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Review for CRT

Ventilation

Breathing air in and out of the lungs

Oxygenation

Getting Oxygen into the blood

Circulation

Moving the blood through the body

Perfusion

Getting Blood and Oxygen into the tissues

Ventilation

Respiratory Rate, Tidal Volume, Chest Movement Breath Sounds, PaCO2

Oxygenation

Heart Rate, Color, Sensorium, PaO2

Circulation

Pulse Heart Rate and Strength. Cardiac Output

Perfussion

Blood Pressure, Sensorium temperature, Urine Output hemodynamics

When you have an emergency what comes first?

1st is Ventilation (establish an open airway and breathe 2nd. Oxygenation (Increase FIO2) 3rd is Circulation (Chest compressions defibrillate, give heart drugs Most Common problem is Oxygenation

What is on a Patient Evaluation?

l) Admission Notes include: Admitting diagnosis History of Present Illness (chief complaint) and past medical history2) Signs and Symptoms things you can see Color, Pulse Edema, Blood Pressure Symptoms Patient must tell you: dyspnea, pain neasea muscle weakness Occupation or Employment History Allergies, Prior Surgeries Illness or Injury Vital Signs, RR, Pulse, BP, Temp Physical Exam of Chest inspection, palpation, purcussion and auscultation

What is smoking history?

Patients number of pkg per day times number of years smoked

What is an Advance Directive?

DNR: Do Not Resuscitate

What is On the Respiratory Care Orders?

Type of treatment, frequency, medication dosage and dilution Physican Signature

What goes on a Patients Progress Notes and Lab Reports

Respirator Notes Date, times Reactions Nursing Notes check patient status boats Reports ABG Pulmonary Function testing Image Reports Xrays Ct, MRI, PET

What are the basic lab Assessments?

CBC, electrolytes, urine analysis, pleural fluid Intake and Output: Normal l liter a day Sensible water loss-urine, vomiting Insensible water loss Lungs and Skin If intake exceeds output could cause: Weight gain, electrolyte imbalance Increased homodynamic pressures... Decreased Lung Compliance

What do you check for bedside interview?

Determine Level of Consciousness Alert and responsive is Norma) Lethargic somnolent sleepy could be COPD Overdose or Sleep Apnea stuporous confused, respond inappropriate could be Drug Overdose, Intoxication Semi Comatose responds only-to painful Stimuli Coma does not respond to painful stimuli Obtunded drowsy state may have decreased cough or gag Check Orientation to time and place and person Assess emotional State Check activities of daily living: Eating, dressing, walking, bathing

What are some subjective symptoms?

Orthopnea difficulty breathing upright CHF General Malaise: electrolyte imbalance Dyspnea Grade I normal dys pnea occurs. after unusual exertion Grade II breathless after going up hills or stairs Grade 111 dyspnea while walking abnormal speed Grade IV dyspnea slowly walking short distances Grade V dyspnea at rest, shaving dressing

What is pain and some signs?

Reaction of specific nervous tissue, BP up and HR also

Whet are some symptoms of Nose and throat?

Excessive nasal secretions Itching and burning of nose and throat Dysphagia difficulty swallowing and hoarseness

What does the Respiratory Care Plan consist of?

Case Management Plan Therapy protocols Disease management Patient and family educational needs

What is a patents physical environment?

Ramps, doorways. stairs

What are open ended questions?

Questions that ask a Patient to describe they provide more detail.

How do you assess a patnent's learning need?

Knowing possible barriers Language Age Education Emotional barriers

Assessment by Inspection What Can you see?

General Appearance age height, weight sex, nourishment Peripheral Edema Caused by CHF and Renal Failure Clubbing of fingers Chronic hypoxemia Venous distention CHF Seen during exhalation COPD Capillary refill indication of peripheral circulation noninvasive and quick Diaphoresis heavy sweating Heart failure Fever infection TB night-sweats Cachectic Muscle Wasting

What do you look at for skin Color?

Normal is pink,tan,brown, black Abnormal is a decrease in color anemia or blood loss Vasoconstriction will cause a change by reducing blood flow Jaundice Increase in bilirubin 17 blood tissue face and trunk Erythema Redness of skin capillary congestion and inflammation Cyanosis blue or blue gray Hypoxia from increased amount of reduced hemoglobin.

What are the chest Configurations?

Normal is normal A-P diameter Kyphosis is hunch back or convex spine curve Scoliosis is lateral curvature of-the Spine Kyphoscoliosis combination hunchback and lateral curvature Barrel chest result of chronic air trapping C0PD increased AP diameter

What is the normal movement of the Chest?

Symmetrical Both sides of chest move at same Time Abdomen moves out due to diaphram dropping chest moves outward and upward

What is Asymmetrical ?

Asymmetrical is an unequal movement of chest Underlying pathology could include Chronic lung disease Atelectasis Pneumotorax Flail Chest Paradoxical Intubated patient with endotacheal tube in one lung

What are some breathing patterns?

Eupnea Normal RR depth and rhythm Tachyphnea Increased RR > 20 Bpm Fever, Hypoxia, Pain, CNS problem Bradypnea Oliaopnea Decreased RR < 8bpm variable depth and Rhythm Apnea is cessation of breathing Cheyne-Stokes Increased and Decreased Rate and Depth with periods of Apnea Caused by increased intracranial pressure meningitis, drug overdose

What is accessory muscle activity?

Muscles used to increase ventilation during times of stress are Diaphragm-intercostals scalene, sternocleidomastoid and abdominal

What is muscle Condition?

Muscle wasting atrophy is loss of muscle tone and occurs in paralysis Increase in muscle size hypertrophy occurs in C0PD patients

What are retractions?

Intercostals and or sternal retractions occur when the chest moves inward during inspiratory efforts instead of outward This is due to a obstructed airway A sign of respiratory distress in infants

What is nasal flaring?

Flaring of the nostrils during inspiration. A sign of respiratory distress in infants Expiratory grunting and retractions occur in newborns to prevent atelectasis

What is the character of a cough?

Strong, moderate or weak. Productive or non productive Frequent or infrequent, tight or moist A dry or nonproductive cough may indicate a tumor in the lungs. A productive cough may indicate an infection.

What is the pulse?

Normal 60-100 bpm Tachycardia >100 bpm indicates hypoxemia anxiety, stress Bradycardia <60bpm indicates heart failure shock code emergency

When is heart rate a cause for concern?

Increased heart rate > 2Obpm is an adverse reaction, stop therapy, notify nurse and doctor Any change in rhythm is indication for further monitoring

What is paradoxical pulses pulse paradoxus?

Pulse blood pressure varies with respirations May indicate severe airtrapping as m status asthmatics tension pneumothorax

What is tracheal deviatlon?

Pulled to Abnormal side? Pulmonary Atelectasis Pulmonary Fibrosis Pnemonectomydiaphragmatic paralysis

Whet is percussion ?

Percussion is done by placing the middle finger between two ribs and tapping the middle fingers first joint with the middle fingertip of your opposite hand Resonance Normal filled air filled lungs\ This gives a hollow sound. Flatness heard over Sternum muscle on area of atelectasis Dullness heard over a loud filled organs such as heart or liver pleural effusion or pneumonia will give this thudding sound Tympany heard over air filled stomach) This is a dreamlike sound and when heard over the lungs indicates increased volume Hyperresonance found in areas of the lung where pnemothorax or emphysemas are present this is a booming sound

What are breath sounds?

Normal breath sounds vesicular Bronchial breath Sounds normal sounds heard over tracheal on bronchi Over the lung would indicate lung Consolidation

Abnormal Breath Sounds

Rates crackles secretion fluid

Coarse rales rhonchi Large Airways Secretions

Patient needs suctioning

Medium Rales

Middle airways secretions Patient needs chest physical therapy

Fine Rales mass crepitate rates

Abrader fluid Patient has cHF pulmonary edema Patient needs IPPB heart drugs diuretics and oxygen

What is wheeze due to?

Broncho spasm, patient needs bronchodilator Unilatenatal Wheeze indicative of a foreign body obstruction, Mucus plug

What is stndor?

Due to upper airway obstruction Supraglottic swelling epiglottis Subglottic swelling croup post extubation Foreign body aspiration solids or fluids

What is Pleural Friction Rub?

Coarse grating or crunching sound visceral and parietal pleura rubbing together

What are normal Heart Sounds)

SI and S2

What are abnormal heart sounds?

S3 and S4 heart sounds You need an Echocardiogram

What is normal blood pressure?

120180 mmHg using a sphygmomanometer Increased Blood Pressure indicates cardiac stress-hypoxemia Decreased blood pressure indicates poor perfusions shock<

What is the position of the endothachial tube?

Below the vocal cords and no closer than 2 cm or I inch above the carina

What are some of the anatomical landmarks?

Trachea seen as a dark area midline Costophrenic angles, Angle made by the outer curve of diaphragm and the chest wall Angles are obliterated by Pleural Effusions Diaphragm Dome Shaped normally Flattened with COPD Vascular Markings are Blood Vessels lymphatics,lung tissue

What are the positions and projections on the chest x-ray?

"AP projection-anterior, posterior
Lateral decubitus position-Patient lying on affected side-valuable for detecting small pleural effusion"

What is normal chest x-ray?

Both hemidiaphragms are frounded (dome-shaped) The right hemidiaphragm is slightly higher than the left, liver pushes it up. The right hemidiaphragm is at the level of the sixth anterior rib.

What are the position of tubes and catheters?

Chest tubes should be located in the pleural spaace surrounding the lung. Nasogastric tubes and feeding tubes should be positioned in the stomach and small bowel below the diaphragm. Central Venous catheters are placed in the right or left subclavian or jugular vein and should rest in the vena cava or right atrium of the heart.

What is a valuable diagnostic tool for an upper airway obstruction in children ? Croup and Epiglottitus

Lateral neck x-ray

What is the classic x-ray sign for croup(larynotrachebronchitis)

Viral disorder , the xray will reveal tracheal narrowing in a classic pattern called steeple sign, pencil point , picket fence all meaning pointing

What is Epiglottitis and what x-ray sign helps identify it?

Epiglottitis is a potentially life-threatening inflammaaton of the supraglottic airway caused by a bacterial infection. A lateral neck x-ray shows supaglottic narrowing showing a thumb sign.

What is Radiolucent?

Dark pattern, air seen on X-ray normal for lungs

What is Radiodense?

White pattern, solid , fluid normal for bones, organs.

What is an Infilttrate?

Any ill-defined radiodensity as in Atelectasis.

What is Consolidation?

"Solid white area, such as Pneumonia(inside)
Pleural effusion (outside)"

What is hyperlucency?

Extra pulmonary air as seen in COPD, asthma attack, pneumothorax.

What are Vascular markings?

"Lymphatics, vessels,lung tissue
Increased with CHF
Absent with Pneunmothorax"

What is Diffuse meaning on X-ray?

Spread throughout as in Atelectasis /Pneumonia

What is Opaque meaning on X-ray?

Fluid , solid as in consolidation

What is Bilateral and what is unilateral?

"Bilateral means on both sides
Unilateral means on one side"

"What are Fluffy infiltrates?
What are Butterfly/Batwing pattern?"

Diffuse whiteness and infiltrate in shape of butterfly as seen with Pulmonary Edema

What are patchy infiltrates and platelike infiltrates?

Scattered densities and thin-layered densities as seen in Atelectasis

What is Ground Glass Appearance and Honeycomb Pattern?

Reticulogranular and Reticulonodular as seen in ARDS/IRDS

What is an Air Bronchogram?

Pneumonia

What are peripheral-wedge-shaped Infiltrate?

Pulmonary Embolus

"What are Concave superior inerface/border?
What are Basilar infiltrates with meniscus?"

Pleural effusion

What is Bronchography?(bronchograms)

Injection of radio-opaque contrast that outlines the airways it allows study of obstruction lesions(tumors) and bronchiectasis.

What is a V/Q scan?

Two scans ventilation and perfusion if the results indicate a normal ventilation scan but abnormal perfusion scan= Pulmonary Emboli

What type of equipment do you need for a MRI?

Manual resuscitation equipment should have detachable non-rebreathing valves made of non-ferrous(non-metallic) materials.

What is an Electroencephalography? (EEG)

Electrical activity of the brain. Indications for brain tumors, injuries, retardation, epilepsy, seizuries, sleep disorders.

What is normal ICP?(intracranial pressure)

5-10 mm Hg

When should ICP be treated?

"If ICP> 20 mmHg
Patient should be hyperventilated until PaCo2 is 25-30 mmHg"

What is Ultrasonography of the Heart? Echocardiogram (ECG)

"Non invasive method for monitoring cardiac performance.
More S1 or S2"

What is the normal RBC? red blood cell count

"Normal value
4-6 mill/cu mm"

What is normal Hemoglobin? Hb

"Normal value
12-16 gm/dl"

What is normal hematocrit?Hct

"Normal value
40-50%"

What is normal White blood cell ? WBC

"Normal WBC
5,000 to 10,000 per cu mm"

What is leukocytosis?

Increased WBC over 10,000 is bacterial infection

What is leukpenia?

Decreased WBC count under 5,000 mean viral infection

What are Electrolytes and their clinical application of imblance?

"K+, Na+, Cl-, HCO3-(CO2 content) are elements required by the body for normal metabolism.
Electroyle imbalance cause muscle weakness, soreness, nausea, mental changes such as lethargy, dizziness and drowsiness - general maliase"

What is the normal value for K+ Potassium?

"Normal = 3.5 - 4.5 range Important for acid-base balance
CO2 +"

What is Hypokalemia?

"Low K+ low potassium, metabolic alkalosis, excessive excretion , renal loss, vomiting
Flattened T waves on EKG"

What is Hyperkalemia?

"High K+ potassium , kidney failure, metabolic acidous
Spiked T wave on EKG"

What is the normal value for Na+ sodium?

"Normal Na+ Sodium is 140mEq/L (135-145 range)
CO2+"

What is hyponatremia?

"Low Na+ low sodium
fluid loss from diuretics, vomiting, diarrhea, fluid gain from: CHF,IV therapy"

What is hypernatremia?

"High Na+ high sodium
Dehydration"

What is the normal value for Cl- Chloride?

"Normal values for Cl- Chloride 90 mEq/L (80-100 range)
Pa-"

What is hypochloremia?

"Low Cl- chloride
metabolic alkalosis"

What is hyperchloremia?

"High Cl- chloride
metabolic acidosis"

"What is normal HCO3?
Bicarbonate (total CO2 content)"

"Normal HCO3 24mEq/L
22-26 range"

What do you look at in Sputum analysis?

"Amount of sputum teaspoons, tablespoon.
Consistency-thin,thick, tenacious
Color"

What does the color of sputum tell you?

"Clear-normal
Mucoid-White/gray, chronic brochitis
Yellow presence of WBCs bacterial infection
Green- stagnant sputum, gram negative bacteria (Bronchiectasis, pseudomonas)
Brown/dark- old blood
Bright red - hemoptysis(bleeding tumor, TB)
Pink frothy- pulmonary edema"

What does the sputum culture tell you?

Identify the bacteria present and what antibiotics will kill the bacteria

What is the difference between the Gram and Acid fast stain?

"Gram stain identifies whether it is gram positive or negative this is a fast test less than 1 hour.
Acid fast stain indicates tuberculosis takes longer to get result"

What is an Oscilloscope?

Oscilloscope is a moniter that is at the head of the bed that provides the visual image of the ECG

What is the Electrocardiograph?

"It is the printed version of recording the electrical activity of the heart.
Always Look at Lead II"

What is a Holter Monitor?

Portable version of an electrocardiograph that is worn under clothes for 24-48 hours continually

What is an Electrode?

Electrode is a sticker placed on the skin to conduct electric current

What is a lead?

A positive and negative electrode that allows electrical current to flow.

How many leads and electrodes are there in a 12 lead?

There are 12 leads and 10 stickers (electrodes)

What lead do you moniter?

"Moniter Lead II
Left leg positive, Right Arm Negative"

What is distintive about the AVR lead?

AVR is the only limb lead that produces an upside down (neg) pattern

What leads give dimension of right heart and where are they placed ?

"V1 - 4th intercostal space on right side of sterum
V2 - 4th intercostal space on left side of sterum"

What leads give dimension of Ventricular septum and where are they placed?

"V3- between V2 and V4 on left side
V4 - 5 th intercostal space, left mid clavicular line"

What leads give dimension of left heart and where are they placed?

"V5- between V4 and V6 on the left side
V6-5th intercostal space, left mid-axillary ling"

What is normal heart rate?

60-100 bpm

What is bradycardia?

<60bpm

What is tachycardia?

>100bpm

What is flutter?

>200bpm

What is fibrillation?

Too fast to count

How do you measure heart rate on a strip?

"You measure the distance between the two R waves and divide 300 by it.
If the two R waves are between 3 and 5 large blocks the the rate is normal 60-100
If the two R waves are closer than 3 large blocks then the rate is greater than 100-tachycardia
If the two R waves are wider than 5 large blocks than the rate is less than 60 - bradycardia"

How do you treat Sinus Rhythm?

Normal rate, no skips, or extra beats, treat other symptoms

How do you treat Sinus Tachycardia?

"Sinus rhythm > 100
Treat with Oxygen"

How do you treat Sinus bradycardia?

"Sinus rhythm <60
Treat with Atropine, Oxygen"

How do you treat PVC's?

"Premature ventricular contractions (PVC)
Absent of P wave
Treat with Oxygen, Lidocaine, Suctioning"

How do you treat V tach?

"Ventricular tachycardia
Ventricular rhythm with rate>100
Treat with Defibrillate (If No Pulse)
Lidocaine and Cardiovert (If Pulse Present)
Oxygen"

How do you treat V-fib?

"Ventricular fibrillation, completely irregular ventricular rhythm
Treat-Defibrillate"

How do you treat Multifocal PVC's?

"Premature ventricular contractions
No P wave , Large QRS
Treat with Oxygen, Lidocaine (this reduces the irritibility of heart)"

How do you treat Asystole?

Confirm in 2 leads first, then Epinephrine, Atropine , 100% Oxygen and CPR

What does the axis of an ECG measure?

Axis measures the direction of all the electricity through the heart during contraction

What do you assess for a perinatal history?

Mother's History: History of pregnancy, age, smoking and substance abuse, nutrition, infecton , previous pregnancies/outcomes. Hypertension, toxemia diabetes ( diabetes prone to have problems with premature babies)

What is the gestation Age of infant?

"Time since the estimated date of conception.
Term-38 to 42 weeks
Preterm(premature) less than 38 wks
Post- more than 42 wks"

What are the five factors for evaluating infant and when are they done?

"APGAR routinely done at 1 and 5 minutes
A isAppearance (Color) Good is 2 completely pink Bad is 1 Body pink , extremities blue, Real Bad is 0 blue all over, pale
Pulse Good(2) is >100 minute
Bad(1) is <100 minute
Real Bad (0) is absent no pulse
Grimace(Reflex irritability) Good(2) cough or sneeze
Bad(1) grimace
Real Bad(0) No response
Activity Good(2) Active motion
Bad(1) some flexion of extremities
Real Bad (0) Limp No movement
Respiratory effort Good(2) Regular, strong cry
Bad(1) slow, irregular weak cry
Real bad(0) Absent no cry"

What action do you take based on APGAR score?

"0-3 RESUSCITATE
4-6 SUPPORT stimulate, warm , administer O2
7-10 MONITOR routine care"

What is a transillumination?

"Bright fiberoptic light placed against the infant's chest in a darkened room
Normally a lighted halo is seen around the point of contact
A Pneumothorax or pneumomediastinum will cause the entire hemithorax to light up"

What are the vital signs of an infant?

"Normal pulse rate 110-160bpm
Respirations normal 30-60breaths per minute(higher in preterm babies)
Blood Pressure Normal term Infant 60/40mmHg
Preterm 50/30 mmHg
Birth Weight Normal Term>3000gm 3kg
28wks 1000gm"

What are some signs of Respiratory Distress in Infants?

"Cyanosis bluish all over
Acrocyanosis is bluish extremities not true cyanosis
Retractions intercostal sucostal substernal or supraclavicular retractions
Nasal Flaring dilation of nasal openings (breathing through nose)
Capillary refill How long it takes for normal color to return -longer than 3 seconds may indicate a decreased cardiac output"

What are some methods of measuring gestional age?

Dubowitz Method and New Ballard Score

What are pre and post ductal blood gas studies and what do they mean/

If the pre-ductal (right radial artery Pao2 is 15 mmHg highter than the post-ductal (umbilical artery) PaO2 , then the patient has a paten ductus arteriosus with a right to left shunt. Needs a Echocardiogram

What are the normal Blood glucose levels in infants?

"Hypoglycemia
Term infants >30 mg/dL
Preterm > 20 mg/dL"

What is L/S ratio and what does it mean?

"Lecithin/sphingomyelin , a ratio
of 2:1 or highter is good. It measures lung maturity.
A ratio less than 2:1 indicates high risk of hyaline membrane disease (HMD) or Infant respiratory distress syndrome (IDS) approaches zero"

What is PG?

Most reliable indicator of pulmonary maturity even with diabetes. Phosphatidylglycerol

What is capnography and what is the normal range?

Measuring exhaled carbon dioxide content using infrared absorption. ETCO2 normal value is 3-5%

What does an increase in Capnograph (PECO2 or PetCO2% ) indicate?

"An increase indicates a decrease in ventilation (ventilatory failure)
Increase Tidal Volume"

What does an decrease in the capnograph indicate?

Decrease indicates an increase in ventilation or decreased perfusion (deadspace disease: pulmonary embolism, hypovolemia

What does low PetCO2 reading immediately following intubation indicate?

"ET tube is in the esophagus
If patient already on ventilator and you get low or 0 reading then reconnect patient to ventilator"

What does the PetCO2 do during CPR?

The PetCO2 should increase during CPR

What are the examples of color change for PCO2?

"Purple=poor
Yellow=normal
False readings may occur in patients who have been without CPR for a period of time"

What is a non-invasive method of monitoring oxygen saturation?

Pulse oximetry measures SaO2 or SpO2 and pulse

What effects accuracy of pulse ox?

Perfusion, shock and hypotension, conditions that interfere with the light transmission, fingernail polish bright ambient lights, erytherma (redness of skin due to capillary dialation)

What will make a pulse ox measure higher?

Carbon Monoxide poisoning

What accurately measures COHb?

"Co-oximeter/hemoximeter
Used to diagnose carbon monoxide poisoning.>20% COHb"

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