Kettering National Seminars Comprehensive Review: Therapeutic Procedures C

Kettering National Seminars Comprehensive Review: Therapeutic Procedures C Ventilation - ANS moving air in and out of the lungs Oxygen - ANS getting oxygen into the blood Circulation - ANS moving the blood through the body Perfusion - ANS getting oxygen into the tissue 4 Life functions - ANS Ventilation, oxygenation, circulation, perfusion Ventilation ( vital signs) - ANS chest movement, breath sounds, vt, resp. rate PaCo2, ETCO2 Oxygenation ( vital signs) - ANS color, sensorium, heart rate, Pao2, Spo2 ( on vent Fio2 & I- Time. circulation (vital signs) - ANS heart rate, strength ( pulse), cardiac output perfusion - ANS blood pressure, sensorium, temperature, urine output, hemodynamics Life functions (priority): when you have an emergency - ANS 1. ventilation 2. oxygenation (most common problem) 3. circulation 4. perfusion Admission notes - ANS admitting diagnosis, history of present illness, chief complaint, past medical history, current medications signs - ANS objective information: those things that you can see or measure ( , pulse, edema, bp, ect.) Symptoms - ANS subjective information: those things that the pt must tell you ( ea, pain, muscle weakness, ect.) physical examination - ANS Inspection,Palpation, Percussion, Auscultation Tobacco use - ANS packs smoke x years smoke= yrs of smoking ( ex. 4pks day x 10yrs= 40 pk yrs) Do Not Resuscitate order (DNR) - ANS Pt does not wish to have cardiopulmonary resuscitation performed. Do Not Intubate order (DNI) - ANS Pt does not wish to be intubated. Non-invasive ventilation can be administered. Respiratory care orders - ANS type of treatment,frequency, med. dosage & route of administration, physician signature Patients progress notes - ANS respiratory notes, nurses notes, admission notes, physician notes, maternal history/neonatal data Patient laboratory reports - ANS ABG analysis, pulmonary function testing, imagining reports ( x-rays, CT, MRI, PET, ect., basic lab assessments (CBC etc.) normal urine output - ANS 40 mL/hr (approximately 1 Liter/day) sensible water loss - ANS urine, vomiting insensible water loss - ANS lungs & skin If intake exceeds output, this could result in - ANS weight gain, electrolyte imbalance, increased hemodynamic pressures, decreased lung compliance normal CVP - ANS 2-6 mmHg decreased CVP ( 2mm Hg) - ANS hypovolemia ( give fluids) increased CVP (6 mmHg) - ANS hypervolemia (give diuretic ex. furosomide) alert & responsive - ANS level of consciousness: normal lethargic, somnolent, sleepy - ANS consider sleep apnea or excessive O2 therapy in pt's with COPD stuporous, confused - ANS responds inappropriately, drug overdose, intoxication semicomatose - ANS responds to painful stimuli with abnormal flexion or extension Obtunded - ANS drowsy state, may have decreased cough or gag reflex coma - ANS does not respond to painful stimuli anxiety, nervousness - ANS watching every movement, resp distress, hypoxemia depressed - ANS quiet or denial anger, combative, irritable - ANS electrolyte imbalance euphoria - ANS consider:drug overdose panic - ANS severe hypoxemia, tension pneumothorax, status asthmaticus Activity of Daily Living (ADL): Katz scoring system - ANS basic tasks of everyday life( bathing, eating, dressing, toilet use, transferring, urine & bowel continence) Orthopnea - ANS (difficulty breathing when lying down) may be associated with CHF) General malaise - ANS feeling run down, nausea, weakness, fatigue, headache ( electrolyte imbalance) Dyspnea - ANS a feeling of shortness of breath or difficulty breathing pain - ANS location, quality ( what kind is it?), severity (1-10), aggravating factor, relieving factors, history (when it started & how do it progress), context ( what circumstances did it occur?), accompanying symptoms symptoms of the nose & throat - ANS 1. Excessive nasal secretions from irritants, pollutants, allergies, upper resp. infections. 2. Itching or burning sensations of the nose or throat. 3. Dysphagia ( difficulty swallowing) and hoarseness are also common symptoms. Respiratory care plan - ANS case management plans, therapy protocols, disease management, patient & family education needs social support system - ANS family, friends, social services, etc. physical environment - ANS ramps, doorways, stairs, electrical wiring, etc. environmental exposures - ANS asthma triggers, heating/ cooling systems, work related ( occupational hazards), second hand smoke nutritional status - ANS usual food intake, food likes/dislikes, appetite, note any recent weight loss/gain, ( carbs=increase CO2 for COPD pt's) Patients /family history - ANS history of present illness, past medical history, family history, social history General appearance (Assessment of inspection) - ANS age, height, weight, nourishment, etc. Peripheral edema - ANS presence of excessive fluid in the tissue known as pitting edema ( arms & ankles), caused by CHF & renal failure. CHF pt's typically leans forward (orthopnea). Rate =+1, +2,+3, higher the number the greater the swelling, recommend diuretics and keep CVP between 2-6 mm Hg. Ascities - ANS accumulation of fluid in the abdomen generally caused by liver failure Clubbing of fingers - ANS Caused by chronic hypoxia, indicating a lack of oxygen. Presence of this is suggestive of pulmonary disease. The thumb,first fingers are affected. The toes can be affected as well. venous distention - ANS increased venous distention, jugular venous distention (JVD), occurs with CHF, Orthopnea breathing patterns seen during exhalation in pt's with obstructive lung diseases. capillary refill - ANS Indication of peripheral circulation; Blanching of one hand and watching the blood return within 3 secs. Longer than 3 secs indicates a decrease cardiac output (Modified Allen's Test) Diaphoresis - ANS A profuse/heavy state of sweating: *Tuberculosis/ night sweats: Recommend: antitubular drugs. * CHF: Recommend: diuretics, positive inotropic agents. *Fever, infection: Recommend: antibiotics * Anxiety, nervousness: Recommend: sedatives Normal skin color - ANS pink, tan, brown, black Abnormal skin color - ANS decrease color( ashen, pailor), due to anemia or acute blood loss (vasoconstriction will cause color change by reducing blood flow) jaundice - ANS increased bilirubin level in blood tissue. ( face & trunk) Erythema - ANS redness of the skin. may be due to capillary congestion, inflammation or infection cyanosis - ANS blue or gray ( dusky) discoloration of skin and mucous membranes. Caused by hypoxia from increased amount of reduced 5g of hemoglobin. In infants *Acrocyanosis is not true cyanosis, so be sure to check mucous membranes of the mouth, tongue, and nail beds*. chest configuration - ANS normal A-P diameter. Straight spine, no alterations in chest size. Pectus carinatum - ANS Anterior protrusion of the sternum Pectus Excavatum - ANS depression of part or all of the sternum kyphosis - ANS convex curvature of the spine ( lean forward) hunchback scolosis - ANS lateral curvature of the spine ( leans side to side) Kyphoscoliosis - ANS combination of kyphosis and scoliosis, which may produce a severe restrictive lung defect as a result of poor lung expansion/volume barrel chest - ANS Result of air trapping in the lungs for a long period of time. Generally due to COPD. Increase in A-P diameter ( air-trapping) symmetrical - ANS chest movement occurs when both sides of the chest move an equal distance at the same time. asymmetrical - ANS unequal movement may indicate underlying pathology ( post lung resection, post- pneumonectomy, atlectasis, pneumothorax, flail chest- paradoxial chest movement, endotracheal tube inserted in right or left mainstem bronchi eupnea - ANS normal resp. rate, depth, rhythm tachypnea - ANS increased resp rate ( 20 bpm), caused by hypoxia, fever, pain , CNS problems bradypnea /( Oligopnea) - ANS decreased resp. rate ( 12 per min), variable depth and irregular rhythm. cause: drugs, alcohol, metabolic disorders apnea - ANS cessation of breathing, especially during sleep. hypernea - ANS increased resp. rate, increased depth, regular rhythm, caused metabolic disorder/ CNS disorders. cheyne stokes - ANS gradual increases and decreases rate and depth in a cycle lasting from 30-180 secs with periods of apnea lasting 60 secs. Cause: increased intracranial pressure, brainstem injury, drug overdose Biot's breathing - ANS increased resp. rate, and depth with irregular periods of apnea. Each breath has the same depth. Cause: CNS problem Kussmaul's breathing - ANS increased resp. rate ( 20 bpm) increased depth, irregular rhythm, breathing sounds labored. cause: metabolic acidosis, renal failure, diabetic ketoacidosis Apneustic breathing - ANS prolonged gasping inspiration followed by extremely short, insuffient expiration. cause: problem with resp. center, trauma or tumor hypertrophy - ANS ( increase in muscle size) of accessory muscles occurs with COPD Atrophy (cachexia) - ANS muscle wasting is loss of muscle tone and occurs in paralysis retractions - ANS intercostal, subcostal, substernal or supraclavicular retractions occurs when the chest moves inward during inspiratory efforts instead of outward. This is caused by a severe airway obstruction or respiratory distress nasal flaring - ANS Flaring of the nostrils during inspiration. A sign of respiratory distress in infants, who must breathe through their nose. ( character of cough) dry or non- productive cough - ANS may indicated a tumor in the lungs. ( character of cough) productive cough - ANS may indicate an infection or chronic lung disease evidence of difficult airway - ANS 1. short receding mandible 2. enlarged tongue (macroglossia) 3. bull neck 4. limited range-of-motion of the neck. pulse rate/heart rate - ANS normal: 60-100 tachycardia - ANS 100 indicates hypoxemia, anxiety, stress ( recommend oxygen) bradycardia - ANS 60 indicates heart failure, shock code/ emergency ( recommend atropine) Paradoxical pulse/pulsus paradoxus - ANS pulse/blood pressure varies with respiration. May indicate severe air trapping (status asthmaticus, tension pneumothorax, cardiac tamponade)-felt on exhalation trachea deviation: pulled to abnormal side (toward pathology) * inside the lungs* - ANS nary atelectasis 2. pulmonary fibrosis 3. pneumonectomy 4. diaphragmatic paralysis trachea deviation: pushed to normal side ( away from pathology) * outside the lungs* - ANS 1. massive pleural effusion 2. tension pneumothorax* 3. neck of thyroid tumors 4. large mediastinal mass tactile fremitus - ANS vibrations that are felt by the hand on the chest wall. vocal fremitus - ANS voice vibration on the chest wall Pleural rub fremitus - ANS A grating sensation felt on the chest wall due to roughened pleural surfaces rubbing together Rhonchal fremitus (palpable rhonchi) - ANS secretions in the airways ( feel secretions moving) Crepitus - ANS bubbles of air under the skin that can be palpated and indicates the presence of subcutaneous emphysema resonant - ANS normal air- filled lung. This gives a hollow sound. flat (less air) - ANS normally heard over the sternum, muscle, or areas of atelectasis. tympanic (more air) - ANS normally heard over air-filled stomach. This is a drum-like sound and indicates pneumothorax or emphysema may be present Hyperresonant ( more air) - ANS booming sound that can be heard in an area of the lung where either a pneumothorax or emphysema is present vesicular - ANS normal breath sounds bronchial breath sounds - ANS normal sounds heard over the trachea or bronchi. These breath sounds over the lung periphery would indicate lung consolidation egophony - ANS the pt is instructed to say"E" and it sounds like "A". This would indicate consolidation of the lung tissue as with a pneumonia-like condition. Bronchophony, whispered pectoriloquy - ANS increased intensity or transmission of the spoken voice and indicate consolidation & pneumothorax. adventitious - ANS abnormal breath sounds crackles/ rales - ANS Secretion/fluid coarse crackles ( rhonchi that clears with a cough) - ANS large airway secrections ( suction pt or instruct pt to cough) medium crackles - ANS middle airway secretions (recommend bronchial hygiene or CPT) Fine crackles (moist crepitant rales) - ANS alveoli, fluid ( associated with CHF/ pulmonary edema) recommend oxygen, positive pressure therapy, positive inotropic agents (Digoxin or Digitalis), diuretics wheeze - ANS Difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways. Most commonly caused by bronchospasms ( recommend bronchodilator).Uniliteral wheeze is indicative of foreign body ( recommend bronchoscopy) stridor - ANS high-pitched or crowing inspiratory sound caused by upper airway obstruction: 1. supraglottic swelling (epiglottitis) 2. subglottic swelling ( croup, post extubation 3. foreign body aspiration ( solids or fluids) specific treatment: 1. racemic epinephrine for swelling and edema. 2. suctioning and /or bronchoscopy secretions and foreign body aspiration. 3. intubation immediately for severe swelling and epiglottitis pleural friction rub - ANS -a coarse grating, raspy, or crunching sound - caused by inflamed surface of the visceral and parietal pleura rubbing together. -May be associated with pleurisy, TB, pneumonia, pulmonary infarction, cancer, etc.* Recommend: steroid and antibiotics* dull ( less air) - ANS normally heard over fluid-filled organs such as the heart or liver. Pleural effusion or pneumonia will cause this thudding sound. S1 heart sound * - ANS is created by the normal closure of the mitral and tricuspid valves at the beginning of ventricular contraction. ( If not normal recommend echocardiogram) S2 heart sound * - ANS is normal and occurs when systole ends. The ventricles relax and pulmonic and aortic valves close. ( If not normal recommend echocardiogram) S3 heart sound - ANS is abnormal and may suggest heart failure S4 heart sound - ANS is indicative of a cardiac abnormality such as uncontrolled hypertension or aortic stenosis adult normal blood pressure - ANS 120/80 mmHg ( mean 93) -Systolic & diastolic and mean arterial (MAP) pressures can be monitored continuously using an indwelling arterial catheter with a pressure( strain- gauge) transducer systolic acceptable range - ANS 90-140 diastolic acceptable range - ANS 60-90 normal chest x-ray/radiograph - ANS -(dome-shape) -Right hemidiaphragm is slightly higher than the left -Right hemidiaphragm is at the level of the Sixth anterior rib -trachea is midline, *bilateral radiolucency*- (look through lung field), with sharp costophrenic angles quality of radiograph image - ANS -head of clavicle should be level -a well penetrated chest x-ray is when the vertebrae are just visible behind the heart. proper exposure (penetration) - ANS will show the intervertebral disc spaces thru the shadow of the mediastinum Underexposed (under penetrated) - ANS image does not allow visualization of the intervertebral discs thru the heart shadow over exposed ( over penetrated) - ANS image will show black lung parenchyma w/o blood vessels trachea (landmarks/chest x-ray) - ANS -seen as a dark area midline -tracheal shift to one side would indicate a unilateral lung problem -the trachea should be the same size as the vertebral column -major bronchi should not be narrowed at the carina or at the distal end. Narrowing may indicate bronchogenic carcinoma mediastinum (landmarks/chest x-ray) - ANS area between the lungs where the heart, lymphatics, blood vessels and major bronchi are found. * May shift with a pleural effusion or pneumothorax* AP diameter (landmarks/chest x-ray) - ANS increased with COPD, barrel chest, hyperinflation costophrenic angle (landmarks/chest x-ray) - ANS angle made by the outer curve of the diaphragm and the chest wall. These angles are obliterated by pleural effusions (blunted/obliterated means the same thing) Diaphragm (landmarks/chest x-ray) - ANS -dome shaped normally, flattened with COPD -left or right hemidiaphragms may shift downward with a pneumothorax, appearing flattened on one side. Landmarks/ chest x-ray: (hyperresonant/tympanic) heart shadow (landmarks/chest x-ray) - ANS left ventricles normally seen, cardiomegaly ( enlarged heart) is seen in CHF soft tissue (landmarks/chest x-ray) - ANS tissue surrounding the chest and above in the neck area. subcutaneous emphysema occurs when air (hyperlucency) is seen in the surrounding soft tissue ribs (landmarks/chest x-ray) - ANS -long curved bones which form the rib cage -look for normal curving or spacing -crowding of the ribs ( close together) is associated with *atelectasis* -straight or horizontal ribs are characteristics of *air trapping* AP view ( standing up) - ANS -x-ray travel from anterior to posterior -image receptor behind back, commonly used for bedridden patients - size of heart will appear enlarge PA view (on back) - ANS x-ray travel from posterior to anterior- image receptor touching the chest with patient's back to x-ray tube - Choose this one for a better picture, if the pt is lying down. lateral position ( on side) - ANS - projection from either the right or left side -adds a third dimension to structures viewed on AP or PA image oblique position - ANS - slanting or diagonal view -aid in localizing lesions - better at determining pleural effusion Lateral decubitus position - ANS -Patient lying on the affected side -better for determining small pleural effusions apical lordotic - ANS projection of the lung apices end expiratory image - ANS - taken when the patient is at end- exhalation - valuable for detecting a small pneumothorax - can measure diaphragmatic excursion Position of ET/Tracheostomy tube tip position - ANS - below vocal cords -approx. 2-6 cm above carina - at the level of the aortic knob or aortic arch ( tube in right spot) evidence of e. t. or tracheostomy tube cuff hyperinflation - ANS the cuff should not extend over the end of the endotracheal or tracheostomy tube. position of pacemaker, catheters, and other tubes - ANS - *cvp* central venous catheters are inserted through the subclavian or jugular vein and should rest in the superior vena cava or right atrium of the heart (4th intercoastal space, right of sternum) - *cvp*- chest tubes should be located in the pleural space surrounding the lung. - *cvp*- nasogastric tubes and feeding tubes should be positioned in the stomach 2-5 cm below the diaphragm - pacemaker wires/electrodes should be normally positioned in the right ventricles. - pulmonary artery catheters should appear in the right lower lung field Croup (laryngotracheobronchitis) - ANS -the x-ray of the neck will reveal tracheal narrowing with subglottic swelling in a classic pattern - steeple sign -picket fence sign - pencil point sign - hourglass sign Epiglottitis - ANS - a lateral neck x-ray shows supraglottic narrowing with an enlarged and flattened -thumb sign extrapulmonary air - ANS - defined as air found outside of the lungs -ex. pneumothorax, pneumoperitoneum, pneumomediastinum, pneumopericardium, subcutaneous emphysema presence of foreign bodies - ANS -examine airways for any aspirated foreign objects -inspiratory/expiratory radiographs are helpful in locating areas of air trapping -majority of aspirated foreign objects are radiolucent (appears dark on x-ray), however some objects may show as radiopaque (appear white ) and may not be seen on chest x-ray radiolucent - ANS -description: dark pattern, air -diagnosis: normal for lungs radiodense/opacity - ANS -description: white pattern, solid, fluid - diagnosis: normal for bones, organs infiltrate - ANS -description: any ill- define radiodensity - diagnosis: atelectasis consolidation - ANS - description: solid white area - diagnosis: pneumonia/pleural effusion hyperlucency - ANS -description: extra pulmonary air -diagnosis: COPD, asthma attack, pneumothorax vascular markings - ANS - description: lymphatics, vessels, lung tissue - diagnosis: increased with CHF absent with pneumothorax diffuse - ANS - description: spread throughout - diagnosis: atelectasis/ pneumonia opaque - ANS -description: fluid, solid - diagnosis: consolidation pulmonary edema - ANS - terminology: fluffy infiltrates, butterfly pattern, batwing pattern -description: diffuse whiteness, infiltrates in shape of butterfly - treatment: diuretics, digitalis, digoxin atlectasis - ANS - terminology: patchy infiltrates, plate-like infiltrates, crowded pulmonary vessels, crowded air bronchograms - description: scattered densities, thin- layered densities -treatment: lung expansion therapy, SMI, IPPB, CPAP, PEEP ARDS or IRDS - ANS - terminology: ground glass appearances, honeycomb pattern, diffuse bilateral radiopacity - description: reticulogranular, reticulonodular - treatment: oxygen, low VT or PIP, CPAP, PEEP pleural effusion - ANS - terminology: blunting/obliteration of costophrenic angle, basilar infiltrates with meniscus, concave superior interface/border - description: fluid level on affected side, possible mediastinal shift to unaffected side - treatment: thoracentesis, chest tube, antibiotics, steroids pneumonia - ANS - terminology: air bronchogram - description: increased density from consolidation and atelectasis - treatment: antibiotics Tuberculosis (TB) - ANS - terminology: cavity formation -description: often in upper lobes - treatment: antitubercular agents pulmonary embolism (PE) - ANS - terminology: peripheral wedge-shaped infiltrates - description: may be normal -treatment: heparin, streptokinase pneumothorax chest x-ray - ANS - pneumothorax right lung starting at mid diaphragm and moving upward -rib fractures on right at rib 3 and 4 -heart shifted to the left, indicating possible tension pneumothorax acute respiratory distress syndrome (ARDS) chest x-ray - ANS - ground glass appearance - diffuse bilateral infiltrates in all lungs fields pleural effusion chest x-ray - ANS Excess fluid that accumulates in the fluid-filled space that surrounds the lungs (X-ray) right mainstem intubation chest x-ray - ANS CT scan - ANS - *1st choice in determining a P.E.* - an x-ray through a specific plane of the body part to be examined. images appear as narrow slices of the organ or body part. -useful in detecting the presence of mediastinal, pleural and parenchymal masses, pulmonary nodules and lesions not visualized on a chest x-ray. - *a spiral CT scan with contrast dye may be used for the diagnosis of pulmonary embolus*. magnetic resonance imaging ( MRI) - ANS - imaging is used to obtain two- dimensional views of an organ or structures w/o the use of radiation. -useful for determining thoracic aneurysms, congenital anomalies of the aorta and major thoracic vessels, especially in the hilar area. - an MRI has the ability to determine the precise position of tumors, soft tissue abnormalities and the involvement of surrounding structures. - aluminum gas cylinders are used in room, instead of steel cylinders V/Q scan Pulmonary ventilation/ perfusion scan ( less invasive) - ANS -ventilation scan-radioiscope (xenon gas) is inhaled and the location of the gas is recorded producing a photographic pattern of distribution throughout the lungs. - ventilation scan-any obstruction to airflow will prevent gas from filling that area. - perfusion scan- albumin. tagged with radioactive iodine, is injected into a peripheral vein and when it passes into the pulmonary circulation, lodges in the capillaries. - perfusion scan- a scanning device is passed over the chest and produces a pattern of radiation that indicates distribution and volume of perfusion. - * a normal ventilation scan with an abnormal perfusion scan indicates a pulmonary embolism.* V/Q scan 2nd in determining a P.E. Barium swallow ( don't pick) - ANS -an esophagram is performed to assist in the diagnosis of abnormalities in hypopharynx, esophagus, or stomach. - a radiopaque is swallowed by pt and traced through the hypopharynx, and into the esophagus by fluoroscope. It is then traced through the esophagus and into the stomach. Lastly an x-ray follows to determine the findings. -Indications for esophagram: suspected esophageal malignancy, *dysphagia ( only if the pt have a problem swallowing)*, congenital detect in hypopharynx, esophagus, gastric reflex(GERD), esophageal varices Positron Emission Tomography (PET) scan ( don't pick) - ANS - PET scan is a procedure used to detect and *diagnose disease earlier than MRI or CT scan*. It can also be used to monitor a pt's response to treatment. -useful in determining the presence of cancer, brain disorders and heart disease. bronchography (bronchogram) - ANS - injection of radiopaque contrast into the tracheobronchial tree. - by outlining the airways it will identify obstructing lesions ( I.e. tumors) and bronchiectasis is the main indication( 3-layers). - identifying the location of involved areas will allow better administration of postural drainage in pt's with bronchiectasis. - hazards include allergic reaction and impairment of ventilation. Electroencephalogram (EEG) - ANS - the brain procedure electrical activity that can be measured as tiny fluctuations in voltage through the scalp in much the same way that an electrocardiogram records the electrical activity of the heart. -indications for EEG: brain tumors, traumatic brain injuries, loss of brain function, epilepsy/ seizures, *evaluation of sleep disorders*. pulmonary angiography ( 3rd in determining P.E.) - ANS -a pulmonary arteriogram or angiograph is a test to diagnose a pulmonary abolism. - indication: high clinical suspicion for pulmonary embolism. Inconclusive V/Q scan and /or CT scan. echocardiogram ( ultrasound of the heart) - ANS -noninvasive -assesses overall cardiac function including left ventricular volume and ejection fraction -indications are valvular disease or dysfunction, myocardial disease, abnormalities of cardiac blood flow, cardiac anomalies in an infant, and abnormal heart sounds ( S1 or S2 are abnormal) - *(test when heart sounds are abnormal)* cardiac catheterization (CC) - ANS insertion of a catheter into the heart through a vein or artery, usually of an arm (brachial approach) or leg (femoral approach) to provide evaluation of the heart. This is done for both diagnostic and therapeutic purposes. - It can be used to perform a number of procedures including angioplasty, percutaneous coronary intervention (PCI) angiography, balloon septostomy, and electrophysiology studies. - diagnostic indications: confirm the presence of suspected heart pathology. quantify the severity of the pathology and its effect on the heart. measure intracardiac and intravascular blood pressures. obtain tissue samples for biopsy. inject various agents for measuring blood flow in the heart. detect and quantify the presence of an intracardiac shunt. inject contrast agents in order to study the shape of the heart vessels and chambers and how they change as the heart beats. reopen foramen ovals. intracranial pressure (ICP) monitoring - ANS -normal ICP 5-10 mmHg - 20 mmHG abnormal initiate treatment - therapy to reduce ICP :hyperventilation target PaCO 25-30 torr ( temp decreases ICP) -lower jugular venous pressure : keep head of bed elevated _ 30 (always) : minimize straining, retching, and coughing : minimize PEEP - sedation and analgesia : narcotics & benzodiazepines - osmotic agents to remove fluid from brain :(use mannitol) to lower 20 (diuretics) : hypertonic saline -cerebral perfusion pressure (CPP) : pressure gradient that determines cerebral perfusion : formula: CPP=MAP-ICP : normal value 70- 90 mm Hg : must be at least 70 mm Hg Exhaled gas analysis: (Carbon Monoxide) CO - ANS - measurement of nitric oxide concentration in pt's exhaled breath. - *used to monitor the pt's response to anit-inflammatory(corticosteroid) treatment. - *useful for monitoring pt's with asthma, cycstic fibrosis, or COPD - *a decrease in FENO suggests a decrease in airway inflammation ( good steroids are working) - measured using a handheld device (NIOX) that provides accurate, reproducible and immediate measurement of fractional exhaled nitric oxide FENO) Exhaled carbon monoxide (FEco) testing - ANS - exhaled CO easily measured with small, portable device - can be used to monitor abstinence in cigarette smokers - exhaled Co levels may also be elevated in pt's with obstructive sleep apnea red blood cells ( RBC) - ANS - *normal value 4-6 mill/mm -contain hemoglobin necessary for oxygen transport -low RBC ( anemia) occurs with blood loss, hemorrhage - low RBC (polycythemia) occurs with chronic tissue hypoxemia (i.e. COPD) *SEE BOOK ON A WAY TO REMEMBER RBC, Hb& HCT RANGE* hemoglobin (Hb) - ANS -carries oxygen(1.34 mL per gram Hb) -normal value: 12-16g/100mL blood g/dL - Low Hb is referred to as anemia. High -Hb is referred to as polycythemia Hematocrit (Hct) - ANS - spin the whole blood & measure the % of RBC in the original blood volume -normal value: 40%-50% -low HCT is referred to as anemia - high HCT is referred to as polycythemia White blood cells (WBC) - ANS -WBC is used to fight infections. -normal value: 5,000-10,000 -Increased WBC (leukocytosis) indicates a bacterial infection ( recommend antibiotics) -decreased WBC (leukopenia) indicates a viral infection ( no antibotics) Neutrophils ( major WBC) - ANS - Bands- immature cells; normally 4% of WBC; increased w/ bacterial infections -Segs- mature cells; normally 60% of WBC; decreased with bacterial infections -*Eosinophils- associated with asthma. 2% of WBC; increased with allergic reaction* -Monocytes- associated with TB; 3% of WBC -Lymphocytes- 30% of WBC -Basophils- 1% of WBC Electrolytes: K+, Na+, Cl-, HCO3 (CO2 contents) - ANS -elements required by the body for normal metabolism -abnormal electrolytes levels indicates abnormal body function - closely associated with fluid levels, muscle function (cardiac) & kidney function -clinical application of electrolytes imbalance( muscle weakness, soreness, nausea, mental changes such as( lethargy, dizziness & drowiness) Potassium (K+) - ANS -important for acid base balance, muscle function including cardiac muscle function -normal: 4.0 mEq/L ( range: 3.5-4.5) * RELATES TO PaCO2* -Hypokalemia refers to low K+. occurs with metabolic alkalosis, excessive excretion, vomiting, flattened T waves on ECG -Hyperkalemia refers to high K+. kidney failure, spiked T wave ( metabolic acidosis) Sodium ( Na+) - ANS -major extracellular cation controlled by the kidney's -normal : 140,Eq/L ( range: 135-145)* RELATES TO PaCO2* -Hyponatremia refers to low Na+, fluid loss from diuretics , vomiting, diarrhea, fluid gain from CHF, IV therapy - Hypernatremia refer to high NA+, dehydration -Na+ is retained in exchange for K+ Chloride (Cl) - ANS -major extracellular anion -levels are closely associated with sodium Na+ -Normal: 90mEq/L ( range 80-100)* RELATES TO O2 RANGE* - Hypochloremia refers to low Cl ( metabolic alkalosis) -Hyperchloremia refers to high Cl ( metabolic acidosis) Bicarbonate ( HCO3-) ( total CO2 content) - ANS - Normal : 24mEq/L ( range 22-26) -A) most of the CO2 in the blood is carried as HCO3, so that changes in total CO2 content reflect changes in the blood. 1. Increase CO2 content reflects increase HCO2 ( leading to metabolic alkalosis) 2. Decrease in CO2 contents reflects decrease in HCO3( leading to metabolic acidosis) B) This is opposite of PCO2 changes: 1. Increase PCO2 leads to respiratory acidosis 2. Decrease in PCO2 leads to respiratory alkalosis Creatine - ANS - excreted by kidneys - evaluates kidney function - normal value: 0.7-1.3 mg/dL -*more specific for kidney failure than the BUN blood urea nitrogen (BUN) - ANS - evaluates kidney function -Normal value: 8-25 mg/dL - Increased BUN indicates kidney failure Sputum analysis - ANS - The amount of sputum ( small, moderate, large, Copious( extremely large) - consistency ( thin, thick, tenacious( extremely sticky) - clear- normal - Mucoid- white/ gray, chronic bronchitis -Yellow- presence of WBC( eosinophils), bacterial infection -Green- stagnant sputum, gram negative bacterial ( bronchiectasis, pseudomonas) -Brown/dark- old blood, anaerobic lung infection -Bright red- hemoptysis( bleeding tumor, TB) - Pink frothy- pulmonary edema sputum culture - ANS identifies the bacteria present, takes 48-72 hr ( 2-3 days) Sensitivity test - ANS identifies what antibiotics will kill bacteria, takes 48-72 hrs. ( 2-3 days) Gram stain - ANS - identifies whether bacteria are gram positive or gram negative, takes ( 1hr) -*Side notes: (If you have less time on test choose Gram stain. If you have more time choose either Sensitivity or Sputum culture, because it's 48-72 hrs. Coagulation studies - ANS -Coagulation studies are a series of tests that evaluate the clotting mechanisms of the body. - Indications for Coagulation Studies: 1. Evaluation of preoperative patients for bleeding risk. 2. Evaluate bleeding signs/symptoms 3. Diagnosis disseminated intravascular coagulation ( DIC) 4. Monitor anticoagulant therapy - normal clotting time (6mins) Platelet count - ANS - an analysis of the number, size, and shape of the platelets should be done if a coagulation defect is suspected -normal value: 150,000-400,000/mm3 -decreased values are associated with bone marrow function and sepsis Activated partial thromboplastin time (APTT) - ANS - measures the length of time required for plasma to form a fibrin clot -normal value: 24-32 secs - used for monitoring heparin therapy Prothrombin Time (PT) - ANS -used to monitor oral warfarin (Coumadin therapy - normal value: 12-15 secs Urinalysis - ANS - reflects metabolic status of patient and is a screening test for kidney disease. -can indicate urinary tract infections before blood culture results -also measures appearance, specific gravity, pH, glucose, ketones, blood bilirubin, and sedimentation -blood in the urine (hematuria) is associated with kidney trauma Troponin - ANS - a protein found in myocardial cells -1. specific damage to heart muscle *2. Patients who suffered a myocardial infarction would have elevated troponin levels. *3. Troponin levels 0.1 ng/mL place the patient at high risk for death for Myocardial Infarction (MI) 4. recommend oxygen, morphine, aspirin, nitroglycerin Brain Natriuretic Peptide (BNP) - ANS 1. secreted by the cardiac muscle when heart failure develops or worsen 2. normal value: 100 pg/mL 3. * measurement of serum BNP is helpful to determine if the patient's symptoms are the results of CHF or another condition, such as COPD 4. Elevated levels indicate CHF a.* 300 pg/mL: mild heart failure b. 600 pg/mL: moderate heart failure c. 900 pg/mL: severe heart failure 5. recommend diuretics, positive inotropic agents Tuberculin Skin Test/ Mantoux test (TB test) - ANS -*consists of intradermal injection of a purified protein derivative(PPD) of mycobacterium tuberculosis - most reliable test for TB sensitivity - a positive test is determined when a hardened, raised red area appears 24 to 72 hrs after injection -recommend antitubercular agents and isolation Allergy Testing - ANS A. May be indicated in patients with *asthma to help indentify allergens triggers such as dust, pollen, mold and food. B. Two types of procedures: 1. Skin-prick or Scratch Test: -a. A drop of allergen in liquid form is placed on the patient's back or forearm. -b. That area is then scratched or pricked to see if the allergen produces a reaction. -c. If the patient is allergic to the substance, a small red bump will appear, usually within 20 mins. 2. Intracutaneous Test -a. This procedure may be indicated if the skin-prick test is inconclusive -b. A small amount of allergen is injected just beneath the skin. -c. The patient should be monitored for a systemic reaction. Oscilloscope (ECG Monitor) - ANS -a. provides a continuous visual image of the electrical activity of the heart on a screen. -b. an oscilloscope is a device that displays rapid changes in voltage as a moving line on a phosphorescent screen. -c. special converters can be attached to an oscilloscope so that mechanical vibrations, pressure waves, sound waves, and other forms of energy can be transformed into electrical impulses and displayed. -d. generally displays a single lead (Lead ll most common) Holter Monitor/Event Monitor - ANS - out patient basis -a. a portable version of an electrocardiograph that is worn under the clothes by the patient for 24-48 hr period to detect cardiac arrhythmias -b. chest electrodes are connected to the monitor and cardiac activity is continually recorded while the patient goes about his usual daily activities. -c. The monitor is worn for 24-48 hrs instructed by the physician. -d. the recording is scanned by an electrocardioscanner and a hard copy of the ECG abnormalities that may occur over an extended period of time. It can also be used to evaluate the effectiveness of anti- arrhythmia drugs and to associate the occurrence of chest pain with stress of physical activity Cerebral Perfusion Pressure (CPP) - ANS 1. pressure gradient that determines cerebral perfusion 2. Formula: CPP=MAP-ICP 3. normal value: 70-90 mmHg 4. must be at least: 70mmHg Complete Blood Count (CBC) - ANS - Measurement of all major ingredients in the blood. Axis - ANS - The axis of an ECG measures the net direction of all the electricity through the heart during contraction. -Normally, the electrical impulse begins in the upper right corner of the heart (SA node, right atrium) and moves in waves down and across the heart to the left ( down & left) -There are two factors that affect the direction of the axis: - Hypertrophy- the enlargement of an organ or tissue from the increase in size of its cells. (an increase in electrical activity will cause the axis to shift toward hypertrophy). -Infarction- dead tissue, no electrical activity, axis will shift away from infarction. ECG Electrodes/Leads - ANS - Electrodes- an object placed on the skin to conduct electric current from the body to a monitoring or measuring device. - Leads- displays movement of electricity from one electrode to another. - There are 12 leads used, six limbs and six precordial chest leads ( 10 electrodes) - Choose Lead II ,it gives the best view of the pt's heart from the axis & heart electrical waves. Chest Electrodes - ANS *KNOW ALL* V1- intercoastal space on right side of sternum ( Right heart) V2- 4th intercoastal space on left side of sternum ( right heart) V3- Between V2 and V4 on left side ( Ventricular septum) V4- intercoastal space, left mid- clavicular line( Ventricular septum) V5- Between V4 and V6 on the left side ( left heart) V6- 5th intercoastal space, left mid-axillary line ( left heart) Sinus Arrhythmia - ANS A sinus rhythm in which the rate varies with respiration, causing an irregular rhythm. -Treatment- Treat any other symptoms Sinus Tachycardia - ANS A sinus rhythm with a heart rate greater than 100 beats/min -treatment- treat with oxygen Sinus Bradycardia - ANS A sinus rhythm with a heart rate of less than 60 beats/min. - treatment-oxygen & Atropine premature ventricular contraction (PVC) - ANS - PVC is a wide & bizzare QRS. - The width is greater than 1.2 secs PVC's often cause few or no symptoms -treatment- Oxygen, consider other causes. * Test purposes*Lidocaine is also considered a treatment. It was once used to treat PVC's, so it may be an option on the exam. Make sure the best option, before you pick it. Multifocal premature ventricular contractions (PVCs) - ANS - PVC are happening at different areas in the ventricles. * Test purposes: This could be caused by suctioning the patient.* - treatment: consider oxygen & other causes Ventricular tachycardia (V-tach) - ANS -Ventricular rhythm with rate 100 - Treatment: pulse present: Cardiovert -Pulse absent- Defibrillate, CPR, Epinephrine, Amiodarone Ventricular fibrillation ( V-fib) - ANS - completely irregular ventricular rhythm. - treatment: defibrillate, CPR, Epinephrine, Amiodarone Asystole - ANS cardiac arrest rhythm in which there is no discernible electrical activity on the ECG monitor -flatline - P wave & QRS complex are not present ( The heart is not functioning) - requires immediate attention - treatment: Confirm in 2 leads first, CPR, Epinephrine * test purposes*- Always look at pt. The pt could be alert and eating and the problem is the lead is loose. Asystole doesn't always mean that a pt has flatlined. Ischemia - ANS - reduced blood flow to tissue Injury - ANS - acute damage to tissue ( often from ischemia) Infarction - ANS -necrosis of tissue due to ischemia ( end result of ischemia and injury) may be recent ( acute) or old Perinatal History - ANS - Mother's history: history of pregnancy, age, smoking and substance abuse, nutrition, infection, previous pregnancies/outcomes, hypertension/ toxemia are all important to review - Mother's with diabetes are prone to have premature and large-for-gestational age infants. -Family history, delivery, and postnatal history will provide important information. Gestational age - ANS the age of the fetus between conception and birth -*Dubowitz or Ballard Method ( ways to calculate gestational age) -The higher the score, the higher the gestational age in weeks. 1) Normal score is 40 corresponding in weeks 2) A score higher than 40 indicates a post-term infant. 3) A score lower than 40 indicates a pre-term infant. New Ballard Score (NBS)- modification of Ballard Score, estimate gestational age in very low birth weight infants. Term infant - ANS 37-42 weeks gestation Preterm Infant (premature) - ANS less than 38 weeks gestational age Post term infant - ANS more than 42 weeks gestational age large for gestational age - ANS LGA small for gestational age - ANS SGA APGAR Score - ANS -provides a clinical method of evaluating the infant immediately after birth. Allows for a rapid appraisal of an infant in determining the need for resuscitation. -routinely done at 1 & 5 mins. a) 1 min score identifies how well the infant tolerated delivery. b) 5 mins score identifies how successful our effort were - five factors are evaluated: color heart rate, reflex irritability, muscle tone , respiratory effort Action based scoring: *0-3 (Resuscitate), *4-6( support- stimulate, warm, administer O2, * 7-10 ( monitor- routine care) *STUDY APGAR SCORING/ TEST* Transillumination - ANS - a bright fiberoptic light is placed against the infant's chest in a darkened room. -recommend when a pneumothorax is suspected in infants. -normally a lighted halo is seen around the point of contact. - a pneumothorax or pneumomediastinum will cause the entire hemithorax to light up * TEST PUPOSES* ( it's quicker than a chest x-ray) Temperature (infant's) - ANS -normal 36.5 C -Infants lose body heat very quickly and may need to be placed in a warm environment to maintain adequate body temperature Pulse/Heart rate ( infant's) - ANS -*normal heart rate in (term infant)-110-160 beats/min (pre-term infants have faster heart rate )* -Tachycardia- 170 bpm or greater -bradycardia- less than 100 bpm -measure using brachial, femoral, or apical pulse - an infant can only increase his/her cardiac output by increasing the heart rate.* Respirations ( infant) - ANS * normal- 30-60 beats/min ( higher in preterm infants) -Respiration pause- apnea for 5-10 secs, normal - short apnea- apnea for 10-20 secs, may be normal - long apnea- apnea for more than 20 secs, always abnormal Blood pressure (infant) - ANS * Term infant- 60/40 mm Hg ( half the size of a normal adult) * Preterm infant- 50/30 ,, Hg ( go down one in size for preterm) Birth weight (infant) - ANS * term infant- 3000g( relate size to e.t. tube) -28 week gestation age- 1000g -low birth weight- infants are at higher risk for respiratory problems. *FORMULA E.T. TUBE* 3.0= 3.0 ( e.t. tube) 3.5= 3.5 ( e.t. tube) Grunting ( infants) - ANS - a sound heard at the end of exhalation that indicates respiratory distress (RDS) from decreased lung volume Pre and Post Ductal Blood Gas Studies - ANS -*1. If right-to-left shunting occurs across the arteriosus, the PaO2 level obtained from a pre-ductal site ( right arm) often exceeds the PaO2 level obtained from a post-ductal site (umbilical artery or a lower extremity vessel). -*2. If the pre-ductal( right artery) PaO2 is 15 torr higher than the post-ductal (umbilical artery) PaO2 then the patient has a patient ductus arteriosus with a right to left shunt. -*3. Recommend an echocardiogram to determine the cause of the shunt. Blood Glucose - ANS - Blood glucose levels are important to monitor in infants. - *Term infants should have values greater than 30 mg/dL -* Premature infants should have values greater than 20 mg/dL Lung Maturity Information - ANS 1. Lecithin/Sphingomyelin (L/S) Ratio a) A ratio of 2:1 or higher is good. Incidence of hyaline membrane disease (HMD) or infant Respiratory Distress Syndrome (IRDS) approaches zero. b) A ratio less than 2:1 indicates high risk of HMD/IRDS Capnography - ANS -ECO2, ETO2, PETCO2(ETCO2) *1. Measures exhaled carbon dioxide using infrared absorption. *2. Once the capnograph is set up, an arterial blood gas is drawn to correlate the values. *3. Normally the PETCO2( ETCO2) will read lower than the arterial PCO2: a) PaCO2= 40 torr b) PETCO2/ETCO2= 30 torr 4. ETCO2 can also be displayed as a percent. Normal value is 3-5%. *5. Sensor should be placed proximal to the patient's airway connection ( at the endotracheal tube). *6. An INCREASE in the PETCO2% would indicate a DECREASE in ventilation. (VENTILATORY FAILURE) *7. A DECREASE in the PETCO2% would indicate an INCREASE in ventilation or decreased perfusion ( deadspace disease: pulmonary embolism, hypovolemia. *8. If capnograph reads low or zero, reconnect patient to ventilator or check for leaks *9. Low PETCO2/ETCO2 readings immediately following intubation would indicate that the ET tube is in the esophagus. *10. During CPR the PETCO2/ETCO2 should increase ( Good CPR/ Compression/ Perfusion) *Look at chart pg.A-50* *11. Moisture and secretions can cause false readings and obstruct the sample tube ( will read zero). *12. Exhaled CO2 detection devices are available to detect esophageal intubation. Colorimetric Detector - ANS - non-electronic portable disposable devices are designed to produce a color change with the presence of exhaled CO2 and have the ability to produce appropriate color changes for a wide range of PCO2 and respiratory patterns. -examples of color changes: 1. Purple= poor 2. Yellow= normal 3. False readings can occur in patients who have been w/o CPR for a period of time. - May be used to confirm tracheal intubation Pulse Oximetry ( SpO2) - ANS - Pulse Oximeters (SpO2) non-invasive -* Normal range of Spo2- 93-97% - Accuracy affected by poor perfusion( shock hypotension) and conditions that interfere with the light transmission (erythema, bright ambient lights, etc.) -* Pulse oximeters will read HIGHER saturation if carbon monoxide poisoning is present.* Co-oximeter/hemoximeter - ANS -*Used to diagnose carbon monoxide poisoning - *Normal COHb: 0-1% -COHb for smokers: 2-12% -%CO poisoning 20% ( John's fav #) a) treat w/ 100% oxygen/non- rebreather mask or hyperbaric chamber, with co-oximeter to verify that all CO is 20. - Best way to evaluate oxygenation in a pt with CO poisoning. -*Invasive and non-continuous measurement ( You have to draw a ABG with a co-oximeter on it) read pg. A-53 notes Transcutaneous PO2 and PCO2 measurement - ANS - Electrodes that allows continuous non-invasive PO and PCO2 measurement by electrodes placed on the skin instead of a single measurement w/o a single a blood sample. -* Heating the skin around the electrode to 43-45C improves the capillary blood flow( perfusion) and enhances gas movement through the skin. -* The electrode site should be changed every 4 hrs. If redness or blistering of the skin (erythema occurs the electrode is moved to a new site more often). - Calibration is done on room air: *PO2= 150 torr *PCO2=0 torr( value should be zero) - If unable to calibrate, check for torn membrane, poor connection etc. -Air leaks will increase the TcPO2 to read higher than the PaO2. - Best place the electrode is over the flat areas with good perfusion. Normally on the chest, just beneath the center of the right or left clavicle. -Accuracy decreases with the increase skin thickness, anemia and conditions of decreased perfusion such as shock, burns, vascular disease or cardiac defects. hemodynamic monitoring - ANS - Hemo means "blood" and dynamic means "motion". Hemodynamics is the movement of blood or Circulation/ Perfusion of the blood. It's the monitoring of blood pressure -The blood movement( Circulation/ Perfusion) occurs because of blood pressure. Physiology of Blood Pressure (Heart) - ANS -* W/o sufficient blood pressure, the cells will not receive the oxygen and nutrients they need to survive. -*high blood pressure causes strain on the heart and will eventually cause heart failure and increases the risk of stroke. - *There are (3) factors that control blood pressure: heart, blood, and vessels. - Heart - the heart is the pump that creates the bp. Changes in the heart rate and contractility will affect the bp directly. *1. INCREASE the heart rate will INCREASE blood pressure. a) Chronotropic drugs increase heart rate (i.e atropine) *2 DECREACES in the heart rate DECREASE blood pressure a) B-blockers or B-antagonists drugs will decrease heart rate ( i.e: atenolol, propranolol, labetalol) Physiology of Blood Pressure ( Blood) - ANS - *The amount of fluid ( blood) in the circulatory system will affect the blood pressure. 1. *Excessive fluids- INCREASE pressure a) Treat with diuretics ( furosemide) 2. Loss of fluids- DECREASE pressure a) Treat with fluids or blood products. Physiology Of Blood Pressure ( Vessels) - ANS - the condition of the blood vessels will cause the blood pressure to change. 1. Vessel constriction- *INCREASES blood pressure. a) Treat w/ vasodilators I) Direct vasodilators ( *Nitroprusside, Hydralazine, Milrinone) II) Ace inhibitors ( Lisinopril, Perindopril, Captopril, Enalapril, Ramipril) 2. Vessel dilation- DECREASES blood pressure a) Treat with vasoconstrictors ( use to increase blood pressure) *Epinephrine, Phenylephrine, *Dopamine, Dobutamine Pressure Transducer - ANS - Device used to convert one form of energy into another form. - The transducer should be at the same level as the tip of the catheter. a) If transducer is ABOVE, the catheter, readings are lower than actual. b) If transducer is BELOW the catheter, readings are higher than actual. Path of blood flow through the heart - ANS a. Beginning with the LEFT VETRICLE where the pressure is normally 120/0 mm Hg, blood leave the heart through the AORTIC VALVE and enters the systemic arterial system. b.* The mean pressure in the SYSTEMIC ARTERIES is normally 90mm Hg( 120/80) and decreases to 30mm Hg as it enter the CAPILLARIES. c. Inside the capillary the pressure is now 20mm Hg and as the blood leaves to enter SYSTEMIC VEINS it is now about 10mm Hg. d.* The systemic venous blood moves slowly back to the right heart. As the blood enters the RIGHT ATRIUM the pressure is now on 2-6mm Hg or 4-12 cm H20. ( * To remember just double 2-6) see notes p. A-57) e. Blood in the right atrium passes through the TRICUSPID VALVE into the RIGHT VENTRICLE where the blood is normally 25/0 mm Hg. f. From the right ventricle, the blood moves through the PULMONIC VALVE into the PULMONARY ARTERY where the pressure is normally 25/8 mm Hg. The mean pressure here is about 14 mm Hg. g. From the pulmonary arteries the blood now passes through the lungs where the capillary pressure is normally about 4-12 mm Hg, and then into the PULOMARY VEINS. h. The blood in the pulmonary veins moves into the left atrium where the pressure has dropped to about 2-6 mm Hg. i. From the LEFT ATRIUM the blood through the MITRAL VALVE ANS into the LEFT VENTRICLE again. * see p. A-57* Pulmonary Artery Catheter Position and Waveforms - ANS - The pressure and waveform pattern will reveal the position of the tip of the pulmonary artery catheter. - When the balloon is inflated the catheter will "wedge" and the back-pressure from the pulmonary capillary will be measured. - Standard pulmonary artery catheter has a proximal and distal port. a) Proximal catheter port measures CVP ( right atrium 2-6 mm or right ventricle 4-12 cm H2O b) Distal port with balloon deflated measures PAP (25/8 mean 14) c) Distal port with balloon inflated measures PCWP ( 4-12 mm Hg) - Dicrotic Notch- The presence of a double spike ( dicrotic notch) is normal for the arterial pressure waveform ( both pulmonary and systemic) occurs when the pulmonic or aortic valve closes. Clinical Assessment of Hemodynamics - ANS -INCREASE CVP: Right heart problems a) Right heart failure b) Cor Pulmonale c) Tricuspid valve stenosis d) Hypervolemia INCREASE Pulmonary Artery Pressure(PAP): Lung Problems a) Lung disorders b) Pulmonary embolism c) Pulmonary hypertension d) Air embolism INCREASE PCWP: Left Heart Problems: a) Left heart failure b) Mitral valve stenosis c) CHF d) High PEEP effects DECREASE CVP: Right heart problems a) Hypovolemia p. A-59 Pulse Pressure/ Mean Arterial Pressure (MAP) - ANS - the difference between systolic and diastolic pressure) a) Formula: Pulse pressure= systolic pressure-diastolic b) *normal value- 40 mmHg - Mean Arterial Pressure calculation: MAP= (2 x diastolic) + systolic/3 Cardiac Output (QT) - ANS - Measures the output of the left ventricles to the systemic arterial circulation and is measured by one of the following: a) Fick equation: QT= VO2/C (a-v) O2 (10) b) Stroke volume: QT heart rate x stroke volume c) Thermal Dilution: cold saline injection, requires pulmonary artery catheter. d) *Normal value: 4-8 L/min and depends upon body size. Cardiac Index (CI) - ANS - is the cardiac output (QT) divided by the body surface area ( BSA) in meters- squared ( m2) Formula: CI = QT/ BSA ( on test they will give the BSA) *Normal value: 2.5-4.0 liter/min./m2 for pt of all ages Systemic Vascular Resistance (SVR) - ANS - The pressure gradient across the systemic circulation divided by the cardiac output. a) Formula: SVR=(MAP-CVP) x80/ Cardiac Output b) * normal value: 20 mmHg/L/min or 1600 Dynes/sec/cm-5 c) To convert mm Hg/L/min to Dynes, multiply by 80( i.e. 20 x80= 1600 Dynes/sec/cm -5 d) SVR is increased with systemic hypertension and/or vasoconstriction (especially from Alpha Type drugs) e. SVR may change with changes in cardiac output or cardiac index if other values remain constant. Pulmonary Vascular Resistance (PVR) - ANS -The pressure gradient across the pulmonary circulation divided by the cardiac output. a) Formula: PVR = (MPAP-PCWP) x 80/ CO b)* Normal value: 2.5 mm Hg/L/min or 200 Dynes/sec/cm-5 c) To convert mm Hg to Dynes, multiply by 80 ( i.e 2.5 x 80 = 200 Dynes/sec/ c m -5 d) PVR is increased with hypoxia, pulmonary hypertension and lung disease. Ventilation - ANS moving air in and out of the lungs Oxygen - ANS getting oxygen into the blood Circulation - ANS moving the blood through the body Perfusion - ANS getting oxygen into the tissue 4 Life functions - ANS Ventilation, oxygenation, circulation, perfusion Ventilation ( vital signs) - ANS chest movement, breath sounds, vt, resp. rate PaCo2, ETCO2 Oxygenation ( vital signs) - ANS color, sensorium, heart rate, Pao2, Spo2 ( on vent Fio2 & I- Time. circulation (vital signs) - ANS heart rate, strength ( pulse), cardiac output perfusion - ANS blood pressure, sensorium, temperature, urine output, hemodynamics Life functions (priority): when you have an emergency - ANS 1. ventilation 2. oxygenation (most common problem) 3. circulation 4. perfusion Admission notes - ANS admitting diagnosis, history of present illness, chief complaint, past medical history, current medications signs - ANS objective information: those things that you can see or measure ( , pulse, edema, bp, ect.) Symptoms - ANS subjective information: those things that the pt must tell you ( ea, pain, muscle weakness, ect.) physical examination - ANS Inspection,Palpation, Percussion, Auscultation Tobacco use - ANS packs smoke x years smoke= yrs of smoking ( ex. 4pks day x 10yrs= 40 pk yrs) Do Not Resuscitate order (DNR) - ANS Pt does not wish to have cardiopulmonary resuscitation performed. Do Not Intubate order (DNI) - ANS Pt does not wish to be intubated. Non-invasive ventilation can be administered. Respiratory care orders - ANS type of treatment,frequency, med. dosage & route of administration, physician signature Patients progress notes - ANS respiratory notes, nurses notes, admission notes, physician notes, maternal history/neonatal data Patient laboratory reports - ANS ABG analysis, pulmonary function testing, imagining reports ( x-rays, CT, MRI, PET, ect., basic lab assessments (CBC etc.) normal urine output - ANS 40 mL/hr (approximately 1 Liter/day) sensible water loss - ANS urine, vomiting insensible water loss - ANS lungs & skin If intake exceeds output, this could result in - ANS weight gain, electrolyte imbalance, increased hemodynamic pressures, decreased lung compliance normal CVP - ANS 2-6 mmHg decreased CVP ( 2mm Hg) - ANS hypovolemia ( give fluids) increased CVP (6 mmHg) - ANS hypervolemia (give diuretic ex. furosomide) alert & responsive - ANS level of consciousness: normal lethargic, somnolent, sleepy - ANS consider sleep apnea or excessive O2 therapy in pt's with COPD stuporous, confused - ANS responds inappropriately, drug overdose, intoxication semicomatose - ANS responds to painful stimuli with abnormal flexion or extension Obtunded - ANS drowsy state, may have decreased cough or gag reflex coma - ANS does not respond to painful stimuli anxiety, nervousness - ANS watching every movement, resp distress, hypoxemia depressed - ANS quiet or denial anger, combative, irritable - ANS electrolyte imbalance euphoria - ANS consider:drug overdose panic - ANS severe hypoxemia, tension pneumothorax, status asthmaticus Activity of Daily Living (ADL): Katz scoring system - ANS basic tasks of everyday life( bathing, eating, dressing, toilet use, transferring, urine & bowel continence) Orthopnea - ANS (difficulty breathing when lying down) may be associated with CHF) General malaise - ANS feeling run down, nausea, weakness, fatigue, headache ( electrolyte imbalance) Dyspnea - ANS a feeling of shortness of breath or difficulty breathing pain - ANS location, quality ( what kind is it?), severity (1-10), aggravating factor, relieving factors, history (when it started & how do it progress), context ( what circumstances did it occur?), accompanying symptoms symptoms of the nose & throat - ANS 1. Excessive nasal secretions from irritants, pollutants, allergies, upper resp. infections. 2. Itching or burning sensations of the nose or throat. 3. Dysphagia ( difficulty swallowing) and hoarseness are also common symptoms. Respiratory care plan - ANS case management plans, therapy protocols, disease management, patient & family education needs social support system - ANS family, friends, social services, etc. physical environment - ANS ramps, doorways, stairs, electrical wiring, etc. environmental exposures - ANS asthma triggers, heating/ cooling systems, work related ( occupational hazards), second hand smoke nutritional status - ANS usual food intake, food likes/dislikes, appetite, note any recent weight loss/gain, ( carbs=increase CO2 for COPD pt's) Patients /family history - ANS history of present illness, past medical history, family history, social history General appearance (Assessment of inspection) - ANS age, height, weight, nourishment, etc. Peripheral edema - ANS presence of excessive fluid in the tissue known as pitting edema ( arms & ankles), caused by CHF & renal failure. CHF pt's typically leans forward (orthopnea). Rate =+1, +2,+3, higher the number the greater the swelling, recommend diuretics and keep CVP between 2-6 mm Hg. Ascities - ANS accumulation of fluid in the abdomen generally caused by liver failure Clubbing of fingers - ANS Caused by chronic hypoxia, indicating a lack of oxygen. Presence of this is suggestive of pulmonary disease. The thumb,first fingers are affected. The toes can be affected as well. venous distention - ANS increased venous distention, jugular venous distention (JVD), occurs with CHF, Orthopnea breathing patterns seen during exhalation in pt's with obstructive lung diseases. capillary refill - ANS Indication of peripheral circulation; Blanching of one hand and watching the blood return within 3 secs. Longer than 3 secs indicates a decrease cardiac output (Modified Allen's Test) Diaphoresis - ANS A profuse/heavy state of sweating: *Tuberculosis/ night sweats: Recommend: antitubular drugs. * CHF: Recommend: diuretics, positive inotropic agents. *Fever, infection: Recommend: antibiotics * Anxiety, nervousness: Recommend: sedatives Normal skin color - ANS pink, tan, brown, black Abnormal skin color - ANS decrease color( ashen, pailor), due to anemia or acute blood loss (vasoconstriction will cause color change by reducing blood flow) jaundice - ANS increased bilirubin level in blood tissue. ( face & trunk) Erythema - ANS redness of the skin. may be due to capillary congestion, inflammation or infection cyanosis - ANS blue or gray ( dusky) discoloration of skin and mucous membranes. Caused by hypoxia from increased amount of reduced 5g of hemoglobin. In infants *Acrocyanosis is not true cyanosis, so be sure to check mucous membranes of the mouth, tongue, and nail beds*. chest configuration - ANS normal A-P diameter. Straight spine, no alterations in chest size. Pectus carinatum - ANS Anterior protrusion of the sternum Pectus Excavatum - ANS depression of part or all of the sternum kyphosis - ANS convex curvature of the spine ( lean forward) hunchback scolosis - ANS lateral curvature of the spine ( leans side to side) Kyphoscoliosis - ANS combination of kyphosis and scoliosis, which may produce a severe restrictive lung defect as a result of poor lung expansion/volume barrel chest - ANS Result of air trapping in the lungs for a long period of time. Generally due to COPD. Increase in A-P diameter ( air-trapping) symmetrical - ANS chest movement occurs when both sides of the chest move an equal distance at the same time. asymmetrical - ANS unequal movement may indicate underlying pathology ( post lung resection, post- pneumonectomy, atlectasis, pneumothorax, flail chest- paradoxial chest movement, endotracheal tube inserted in right or left mainstem bronchi eupnea - ANS normal resp. rate, depth, rhythm tachypnea - ANS increased resp rate ( 20 bpm), caused by hypoxia, fever, pain , CNS problems bradypnea /( Oligopnea) - ANS