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60 Cards in this Set

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A chart review should include what?
1. Diagnoses primary/secondary
2. Date of onset/time line
3. PMH, hospitalizations, ER visits
4. Medications
5. Relevant social history
6. Lab or medical test results (imaging, swallow, reflux or sleep studies, blood gases/tests)
7. O2 therapy
8. Surgeries or other procedures
9. Hospital course since admission
A patient interview should include...
-Clarification of info. in chart
-Goals
-PLOF, assistive device?
-Physical obstacles to going home
-Family, friend support at home
-Assess cognition
-Discuss symptoms
-W/ children, ask if parents have noticed change in behaviors
How would you assess functional impact of medical history on the patient?
PLOF and SINS
Ask about:
-# of school/work days missed
-How many times they have been to the ER
-How many hospital admissions, pulmonary or cardiac episodes
What are the objectives for a cardiopulm chest examination?
1. Identify impairments/create a problem list
2. Assess medical status and it's impact on prognosis
3. Determine what needs clairification or further testing.
4. Identify treatment goals and POC
What are the 5 components to a CP exam?
1. Inspection/observation
2. Auscultation
3. Palpation
4. Percussion
5. Vitals at rest and w/ activity
What does body habitus mean?

What does cachexia mean?

What is another "medical" term for obese?
How you describe your patient.

A state of ill health, malnutrition and wasting.

Panniculus aka Pannus: describes adipose tissue
What are some signs that a patient is in distress?
Sweating, facial expressions, vitals, face color
What is cyanosis and what are some signs of it?
A bluish or purplish discoloration (as of skin) due to deficient oxygenation of the blood.

Signs: Blue lips, tongue, nail beds and mucous membranes because they are very superficial and highly vascularized. Nasal flarring, digital clubbing (>180degrees).
How can you tell if someone has an increased work of breathing?
1. Nasal Flarring
2. Shoulder retraction
3. Pursed-lip breathing
4. Over use of accessory muscles.
5. Professorial posture
6. Panic look
How can you tell someone has been over using their accessory muscles?
1. Prominent clavicles
2. Forward head
3. Shortened SCM
4. Rounded shoulders
5. Tight pecs

i.e. SCM, scalenes will be huge due to COPD.
Describe Professorial posture.
A triad posture. Sitting, leaning forward with UEs braced on table or knees.
What are 6 postural deviations that you might see with someone who has CP compromise?
1. Kyphosis
2. Scoliosis
3. Pectus Excavatum
4. Pectus Carinatum
5. Professorial posture
6. Spinal alignment
What type of postural deformity restricts ventilationa and which does not?
All of them restrict CP function EXCEPT pectus carinatum. Pectus excavatum only when severe.
Why would someone get pectus excavatum?
Kids with asthma, overgrowth of rib cartilages, hereditary.
What would the skin of someone with CP problems look like?
A smoker would have nicotine stains, shiny skin due to steroid dependency, edema, gray.
What must we remember in regards to level of consciousness?
Patients on anestesia may not be able to breath on their own and will slowly ween off ventilator. Slower, shallow breating when on meds.
How can we tell if someone has distended neck veins?

What will you see?
Ask pt to lie with head and neck at 45 degree angle.

Right atrial pressure is evident based on the extent to which the jugular venous pulse can be visualized.
What does it mean if the jugular veins are distended bilaterally? Unilaterally?
Bilateral: cardiac cause such as CHF

Unilateral: localized problem
Where do the jugular veins empty into?
Superior vena cava
What should you look for in the non-moving thorax and chest? (5)
Scoliosis, scars, skin, shape and symmetery, intercostal spaces.
What are 5 things you would look at when evaluating the moving chest?
1. Breathing sequence - what moves 1st, 2nd, etc.
2. Primary mvmt pattern - diaphragmatic, lateral, upper chest, asymmetrical, inconsistent, paradoxical. What muscles are used?
3. Quality of pattern - apparent work of breathing, easy, smooth, continuous vs. harsh onset, labored, asynchronous, nasal flares.
5. Changes in different postures/activities
4. Ratio of inspiration to expiration - normal is 1:2.
What is the idea behind pursed lip breathing?
To prolong expiratory phase.
What does eupnea mean?
Normal breathing cycle.
What does apnea mean?
Temporary halt in breathing.
What does tachypnea mean?
Rapid, shallow breathing
What does bradypnea mean?
Less than 12 bpm
What does dyspnea mean?
Sensation of breathlessness
What are two questions we should ask ourselves as we are evaluating a patient?
-Does the pt have the musculoskeletal mobility to breathe any differently?
-Does the patient have the neuromuscular/cardiopulmonary ability to breathe any differently?
What are two objective values to consider during a patient evaluation?
-Incentive spirometry, a inspiration measure usually used in inpatient.
-Values on ventilator
If patients can't clear their own airways effectively, they are at high risk for what?
Acute pulmonary dysfunction
What are the four phases of a cough?
1. Inhalation
2. Hold
3. Pressure or force
4. Expulsion
What value do you need for adequate inspiratory lung volume for coughing?
>60% of predicted FVC. Keep in mind that the problem could be due to posture.
What happens during the holding phase of a cough?
Glottal closure. Builds up force. Trach patients can't do this step.
What determines how much pressure or force is built up for a cough?
The strength of the expiratory muscles. i.e. abs and intercostals.
How much force is needed for the expulsion phase of a cough?
162 L/minute peak expiratory flow rate.
Aside from analyzing each step of the cough, what is another way to evaluate this?
Assess number of coughs per breath.
What are three things you look at when considering a pt's secretions?
1. Texture - thick, mobile, thin, tenacious
2. Color - clear, white, yellow, green (active infection)
3. Volume - how many cc's?
What should we consider in regards to hydration?
cc intake/output
Urine color, odor
What questions should we ask when considering a pt's diagnosis?
-Is it a secretion mobilization or expectoration problem?
-Does the pt's PMH indicate a high risk or low risk for secretion retention or secretion management problems?
What are 3 possible interventions?
1. Improve hydration
2. Secretion mobilization and/or expectoration program or device
3. Ventilatory strategies to improve cough
Other than respiration, what are three other areas we should be looking at when evaluating our patients?
1. Sleeping - i.e. positions
2. Eating
3. Talking - i.e. syllables/breath, holding a vowel sound
4. Evaluate chest pain
What is the normal amt. of time a normal child and adult should be able to hold a vowel sound?
Kids = 10 seconds
Adult = 15 seconds
What type muscle contraction is being used for:
1. Expiratory
2. Inspiratory
3. No contraction
1. Concentric
2. Eccentric
3. Passive
What are 3 objective things that you would do in a physical exam?
1. Auscultation
2. Palpation
3. Percussion
When should you measure vitals?
At rest and w/ activity
What are 6 vital measurements?
1. Respiratory rate
2. Pulse
3. BP
4. O2 saturation
5. RPE
6. Dyspnea
What is a normal RR value for an adult?
15-20bpm
What is the normal RR value for a neonate?
30-80bpm
Why wouldn't HR and pulse not be the same thing?
A murmur. Also a true heart rate is measured w/ EKG leads over the heart of auscultation over the heart. A pulse is measured by the radial pulse.
How is RPE measured? What level should pts work at?
Borg Perceived Exertion Scale.
13 is a "somewhat hard"
How is dyspnea measured?
1. RPD - rate of perceived dyspnea
2. Dyspnea scale - different levels that makes pt count to 15
3. Dyspnea scale - ACSM, difficulty
4. Talk test - scale of 1-3
What is orthopenea? And how is it measured?
Inability to breathe in supine.
Rated by number of pillows a person needs in order to comfortably breathe recumbently.
What is paroxysmal nocturnal dyspnea?
When pt is sleeping and 1 to 2 hrs later, wakes w/ acute SOB.
What is the mechanism behind paroxysmal nocturnal dyspnea?
Transfer of fluid from extravscular tissues into the bloodstream during sleep. Left atrial pressure rises when the rate of lymphatic drainage from the lungs is unable to keep up with the increase volume of fluid.
What is paroxysmal nocturnal dyspnea a strong predictor of?
A sign of CHF
What 5 things should we look at when doing an activity evaluation?
1. Basic mobility/ADLs
2. What is pts response to activity?
3. Monitor vitals during activity
4. Formalized test
5. METs
Name three formalized tests used to evaluate activity.
1. Walk Tests - 6 minute, 1-mile, etc.
2. Graded Exercise Tests - treadmill walk/run, UBE
3. Step tests
What is a metabolic equivilant?
Multiple of resting energy metabolism.
1 MET is equal to what 2 things?
1. Resting metabolic rate in sitting
2. 3.5 mL of oxygen/kg/min.
What assumptions should we make about assessing activity or exercise?
1. That it is primarily aerobic
2. Activity is performed at a steady state (demand = supply)
3. Subject is performing task w/ biomechanical efficency.