secondary to inflammation from rheumatic fever. rheumatic fever can occur from strep bacteria and is classified as an autoimmune disease. can affect connective tissues. acute rheumatic fever has a low mortality rate. symptoms: carditis with chest pain, acute onset of polyarthritis, chorea, arthralgias and weakness, fever and palpitations
ped: cystic fibrosis
disease of exocrine glands that primarily affects respiratory and gi systems. cause: mutation of chromosome seven to include cystic fibrosistransmembrane conductance regulator (CFTR). cystic fibrosis is an autosomal recessive genetic disorder and a terminal disease. presents with increased secretion of thick mucus, gi distress, abnormal bowels, recurrent pulmonary infection, salty tasting skin, wheezing, productive cough, barrel chest, dyspnea, and progressive use of accessory muscles with respiration. trtmt includes antibiotics, supplements, pancreatic enzyme replacements, mucus thinning medications, bronchodilators. pt is essential and includes bronchial drainage, percussion, vibration, suctioning, breathing techniques, assisted cough, and ventilatory muscle training for optimal pulmonary function.
ped: patent ductus arteriosus
disorder where ductus arteriosus which normally shunts blood in utero from pulm artery to descending aorta, fails to close shortly after birth. causes: premature birth, respiratory distress syndrome, fetal alcohol syndrome, trisomy 13, and trisomy 18. presents: tachycardia, respiratory distress, poor nutrition, weight loss and congestive heart failure. initial treatment attempts to non surgically reduce the size of the ductus with use of diuretics and indomethacin when indicated. surgical repair may be necessary for a large ductus or when initial management fails.
ped: respiratory distress syndrome
pulmonary condition seen in neonates born before 37 weeks of gestation. rds is also known as hyaline membrane disease and is leading cause of death in the neonate. causes: immaturity of lungs and inability to produce necessary levels of surfactant. results in increased alveloary tension, alveolar collapse, atelectasis, and difficulty breathing. associated factors with rds include being the second born twin, c section delivery, hypoxia and acidosis. presents with: infant working hard to breathe and reinflate collapsed lung. tachypnea, flaring of nostrils, use of accessory muscles and respiratory distress are observed within one to two hours. untreated, the infant lacks oxygen and presents with metabolic acidosis and acute respiratory failure. treatment will vary and can include mechanical ventilation, supplemental oxygen, administration of artificial surfactant, nutritional support, bronchial drainage, and chest physical therapy.
ped: tetralogy of fallot
most common cyanotic heart defect where following four abnormalities exist: ventricular septal defect, right ventricular hypertrophy, aortic override of interventricular septum, pulmonary stenosis.
pharmacological interventions for cardiac management
include diuretic agents, beta-adrenergic blocking agents (betablockers), alpha-adrenergic blocking agents, antiotensin-converting enzyme inhibitor agents (ACE), angiotensin II receptor antagonist agents, nitrates, antiarrhythmic agents, calcium channel blocker agents
normal tracheal and bronchial sounds
loud and tubular sounds with a high pitch noted during inspiration and expiration, pausing between the two components
vesicular breath sounds
normal, soft, low pitched sounds heard over the more distal airways primarily during inspiration. during expiration the soft sound is diminished and only heard during beginning of expiration
abnormal breath sounds
sounds that are heard outside of their normal location or phase of respiration
adventitous breath sounds
abnormal breath sounds heard using a stethoscope with inspiration and/or expiration. these sounds can be continuous or discontinuous sounds
wheeze
continuous adventitious sounds comprised of a musical nature, constant pitch (high or low) and varying duration. usually heard during expiration but may also be present on inspiration. typically a sign of airway obstruction from retained secretions or due to bronchoconstriction. wheezes found with inspiration indicate a more severe airway obstruction
stridor
continuous adventitious sound comprised of a very high-pitched wheeze that can be heard with inspiration and expiration and also indicates upper airway obstruction. stridor that is heard without a stethoscope can indicate an emergency
crackles (formerly rales)
discontinuous adventitious sound heard with a stethoscope that bubbles or pops. crackles typically represent the movement of fluid or secretions during inspiration (wet crackles) or occur from the sudden opening of closed airways (dry crackles). crackles that occur during latter half of inspiration typically represent atelectasis, fibrosis, or pleural effusion. crackles secondary to the mvmt of secretions are usually low-pitched.
bronchial breath sounds
abnormal breath sounds when heard in locations that vesicular sounds are normally present. pneumonia may produce these sounds
decreased or diminished sounds
less audible sound may indicate severe congestion, emphysema or hypoventilation
absent breath sounds
may indicate pneumothorax or lung collapse
voice sounds: egophony:
while auscultating lung segments the patient repeatedly says the letter “e”. if it sounds like an “a” fluid is expected in the air spaces or lung parenchyma.
voice sounds: bronchophony:
patient repeatedly says “99”. if word is clearly audible in distal lung fields the test is positive for consolidation. if word is less audible, softer or weaker sounding, test is positive for hyperinflation
voice sounds: whispering pectoriloquy:
while auscultating lung segments the patient repeatedly whispers words. clearly audible and less audible words indicate the same findings as bronchophony testing.
pulmonary function testing
series of tests to determine pulmonary function
anatomic dead space volume (VD)
volume of air that occupies the non respiratory conducting airways
expiratory reserve volume (ERV)
max volume expired after normal expiration
forced expiratory volume (FEV)
amount of air exhaled in the 1st, 2nd, and 3rd second of a forced vital capacity test
forced vital capacity (FVC)
amount of air forcefully expired after a max inspiration
functional residual capacity (FRC)
volume in lungs after normal exhalation
inspiratory capacity (IC)
amount of air that can be inspired after a normal exhalation
inspiratory reserve volume (IRV)
max volume inspired after normal inspiration
minute volume ventilation (VE)
amount of air expired in one minute. equal to the product of the tidal volume and the RR
peak expirator flow (PEF)
max flow of air during the beginning of a forcd expiratory breath.
residual volume (RV)
lung volume remaining in the lungs at the end of a max expiration
tidal volume (TV)
total volume inspired and expired per breath
total lung capacity (TLC)
lung volume measured at the end of a max inspiration
vital capacity (VC)
max volume forcefully expired after a max inspiration
pulmonary function reference values
a value is usually considered abnormal if it is less than 80% of the reference value
total lung capacity (TLC)=
inspiratory reserve volume (IRV) + tidal volume (TV) = expiratory reserve volume (ERV) = residual capacity (RC)
vital capacity (VC)=
inspiratory reserve volume (IRV) + tidal volume (TV) + expiratory reserve volume (ERV)
inspiratory capacity (IC)=
tidal volume (TV) + inspiratory reserve volume (IRV)
functional residual capacity (FRC)=
expiratory reserve volume (ERV) + residual volume (RV)
typical lung volumes and capacities
…
tidal volume
500 mL
expiratory reserve volume
1000 mL
vital capacity
4000-5000 mL
inspiratory capacity
3000-4000 mL 75-80% of vital capacity, 55-60% of total lung capacity
forced expiratory volumes
…
FEV1 (forced expiratory volume in one second)
83% of VC
FEV2 (forced expiratory volume in 2 seconds)
94% of VC
FEV3 (forced expiratory volume in 3 seconds)
97% of VC
gas pressure
mm Hg: see chart on page 132
arterial blood gases (ABG)
uses as a tool to determine the effectiveness of alveolar ventilation. expressed as the partial pressure of the gas.
PaO2
partial pressure of oxygen within arterial system, usually 95-100 mmHg.
PaCO2
partial pressure of carbon dioxide within arterial system, normally 35-45 mm Hg.
range of acid-base balance or pH
7.35-7.45
hypercapnia
increased amount of CO2 in blood
hyperkalemia
increased amount of potassium in blood
hypocapnia
decreased amount of CO2 in blood
hypoxemia
when PaO2 is less than 80 mm Hg
physical signs observed in various pulmonary disorders
see chart on page 133
respiratory alkalosis
pH is high, PaCO2 is low. caused by alveolar hyperventilation. symptoms: dizziness, syncope, tingling, numbness, early tetany
respiratory acidosis
pH is low, PaCO2 is high. caused by alveolar hypoventilation. early symptoms: anxiety, restlessness, dyspnea, headache. late symptoms: confusion, coma
metabolic alkalosis
pH is high, PaCO2 is normal. causes: bicarbonate ingestion, vomiting, diuretics, steroids, adrenal disease. symptoms: weakness, mental dullness, possibly early tetany
metabolic acidosis
pH is low, PaCO2 is normal. causes: diabetic, lactic, or uremic acidosis, prolonged diarrhea. symptoms: secondary hyperventilation, nausea, vomiting, cardiac dysrhythmias, lethargy and coma
pH normal value
7.4
PCO2
40 mm Hg
PO2
97 mm Hg
HCO3
24 mEq/L
% Sat
95-98%
values of metabolic alkalosis
pH greater than 7.45
values of metabolic acidosis
pH lower than 7.35
acute alveolar hyperventilation
pH greater than 7.5
acute ventilatory failure
pH less than 7.3
respiratory alkalosis
PCO2 less than 40 mm Hg (hypocapnia, hyperventilation)
respiratory acidosis
PCO2 greater than 40 mm Hg (hypercapnia, hypoventilation)
chest physical therapy
indications: patients who have acute or chronic respiratory problems: inability to expel secretions, ineffective cough, swallowing difficulties
contraindications for postural drainage
congestive heart failure, pulmonary edema, pleural effusion, pneumothorax, cardiac arrhythmia, history of recent MI, unstable angina, pulm embolism
contraindications for percussion
fracture, spinal fusion, osteoporotic bone, unstable angina, low platelet count, anticoagulation therapy, pulm embolism
guidelines for chest PT
treatment should be before eating, or at least one hour after meals, percuss and vibrate over each segment to be treated for at least 3-5 mins, cough after each segment is treated, allow for a rest period after each segment is treated, review breathing exercises in each drainage position, not to exceed 45-60 mins secondary to patient fatigue
goals for chest PT
mobilize secretions, expel secretions, improve breathing patterns, improve ventilation throughout all lobes, improve overall function
percussion
using cupped hands to strike over a particular lung segment in alternating fashion during inspiration and expiration in order to mobilize secretions. should last for several minutes and should not be painful
vibration
technique using both hands (one on top of the other) directly over the chest wall to provide pressure and manual vibration during exhalation. should be used in conjunction with percussion and only during expiration. pressure should be applied in same direction as chest wall mvmt during expiration
trendelenburg position
patient in head down position with bottom of bed inclined to approx 45%. ideal to assist with secretion drainage from lower lobes of lungs. can also assist with increasing blood pressure in case of hypotension. do not use with patients with CHF, pulm edema, hypertension, SOB or other circulatory problems
reverse trendelenburg
places a patient in supine with head raised above their trunk and LEs. may be used with patients diagnosed with hypertension or other cardiac conditions. also decreases the weight of the abdominal contents on the diaphragm providing it with less resistance to mvmt during breathing
semi-fowler’s position
places patient supine with head of bed elevated to 45% and pillows under patient’s knees for support and maintenance of a proper lumbar curve. used quite often for patients with CHF or other cardiac conditions
bronchial drainage positions/procedures
…
Upper lobes: apical segment (anterior)
sitting: lean back against a pillow; clap above clavicles btwn neck and shoulder
Upper lobes: apical (posterior)
sitting: lean forward onto a pillow; clap on both sides of back above scapula. fingers should be positioned slightly over shoulder
Upper: Anterior segment
supine: lie flat on back with pillow under knees for comfort; clap on both sides just below clavicles and above nipple line
Upper: Left posterior segment
side: lie on rt side w/head and shoulders elevated on pillows. make 1/4 turn forward, clap over left scapula
Upper: Right posterior segment
side: lie on lt side. place a pillow in front from shoulders to hips and roll slightly forward onto it; clap over right scapula
Upper: Left lingula
side: elevate bottom of bed 14-16 inches. lie on right side. place pillow behind from shoulders to hips and roll slightly back onto it; clap over left nipple
Middle Lobes: Right middle lobe
side: elevate bottom of bed 14-16 inches. lie on left side. place pillow behind from shoulders to hips and roll slightly back onto it; clap over selected lobe.
Lower Lobes: superior segments
prone: lie flat on stomach. place pillow under stomach area for added comfort and clap over middle back at tip of scapula
Lower Lobes: lateral basal segment
side: elevate bottom of bed 20 inches. lie on opposing side; clap at lower ribs. pillow under waist may help to keep spine straight
Lower Lobes: anterior basal segment
supine: elevate bottom of bed 18-20 inches. lie on back and place a pillow under knees; clap at lower ribs on both sides
Lower Lobes: posterior basal segment
prone: elevate bottom of bed 18-20 inches. lie on stomach and place pillow under hips. clap at lower ribs on both sides.
inspiratory muscle training
used for patients that exhibit decreased chest expansion, SOB, bradypnea, and decreased breath sounds. attempts to increase ventilating capacity and decrease dyspnea through strengthening of diaphragm and intercostal muscles.
inspiratory muscle training (treatment protocol)
2-4 sessions of 30 to 60 minutes of deep breathing with proper diaphragmatic breathing
diaphragmatic breathing
attempts to enhance movement of diaphragm upon inspiration and expiration and diminish accessory muscle use. position patient in bed with head and trunk elevated 45 degrees. place dominant hand over rectus abdominis. place non dominant hand over sternum. direct patient to inspire slowly and feel dominant hand rise. instruct patient to control both inspiration and expiration. non dominant hand should only have minimal movement.
low frequency breathing
slow deep breathing designed to improve alveolar ventilation and oxygenation.
incentive spirometry
used to increase inspiration using a device that provides immediate fb to patient regarding performance. commonly utilized to treat patients status post surgery in order to strengthen weak inspiratory muscles and to prevent alveolar collapse. have patient breathe into spirometer and instruct patient to perform a max inhalation into spirometer. repeat 7 - 10 times per session and repeat 3-4 times per day.
pursed lip breathing
attempts to improve ventilation by decreasing RR and increasing tidal volume. in through nose and out through mouth
segmental breathing
used to prevent accumulation of fluid and to increase chest mobility by directing inspired air to predetermined areas. place hands on target area and apply pressure down and in during exhalation. apply quick stretch immediately before inspiration. instruct patient to slowly inspire air into the target lung area under hands. give mild resistance during inspiration. observe accessory muscles during exercise in order to limit use.
asthma
reversible, obstructive lung condition characterized by increased responsiveness of trachea and bronchi to stimuli, inflammation, and overproduction of mucous glands with widespread narrowing of airways.
bronchiectasis
progressive obstructive lung disease that produces abnormal dilation of a bronchus. irreversible condition that usually is associated with chronic infections, aspiration, cystic fibrosis or immune system impairment. bronchial walls weaken over time secondary to infection and allow for permanent dilation of bronchi and bronchioles. symptoms: consistent productive cough, hemoptysis, weight loss, anemia, crackles, wheezes, and loud breath sounds.
chronic bronchitis
increased mucus secretions from bronchioles as well as structural changes to bronchi. productive cough is usually present for 3 months during two consecutive years. major impairments include hypertrophy of mucus secreting glands and insufficient oxygenation of alveoli due to mucus blockage. symptoms: increased pulmonary artery pressure, thick sputum, increased use of accessory muscles, persistent cough, wheezing, dyspnea, and cyanosis. patients are often called “blue bloaters”
COPD
chronic obstructive pulmonary disease. increased resistance to passage of air in and out of the lungs due to narrowing of bronchial tree. symptoms: dyspnea, chronic productive cough, excessive mucus production. progression of disease includes alveolar destruction and subsequent increases in amount of air that remains in lungs. overall increased total lung capacity with a significant increase in residual volume. diagnosed by determining the amount of air forcibly expired from lungs in one second.
cor pulmonale
sudden dilation of rt ventricle of heart secondary to pulm embolus. rt sided heart failure will occur if condition is not treated. as condition progresses, symptoms resemble congestive heart failure. symptoms include: chronic cough, chest pain, distal swelling, dyspnea, fatigue and weakness.
Reveresed
carotid, brachial, radial, ulnar, femoral, popliteal, post tib, dorsalis pedis
common circulatory pulse locations
Reveresed
hematocrit, hemoglobin, partial thromboplastin time, platelet count, prothombin time, white blood cell count
cardiac lab testing
Reveresed
percentage of packed RBC in total blood volume.
hematocrit
Reveresed
iron containing pigment of RBC. function is to carry oxygen from lungs to tissues. used to assess blood loss, anemia, and bone marrow suppression. low hemoglobin=blood loss, high hemoglobin=hemoconcentration caused by polycythemia or dehydration
hemoglobin
Reveresed
used to monitor oral anticoagulant therapy or to screen for selected bleeding disorders. more sensitive than prothrombin time in detecting minor deficiencies.
partial thromboplastin time
Reveresed
refers to number of platelets per mL of blood. important for blood coagulation, homeostasis, blood thrombus formation. low platelet counts increase risk of bruising and bleeding. high platelet counts increase the risk of thrombosis
platelet count
Reveresed
most commonly used to monitor oral anticoagulant therapy or to screen for selected bleeding disorders. examines extrinsic coagulation factors V, VII, X, prothrombin, and fibrinogen
prothrombin time
Reveresed
refers to number of white blood cells per milliliter of blood. commonly used to identify presence of infection. increase=after hemorrhage, surgery, coronary occlusion or malignant growth
WBC count
Reveresed
cholesterol: under 200 (LDL 60-180, HDL 30-80). Oxygen= partial pressure (PaO2): 80-100 mm Hg, saturation: 95-98%. pH: arterial blood: 7.35-7.45
clinical chemistry values
Reveresed
measures electrical activity of heart
ECG
Reveresed
atrial depolarization
P wave
Reveresed
time required for conduction from SA node to AV node. time btwn atrial and ventricular depolarization. normal .12 to .2 seconds
PR interval
Reveresed
ventricular depolarization and atrial repolarization
QRS complex
Reveresed
electrical systole that is measured by time elapsed from start of Q wave to end of T wave. normally .32 to .40 secs
QT interval
Reveresed
delay before repolarization of ventricles; useful in assessing myocardial ischemia
ST segment
Reveresed
ventricular repolarization
T wave
Reveresed
heart failure, ischemia, pericardial effusion, obesity, COPD
depressed QRS
Reveresed
location where abnormal myocardial depolarization originates
ectopic foci
Reveresed
hypertrophy of myocardium
elevated QRS
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previous MI
Q wave
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acute MI
ST sgmt elevation
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irregular atrial rhythm, no rate, no P waves, F waves absent, quivers noted, ventricular rhythm varies. common causes: hypertension, CHF, CAD, rheumatic heart disease, cor pulmonale, pericarditis, drug use
A fib
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rate varies btwn 160-250 bpm, regular rhythm, originates from a location above AV node, will start and stop w/o cause. common causes: mitral valve prolapse, cor pulmonale, digitalis toxicity, and rheumatic heart disease
supraventricular tachycardia
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occurs when ectopic focus in atrium fires and supersedes the SA node. P wave is premature with abnormal configuration, rate normal btwn 60-100 bpm, irregular rhythm can be regularly irregular such as consistently skipping every 3rd beat, can be indicative of ischemia or valve pathology. common causes: caffeine, emotional stress, smoking, and pathologies like CAD, electrolyte imbalance, infection and CHF.
premature atrial contractions (PAC)
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rate usually above 100 bpm. rhythm usually regular. no P wave or it appears after QRS complex with retrograde conduction. requires immediate medical attention. common causes: post MI, rheumatic heart disease, CAD and cardiomyopathy
ventricular tachycardia (VT)
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no regular rate or rhythm, emergency, requires immediate medical attention. causes: long term or severe heart disease, post MI, hypercalcemia, hypokalemia, and hyperkalemia.
v fib
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rate over 150 bpm, irregular rhythm, no P waves, QRS complex is wide, requires immediate medical intervention. causes include: hypokalemia, hypomagnesemia, hypothermia, and drug induced through antiarrhythmic medications.
multifocal v tachycardia
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occur when an ectopic focus in the ventricles or Purkinjue fibers fires and supersedes normal conduction. focal PVCs occur from one ectopic foci and have the same waveform. rate is normal between 60-100 bpm, P wave is absent, ST sgmt is distorted, and QRS complex occurs early. irregular rhythm that can be regularly irregular such as consistently skipping every 3rd beat. common causes: caffeine intake, emotional stress, smoking, CAD, digitalis toxicity, cardiomyopathy, and MI.
premature v contractions (PVC)
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regular rhythm, atrial rate is higher than ventricular rate, requires immediate medical intervention (pacemaker). causes include: infection, electrolyte imbalance, CAD, anteroseptal MI, impairment with the AV conduction system.
complete heart block (3rd degree AV block)
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no rhythm, absence of P wave, QRS and T waves, can have abrupt onset, requires immediate medical attention. causes: failure of all pacemakers to initiate, conduction system failure, acute MI and ventricular rupture
asystole
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(upper number bp reading) contraction of cardiac muscle
systole
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(lower number bp reading) relaxation of cardiac muscle
diastole
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atrial emptying of blood
atrial systole
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atrial filling of blood
atrial diastole
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ventricular contraction that causes a rapid ejection of blood (emptying)
ventricular systole
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ventricular filling in combination with atrial contraction
ventricular diastole
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elevated arterial blood pressure both for systole and diastole.
hypertension
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5 phases - sounds that are heard sounds over an artery when blood pressure is determined by the auscultatory method
korotkoff’s sounds
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values are usually slightly higher in left UE vs. the right UE. inflate cuff to 20 mm Hg above reading where brachial pulse disappears. 1st sound indicates systolic pressure, last audible sound indicates diastolic pressure.
bp prep and procedure
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test that measures arterial perfusion using a Doppler unit. blood pressures are measured in both UEs and LEs and highest LE systolic pressure is divided by brachial systolic pressure.
ABI: ankle-brachial index
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Normal=1.0. .5-.9=arterial occlusion, impairment with wound healing. less than .5=severe arterial occlusion.
ABI scale
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0-3 scale: 0=absent, 3+=full, firm pulse. pulse amplitude classification: 0=absent, 1+=diminished thru to 4+=markedly increased
peripheral pulse assessment grading system
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to breathe air into the lungs
inspiration
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to breathe air out of the lungs
expiration
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12-18 per minute for adults, 30-50 per minute for infants
normal RRs:
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metabolic equivalents: amount of oxygen consumed per kilogram of body weight per minute to perform a given activity. at rest a person consumes 3.5 ml/kg/minute.
METS
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eating=1, dressing=2, light housework=2-4, dancing=4-5
MET chart
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see page 121
borg’s rate of perceived exertion scale and the revised 10-grade scale
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affects pulmonary
left sided heart failure
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causes swelling in extremities
right sided heart failure
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max heart rate is determined by subtracting patient’s age from 220. normal training intensity ranges from 60-90% of age-adjusted max heart rate.
target heart rate
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max heart rate is obtained by an exercise stress test and resting heart rate is subtracted from it. number is termed the heart rate reserve.
karvonen’s formula: heart rate reserve method
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MI, angina (stable), CABG, cardiac surgery, high risk for CAD, hypertension, end stage renal disease, status post pacemaker insertion, cardiomyopathy, heart transplant, high risk for diabetes
cardiac rehab indications
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heart rate that increases over 50 bpm with low level activity, increasing bp, any ST segment chgs, severe LE claudication, angina, confusion, extreme fatigue, ventricular gallop
contraindications to stop exercising during cardiac rehab
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uncontrolled atrial/ventricular arrhythmias, embolism, thrombophlebitis, orthostatic bp, acute infection, unstable angina, resting ST sgmt deplacement, uncompensated CHF
contraindications for cardiac rehab
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third degree heart block, uncompensated CHF, PVCs of vent tachycardia at rest, multifocal PVCs, chest pain with ST sgmt changes, ECG changes that indicate ischemia, dissecting aortic aneurysm
absolute contraindications for treatment of an unstable cardiac patient
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consists of 4 phases. 1st phase averages 3-5 days, 2nd phase 2-12 weeks, 3rd phase 6-8 weeks, 4th phase lasts throughout pt’s lifetime
cardiac rehab program
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active ROM, ambulation, self care, in inpatient (hospital)
phase 1
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begins after hospitalization, monitored closely. 2-3 visits per week. does not require ECG monitoring.
phase 2
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continuation of phase 2. exercise training, phys fitness, endurance and risk factor modifications are goals in this phase. once a week visits
phase 3
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lasts throughout patient’s life and is designed to promote optimal health. self monitoring of exercise, stable cardiac status, no contraindications to exercise, and at least a 5 MET capacity for activities
phase 4
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provides constant monitoring of heart rate, blood pressure, and ECG interpretation before, during and after each session, use of exertion scale to identify intensity of exercise, promote proper technique and breathing patterns during exercise, progress activities based on METs tolerated
therapist’s role during inpatient cardiac rehab
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initially close monitoring of ECG, heart rate, and blood pressure throughout session is required, constant measurement of vitals, exercise should be gradual in progression, isometrics are contraindicated
therapist’s role during outpatient cardiac rehab
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no mvmt-phone 911-open airway, check breathing-if NO breathing, administer 2 breaths that make chest rise. if NO response, check pulse. if pulse, rescue breathing only at 10-12 breaths per minute. if NO pulse, begin CPR with 30 compressions and 2 breaths. continue to perform CPR until medical assistance arrives
ADULT: CPR flow chart
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Airway-maintain open airway. Breathing-rescue (look, listen, feel). Circulation-compressions: check pulse.
Cardiopulmonary ABCs
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weakening in wall of a vessel that produces a sac like area. 50% increase in normal vessel diameter with weakening of all layers of arterial or venous wall. most common sites include aorta, abdominal aorta, femoral, and popliteal arteries. surgical repair prior to rupture has a good prognosis; ruptured aneurysm is a medical emergency with high mortality rate. symptoms: abnormal heart beat, MI, stroke, renal failure, embolization, intermittent or constant pain
aneurysm
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when coronary arteries are unable to supply the heart with adequate oxygen. sudden onset is common once the myocardial oxygen demand is higher than the supply. CAD accounts for 90% of all angina.
angina pectoris
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angina that will wake someone up from sleep
nocturnal angina
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occurs while at rest secondary to CAD or spasm. can be severe and not readily relieved by nitroglycerin
prinzmetal’s angina
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angina that usually occurs at predictable level of exertion, exercise or stress and responds to rest or nitro.
stable angina
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occurs at rest or with exertion and has changed intensity, frequency, and/or duration
unstable angina
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temporary pain, sudden onset, pain may radiate, usually lasts one to five minutes, usually relieved with rest or nitroglycerin
symptoms of angina
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condition of progressive accumulation of fatty plaques on inner walls of vessels that ultimately produces stenosis. begins in childhood and usually affects medium sized arteries. over time the plaque that produces stenosis inside the vessel can also block blood flow. heart attack or stroke can result from atherosclerosis
atherosclerosis
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group of conditions that affect the myocardium muscle itself, impairing the ability for the heart to contract and relax. 3 types are dilated, hypertrophic, and restrictive. symptoms: same as heart failure, neck vein distension, fatigue and weakness, possible chest pain, sudden death, exercise intolerance
cardiomyopathy
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congestive heart failure: results usually from coronary artery disease when heart is unable to maintain an adequate cardiac output. characterized by abnormal retention of fluid and results in diminished blood flow to tissue and congestion of the pulmonary and or systemic circulation. symptoms: pulmonary edema, dyspnea, cough (nonproductive), S3 gallop, exertional hypotension, weight gain within hours, increased resting heart rate.
CHF
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coronary artery disease: narrowing or blockage of coronary arteries that may produce ischemia and necrosis of the myocardium. inability for vasodilation and as a result the arteries cannot meet the metabolic demands. will produce ischemia and ultimately necrosis. CAD includes thrombus, vasospasms, and atheroscelerosis. results from inheritance, environment, culture, nutrition and smoking. symptoms: appear after significant blockage is present, over 75%. pain in occluded artery’s region. if untreated, MI or death.
CAD
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inability of heart to maintain a proper cardiac output of 4 liters per minute while at rest. chronic hypertension is most common cause
heart failure
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inflammation of endothelium that lines heart and cardiac valves. most commonly damages mitral valve, then aortic and tricuspid valves. commonly caused by bacteria that are normally present in the body. can also occur after an invasive medical or dental procedure. symptoms: valvular dysfunction, may affect organ systems, chest pain, CHF, clubbing, meningitis, low back pain, arthralgia, arthritis
infective endocarditis
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causes irreversible damage to a segment of heart muscle due to prolonged ischemia. causative factors include narrowing of coronary arteries due to atherosclerotic occlusion, poor coronary perfusion secondary to hemorrhage or occlusion or one of the major coronary arteries.
MI: myocardial infarction
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expected damage: anterior heart-left anterior descending artery, high risk of large infarction, heart failure, sudden death. inferior heart-rt coronary artery, right ventricle damage, AV block, medium infarct possible, lateral heart and/or superior heart-least area of muscle affected, usually least overall damage, minor impairment or complications
areas of MI
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uncommon condition of inflammation to myocardium muscle usually due to infection. can be treated with antimicrobial therapy. if left untreated can quickly progress to a dilated cardiomyopathy with heart failure. symptoms: mild, low level chest pain, soreness, fatigue, palpitations
myocarditis
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inflammation of the pericardium (outer membrane) of heart. condition may be acute or chronic. can be painful or asymptomatic. can be caused by infection, MI, radiation therapy, post cardiac surgery, aortic dissection. symptoms: auscultation reveals pericardial friction rub, pleuretic chest pain, diffuse ST segment elevation, retrosternal chest pain, cough and hoarseness, fever, fatigue and weakness, joint pain.
pericarditis
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result of damage to heart secondary to inflammation from rheumatic fever. rheumatic fever can occur from strep bacteria and is classified as an autoimmune disease. can affect connective tissues. acute rheumatic fever has a low mortality rate. symptoms: carditis with chest pain, acute onset of polyarthritis, chorea, arthralgias and weakness, fever and palpitations
rheumatic heart disease
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disease of exocrine glands that primarily affects respiratory and gi systems. cause: mutation of chromosome seven to include cystic fibrosistransmembrane conductance regulator (CFTR). cystic fibrosis is an autosomal recessive genetic disorder and a terminal disease. presents with increased secretion of thick mucus, gi distress, abnormal bowels, recurrent pulmonary infection, salty tasting skin, wheezing, productive cough, barrel chest, dyspnea, and progressive use of accessory muscles with respiration. trtmt includes antibiotics, supplements, pancreatic enzyme replacements, mucus thinning medications, bronchodilators. pt is essential and includes bronchial drainage, percussion, vibration, suctioning, breathing techniques, assisted cough, and ventilatory muscle training for optimal pulmonary function.
ped: cystic fibrosis
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disorder where ductus arteriosus which normally shunts blood in utero from pulm artery to descending aorta, fails to close shortly after birth. causes: premature birth, respiratory distress syndrome, fetal alcohol syndrome, trisomy 13, and trisomy 18. presents: tachycardia, respiratory distress, poor nutrition, weight loss and congestive heart failure. initial treatment attempts to non surgically reduce the size of the ductus with use of diuretics and indomethacin when indicated. surgical repair may be necessary for a large ductus or when initial management fails.
ped: patent ductus arteriosus
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pulmonary condition seen in neonates born before 37 weeks of gestation. rds is also known as hyaline membrane disease and is leading cause of death in the neonate. causes: immaturity of lungs and inability to produce necessary levels of surfactant. results in increased alveloary tension, alveolar collapse, atelectasis, and difficulty breathing. associated factors with rds include being the second born twin, c section delivery, hypoxia and acidosis. presents with: infant working hard to breathe and reinflate collapsed lung. tachypnea, flaring of nostrils, use of accessory muscles and respiratory distress are observed within one to two hours. untreated, the infant lacks oxygen and presents with metabolic acidosis and acute respiratory failure. treatment will vary and can include mechanical ventilation, supplemental oxygen, administration of artificial surfactant, nutritional support, bronchial drainage, and chest physical therapy.
ped: respiratory distress syndrome
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most common cyanotic heart defect where following four abnormalities exist: ventricular septal defect, right ventricular hypertrophy, aortic override of interventricular septum, pulmonary stenosis.
ped: tetralogy of fallot
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include diuretic agents, beta-adrenergic blocking agents (betablockers), alpha-adrenergic blocking agents, antiotensin-converting enzyme inhibitor agents (ACE), angiotensin II receptor antagonist agents, nitrates, antiarrhythmic agents, calcium channel blocker agents
pharmacological interventions for cardiac management
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loud and tubular sounds with a high pitch noted during inspiration and expiration, pausing between the two components
normal tracheal and bronchial sounds
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normal, soft, low pitched sounds heard over the more distal airways primarily during inspiration. during expiration the soft sound is diminished and only heard during beginning of expiration
vesicular breath sounds
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sounds that are heard outside of their normal location or phase of respiration
abnormal breath sounds
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abnormal breath sounds heard using a stethoscope with inspiration and/or expiration. these sounds can be continuous or discontinuous sounds
adventitous breath sounds
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continuous adventitious sounds comprised of a musical nature, constant pitch (high or low) and varying duration. usually heard during expiration but may also be present on inspiration. typically a sign of airway obstruction from retained secretions or due to bronchoconstriction. wheezes found with inspiration indicate a more severe airway obstruction
wheeze
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continuous adventitious sound comprised of a very high-pitched wheeze that can be heard with inspiration and expiration and also indicates upper airway obstruction. stridor that is heard without a stethoscope can indicate an emergency
stridor
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discontinuous adventitious sound heard with a stethoscope that bubbles or pops. crackles typically represent the movement of fluid or secretions during inspiration (wet crackles) or occur from the sudden opening of closed airways (dry crackles). crackles that occur during latter half of inspiration typically represent atelectasis, fibrosis, or pleural effusion. crackles secondary to the mvmt of secretions are usually low-pitched.
crackles (formerly rales)
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abnormal breath sounds when heard in locations that vesicular sounds are normally present. pneumonia may produce these sounds
bronchial breath sounds
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less audible sound may indicate severe congestion, emphysema or hypoventilation
decreased or diminished sounds
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may indicate pneumothorax or lung collapse
absent breath sounds
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while auscultating lung segments the patient repeatedly says the letter “e”. if it sounds like an “a” fluid is expected in the air spaces or lung parenchyma.
voice sounds: egophony:
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patient repeatedly says “99”. if word is clearly audible in distal lung fields the test is positive for consolidation. if word is less audible, softer or weaker sounding, test is positive for hyperinflation
voice sounds: bronchophony:
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while auscultating lung segments the patient repeatedly whispers words. clearly audible and less audible words indicate the same findings as bronchophony testing.
voice sounds: whispering pectoriloquy:
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series of tests to determine pulmonary function
pulmonary function testing
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volume of air that occupies the non respiratory conducting airways
anatomic dead space volume (VD)
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max volume expired after normal expiration
expiratory reserve volume (ERV)
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amount of air exhaled in the 1st, 2nd, and 3rd second of a forced vital capacity test
forced expiratory volume (FEV)
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amount of air forcefully expired after a max inspiration
forced vital capacity (FVC)
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volume in lungs after normal exhalation
functional residual capacity (FRC)
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amount of air that can be inspired after a normal exhalation
inspiratory capacity (IC)
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max volume inspired after normal inspiration
inspiratory reserve volume (IRV)
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amount of air expired in one minute. equal to the product of the tidal volume and the RR
minute volume ventilation (VE)
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max flow of air during the beginning of a forcd expiratory breath.
peak expirator flow (PEF)
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lung volume remaining in the lungs at the end of a max expiration
residual volume (RV)
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total volume inspired and expired per breath
tidal volume (TV)
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lung volume measured at the end of a max inspiration
total lung capacity (TLC)
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max volume forcefully expired after a max inspiration
vital capacity (VC)
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a value is usually considered abnormal if it is less than 80% of the reference value
pulmonary function reference values
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inspiratory reserve volume (IRV) + tidal volume (TV) = expiratory reserve volume (ERV) = residual capacity (RC)
total lung capacity (TLC)=
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inspiratory reserve volume (IRV) + tidal volume (TV) + expiratory reserve volume (ERV)
vital capacity (VC)=
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tidal volume (TV) + inspiratory reserve volume (IRV)
inspiratory capacity (IC)=
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expiratory reserve volume (ERV) + residual volume (RV)
functional residual capacity (FRC)=
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…
typical lung volumes and capacities
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500 mL
tidal volume
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1000 mL
expiratory reserve volume
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4000-5000 mL
vital capacity
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3000-4000 mL 75-80% of vital capacity, 55-60% of total lung capacity
inspiratory capacity
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…
forced expiratory volumes
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83% of VC
FEV1 (forced expiratory volume in one second)
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94% of VC
FEV2 (forced expiratory volume in 2 seconds)
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97% of VC
FEV3 (forced expiratory volume in 3 seconds)
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mm Hg: see chart on page 132
gas pressure
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uses as a tool to determine the effectiveness of alveolar ventilation. expressed as the partial pressure of the gas.
arterial blood gases (ABG)
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partial pressure of oxygen within arterial system, usually 95-100 mmHg.
PaO2
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partial pressure of carbon dioxide within arterial system, normally 35-45 mm Hg.
PaCO2
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7.35-7.45
range of acid-base balance or pH
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increased amount of CO2 in blood
hypercapnia
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increased amount of potassium in blood
hyperkalemia
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decreased amount of CO2 in blood
hypocapnia
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when PaO2 is less than 80 mm Hg
hypoxemia
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see chart on page 133
physical signs observed in various pulmonary disorders
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pH is high, PaCO2 is low. caused by alveolar hyperventilation. symptoms: dizziness, syncope, tingling, numbness, early tetany
respiratory alkalosis
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pH is low, PaCO2 is high. caused by alveolar hypoventilation. early symptoms: anxiety, restlessness, dyspnea, headache. late symptoms: confusion, coma
respiratory acidosis
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pH is high, PaCO2 is normal. causes: bicarbonate ingestion, vomiting, diuretics, steroids, adrenal disease. symptoms: weakness, mental dullness, possibly early tetany
metabolic alkalosis
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pH is low, PaCO2 is normal. causes: diabetic, lactic, or uremic acidosis, prolonged diarrhea. symptoms: secondary hyperventilation, nausea, vomiting, cardiac dysrhythmias, lethargy and coma
metabolic acidosis
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7.4
pH normal value
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40 mm Hg
PCO2
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97 mm Hg
PO2
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24 mEq/L
HCO3
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95-98%
% Sat
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pH greater than 7.45
values of metabolic alkalosis
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pH lower than 7.35
values of metabolic acidosis
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pH greater than 7.5
acute alveolar hyperventilation
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pH less than 7.3
acute ventilatory failure
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PCO2 less than 40 mm Hg (hypocapnia, hyperventilation)
respiratory alkalosis
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PCO2 greater than 40 mm Hg (hypercapnia, hypoventilation)
respiratory acidosis
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indications: patients who have acute or chronic respiratory problems: inability to expel secretions, ineffective cough, swallowing difficulties
chest physical therapy
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congestive heart failure, pulmonary edema, pleural effusion, pneumothorax, cardiac arrhythmia, history of recent MI, unstable angina, pulm embolism
contraindications for postural drainage
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fracture, spinal fusion, osteoporotic bone, unstable angina, low platelet count, anticoagulation therapy, pulm embolism
contraindications for percussion
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treatment should be before eating, or at least one hour after meals, percuss and vibrate over each segment to be treated for at least 3-5 mins, cough after each segment is treated, allow for a rest period after each segment is treated, review breathing exercises in each drainage position, not to exceed 45-60 mins secondary to patient fatigue
guidelines for chest PT
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mobilize secretions, expel secretions, improve breathing patterns, improve ventilation throughout all lobes, improve overall function
goals for chest PT
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using cupped hands to strike over a particular lung segment in alternating fashion during inspiration and expiration in order to mobilize secretions. should last for several minutes and should not be painful
percussion
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technique using both hands (one on top of the other) directly over the chest wall to provide pressure and manual vibration during exhalation. should be used in conjunction with percussion and only during expiration. pressure should be applied in same direction as chest wall mvmt during expiration
vibration
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patient in head down position with bottom of bed inclined to approx 45%. ideal to assist with secretion drainage from lower lobes of lungs. can also assist with increasing blood pressure in case of hypotension. do not use with patients with CHF, pulm edema, hypertension, SOB or other circulatory problems
trendelenburg position
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places a patient in supine with head raised above their trunk and LEs. may be used with patients diagnosed with hypertension or other cardiac conditions. also decreases the weight of the abdominal contents on the diaphragm providing it with less resistance to mvmt during breathing
reverse trendelenburg
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places patient supine with head of bed elevated to 45% and pillows under patient’s knees for support and maintenance of a proper lumbar curve. used quite often for patients with CHF or other cardiac conditions
semi-fowler’s position
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…
bronchial drainage positions/procedures
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sitting: lean back against a pillow; clap above clavicles btwn neck and shoulder
Upper lobes: apical segment (anterior)
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sitting: lean forward onto a pillow; clap on both sides of back above scapula. fingers should be positioned slightly over shoulder
Upper lobes: apical (posterior)
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supine: lie flat on back with pillow under knees for comfort; clap on both sides just below clavicles and above nipple line
Upper: Anterior segment
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side: lie on rt side w/head and shoulders elevated on pillows. make 1/4 turn forward, clap over left scapula
Upper: Left posterior segment
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side: lie on lt side. place a pillow in front from shoulders to hips and roll slightly forward onto it; clap over right scapula
Upper: Right posterior segment
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side: elevate bottom of bed 14-16 inches. lie on right side. place pillow behind from shoulders to hips and roll slightly back onto it; clap over left nipple
Upper: Left lingula
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side: elevate bottom of bed 14-16 inches. lie on left side. place pillow behind from shoulders to hips and roll slightly back onto it; clap over selected lobe.
Middle Lobes: Right middle lobe
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prone: lie flat on stomach. place pillow under stomach area for added comfort and clap over middle back at tip of scapula
Lower Lobes: superior segments
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side: elevate bottom of bed 20 inches. lie on opposing side; clap at lower ribs. pillow under waist may help to keep spine straight
Lower Lobes: lateral basal segment
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supine: elevate bottom of bed 18-20 inches. lie on back and place a pillow under knees; clap at lower ribs on both sides
Lower Lobes: anterior basal segment
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prone: elevate bottom of bed 18-20 inches. lie on stomach and place pillow under hips. clap at lower ribs on both sides.
Lower Lobes: posterior basal segment
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used for patients that exhibit decreased chest expansion, SOB, bradypnea, and decreased breath sounds. attempts to increase ventilating capacity and decrease dyspnea through strengthening of diaphragm and intercostal muscles.
inspiratory muscle training
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2-4 sessions of 30 to 60 minutes of deep breathing with proper diaphragmatic breathing
inspiratory muscle training (treatment protocol)
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attempts to enhance movement of diaphragm upon inspiration and expiration and diminish accessory muscle use. position patient in bed with head and trunk elevated 45 degrees. place dominant hand over rectus abdominis. place non dominant hand over sternum. direct patient to inspire slowly and feel dominant hand rise. instruct patient to control both inspiration and expiration. non dominant hand should only have minimal movement.
diaphragmatic breathing
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slow deep breathing designed to improve alveolar ventilation and oxygenation.
low frequency breathing
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used to increase inspiration using a device that provides immediate fb to patient regarding performance. commonly utilized to treat patients status post surgery in order to strengthen weak inspiratory muscles and to prevent alveolar collapse. have patient breathe into spirometer and instruct patient to perform a max inhalation into spirometer. repeat 7 - 10 times per session and repeat 3-4 times per day.
incentive spirometry
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attempts to improve ventilation by decreasing RR and increasing tidal volume. in through nose and out through mouth
pursed lip breathing
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used to prevent accumulation of fluid and to increase chest mobility by directing inspired air to predetermined areas. place hands on target area and apply pressure down and in during exhalation. apply quick stretch immediately before inspiration. instruct patient to slowly inspire air into the target lung area under hands. give mild resistance during inspiration. observe accessory muscles during exercise in order to limit use.
segmental breathing
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reversible, obstructive lung condition characterized by increased responsiveness of trachea and bronchi to stimuli, inflammation, and overproduction of mucous glands with widespread narrowing of airways.
asthma
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progressive obstructive lung disease that produces abnormal dilation of a bronchus. irreversible condition that usually is associated with chronic infections, aspiration, cystic fibrosis or immune system impairment. bronchial walls weaken over time secondary to infection and allow for permanent dilation of bronchi and bronchioles. symptoms: consistent productive cough, hemoptysis, weight loss, anemia, crackles, wheezes, and loud breath sounds.
bronchiectasis
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increased mucus secretions from bronchioles as well as structural changes to bronchi. productive cough is usually present for 3 months during two consecutive years. major impairments include hypertrophy of mucus secreting glands and insufficient oxygenation of alveoli due to mucus blockage. symptoms: increased pulmonary artery pressure, thick sputum, increased use of accessory muscles, persistent cough, wheezing, dyspnea, and cyanosis. patients are often called “blue bloaters”
chronic bronchitis
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chronic obstructive pulmonary disease. increased resistance to passage of air in and out of the lungs due to narrowing of bronchial tree. symptoms: dyspnea, chronic productive cough, excessive mucus production. progression of disease includes alveolar destruction and subsequent increases in amount of air that remains in lungs. overall increased total lung capacity with a significant increase in residual volume. diagnosed by determining the amount of air forcibly expired from lungs in one second.
COPD
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sudden dilation of rt ventricle of heart secondary to pulm embolus. rt sided heart failure will occur if condition is not treated. as condition progresses, symptoms resemble congestive heart failure. symptoms include: chronic cough, chest pain, distal swelling, dyspnea, fatigue and weakness.
cor pulmonale
