FULL EXAM REVIEW CRT/RRT (NBRC) 100% Correct Questions and Answers Ascites - accumulation of fluid in the abdomen caused by LIVER FAILURE Venous distention - -occurs with CHF -seen with obstructi... ve patients (seen in exhalation phase) Capillary refill - -indication of peripheral circulation -Normal < 3 seconds Jaundice skin color - -increase in bilirubin. -mostly in face and trunk Bradypnea (oligopnea) - -decreased respiratory rate (<12bpm) variable depth and irregular rhythm Hyperpnea - -increased rate, depth, with regular rhythm Cheyne-Stokes - -gradually increasing then decreasing rate and depth in a cycle lasting from 30 - 180 secs, with apnea up to 60 secs -increased ICP, meningitis, overdose Biots - -increased rate and depth with irregular periods of apnea -CNS problem, head/brain injury Kussmaul's - -increased rate, depth, irregular rhythm, breathing sounds labored -Raspy voice Apneustic - prolonged gasping inspiration followed by extremely short, insufficient expiration -respiratory center problems, trauma, tumor cachectic - muscle atrophy/loss of muscle tone retractions - -chest moves inward during inspiratory efforts instead of outward -blocked airway in adults = INTUBATE -RDS in infants Character of cough - -dry, non-productive cough may indicate tumor in the lungs or asthma -productive cough may indicate infection evidence of difficult airway - -short receding mandible (chin) -enlarged tongue (macroglossia) -bull neck -limited neck range-of-motion pulsus paradoxus - -pulse/blood pressure varies with respiration. may indicate severe air trapping (status asthmaticus or cardiac tamponade) tactile fremitus - -vibrations felt by hand on chest wall -vocal fremitus: voice vibrations on the chest wall -pleural rub fremitus: grating sensation due to roughened pleural spaces -Rhonchial fremitus(palpable rhonchi): secretions in airways Crepitus - -bubbles of air under skin that can be palpated and indicates subcutaneous emphysema Resonant percussion - -hollow sound -normal lungs Flat percussion - -heard over sternum, muscles, or areas of atelectasis Dull percussion - -heard over fluid-filled organs such as heart or liver (thudding) -pleural effusion or pneumonia Tympanic percussion - -heard over air-filled stomach. -drum-like sound and when heard over lung = increased volume Hyperresonant - -found where pneumothorax or emphysema is present. -booming sound vesicular breath sounds - normal sounds in lungs bronchial breath sounds - -normal sounds over airways. -breath sounds over lungs indicate LUNG CONSOLIDATION Egophony - -patient instructed to say E and sounds like A. -lung consolidation Bronchophony / whisphered pectoriloquy - -increased intensity or transmission of the spoken voice and indicate CONSOLIDATION or PNEUMONIA -increase in spoken voice = consolidation -decrease in spoken voice = obstructon, pneumo, emphysema Rales - -crackles -secretions/fluid Coarse rales - -rhonchi -LARGE airway secretions -needs suctioning medium rales - -middle airway secretions -needs CPT Fine rales - -fluid in alveoli -CHF, pulmonary edema -IPPB, heart drugs, diuretics and O2 Wheeze - -due to bronchospasm -bronchodilator Tx -unilateral wheeze indicative of a foreign body obstruction stridor - -upper airway obstruction -supraglottic swelling (epiglottitis) (thumb sign) -subglottic swelling (croup, postextubation) (steeple sign) -foreign body aspiration -Racemic epinephrine -intubation if MARKED stridor -Lateral neck Xray for confirmation Pleural friction rub - -coarse grating or crunching sound -visceral and parietal pleura rubbing together -associated with TB, pneumonia, pulmonary infarction, cancer -steroids and antibiotics Heart Sound S₁ - -closure of the mitral and tricuspid valves at the beginning of ventricular contraction Heart Sound S₂ - -closure of pulmonic and aortic valves -occurs when systole ends; ventricles relax Heart Sound S₃ - -abnormal and may suggest CHF Heart Sound S₄ - -abnormal and indicative of cardiac abnormality such as myocardial infarction or cardiomegaly Heart murmurs - -sounds caused by turbulent blood flow -heart valve defects or congenital heart abnormalities -can occur when blood is pushed through an abnormal opening (ASD, PDA) Bruits - -sounds made in an artery or vein when blood flow becomes turbulent or flows at an abnormal speed. -usually heard via stethoscope over the identified vessel (carotid artery) Blood pressure - -systolic and diastolic pressures -sphygmomanometer to measure cuff pressures -↑BP = cardiac stress = hypoxemia -↓BP = poor perfusion = hypovolemia, CHF Costophrenic Angle - -angle made by the outer curve of the diaphragm and the chest wall -obliterated by pleural effusions and pneumonia Diaphragm - -dome shaped normally -flattened with COPD -hemidiaphragms may shift downward with pneumothorax -right hemidiaphragm is level of 6th anterior rib and slightly higher than the left -right lung: 55% and appear larger than left lung Lateral decubitus CXR - -patient lying on affected side -detecting small pleural effusions End expiratory film - -taken when patient is at end-exhalation -detecting small pneumothorax/foreign body aspiration (FBA) Position of ET/Tracheostomy tube - -tip should be positioned below the vocal chords and no closer than 2 cm or 1 inch above the carina. -approx same level of the aortic knob/arch -observation and auscultation will quickly determine adequate ventilation before CXR is taken -cuff should not extend over the end of the ET or tracheostomy tube Pacemaker, catheters, Etc. - -pacemaker should be positioned in the right ventricle -PAC should appear in right lower lung field -central venous catheters are placed in the right or left subclavian or jugular vein and should rest in the vena cava or right atrium -chest tubes should be located in the pleural space surrounding the lung -NG tubes should be in stomach 2-5 cm below the diaphragm Croup (laryngotracheobronchitis) - -viral disorder -narrowing subglottic swelling -steeple/picket fence/pencil sign -gradual onset -infants -Mist tent, O2, Racemic epi, corticosteroids -barking cough Epiglottitis - -bacterial infection -supraglottic swelling with an enlraged and flattened epiglottis and swollen aryepiglottic folds -Thumb sign -Rapid onset -pediatrics -provide airway and antibiotics Computerized Tomography (CT scan) - -X-ray through a specific plane and appear as slices of organs/body parts -diagnosis of bronchiectasis -spiral CT scan w/ contrast dye for PE Magnetic Resonance Imaging (MRI) - -2D view without use of radiation -used for determining thoracic aneurysms, congenital abnormalities of the aorta and major thoracic vessels esp. the hilar area -able to locate precise position of tumors V/Q scan - Ventilation scan -Radioisotope (xenon) gas is inhaled -and obstruction to airflow will allow little gas to enter Perfusion scan -albumin, tagged with radioactive iodine is injected into a peripheral vein and lodges in the pulmonary capillaries -scanned over chest and shows distribution and volume of perfusion Ventilation with no perfusion = PE (deadspace disease) Barium swallow (esophagram) - -for diagnosing of abnormalities in the hypopharynx, esophagus, or stomach -ingested and traced through the hypopharynx and into the esophagus via fluoroscope and xray at the end -suspected esophageal malignancy, dysphagia, congenital defect in hypopharync, esophagus, gastric reflux, esophageal varices. Positron Emission Tomography (PET scan) - -for determining cancer, brain disorders and heart disease -injected with radioactive substance bronchography (bronchogram) - -injection of radio-opaque contrast into tracheobronchial tree -study of OBSTRUCTING LESIONS (tumors) and BRONCHIECTASIS -better administration of postural drainage Electroencephalography (EEG) - -measures electrical activity in the brain -brain tumors, traumatic brain injuries, retardation, loss of brain function, epilepsy/seizures, -EVALUATION OF SLEEP DISORDERS Pulmonary Angiography - -most definitive for DX of pulmonary embolism -pressures in cardiac chambers can be measured -inserted into the femoral vein and advanced through the right heart and into the pulmonary artery which could identify filling defects ultrasonography of the heart (Echocardiogram) - -noninvasive for monitoring cardiac performance -doppler color flow mapping with 2D and M-Mode achocardiography to assess overall ventricular function including LEFT VENTRICULAR VOLUME and EJECTION FRACTION -Valvular disease or dysfunction -myocardial disease -abnormalities of cardiac blood flow -cardiac anomalies in the infant -abnormal heart sounds ICP monitoring - -track the dynamics inside the skull such as volume-pressure relationships, pressure waves, and cerebral perfusion pressures -ICP > 20 mm Hg = hyperventilated until PaCO2 is 25-30 mmHg CAUSES -Intracranial tumors -Abscesses -Meningitis -Cerebral Edema -Subdural Hematoma 3 types of ICP monitoring - -Ventricular Catheter: inserted through a burr hole (surgical opening into the skull -Subarachnoid bolt: metal screw with sensor chip that is inserted through a hole drilled into the subdural or subarachnoid space -Epidural Sensor: consists of placement of a fiberoptic sensor, radio transmitter, or tiny balloon in the epidural space through a burr hole in the skull Cerebral Perfusion Pressure (CPP) - -Pressure gradient that determines cerebral perfusion -CPP = MAP - ICP -Normal Value 70 - 90 mmHg Exhaled Nitric Oxide (NIOX) Testing - -Measurement of nitric oxide concentration (FENO) in patient's exhaled breath -used to monitor asthma patient's response to anti-inflammatory (corticosteroid) treatment -decrease in FENO suggests a decrease in airway inflammation Sputum colors - Clear = normal Mucoid = white/gray, chronic bronchitis Yellow = presence of WBC, bacterial infection Green = stagnant sputum, gram neg bacteria (Bronchiectasis, pseudomonas Brown/dark = old blood Bright red = hemoptysis (bleeding tumor, TB) Pink frothy = pulmonary edema Sputum tests - sputum culture = identify bacteria present (days) Sensitivity = identify what antibiotics will kill bacteria Gram Stain = whether Gram positive or negative (5mins) Acid Fast Stain = identify mycobacterium tuberculosis can be done on blood, urine, and pleural samples. collect samples prior to mouthcare, meals, and treatments Oscilloscope - -provides a continous visual image of the electrical activity of the heart on a screen -displays rapid changes in voltage as a moving line on a phosphorescent screen Four Critical Life Functions - -Ventilation -Oxygenation -Circulation -Perfusion Signs - -Objective information -things that can be seen or measured Symptoms - -subjective information -things that the patient must tell you Respiratory care orders - -type of treatment -frequency -medication dosage and dilution -physician signature CALL MD IF MISSING CVP abnormalities - -decreased CVP = hypovolemia -increased CVP = hypervolemia Katz ADL - -Activities of Daily Living: Bathing, eating, dressing, toilet, transferring, urine and bowel continence -patient is unable to perform or needs assistance = score of ZERO -patient needs no direction or assistance = score of ONE -6 = independent -4 = impairment -2 = severe impairment General malaise - -run down feeling, nausea, weakness, fatigue, headache -ELECTROLYTE IMBALANCE Diagnosis of Pulmonary Embolism (PE) - -Pulmonary Angiography -V/Q Scan -Spiral CT Scan Chest ECG electrodes - -V1 = 4th intercostal space on right side of sternum -V2 = 4th intercostal space on left side of sternum -V3 = between V2 and V4 on left side -V4 = 5th intercostal space, left mid-clavicular line -V5 = between V4 and V6 on left side -V6 = 5th intercostal space, left mid-axillary line Estimating heart rate on ECG - -two R waves between 3-5 large boxes = normal -two R waves closer and 3 large boxes = tachycardia -two R waves wider than 5 large boxes = bradycardia Sinus Bradycardia - Rate less than 60 Treat with Oxygen/Atropine Multifocal PVC - Premature Ventricular Contraction (PVCs) - Ventricular Tachycardia (V-Tach) - Ventricular Fibrillation (V-Fib) - Asystole - 1st Degree AV Block - 2nd Degree AV Block - 3rd Degree AV Block - Ischemia - -reduced blood flow to tissue -indicated by a depressed or inverted T-WAVE Injury - -indicated by an elevated ST segment Infarction - -diagnosed by significant Q waves APGAR Score - -1 minute will determine neonatal survival -5 minute predicts future neurological outcome -0-3 resuscitate -4-6 Stimuiate (stimulate, warm, O2) -7-10 Monitor (Routine care) Transillumination - -Normally a small lighted halo around point of contact -a pneumothorax or pneumomediastinum will cause the entire hemithorax to light up (LARGE HALO) Dubowitz Method - -assessment of gestation age - >40 = post term (meconium) - <40 = pre term (IRDS) New Ballard Score (NBS) - -modification of dubowitz -score of 40 = 40 weeks Pre and post ductal blood gas - -R to L shunt across ductus arteriousus, PaO2 from preductal(right arm) often exceeds PaO2 from post-ductal(umbilical or legs) -pre ductal is 15 torr higher than post ductal = PDA w/ R to L shunt -echocardiogram recommended Capnography - -PaCO2 = 40 torr/PetCO2 = 30 torr -increase in PECO = decreased ventilation (vent failure) -decrease in PECO = increase in ventilation (PE, hypovolemia) -low petco2 after intubation = esophagus -during CPR, PETCO would increase Transcuataneous Monitoring - PO2 and PCO2 measurement -heat to 43-45 °C -correlates well with arterial values as long as perfusion is adequate Pressure Transducer - -if transducer is above the catheter, readings are LOWER -if transducer is below the catheter, readings are HIGHER Hemodynamics - Swan-Ganz Catheter - -When the balloon is inflated, the catheter will WEDGE and the back pressure from the pulmonary capillary will be measured -measuring PAP = balloon deflated -double spike (dicrotic notch) is normal for PAP -Pressure Dampening = obstructed catheter (blood clot, bubble, kink) -if a blood clot occurs: ASPIRATE-FLUSH-ROTATE catheter Oropharyngeal Airway - -UNCONSCIOUS PATIENT -supports base of tongue -Bite block -facilitate oral suctioning -should be left unsecured -gagging: remove-suction-oxygen Nasopharygeal Airway - -CONSCIOUS PATIENT -supports base of tongue -facilitate deep tracheal suctioning -decrease trauma during NT suctioning -increased airway resistance (USE LARGEST SIZE) -inserted anatomically shaped with lubricant NARCAN - -Narcan - Narcotic overdose -Atropine - Bradycardia -Valium/Versed - Sedatio [Show More]
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