Diagnostic & Therapy Principles Test 1
List some things you should ask during a patient interview.
- CC (Chief complaint- What brought them into the hospital?)
- Past Medical History
- Medications they are taking
- Living environment
- Nutritional assessment
What can a nonproductive cough be caused by?
- Irritation of the airways
- Acute inflammation of mucosal membrane
- Presence of growth
- Irritation of pleura
Describe what causes different sputum colors and what they mean.
1. White and clear
4. Green and foul smelling
2. Indicates infection and contains WBC's
3. Retained secretions; infection
4. Pseudomonas Aeruginosa
5. Old Blood
6. Fresh blood
What causes hemoptysis (blood in the sputum)?
Pneumonia, TB, bronchiectasis, Lung abscess, Fungal lung infection. Lung cancer, Pulm. embolism, Valvular heart disease, Mitral valve stenosis, GI tract.
What is important to report when cough is productive?
It's important to report the amount, consistency, smell, and color.
What must you do if there is a change in sputum condition?
Send a sample of it to lab for a culture and sensitivity test.
Characteristics of a Cough
- Bark like cough?
- Harsh, dry cough with inspiratory stridor?
- What is wheezing associated with?
- Chronic productive cough?
- Frequent hacking cough?
- Post extubation, Allergy Attack
- Asthma, Pneumonia
- Chronic bronchitis, Emphysema
- Regular Cold, Virus
What are some causes of chest pain?
Pleurisy, Pulmonary Hypertension, Angina Pectoralis, Ruptured aorta.
What would you do if a patient was experiencing severe chest pain?
I would put the patient on 2-4L of oxygen. Then perform an EKG to assess the problem.
What are some causes of Dyspnea (difficulty breathing.0
Increased RAW, upper airway obstruction (choking), Asthma, Decrease in lung compliance, Pulm. Fibrosis, Pneumothorax, Pleural effusion (fluid in the pleural spaces.), Anxiety. Abnormal Chest Wall. (ex. spina bifida.)
Describe Kussmaul, Biots and Cheyne-Stokes breathing.
- Kussmaul is mostly seen in diabetics, it is hyperventilation caused by ketoacidosis.
- Biots is short burst of uniformed, deep respirations, followed by 10-30 seconds of apnea.
- Cheyne is slow shallow breaths that gradually increase then decrease into a 10-30 second period of apnea
What can unequal expansion of the chest indicate?
It can indicated:
- Chest deformaties
- Flail chest (caused by fractured ribs)
Barrel Chest. Can be caused by hyperinflation and can be seen in lung disease patients/
Kyphosis. Seen mostly in the elderly.
Lordosis. Seen in pregnant women / obese pts.
Kyphoscoliosis. Both conditions in the same pt.
Scoliosis. Can be caused by bad posture / deformity.
Pectus carinatum. Outward chest.
Pectus excavatum. Inward chest.
Digital Clubbing. Caused by chronic hypoxia.
When is it considered bad?
When it is at least 5 g/dl decrease in oxygenated Hb.
It is defined as the palpation of vibrations of the chest wall as a patient speaks. By pressing the bony part of the palm against the chest wall.
Describe Vocal Fremitus.
Technique in which you have the patient repeat '99' in order to feel the vibrations in the chest.
Percussion of the chest. (sounds + meaning)
- Hyperresonance sound
1. Loud, low pitch, air in the space. Can be caused by emphysema. (similar to the sound when percussing over the stomach.
2. Normal lung sound, low pitch.
3. Medium intensity and pitch. Could be caused by atelectasis, consolidation, pleural thickening, pulmonary edema.
4. Low pitch = massive pleural effusion, massive atelectasis, penumonectomy.
5. Drum-like sound = Tension ptx
Ascultation of Breath Sounds.
1. Vesicular sounds are heard over most lung fields, they have a low pitch with soft and short expirations
2. bronchial sounds are heard only over the trachea, high pitch, loud and long expiration
3. bronchovesicular sounds heard over the main bronchus area and upper right posterior lung field.
Abnormal breath sounds.
- Pleural friction
1. Heard at the end of inspiration due to fluid/secretion accumulating in the lower lung bases. (ex. CHF)
2. Heard on expiration in asthma patients.
3. Caused by post extubation or croup in children.
4. When the visceral and pleura rub against each other.
5. Deeper, rumbling sounds on expiration. Caused by air passing through an airway partially obstructed by thick secretions, bronchoconstriction, tumor.
*https://www.youtube.com/watch?v=MzTcy6M3poM * abnormal breath sounds.
CT scan. Can assess bony abnormalities, soft tissue abnormalities, pleural abnormalities, interstitial lung diseases, PE, aortic dissection.
what is the disadvantage of this CXR.
MRI. can assess soft tissue abnormality, bone marrow pathophysiology, pleural disease, diaphragmatic disease, congenital heart disease.
Disadvantages: limited pt monitoring, motion artifact caused by resp and cardiac motion, contraindicated with pt with pacemakers, most ventilators can not be used due to the strength of some MRI magnents
Detects pathologic processes, esp tumors of the thorax. It can distinguish between a benign and malignant thoracic tumors that can't be detected with a CT scan.
Assessing the pulse.
What is the normal pulse rate for an adult, child and newborn.
Adult: 60-100 BPM
child: 90-120 BPM
Newborn: 90-170 BPM
Describe Paradoxical Pulse and Pulses Alternans.
Paradoxical Pulse: an exaggeration of the normal variation in the pulse during respiration, in which the pulse becomes weaker as one inhales (The drop is more than 10 mmHg) and stronger as one exhales
Pulses Alternans: Alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis.
Assessing the Blood Pressure.
What is the normal BP range in adults, children and newborns.
Adults: 100/60 - 140/90
children: 95/60 - 110/65
newborns: 60/30 - 90/60
Assessing the Body Temperature.
What is the normal body tempt. range for adults and children.
adults: 98.6 (37 C)
children: Slightly Higher.
Assessing Lab Tests.
What is the normal range for Na.
What a higher than normal and lower than normal range called?
>145 : Hypernatremia
Assessing Lab Tests.
What is the normal range for K.
What is a higher than normal and lower than normal range called?
>5.0 : Hyperkalemia
<3.5 : Hypokalemia
Assessing Lab Tests.
What is the normal range for CL.
What is a higher than normal and lower than normal range called?
<95 : Hypochloremia
Assessing Lab Tests.
What are the normal ranges for:
- 4.25-5.25 mEq/L
- 7-20 mg/dl
- 70-105 mg/dl
- 15.5-18.0 g/dl
Acid Base Balance:
What are the normal ranges for.
Where does the control of breathing originate from? What are the 2 regulatory mechanisms for breathing?
The control of breathing originates from the Central Nervous System.
The two regulatory mechanisms are involuntary and voluntary control.
What regulates breathing?
The medulla oblongata and the pons (located above the medulla)
What is the role of the medulla oblongata?
It contains the respiratory control center which controls the normal, rhythmic pattern of breathing. It receives impulses from the cerebral cortex, pons, upper airway reflexes, phrenic nerve, peripheral and central chemoreceptors.
What is the role of afferent and efferent impulses?
Afferent impulses are carried toward the medulla which are interpreted within the respiratory control center.
Efferent impulses are created within the CNS and sent to other areas of the body.
Describe the Dorsal Respiratory Group. (DRG)
It is located within the lateral walls within the medulla. It is the initial processing center for afferent impulses from the vagus and glossopharyngeal nerves. These afferent nerves modify the basic breathing pattern by stimulating inspiration. It is the place of origin for efferent impulses to phernic nerve, which stimulates diaphragmatic movement and to external intercostal motor nerves.
DRG is the primary controller of the depth and rate of inspiration.
Describe the Ventral Respiratory Group (VRG)
It is located in the medulla in two seperate nuclei, anterior and lateral to the DRG. Neurons are located in the nucleus ambiguous and nucleus retro-ambiguous.
What does the nucleus ambiguous contain?
It contains inspiratory neurons that send efferent impulses to innervate laryngeal and pharyngeal muscles.
What does the nucleus retro-ambiguous contain?
It contains both inspiratory neurons: which send efferent impulses to the diaphragm and external intercostal via phrenic and intercostal nerves
AND expiratory neurons: which send efferent impulses to the internal intercostal and abdominal muscles.
What 2 centers does the pons house?
It houses two centers that contain afferent respiratory neurons, the Pneumotaxic center (located above the pons) and the Apneutic center (located under the pons.)
What do inspiratory neurons do?
They send efferent impulses to the diaphragm and external intercostal muscles via the phrenic and intercostal nerves.
What do expiratory neurons do?
They send efferent impulses to the internal intercostal and abdominal muscles.
Describe the Pneumotaxic center and the types of signals it receives.
It receives afferent impulses from the vagus nerve that fine tunes the rhythmic breathing pattern and blocks the stimulation of the DRG and the VRG from the apneustic centers.
- A strong signal from impulses results in a shorter inspiratory time and faster respiratory rate, resulting in a lower tidal volume.
- A weak signal results in a longer inspiratory time and slower respiratory rate, resulting in a higher tidal volume.
If this center is destroyed, the apneustic takes over !*
Describe the apneustic center?
Stimulates the inspiratory neurons of the DRG and VRG.
What happens if the pneumotaxic center is destroyed?
The afferent impulses prevents the inspiratory ramp signal from shutting off. Resulting in Apneustic breathing pattern.
What are some causes of Apneustic breathing pattern?
Cerebral Edema, and meds that cause CNS depression.
What happens if both the Pneumotaxic and Apneustic centers are destroyed?
The respiratory is the rapid and irregular.
Define Hering-Breur reflex.
Are located in the walls of the bronchi and the bronchioles. These receptors are stimulated when the lung inflates and the trans-pulmonary pressure rises, the receptors send an afferent impulse to the DRG to stop inhalation.
Define deflation reflex.
Is mediated by the vagus nerve. The vagus nerve carries the afferent impulse to the DRG in the medulla oblongata. This reflex causes the respiratory rate to increase during the time of lung collapse. For example when a patient suffers a pneumothorax, the tidal volume drops significantly. (hyperpnea)
Define Juxtacapillary receptors.
(Also called C-fibers) are located in the lung parenchyma near the capillary walls. Because they are located near the capillary wall, they are stimulated by conditions that affect the capillaries such as alveolar inflammation, pulmonary vascular congestion and edema.
This stimulation may result in rapid shallow breathing, dyspnea, expiratory narrowing of the glottis, and bradycardia.
Define Head paradoxical reflexes.
When the lung is over-inflated, the stimulus allows the lungs to continue to inflate and does not stop the inflation. This may help maintain an increased tidal volume during exercise. This reflex is responsible for the babys first breath during delivery.
Define Peripheral Prioreceptors.
Touch activates breathing. Such as when neonates experience periods are apnea and are stimulated to breathe by touching their feet. When these receptors are stimulated , afferent impulses to the medulla cause an increase in respiratory activity called hyperpnea.
When does breathing occur?
Breathing occurs when there is a change in intrapulmonary pressures. The phrenic nerve and diaphragm send signals.
Describe Peripheral Chemoreceptors?
Are stimulated by the amount of dissolved O2. When O2 is not enough they are stimulated to increase ventilation.
What happens when the PaO2<60?
The peripheral chemo receptors send afferent impulses to the DRG to increase ventilation.
What happens when the PaO2<30 mmHg
At this point it wont stimulate an increase in ventilation which means it is fatal.
Describe Central chemoreceptors.
The most powerful stimulus known to influence the medulla respiratory centers. They are responsible for monitoring the H+ in the CSF. They regulate ventilation through indirect effects of CO2 and pH in the CSF.
Describe Acute Mountain sickness.
It occurs at altitudes >8202ft and can cause a headache which is the cardinal sign. It can be treated with rapid descent, analgesics, antiemetics.
Describe Hypoxic Drive.
Seen in COPD. Patients are CO2 retainers. lack of PaO2 becomes their stimulus to breathe and increase RR. However, an increase in PaO2 can cause the O2 chemo receptors to decrease RR.
What are the goals of oxygen therapy?
- To correct hypoxemia. (PaO2, SaO2, SpO2)
- Decrease symptoms associated with acute/chronic hypoxemia : SOB, Mental Function.
- Decrease the workload that hypoxemia places on the heart.
Adult, children, infants >28 weeks gestation:
>___________ mmHg; SaO2 >______%
PaO2<_______mmHg ; SaO2 < _______%
Precautions and complications
What does a PaO2 >60 mmHg causes?
What does an FiO2 >50 cause?
What does a PaO2 >80 in premature babies cause?
Atelectasis, O2 toxicity, ciliary depression
What is central cyanosis?
Central relates to the gums and nail beds which turn white!
Peripheral refers to the outer extremities, blue/white hands and feet
What does O2 toxicity cause?
- It damages the capillary endothelium
- Causes interstitial edema, thickening the alveolar capillary membrane
- Type 1 & 2 cells are destroyed, killing off surfactant, lungs then get stiff
- Alveolar fluid builds up causing low ventilation and perfusioin
- Pulmonary Fibrosis and Hypertension develops
- Overproduction of O2 free radicals (Vitamin E, C, Beta carotene fight against them)
Describe absorption Atelectasis.
FiO2 >50% causes high concentration of O2 to deplete the nitrogen in the lungs which causes the lungs to collapse.
Human eyes can't see particles less than _________.
50 - 100 micro meters in diameter.
Particles are measures in two ways, _____________ and _______.
MMAD and VMD.