CHAPTER 3 ASSESSMENT OF THE CARDIOPULMONARY PATIENT
PRETEST QUESTIONS
1. A patient coughs up yellow sputum after an IPPB treatment. Which one of the following statements is TRUE in regard to this sputum production?
2. The term used to describe a condition in which a patient has difficulty breathing while in a supine position is which of the following?
3. A patient enters the emergency department, and on initial examination the respiratory therapist observes paradoxical chest movement. Which of the following should the practitioner suspect?
4. Perfusion in the extremities may best be determined by which of the following methods?
5. While palpating the chest, the respiratory therapist determines that there are decreased vibrations over the right lower lobe. This may be the result of which of the following?
6. A chest x-ray film obtained after ET intubation shows the tip of the ET tube is resting at the fourth rib. Which of the following actions should be taken?
7. A patient is suspected of having intrathoracic metastatic nodal disease. Which of the following imaging studies should the respiratory therapist recommend to determine, with the highest accuracy, whether disease is present?
8. Which of the following imaging studies may be useful in determining whether a pulmonary embolism is present?
REVIEW
CRT Exam Content Matrix: IA1, IB5a-f
1. Introduce yourself and establish a rapport with the patient so that the patient feels comfortable and open to discussion.
2. Try to avoid leading questions, such as “Are you still short of breath?” These questions may elicit a different response than would “How is your breathing at this time?”
4. Promote a relaxed atmosphere and avoid difficult medical terms that the patient may not understand.
CRT Exam Content Matrix: IA2, IB1c, IB5a-f, IIIE5a
RRT Exam Content Matrix: IA2, IB1c, IB5a-e
Foul-smelling sputum that often settles into several layers is characteristic of bronchiectasis. (See Chapter 12 on disorders of the respiratory system.)
c. When a cough is productive, it is important to record the amount, consistency, odor, and color of sputum because changes in these qualities over 24 h are important in the diagnosis of pulmonary disease.
Exam Note(5) Frequent hacking cough and throat clearing may be the result of smoking or sinus or viral infection.
a. It is a subjective symptom, meaning the patient expresses breathing difficulty, and can be influenced by the patient’s reactions and emotional state.
Exam Note(1) Orthopnea is dyspnea while lying down. The condition is usually seen in patients with heart failure and is caused by increased congestion of the lungs while lying down. It is often observed in patients with emphysema because of their inadequate diaphragmatic movement during ventilation.
(2) Paroxysmal nocturnal dyspnea is sudden onset of shortness of breath after being in bed for several hours. It is seen in cardiac patients and results in acute pulmonary edema, which usually subsides quickly after the patient is positioned upright.
(3) Exertional dyspnea is often seen in patients with cardiopulmonary disease. The severity is determined by the amount of exertion. It is important to determine at what point the patient experiences dyspnea: Does it begin after walking up a flight of stairs or after simply walking across the room?
b. Hemoptysis is determined by the coughing up of a certain volume of blood; the amount indicates the severity of the symptom.
d. Patients may think they are “coughing up blood” from the lungs when the blood is from the gastrointestinal tract. The origin of the blood must be determined.
d. The parietal pleura (layer lining the chest wall) is very sensitive to pain and is usually the source of pain associated with pneumonias, pleurisy, and other inflammatory processes.
e. Chest pain may be associated with pulmonary hypertension caused by the increased tension on the walls of the vessels and increased workload on the right side of the heart.
f. Chest pain may originate from the heart as a result of an inadequate blood supply. This pain is called angina pectoris.
g. Chest pain is also associated with a ruptured aorta, myocardial infarction, and esophageal problems.
III. OTHER PHYSICAL ASSESSMENTS
RRT Exam Content Matrix: IA2, IA6, IA8a-b, IB1a, IB2a-b, IB4a-c, IB7a-e, IB8, IC2, IIIA1b3, IIIE1
2. Bradypnea: less than the normal respiratory rate. May be seen with respiratory center depression caused by head trauma or drug overdose.
3. Apnea: absence of breathing for a specific period of time (usually at least 10 s). Seen in patients with respiratory arrest caused by asphyxia, severe drug overdose, central and obstructive sleep apnea, and other central respiratory center disorders.
4. Tachypnea: faster than the normal respiratory rate but with the normal depth of breathing. May indicate decreased lung compliance and is associated with restrictive diseases, pneumonia, and pulmonary edema.
5. Hypopnea: shallow respirations (about half of normal depth) with slower than normal respiratory rate. Hypopnea is normal in well-conditioned athletes and is accompanied by a slow pulse rate. May be seen in patients with damage to the brainstem and is accompanied by a weak, rapid pulse.
6. Hyperpnea: deep, rapid, and labored breathing. Associated with conditions in which there is an inadequate oxygen supply, such as cardiac and respiratory diseases. Usually refers to hyperventilation.
7. Kussmaul respiration: increased rate and depth of breathing. Usually seen in patients with severe metabolic acidosis (diabetic ketoacidosis).
8. Biot respiration: irregular breathing pattern characterized by short periods of deep, consistent volumes with periods of apnea. The apneic period may last 10 to 30 s. Associated with elevated ICP or meningitis.
9. Cheyne-Stokes respiration: deep, rapid breathing followed by apnea. The breaths begin slow and shallow and gradually increase to above normal volume and rate, then gradually diminish in volume and rate, followed by apnea. Apnea may last 10 to 20 s before the cycle is repeated. Seen with respiratory center depression caused by stroke or head injury, pneumonia in the elderly, congestive heart failure, or drug overdose.
B. Chest Inspection: This should be performed with the patient seated and with clothing removed above the waist. If the patient is not able to sit in a chair, he or she should be placed in bed in Fowler position (i.e., head of bed elevated 45 degrees). Inspection should include
1. The rate, depth, and regularity of breathing compared with the norms for the patient’s age and activity level.
2. Skin color, temperature, and condition, such as bruises or scars. Is the patient diaphoretic (perspiring)?
a. Observe chest excursion while standing in front of the patient to determine whether both sides are expanding equally.
(4) Flail chest: “Paradoxical” respirations may be observed, in which the chest moves in on inspiration and out on expiration. Flail chest is the result of chest trauma, a fractured sternum, or fractured ribs.
The intercostal muscles and diaphragm are the major muscles for normal ventilation. The accessory muscles are the scalene and the sternomastoid muscles in the neck and the pectoralis major muscle in the anterior chest. When accessory muscles are used during ventilation, it is a sign of respiratory distress.(9) Are substernal, suprasternal, or intercostal retractions or nasal flaring observed? These are all signs of respiratory distress.
a. Digital clubbing is indicative of long-standing pulmonary disease: 75% to 85% of all clubbing is the result of pulmonary disease.
b. Consists of enlargement of the distal phalanges of the fingers and, less commonly, the toes. There is a loss of the angle between the nail and dorsum of the terminal phalanx.
b. This symptom is commonly observed in patients with chronic pulmonary disease, in which their chronic hypoxemic state results in pulmonary vasoconstriction.
c. The right side of the heart works harder as it pumps blood through narrowed pulmonary vessels, which results in an increased workload on the right side of the heart, right ventricular hypertrophy, and, eventually, right-sided heart failure (cor pulmonale).
d. As right-sided heart pressures increase, venous blood flow returning to the heart is diminished, and the peripheral blood vessels become engorged. The ankles are most affected as a result of gravity. This is often accompanied by jugular venous distention (JVD). The jugular veins returning blood from the upper body also become engorged as a result of elevated pressure in the right side of the heart.
a. Refers to the bluish discoloration of the skin and nailbeds resulting from a 5 g/dL decrease in oxygenated Hb. For example, a patient with an Hb level of 15 g/dL would have cyanosis if the oxygen saturation dropped to a level where only 10 g/dL was saturated with oxygen.
c. Patients with decreased Hb levels (anemia) may not exhibit cyanosis even if tissue hypoxia is present. An anemic patient has a low oxygen-carrying capacity, which may result in tissue hypoxia but does not cause cyanosis unless 5 g/dL of unsaturated Hb is present. If there is not enough Hb in the blood to manifest it, cyanosis will not occur.
d. Conversely, a patient with an increased level of Hb (polycythemia) has an increased capacity for carrying oxygen. This patient may have a level of 5 g/dL of unsaturated Hb and therefore may have cyanosis yet have enough saturated Hb to adequately oxygenate the tissues.
b. This is performed by compressing the patient’s fingernail for a short time, then releasing it and observing the time it takes for blood flow to return to the nailbed.
a. Concave curvature of the spine, resulting in a “hunchback” appearance. It is best assessed from an anterior view.
a. Lateral curvature of the thoracic spine, resulting in chest protrusion posteriorly and the anterior ribs flattening out. Chest protrudes on right or left side.
a. Also called pigeon breast; results in the forward projection of the xiphoid process and lower sternum.
c. May cause dyspnea on exercise and more frequent respiratory infections as a result of interference with heart and lung movement.
a. The natural recoil properties of the lungs are decreased because of air trapping and subsequent hyperinflation. This loss of lung elasticity causes the ribs to move more outward, which causes the barrel appearance.
b. The increased tone and development of the accessory muscles, which are used during breathing by patients with COPD, also contributes to the barrel appearance.
d. This hyperinflated state of the lungs pushes down on the diaphragm, which restricts its movement. The diaphragm is a dome-shaped muscle that is innervated by the phrenic nerve. Contraction of the muscle causes a decrease in pressure within the lungs below atmospheric levels, and air enters the airway. Hyperinflated lungs tend to flatten the diaphragm, diminishing its contracting ability. This decreases alveolar ventilation and chest excursion, which results in labored breathing.
e. Muscles normally used for ventilation are the diaphragm and external intercostals, but because the diaphragm of patients with COPD is flattened, they use their accessory muscles during normal ventilation.
3. Vibrations felt on the chest wall as the patient speaks are called tactile fremitus. The vibrations originate at the vocal cords and are transmitted down the tracheobronchial tree, through the alveoli to the chest wall.
a. The practitioner places his or her hands on the patient’s chest and asks the patient to say certain words, such as “ninety-nine,” as the practitioner palpates over different areas of the chest.
b. Vibrations are decreased over pleural effusions, fluid, pneumothorax and in overly muscular or obese patients.
4. For patients with suspected chest trauma or after thoracic surgery, assess for subcutaneous emphysema and crepitus. After chest trauma with pneumothorax or after thoracic surgery, air can leak into the subcutaneous tissues (subcutaneous emphysema). Palpating over subcutaneous air feels like crackling under the skin, which is referred to as crepitus.
a. Assessed by placing both thumbs on each side of the suprasternal notch and gently pressing inward. Only soft tissue should be palpable. If the trachea is felt, it indicates that the trachea has shifted and is no longer positioned midline, as it should be.
b. A shift of the trachea’s position may be the result of a tension pneumothorax or massive atelectasis.
Exam Note1. This involves tapping on the chest directly with one finger or indirectly by placing one finger on a chest area and tapping on that finger over different areas of the chest.
(1) A loud, low-pitched sound of long duration that is produced over areas that contain a greater proportion of air than tissue
(1) A low-pitched sound of long duration that is produced over areas with equal distribution of air and tissue
(1) A sound of medium intensity and pitch of short duration that is produced over areas that contain a higher proportion of tissue or fluid than air
(1) A sound of low amplitude and pitch that is produced over areas that contain a higher proportion of tissue than air
(1) Gentle rustling sound heard over the entire chest wall, except the right supraclavicular area. In a healthy person, vesicular sounds are often difficult to hear
(1) Loud and generally high-pitched sound heard over the upper portion of the sternum, trachea, and both mainstem bronchi
(1) A combination of bronchial and vesicular breath sounds, normally heard over the sternum, between the scapulae, and over the right apex of the lung
(a) A bubbling or crackling sound that can be heard during inspiration or expiration and produced by air flowing through airways containing secretions or fluid.
(b) Early inspiratory crackles, or crackles occurring in the early part of inspiration, are the result of larger proximal airways collapsing during expiration and are heard most commonly in patients with emphysema, chronic bronchitis, or asthma.
(c) When peripheral alveoli and airways collapse during exhalation, late inspiratory crackles are heard as these airways pop open. Late inspiratory crackles are most commonly heard in patients with pulmonary edema, atelectasis, pneumonia, or restrictive lung disorders such as pulmonary fibrosis.
(a) Breath sounds with a musical quality that are produced as air flows through constricted airways.
(b) Airways may become constricted as a result of bronchospasm, mucosal edema, excessive sputum, or presence of foreign bodies.
(d) Wheezes may be heard with asthma, bronchitis, congestive heart failure, and foreign body obstruction.
(a) Most commonly heard during inspiration and produced as air passes through a narrowed upper airway structure such as the glottis (glottic edema).
(b) The diameter of the upper airway may be decreased as a result of infection, as in epiglottitis or croup, or with inflammation and swelling of the glottic area after extubation.
(c) Stridor is a life-threatening sign that ventilation is compromised and immediate intervention is necessary. (See Chapter 4 on airway management.)
(a) A clicking or grating sound caused by friction that is produced as the parietal and visceral pleura rub against each other during the breathing process.
1. Normal heart sounds: Heart sounds are thought to be produced as a result of sudden changes in blood flow through the heart that cause a vibration of the valves and chambers inside the heart. The normal heart sound is a “lubb-dub” sound.
(1) The AV valves are the mitral valve (between the left atrium and left ventricle) and the tricuspid valve (between the right atrium and right ventricle).
(1) The semilunar valves consist of the pulmonic valve (between the right ventricle and the pulmonary artery) and the aortic valve (between the left ventricle and aorta).
c. A third and fourth heart sound (S3 and S4) may be heard, but they are more difficult to hear than S1 and S2 and are more easily heard in children.
(1) S3 is thought to result from blood rushing into the ventricles during early ventricular diastole.
a. Murmurs usually occur when blood flows in a turbulent fashion through heart structures that have a decreased cross-sectional area.
b. Murmurs are described by the location of the sound, the part of the cardiac cycle in which they occur, and the intensity of the sound.
Exam Notea. Consolidation: well-defined, solid-appearing lung that appears light on the film and is caused by pneumonia
b. Radiopaque: white areas on the film that indicate fluids and solids (also referred to as opacity or opacification) and that are caused by pneumonia and pleural effusion, for example
c. Infiltrates: scattered or patchy white areas on the film that are caused by inflammatory processes that indicate atelectasis or disease
d. Radiolucency: dark areas on x-ray film caused by the presence of air; hyperlucency is characteristic of emphysema, asthma, or subcutaneous emphysema.
(3) The x-ray passes through the chest from back (posterior) to front (anterior), and the film is anterior to the patient’s chest.
(3) The heart is more easily seen in this position, but the quality of the film is inferior to that of the PA film.
(1) The image is obtained from the side with the patient upright while the x-ray passes through the chest laterally.
(2) This position allows for visualization of the lung parenchyma behind the heart and the bases of the lungs.
(2) This position is used to help differentiate a pulmonary or mediastinal lesion from structures that overlie it. This view is often used when bilateral lesions are present.
(2) This position moves the shadow of the clavicles out of the way for better visualization of the upper lobes of the lungs.
(1) The image is obtained with the patient lying on his or her side (side-lying position) with the film resting on the posterior surface of the chest.
(2) This position is used to identify whether free fluid (pleural effusion or blood) is present in the chest. Fluid drains to the dependent area of the lung—the lung the patient is lying on—and creates a shadow. For example, if right-sided fluid is suspected, the patient should be placed on the right side.
(3) This view is also helpful in determining the presence of a pneumothorax. Because air rises, the patient should be placed on the left side if a right pneumothorax is suspected.
Chest radiographs are usually obtained with the patient at maximal inspiration, which should show the lungs well aerated and the diaphragm descended to about the level of the tenth rib. An image obtained on expiration may be beneficial in detecting a small pneumothorax that would otherwise be difficult to see on a routine inspiratory film. As the patient exhales, the lung volume is reduced while the pleural air volume remains the same. The pneumothorax then occupies more of the thoracic volume and may be better visualized.
Before viewing a patient’s chest film, verify that the patient’s name on the folder containing the film matches the patient’s name on the upper corner of the film.(2) May be indicated by elevated diaphragm, mediastinal shift (toward area of atelectasis), or increased density and decreased volume of a lung area.
(2) Tension pneumothorax may result in a mediastinal shift and a tracheal shift away from the side of the pneumothorax.
(1) The tube should rest about 2 to 5 cm above the carina. On an inspiratory film, the carina is located at the level of the fourth rib or fourth thoracic vertebra.
(2) If the ET tube is inserted too far, it has a greater tendency to enter the right mainstem bronchus.
(3) If the right mainstem is inadvertently intubated, diminished breath sounds are heard on the left and asymmetrical chest movement may be observed.
(1) Should appear white in the middle of the chest, and the left heart border should be easily determined.
(2) A normal heart should be less than half the width of the chest at the level of the diaphragm. Increased heart size may indicate congestive heart failure (CHF).
(5) The dome of the right hemidiaphragm is normally 1 to 2 cm higher than the left because of space needed for the liver.
(1) Determining the penetration of the x-ray is done by assessing the spinal processes in the center of the chest. They should be just barely distinguishable from each other. If the spinal processes are very distinct, with dark lines separating them, the film is overexposed.
a. CT is an imaging modality used to gain significant information of the thorax that a conventional chest radiograph cannot indicate.
c. CT provides three-dimensional images of the thorax and is more accurate than ventilation/perfusion (V/Q) scanning in the diagnosis of pulmonary embolism. (See Chapter 12 on disorders of the respiratory system.)
a. MRI is another useful imaging technique of the thorax that provides accurate anatomic detail of the thorax.
(4) Because of the strength of the MRI magnets, most ventilators cannot be used near an MRI. Ventilators constructed of nonmagnetic materials have been developed. If these are not available, a ventilator-dependent patient must receive manual ventilation during the procedure.
a. PET is a relatively new imaging technique that detects pathologic processes, especially tumors of the thorax.
b. PET can distinguish between benign and malignant thoracic tumors and often detects tumors that are not easily recognizable on CT.
4. An abnormally low heart rate is called bradycardia and is caused by infection, hypothermia, heart abnormalities, and vagal stimulation.
5. An abnormally high heart rate is called tachycardia and is caused by hypoxemia, fever, loss of blood volume, heart abnormalities, and anxiety.
6. Peripheral edema and venous engorgement indicate inadequate pumping action of the heart, resulting from right-sided heart failure (cor pulmonale) or left-sided heart failure (CHF).
7. Paradoxical pulse (pulsus paradoxus) is a pulse that becomes weaker on inspiration; it may be defined as a decrease in systolic pressure of more than 10 mm Hg during inspiration and may be seen in patients with severe COPD, including asthma, pericarditis, pulmonary embolism, CHF, and pericardial effusion. If paradoxical pulse is observed after chest trauma or cardiothoracic surgery, cardiac tamponade should be suspected. Cardiac tamponade is a life-threatening condition in which blood collects in the pericardial sac and causes pressure that prevents the heart from pumping adequately.
8. Pulsus alternans is an alternating pattern of strong and weak pulses. The ventricle ejects more than the normal amount of blood with a contraction and then less than the normal amount of blood with the next contraction. This is commonly observed in patients with left ventricular failure (LVF) and usually indicates bigeminal premature ventricular contractions (PVCs). (See Chapter 9 on cardiac monitoring.)
6. Diastolic pressure (last or bottom number) is the pressure measured while the ventricles are at rest.
7. The diastolic pressure is the most critical measurement because it is the lowest pressure that the heart and arterial system experience.
8. An abnormally low blood pressure is called hypotension and is usually caused by shock, high-volume blood loss, positioning, and central nervous system (CNS) depressant drugs.
9. An abnormally high blood pressure is called hypertension and is usually caused by cardiovascular imbalances, stimulant drugs, stress, and fluid retention resulting from renal failure.
3. An abnormally low body temperature is called hypothermia and is caused by sweating (diaphoresis), blood loss, exposure to cold temperatures, and abnormally high heat loss.
4. An abnormally high body temperature is called hyperthermia and is caused by decreased heat loss, infection, or increased environmental temperature.
A fever results in increased oxygen consumption, which leads to an increased work of breathing to meet the increased oxygen demands of the body.5. The term used to describe a person with normal body temperature is afebrile; the term used to describe a person with a fever is febrile.
IV. ASSESSMENT OF LABORATORY TEST RESULTS
RRT Exam Content Matrix: IA3, IC1, IIIE8
Exam Noteb. Sodium is the major cation in the extracellular fluid, and its concentration is controlled by the kidneys by means of regulating the amount of water in the body.
b. Chloride is the major anion in the body; two thirds of chloride in the body is found in extracellular compartments. Because chloride is generally excreted with potassium as potassium chloride by the kidneys, decreased levels of one results in decreased levels of the other.
Hypochloremia may result in metabolic alkalosis.b. Most of the body’s calcium is contained in the bones; it plays a major role in neuromuscular function and cellular enzyme reactions.
1. Urea is a substance produced in the liver; it is carried in the blood to the kidneys, where it is excreted in the urine.
2. If the kidneys fail to remove urea from the blood adequately, the blood urea concentration increases.
2. Elevated levels observed in diabetic ketoacidosis; patient compensates with alveolar hyperventilation (Kussmaul respirations, as mentioned earlier in this chapter).
a. The number of RBCs, also referred to as erythrocytes, determine the adequacy of oxygen transport.
c. A decreased RBC count (or anemia) indicates an inadequate oxygen-carrying capacity of the blood. Treatment is a blood transfusion.
a. Hb is the portion of the RBC that carries oxygen, so it is an indicator of the oxygen-carrying capacity of the blood.
c. A subnormal Hb level indicates inadequate oxygen-carrying capacity in the blood. Treatment is a blood transfusion.
c. A decreased Hct level indicates inadequate oxygen-carrying capacity in the blood. Treatment is a blood transfusion.
a. The WBC count determines the presence or absence of infection. WBCs are also referred to as leukocytes.
c. An elevated WBC count indicates the presence of infection. The RCP should recommend a chest x-ray film and sputum culture to determine lung involvement.
c. Decreased platelet count may be the result of bone marrow diseases or disseminated intravascular coagulation (DIC).
It is important for the respiratory therapist to assess these coagulation studies. Patients with decreased platelet counts or increased PT or PTT are at increased risk of hemorrhaging. This means great care must be taken during nasotracheal suctioning or arterial puncture. Nasotracheal suctioning should be minimized, and puncture sites should be compressed longer after an arterial stick than for other patients.F. Urinalysis is a routine analysis that includes chemical analysis to detect protein (proteinuria), sugar (glucosuria), and ketones (ketonuria) and microscopic analysis to detect WBCs and RBCs.
3. Ketonuria is observed in patients affected by starvation, diabetes, and alcohol intoxication. Ketones are formed as the body breaks down fat.
4. Hematuria is defined as blood in the urine and is observed in patients with renal and genitourinary disorders.
Exam NoteV. REVIEWING THE PATIENT CHART
CRT Exam Content Matrix: IA1-8
RRT Exam Content Matrix: IA1-8
A. Once the patient has been admitted and requires respiratory care, the chart should be reviewed for the following information.
b. Respiratory rate: If the rate remains elevated or there is little or no change in the patient’s respiratory distress, the therapist should recommend modifications in the prescribed oxygen therapy (e.g., increasing the FiO2, placing the patient on CPAP or bilevel positive airway pressure (Bi-PAP), or instituting mechanical ventilation). (See Chapter 11 on ventilator management.)
c. Blood pressure: A decrease in blood pressure may indicate excessive positive end-expiratory pressure (PEEP) levels, requiring a decrease in the prescribed level of PEEP. (See Chapter 11 on ventilator management.)
6. ABG levels: Abnormal values in PaO2 or PaCO2 indicate that changes in oxygen therapy or ventilatory variables are necessary. (See Chapters 10 and 11 on ABG interpretation and ventilator management.)
c. Determine recommendations for before and after bronchodilator studies to determine responsiveness to therapy.
VI. CLINICAL APPLICATION OF COMPUTERS
CRT Exam Content Matrix: IIIA1-4
RRT Exam Content Matrix: IIIA1-2
1. Practitioners are now using handheld computers to chart information rather than recording in the patient chart manually.
2. Patient orders, progress notes, treatment times, and ventilator settings are often charted through the computer. This information can be downloaded into a central workstation or may be printed for all practitioners to use. This can be very helpful when giving reports to the oncoming shift.
3. Individual treatment monitoring should be done to include the frequency of therapy, date and time of therapy, positive and adverse effects of therapy, and medication administered. Breath sounds, secretion color and amount, and cough effort should also be monitored.
1. The most common types of computer monitoring of the patient are hemodynamic monitoring, ventilator monitoring, and ECG monitoring. Data collected can be stored so that an interpretation may be done at any time.
2. Interpretations of ABG levels may be accomplished through computer software specifically designed for this purpose.
3. Computer software provides for the calculation and interpretation of ventilation variables, such as static lung compliance, P(A−a)O2, shunt calculations, and many other pulmonary and hemodynamic variables.
4. Computerized technology has been used for pulmonary function testing for several years. Interpretation of results is accomplished with program algorithms.
5. Computerized technology also helps document patient management and monitor therapist workload assignments.
VII. DEVELOPING RESPIRATORY CARE PLANS AND PROTOCOLS
CRT Exam Content Matrix: IIIH6-8
RRT Exam Content Matrix: IIIH6-8
A. Therapist-driven protocols (TDPs) are guidelines that are used to determine the appropriateness of respiratory care treatments; they include the correct delivery method, indications, and discontinuation protocols.
1. Active involvement of the practitioner in determining therapy modifications as the patient’s clinical status changes
POSTCHAPTER STUDY QUESTIONS
1. What is yellow sputum indicative of?
2. What bacterial organism should be suspected if the patient’s sputum is green and foul smelling?
3. List nine causes of dyspnea.
4. What does the term orthopnea mean and in which patients is it most commonly found?
5. Describe Kussmaul respirations and in which patients this breathing pattern is most often seen.
6. List three conditions in which asymmetrical chest movement may be observed.
7. Describe paradoxical respiration and name a condition in which it is most commonly observed.
8. Define pedal edema and what causes it.
9. Name a condition that results in the trachea shifting toward the side of the body that the condition is affecting.
10. Name a condition that results in the trachea shifting away from the affected side.
11. Which muscles are used for normal ventilation?
12. What causes the “barrel chest” appearance in patients with COPD?
13. Name two conditions in which a hyperresonant percussion note would be heard.
14. Name two conditions in which a dull percussion note would be heard.
15. List four conditions that result in heart murmurs.
16. List the normal values for the following electrolytes: sodium, potassium, and chloride.
17. Why would decreased sodium and potassium levels make weaning a patient from the ventilator more difficult?
18. What does an elevated BUN level indicate?
19. How does the respiratory system compensate when glucose levels increase in a diabetic patient?
20. List the normal levels for each of the following: RBC count, Hb level, Hct, and WBC count.
21. What do decreases in Hb level, Hct, and RBC count indicate?
22. Name two conditions that cause a decreased platelet count.
23. Patients with a decreased platelet count and increased PT are at a greater risk of what occurrence?
Farzan S. A concise handbook of respiratory diseases, ed 4. Stamford, CT: Appleton & Lange; 1997.
Hess D, Respiratory care principles and practice, ed 1, Philadelphia, Saunders, 2002.
Wilkins RL, Stoller JK, Kacmarek R. Egan’s fundamentals of respiratory care, ed 9. St Louis: Mosby; 2009.
Wilkins R, Dexter JR, Heuer AJ. Clinical assessment in respiratory care, ed 7. St Louis: Mosby; 2010.
Wyka K, Matthews P, Clark W. Foundations of respiratory care, ed 1. Albany: Delmar; 2002.
