Transcript File - Respiratory Therapy Files

Assessment of The
Patient
210a
Objectives
• List The Elements of an Effective And
Thorough Bedside Interview
• List The Factors That Influence
Communication Positively And Negatively
• Define The Difference Between Objective
And Subjective Data
Objectives
• List The Causes of Cough, Sputum
Production, Hemoptysis, Dyspnea, Chest
Pain, Swelling of Feet And Ankles, Fever,
Altered Mental Status, And Dizziness
• Identify Normal And Abnormal Breathing
Patterns
Objectives
• Identify Normal And Abnormal Breath
Sounds
• List The Normal Values of a CBC
• List The Normal Values of a Chemistry
Panel And The Causes of Deviations From
The Normal Values
Objectives
• List The Common Normal Flora Found
During Culture
• List The Pathogens Found During Culture
• List The Normal Values For an Arterial
Blood Gas
Objectives
• List The Indications For Chest Radiography
• List The Common Views And The
Indications For Each
• List The Normal Parts of an ECG Wave
Objectives
• List The Abnormalities of an ECG And
Significance of Each
• Explain The Need for Nutritional
Assessment
Chart Review
• Demographic Data (name, address, next of
kin, medical insurance info…)
• Chief Complaint
• History of Present Illness
• Past Medical History
Chart Review
• Chief Complaint:
• formally known as CC is a concise statement describing the
symptom, problem, condition, diagnosis, physician
recommended return, or other factor that is the reason for a
medical encounter.
• The patient's initial comments to a physician, nurse, or other
health care professional help form the differential diagnosis.
• In some instances, the nature of a patient's chief complaint
may determine whether or not services are covered by
medical insurance
• Open-ended questions are used in order to obtain the
presenting complaint.
• Other terms sometimes used include Reason for
Encounter (RFE), Presenting Problem, Problem on
admission and Reason for Presenting
Chart Review
• History of Present illness (HPI)
• refers to a detailed interview prompted by the chief
complaint or presenting symptom (for example, abdominal
pain).
• SAMPLE history is an mnemonic acronym to remember
key questions for a person's assessment
• The SAMPLE history is usually taken along with vital signs.
It is used for alert people, but often much of this information
can also be obtained from the family of an unresponsive
person.
• Signs and Symptoms
• Allergies
• Medications
• Past medical history
• Last oral intake
• Events leading up to the injury and/or illness
Chart Review
• Past Medical History:
• is the total sum of a patient's health status prior to the
presenting problem. Includes:
• ifferent sources include different questions to be asked while
conducting a PMH, but in general, they include the following:
• General state of health: e.g. excellent, good, fair, poor.
Note any significant change from previous state.
• Past illnesses: e.g. cancer, heart disease, hypertension
,diabetes.
• Hospitalizations: including all medical, surgical, and
psychiatric hospitalizations. Note the date, reason, duration
for the hospitalization.
• Injuries, or accidents: note the type and date of injury.
Chart Review
• Past medical Hx:
• Surgeries: note the type of procedure, date, hospital,
surgeon, and any complications.
• Current medications: note name, dosage, frequency of any
medication, including any over-the-counter medications and
herbal remedies. Note whether patient is taking the
medications according to the prescribed instructions.
• Allergies: note any environmental, food, or drug allergies,
as well as the specific type of reaction, e.g. anaphylaxis,
rash, itching.
• Immunizations: take a careful record of all immunizations,
including tetanus, diphtheria, pertussis, polio, Hepatitis B,
measles, mumps, rubella, Haemophilus influenzae type B,
influenza
• Substance abuse: note any alcohol, tobacco, and illicit drug
use, include type, amount, and duration, as well as any past
treatment or drug rehabilitation.
Chart Review
• Past Medical Hx:
• Diet: ask about everything the patient has eaten the day
before and for the past week. Note the type of food
consumed and do a nutritional status assessment.
• Sleep: a useful mnemonic for sleep patterns is BEARS, for
Bedtime problems (e.g. snoring, sleep apnea, or
nightmares), Excessive daytime sleepiness, Awakenings at
night, Regularity and duration of sleep, Snoring.
• Alternative therapies: e.g. acupuncture, massage…
• sexual history and any history of sexually transmitted
diseases
• . Birth history: details of labor and delivery of patient,
admission to NICU, maternal fever, duration of rupture of
membranes, Apgar scores (particularly import in first three
months of life) Growth and development: plots of height,
weight, and head circumference are standard content for
pediatric records
Chart Review
• If possible, before every patient encounter,
you should review the patients chart
including:
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History and physical
Pulmonologist consultation
Orders (verify your orders!!)
MAR
Labs
Diagnostics (Chest X-ray, PFT, V/Q scan…)
Chart Review
• In order to assess your patient fully and
thoroughly you must first have a good idea
of the patients chief complaint, admitting
diagnosis and history
• The goal is to correlate all the information
you collect in the chart and from the patient
to formulate an appropriate respiratory
therapy plan or course of action (for you
case studies, you will also need to
formulate a overall plan, not just a RT plan)
Chart Review
• Family History: genetic factors, smoking in
home…
• Social And Environmental History: Work
related illness, smoking/alcohol/drug use?
• Review of Systems: This is found on the
History and Physical, performed by every
consulting MD and the primary care provider
(PCP)
Chart Review
• Review of Systems:
• A review of systems (also called a
systems enquiry) is a technique used by
health-care providers for eliciting a history
from a patient. It is often structured as a
component of an admission note covering
the organ systems, with a focus upon the
subjective symptoms perceived by the
patient (as opposed to the objective signs
perceived by the clinician). It can be
particularly useful in identifying conditions
that don't have precise diagnostic tests
Chart Review
• Review of systems:
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Eyes
Head, Ears, Nose, Throat (HENT)
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Pyschiatric
Hematologic
Immunological
Patient Encounter
• Before seeing your patient:
– Know their name
– Review their chart
– Have your equipment ready (if needed)
• Abide by any isolation requirement as
necessary
• Knock on door, introduce yourself as a
student respiratory therapist state purpose
of visit
• Wash hands at door way
• Ask patient to state their name
• Put on gloves
• Identify further by asking birth date, look at
arm band to confirm
Patient Encounter
• Ensure patient is understanding of your
purpose, ask questions, and answer
patient
• Continue assessment
The Patient Interview
• Purpose
– Establish Rapport
– Obtain Diagnostic Information
– Monitor Changes in Patient Condition
The Patient Interview
• Guidelines
– Give The Patient Your Complete Attention
– Be Professional in Both Demeanor And
Speech (address patient by Mr or Mrs)
– Take into consideration cultural diversity
The Patient Interview
• Guidelines
– Respect The Patient’s Beliefs, Attitudes, And
Rights (some patients will be combative,
confused, rude, angry…TREAT ALL
PATIENTS AS CUSTOMERS)
– Use a Friendly, Relaxed, Conversational Tone
The Patient Interview
• Guidelines
– Obtain Information Through Asking Questions
• Open-Ended Question
• Closed, Specific Questions
• Indirect Questions (Less Threatening)
• Neutral Questions (Not Implying an Answer)
The Patient Interview
• What you should ask in a initial RT
protocol interview: (RT focused)
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Smoking history (pack years)
Hx of respiratory illness/disease
Cough/congestion hx
Use of Oxygen and Respiratory medications
at home
– Based on this interview, chart review and
physical respiratory assessment, you may
then come up with a treatment plan
The Physical Examination
• Vital Signs
– Pulse (do Not rely on P.Ox)
• Rate (normal 60-100)
• Rhythm (strong but not bounding)
• http://www.youtube.com/watch?v=36zbMwxo
M6g
The Physical Examiniation
• Pulse:
• Pulsus alternans is a physical finding with arterial
pulse waveform showing alternating strong and weak
beats. It is almost always indicative of left ventricular
systolic impairment, and carries a poor prognosis.
• In left ventricular dysfunction, the ejection fraction will
decrease significantly, causing reduction in stroke
volume, hence causing an increase in end-diastolic
volume
• There may initially be a tachycardia as a
compensatory mechanism to try to keep the cardiac
output constant. As a result, during the next cycle of
systolic phase, the myocardial muscle will be stretched
more than usual and as a result there will be an
increase in myocardial contraction, This results, in
turn, in a stronger systolic pulse
The Physical Examiniation
• Pulse:
• http://www.youtube.com/watch?v=jTsjCZ9
QxW8
• abnormally large decrease in systolic blood pressure and
pulse wave amplitude during inspiration. The normal fall in
pressure is less than 10mmHg or 10torr. When the drop is
more than 10mmHg, it is referred to as pulsus paradoxus.
That is, pulsus paradoxus has nothing to do with pulse rate
or heart rate. The normal variation of blood pressure during
breathing/respiration is a decline in blood pressure during
inhalation/inspiration and an increase during
exhalation/expiration. Pulsus paradoxus is a sign that is
indicative of several conditions including cardiac tamponade,
pericarditis, chronic sleep apnea, croup, and obstructive
lung disease
The Physical Examination
• Bounding pulse:
• normal under heavy exercise, pregnancy,
alcohol consumption, or high anxiety.[
• It is common for people over the age of 60
to develop signs of this due to an overall
increase in the systolic pressure from
hardening arteries (Atherosclerosis).
• A bounding pulse is also often associated
with high blood pressure and large stroke
volume, and HYPOXEMIA
The Physical Examination
• Weak/Thready Pulse:
• Possible hypotension, failing heart, low
heart rate
• Besides the pulse, the rate is also
important, note Tachycardia vs.
Bradycardia. If patient is on a ECG monitor
not presence of arrhythmias:
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PVC
A-fib/A-flutter
VT/VF
Sinus rhythm vs. Junctional
Blocks…
The Physical Examination
• Vital Signs
– Respiration
• Rate (normal is 12-18)
• Breathing Pattern (Accessory muscle use?)
Heart Rate/Rhythm
Cardiac monitors used in Telemetry floors, ER, ICU
The Physical Examination
• Breathing should be a quiet process, so
when it is obvious/noticeable, it typically
means distress.
• Note presence of accessory muscle use,
belly breathing, tripod breathing, grunting,
diaphoresis, tachypnea/bradypnea,
hyperventilation, Biots, Kussmauls,
Cheyne Stokes…
• Assess by placing hand on shoulder/upper
chest
• http://www.medicalvideos.us/play.php?vid=
260
The Physical Examination
• Increased rate:
– Metabolic acidosis compensation
– Decreased tidal volume/decreased VA
(increased deadspace, pulmonary emboli,
edema, airtrapping…)
– Increased VO2
– Anxiety/Pain/Fear
– Fever/increased metabolic demand
– Neurological impairment
– Increased heart rate
– Exertion
– Medication (stimulants)
– *Tx if indicated/sedatives? Fix underlying cause
The Physical Examination
• Decreased Rate:
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Metabolic Alkalosis compensation
Increased tidal volume
Hypothermia
Sedatives
Sleeping
Neurological impairment
– *We must ensure patient with decreased
rate has a adequate minute volume/VA, to
ensure proper acid/base balance.
– Possible assistance in ventilation required
Apnea Monitor
Common with post surgical patients, risk of SIDS and
OSA patients
The Physical Examination
– Blood Pressure (normal 90-130/40-60)
• Hypertensive (possible stroke, stress, diabetes,
hypervolemia, CAD, COPD)
• Hypotensive (shock, dehydration, hypovolemia, sepsis,
medications)
• Manual/automatic or continuous with A-line
– Temperature (36-38 Celsius)
• Hyperthermia (seizures, increased VO2…)
• Hypothermia
• (thermometer, temporal scan)
Blood Pressure/ sphygmomanometer
composed of an inflatable cuff to restrict blood flow, and a mercury
or mechanical manometer to measure the pressure. It is always used
in conjunction with a means to determine at what pressure blood
flow is just starting, and at what pressure it is unimpeded. Manual
sphygmomanometers are used in conjunction with a stethoscope.
Physical Examination
• Hyperthermia occurs when the body produces or absorbs
more heat than it can dissipate. When the elevated body
temperatures are sufficiently high, hyperthermia is a medical
emergency and requires immediate treatment to prevent
disability or death.
• The most common causes are heat stroke and adverse
reactions to drugs. Heat stroke is an acute condition of
hyperthermia that is caused by prolonged exposure to
excessive heat or heat and humidity. The heat-regulating
mechanisms of the body eventually become overwhelmed
and unable to effectively deal with the heat, causing the
body temperature to climb uncontrollably. Hyperthermia is a
relatively rare side effect of many drugs, particularly those
that affect the central nervous system. Malignant
hyperthermia is a rare complication of some types of general
anesthesia.
General
• Level of Consciousness
•
http://www.youtube.com/watch?v=aH0SsX51bd0
Consciousness
• Consciousness is defined as the state of
being aware of physical events or mental
concepts. Conscious patients are awake
and responsive to their surroundings
• The level of consciousness has been
described as the degree of arousal and
awareness. A manifestation of altered
consciousness implies an underlying brain
dysfunction. Its onset may be sudden, for
example following an acute head injury, or
it may occur more gradually, such as in
hypoglycaemia.
Consciousness
• Causes of altered consciousness
• A range of situations can lead to altered
consciousness. These include: profound
hypoxemia; hypercapnia; cerebral
hypoperfusion; stroke; convulsions;
hypoglycemia; recent administration of
sedatives or analgesic drugs; drug
overdose; subarachnoid hemorrhage; and
alcohol intoxication
LOC
• Level of consciousness
• It is not possible to directly assess the level
of consciousness - it can only be assessed
by observing the patient’s behavioural
response to different stimuli.
• During the initial rapid assessment of the
critically ill patient, it is helpful to use the
AVPU scale, with an examination of the
pupils; the GCS should be used in the full
assessment
LOC
• The AVPU scale is a quick and easy
method to assess level of consciousness.
It is ideal in the initial rapid ABCDE
assessment:
• Alert;
• Responds to voice;
• Responds to pain;
• Unconscious
LOC
• Glasgow Coma Scale or GCS is a
neurological scale that aims to give a
reliable, objective way of recording the
conscious state of a person for initial as
well as subsequent assessment. A patient
is assessed against the criteria of the
scale, and the resulting points give a
patient score between 3 (indicating deep
unconsciousness) and 15 (most
awake/alert)
LOC
• GCS
• Individual elements as well as the sum of
the score are important.
• Generally, brain injury is classified as:
• Severe, with GCS ≤ 8
• Moderate, GCS 9 - 12
• Minor, GCS ≥ 13.
• Tracheal intubation and severe facial/eye
swelling or damage make it impossible to
test the verbal and eye responses. In these
circumstances, the score is given as 1 with
a modifier attached
LOC terms
•
•
•
•
•
•
•
Awake/Alert
Awake/confused
Confused/combative
Stupordous
Lethargic
Obtunded
Comatose
Skin Appearance
• Skin
– Color – Normal, Pale (shock), Flushed
Cyanotic
– Warm, Cold
– Dry, Diaphoresis (sweating)
General
• Eyes
– Pupil dilation/constriction
– Certain drugs cause constriction of the pupils,
such as alcohol and opioids. Other drugs,
such as atropine, LSD, MDMA, mescaline,
psilocybin mushrooms, cocaine and
amphetamines may cause pupil dilation.
• Neck
– Jugular Venous Distension (JVD)
• Raised JVP, normal waveform Bradycardia
• Fluid overload
• Heart Failure
• Tracheal Position
• http://www.youtube.com/watch?v=DKRj
4k7thEY
General
• Thorax
– Configuration
– Movement
– Synchronicity
– Effort
Abnormal Thorax movement
• Flail Chest
• http://www.youtube.com/watch?v=a8H8emId-M&feature=related
• Accessory muscle use/stridor
• http://www.youtube.com/watch?v=Zkau4y
HsLLM&feature=related
• Retractions (seen in neonates/infants)
• http://www.youtube.com/watch?v=42jJ18fk
Z0Y
• Abdominal breathing (air-trapping)
Examination of the Thorax
• A Barrel Chest is Seen With Emphysema
And Indicates That Lung Recoil is Poor
General
• Palpation of The Chest
– Vocal Fremitus
– Thoracic Expansion
– Diaphragmatic Excursion
Vocal/Tactile Fremitus
• the vibration of the chest wall as a person
speaks or sings that allows the person's
voice to be heard by auscultation of the
chest with a stethoscope. Vocal fremitus is
decreased in emphysema, pleural effusion,
pulmonary edema, and bronchial
obstruction and is increased in
consolidation, as in pneumonia.
• http://www.youtube.com/watch?v=dx4_M0
GEZrg
Tactile Fremitus
• is a vibration felt on the patient's chest during low
frequency vocalization. Commonly, the patient is
asked to repeat a phrase while the examiner feels
for vibrations by placing a hand over the patient's
chest or back. Phrases commonly used 'Ninetynine' is classically included,
• Tactile fremitus is normally more intense in the
right second intercostal space, as well as in the
interscapular region, as these areas are closest to
the bronchial bifurcation. Tactile fremitus is
pathologically increased over areas of
consolidation and decreased or absent over areas
of pleural effusion or pneumothorax (where there
is liquid or air instead of usual lung).
General
• Percussion of The Chest
– Use of Indirect Percussion
– Evaluated for Intensity And Pitch
General
• Auscultation of Lungs
– Normal Breath Sounds
• Vesicular – Lung Periphery
• Bronchovesicular – Upper Part of Sternum,
Between Scapulae
• Tracheal – Over Trachea
• http://www.youtube.com/watch?v=nUJQvFXmTxQ&feat
ure=related
General
• Auscultation of Lungs
– Abnormal (Adventitious) Breath Sounds
• Diminished
• Crackles
• Wheezes
• Stridor
• Friction Rub
• http://www.youtube.com/watch?v=h7BtrWATfg8
• http://www.youtube.com/watch?v=5JA6D1Mguh0
Diminished
• Typically associated with air trapping,
COPD.
• Listen carefully for changes after breathing
treatment
• Also caused by collapsed lungs
Crackles
• Fine: inspiratory, as alveoli open, typically
caused by fluid/pulmonary edema in the
small airway. May become audible
depending on severity
• Caused by CHF, ARDS, Pneumonia,
atelectasis
• Coarse: another name for Rhonci,
secretions in the large airway
Wheezes
• May be inspiratory, expiratory or both
• A wheeze (formally called "sibilant rhonchi" in
medical terminology) is a continuous, coarse,
whistling sound produced in the respiratory
airways during breathing.
• For wheezes to occur, some part of the
respiratory tree must be narrowed or obstructed,
or airflow velocity within the respiratory tree must
be heightened.
• Asthma, pulmonary emboli, cardiac wheeze,
pneumonia, lung cancer…
• Unilateral vs bilateral
Pleural friction rub
• or simply pleural rub, caused by diagnosis of
pleurisy and other conditions affecting the chest
cavity.
• Pleural friction rubs are the squeaking or grating
sounds of the pleural linings rubbing together and
can be described as the sound made by treading
on fresh snow. They occur where the pleural
layers are inflamed and have lost their lubrication.
Pleural rubs are common in pneumonia,
pulmonary embolism, and pleurisy (pleuritis).
Because these sounds occur whenever the
patient's chest wall moves, they appear on
inspiration and expiration
General
• Voice Sounds
• Auscultation of Heart Sounds
– First Sound (S1)– Closure of Mitral And
Tricuspid Valves During Systole
– Second Sound (S2) – Closure of Pulmonic
And Aortic Valves During Diastole
– http://www.youtube.com/watch?v=cFHlEDwzc
Zk
General
• Extremities
– Clubbing
– Cyanosis
– Pedal Edema
– Capillary Refill
– Peripheral Temperature
Examination of The Extremities
• Digital Clubbing is Not Common But is Seen
in a Large Variety of Chronic Conditions:
Congenital Heart Disease, Bronchiectasis,
Various Cancers, And Interstitial Lung
Diseases
Peripheral Edema
Peripheral Edema
• Can be caused by many other conditions,
including congestive heart failure, trauma,
alcoholism, altitude sickness, pregnancy,
hypertension, or merely long periods of
time sitting or standing without moving.
• Pitting edema
Capillary Refill
• http://www.youtube.com/watch?v=YaBzQg
TK9Yk
Clinical Laboratory Studies
• Complete Blood Count (CBC)
– Red Blood Cell (RBC) Count
– Hemoglobin
– Hematocrit
– White Blood Cell (WBC) Count
– Platelet Count
Normal Values
RBCs
Men
Women
Hemoglobin
Men
Women
Hematocrit
Men
Women
4.6 – 6.2 x 106/mm3
4.2 – 5.4 x 106/mm3
13.5 – 16.5 g/dl
12 – 15 g/dl
40% - 54%
38% - 47%
CBC
• Anemia: caused by blood loss, iron
deficiency, chronic renal failure, decreases
CaO2, energy levels…. Treat with blood
transfusion, oxygen. Patient will not be
breathing faster, SpO2 will not be affected
• Polythcemia: caused by chronic lung
disease not treated with O2, or high
altitude. Treat with O2, risk for thrombis
• http://www.youtube.com/watch?v=j7PJrUF
ciec
Normal Values
WBCs – Differential
Segmented Neutrophils
40% - 75%
Bands
0% - 6%
Eosinophils
0% - 6%
Basophils
0% - 1%
Lymphocytes
20% - 45%
Monocytes
2% - 10%
Normal Values
WBCs–Absolute Value
Neutrophils
1800 – 7500
Eosinophils
0 – 600
Basophils
0 – 100
Lymphocytes
90 – 1000
Monocytes
900 - 4500
Platelets
150,000– 400,000/mm3
Neutrophilss
• Neutrophils, are also known as "segs“
• Normally, most of the neutrophils circulating in the
bloodstream are in a mature form, with the
nucleus of the cell being divided or segmented.
HENCE term Segs
• Because of the segmented appearance of the
nucleus, neutrophils are sometimes referred to as
"segs." The nucleus of less mature neutrophils is
not segmented, but has a band or rod-like shape.
Less mature neutrophils - those that have recently
been released from the bone marrow into the
bloodstream - are known as "bands" or "stabs".
Stab is a German term for rod.
• Bands: new infection; Segs: less new
Acute infection
• An increased need for neutrophils, as with an acute bacterial
infection, will cause an increase in both the total number of mature
neutrophils and the less mature bands or stabs to respond to the
infection. The term "shift to the left" is often used when
determining if a patient has an inflammatory process such as
acute appendicitis or cholecystitis. This term is a holdover from
days in which lab reports were written by hand. Bands or stabs,
the less mature neutrophil forms, were written first on the left-hand
side of the laboratory report. Today, the term "shift to the left"
means that the bands or stabs have increased, indicating an
infection in progress.
• For example, a patient with acute appendicitis might have a "WBC
count of 15,000 with 65% of the cells being mature neutrophils
and an increase in stabs or band cells to 10%". This report is
typical of a "shift to the left", and will be taken into consideration
along with history and physical findings, to determine how the
patient's appendicitis will be treated.
Neutrophils
• Defend against bacterial or fungal infection
and other very small inflammatory
processes that are usually first responders
to microbial infection; their activity and
death in large numbers forms pus.
• Neutrophils are the most common cell type
seen in the early stages of acute
inflammation, and make up 60-70% of total
leukocyte count in human blood.
• The life span of a circulating human
neutrophil is about 5.4 days
Eosinophil's
• Eosinophils primarily deal with parasitic
infections. Eosinophils are also the
predominant inflammatory cells in allergic
reactions. The most important causes of
eosinophilia include allergies such as
asthma, hay fever, and hives; and also
parasitic infections. In general, their
nucleus is bi-lobed. The cytoplasm is full of
granules that assume a characteristic pinkorange color with eosin stain.
Basophils
• Basophils are chiefly responsible for
allergic and antigen response by releasing
the chemical histamine causing
vasodilation.
• The nucleus is bi- or tri-lobed, but it is
hard to see because of the number of
coarse granules that hide it. They are
characterized by their large blue granules.
Lymphocytes
• The blood has three types of lymphocytes:
• B cells: B cells make antibodies that bind to
pathogens to enable their destruction. some B
cells will retain the ability to produce an antibody
to serve as a 'memory' system.
• T cells:
– CD4+ (helper) cells co-ordinate the immune
response and are important in the defense
against intracellular bacteria. In acute HIV
infection, these T cells are the main index to
identify the individual's immune system
activity
– T cells are able to kill virus-infected and
tumor cells.
Monocytes
• Monocytes share the "vacuum cleaner"
(phagocytosis) function of neutrophils, but
are much longer lived as they have an
additional role: they present pieces of
pathogens to T cells so that the pathogens
may be recognized again and killed, or so
that an antibody response may be
mounted. Monocytes eventually leave the
bloodstream to become tissue
macrophages, which remove dead cell
debris as well as attacking
microorganisms.
WBC
• Leukocytosis is a raised white blood cell count
above the normal range It is frequently a sign of
an inflammatory response,[most commonly the
result of infection, and is observed in certain
parasitic infections. It may also occur after
strenuous exercise, convulsions such as epilepsy,
emotional stress, pregnancy and labor,
anesthesia, and epinephrine, steroid
administration.
• WBC total, bands (immature neutrophils),
neutrophils, eosinophils, basophils, lymphocytes,
and monocytes. This is the basis for a "shift to the
left."
WBC
• Leukopenia is a decrease in the number
of white blood cells in which places
individuals at increased risk of infection.
• Neutropenia is a sub-type of leukopenia
that refers to a decrease in the number of
circulating neutrophil granulocytes, the
most abundant white blood cells. The
terms leukopenia and neutropenia may
occasionally be used interchangeably, as
the neutrophil count is the most important
indicator of infection risk.
Chemistry Results
• Sodium (Na+)
• Mainly Responsible For Osmotic Pressure of
Extracellular Fluid
• Normal Value: 137 – 147 mEq/L
Sodium
+
(Na )
• Causes of Hypernatremia (High Na+)
– Profuse Sweating
– Diarrhea
– Renal Disease
– Prolong Hyperpnea
– Essentially fluid loss
Hypernatremia is generally not caused by an excess of
sodium, but rather by a relative deficit of free water in the
body. For this reason, hypernatremia is often synonymous
with the less precise term, dehydration.
Sodium (Na+)
• The cornerstone of treatment is
administration of free water to correct the
relative water deficit. Water can be
replaced orally or intravenously.
• Water alone cannot be administered as
intravenously (because of osmolarity
issue) rather can be given with addition to
dextrose or saline infusion solutions.
Sodium
+
(Na )
• Causes of Hyponatremia (Low Na-)
– Excessive Free Water Intake/Retention
– Excessive Sodium Loss
Potassium
• Major Cation Occurring Within Cells
• Normal Value: 3.5 – 4.8 mEq/L
+
(K )
Potassium (K+)
• Causes of Hypokalemia (Low K+)
– Decreased K+ Intake
• Low Potassium Diet
• Alcoholism
Causes of Hypokalemia (Low K+)
• Increased Loss of Potassium
– Gastrointestinal Loss
– Renal Disease
– Diuretics
Causes of Hypokalemia (Low K+)
• Extracellular to Intracellular Shift of
Potassium
– Alkalosis
– Increased Plasma Insulin
– Diuretic Use
Causes of Hyperkalemia (High K+)
• Increase K+ Intake
– High Potassium Diet
– Oral Potassium Supplements
– Transfusion of Old Blood
– Extreme hyperkalemia is a medical
emergency due to the risk of potentially fatal
abnormal heart rhythms
Causes of Hyperkalemia (High K+)
• Decreased Potassium Excretion
– Renal Failure (unable to eliminate)
– Hypoaldosteronism
Causes of Hyperkalemia (High K+)
• Intracellular to Extracellular Shift of
Potassium
– Acidosis
– Crush Injuries
– Tissue Hypoxia
Causes of Hyperkalemia (High K+)
• Pseudohyperkalemia
– Hemolysis
– Leukocytosis
Symptoms
• Symptoms are fairly nonspecific and
generally include malaise, palpitations and
muscle weakness; mild hyperventilation
may indicate a compensatory response to
metabolic acidosis, which is one of the
possible causes of hyperkalemia. Often,
however, the problem is detected during
screening blood tests for a medical
disorder, or it only comes to medical
attention after complications have
developed, such as cardiac arrhythmia or
sudden death.
Chloride (Cl-)
• Chief Anion in Extracellular Fluid
• Normal Value: 98 – 105 mEq/L
Chloride (Cl-)
• Causes of Hypochloremia
– Prolonged Vomiting
– Chronic Respiratory Acidosis
– Addisonian Crisis
– Certain Kidney Diseases
Chloride (Cl-)
• Causes of Hyperchloremia
– Prolonged Diarrhea
– Certain Kidney Diseases
– Hyperparathyroidism
SCHEDULE
• FRIDAY: PT ASSESSMENT PPT, CXR
• MONDAY: PT ASSESSMENT LAB
• BRING LAB COMPENTENCIES BOOK TO
GET CHECKED OFF
• TUESDAY: QUIZ, BRONCHOSCOPY,
ELECTROLYTES/LABS
• WEDNESDAY: UNIT EXAM, AIRWAY
MANAGEMENT
• THURSDAY: AIRWAY MANAGEMENT
• FRIDAY: AIRWAYMANAGEMENT LAB
• BRING LAB COMPENTENCIES BOOK TO
GET CHECKED OFF
Carbon Dioxide/Bicarbonate (HCO3)
• Second Most Plentiful Anion in The Serum
• Normal Value: 25 – 33 mEq/L
• Increased in Metabolic Alkalosis or
Compensation For Respiratory Acidosis
• Decreased in Metabolic Acidosis or
Compensation For Respiratory Alkalosis
Blood Urea Nitrogen (BUN)
• Used in Assessing Renal Function and also
cardiac function
• Normal Value: 7 – 20 mg/dl
• Urea is a by- product from metabolism of
proteins by the liver and is removed from the
blood by the kidneys.
• The liver produces urea in the urea cycle as
a waste product of the digestion of protein.
Blood Urea Nitrogen (BUN)
• Causes of Increased BUN
– Kidney Disease Leading to Decrease in
Filtration, Increase in Retention of Urea
– Conditions Causing Decreased Renal
Perfusion (Shock, Heart Failure)
– Diet
– State of Hydration
Creatinine (Cr)
• Waste Product Formed Within Muscle Tissue And
Filtered Out by The Kidneys
• Use BUN/Cr to assess kidney function
• Normal Value: 0.7 – 1.3 mg/dl
• Measuring serum creatinine is a simple test and it is the
most commonly used indicator of renal function.
• A rise in blood creatinine level is observed only with
marked damage to functioning nephrons. Therefore, this
test is not suitable for detecting early-stage kidney
disease.
Creatinine (Cr)
• Increased in Kidney Disease in Which >50%
of Renal Nephrons Destroyed
• Increased in Certain Muscle Disease
Total Protein
• Screening Test to Detect Gross
Abnormalities in Overall Protein Synthesis
• Normal Value: 6.3 – 7.9 g/dl
• Decrease in Total Protein in Liver Disease,
Nephrotic Syndrome, Severe Malnutrition
Albumin
• Protein That Functions as a Transport And
Storage Substance For Hormones, Drugs,
And Electrolytes
• Secreted by Liver Cells
• Normal Value: 3.5 – 5.0 g/dl
Albumin
• Albumin is the main protein of plasma; it
binds water, cations (such as Ca2+, Na+
and K+), fatty acids, hormones, bilirubin,
thyroxine (T4) and drugs (including
barbiturates) - its main function is to
regulate the colloidal osmotic pressure of
blood.
Albumin
• Decrease in Albumin (Hypoalbuminemia)
– Protein Malnutrition
– Severe Liver Disease
• Leads to Loss of Fluid From Vascular
Spaces And Edema Throughout The Body
Cholesterol
• Used as Fuel Storage And Building Blocks
For Hormones, Cell Walls, Etc
• Normal Value: 150 – 220 mg/dl
• Separated by Centrifuge Into High Density
Lipids (HDL) And Low Density Lipids (LDL);
HDL Has Decreased Cardiac Risk
Cholesterol
• Cholesterol is required to build and maintain
membranes; it modulates membrane fluidity over the
range of physiological temperatures. The hydroxyl
group on cholesterol interacts with the polar head
groups of the membrane phospholipids and
sphingolipids, while the bulky steroid and the
hydrocarbon chain are embedded in the membrane,
alongside the nonpolar fatty acid chain of the other
lipids. Through the interaction with the phospholipid
fatty acid chains, cholesterol increases membrane
packing, which reduces membrane fluidity.
• In this structural role, cholesterol reduces the
permeability of the plasma membrane to neutral
solutes,[protons, (positive hydrogen ions) and sodium
ions
Glucose
• Normal Value: 70 – 105 mg/dl
• Increase in Glucose (Hyperglycemia)
– Medications, Such as Steroids
– Acidosis Caused by Accumulation of
Ketoacids (Ketoacidosis)
– Associated With Increased Risk of Stroke,
Cardiovascular Disease, And Renal Failure
– Tx: Insulin,
• People with both type 1 and type 2 diabetes can become
hyperglycemic. For example, if a person with type 1
diabetes doesn’t take their insulin
• People who eat too much, aren’t active and undergo either
physical or emotional stress are at high risk for
hyperglycemia.
• Diabetics experience two types of hyperglycemia: fasting
hyperglycemia and postprandial hyperglycemia. With
fasting hyperglycemia, the blood sugar level is higher than
130 after not eating for eight hours. In postprandial
hyperglycemia, the blood sugar level is higher than 180.
This often occurs a couple of hours after eating a large
meal. If a person’s blood sugar level is elevated after most
meals, they may be at risk for type 2 diabetes.
Glucose
• Decrease in Glucose (Hypoglycemia)
– Uncommon Problem
– Usually Caused by Excessive Insulin in The
Blood
– Causes a decreased LOC
Culture & Sensitivity Studies
• Used to Determine The Presence of
Pathogens And The Use of Antibiotics
• Collecting sputum:
– Induce cough
– Suctioning patient
Leukens/Suctioning Trap
• http://www.youtube.com/watch?v=1dhb6e
BEV8o
Gram Staining
• Gram Positive – Organisms Stain Purple
• Gram Positive Cocci – Micrococcus,
Staphylococcus, Streptococcus
• Gram Positive Rods – Bacillus, Clostridium,
Mycobacterium, Lactobacillus
Gram Staining
• Gram Negative – Organisms Stain Red
• Gram Negative Cocci – Neisseria, Moraxella
• Gram Negative Rods – Pseudomonas,
Escherichia, Enterobacter, Proteus,
Salmonella, Shigella, Klebsiella
Acid-Fast Staining
• Acid-Fast – Organisms Stain Pink
• Non-Acid-Fast – Organisms Stain Blue
• Used Most Commonly as a Specific Test to
Detect Mycobacterium Tuberculosis
Sensitivity Testing
• Organisms Cultured in The Presence of
Various Antibiotics
• Lack of Growth in The Area of a Certain
Antibiotic Indicates Organism is Sensitive to
That Antibiotic
Arterial Blood Gas Results
• Findings Indicating a Need For Arterial
Puncture
– Acute Dyspnea
– Chest Pain
– Cough, Fever, Sputum Production Consistent
With Pneumonia
Findings Indicating a Need For
Arterial Puncture
• Possible CO Poisoning
• History of COPD
• Cyanosis
• Diffuse Crackles or Wheezing on
Auscultation
Findings Indicating a Need For
Arterial Puncture
• Severe Tachypnea or Abnormal Breathing
Pattern
• Unexplained Confusion
• Chest Trauma
Findings Indicating a Need For
Arterial Puncture
• Unexplained Polycythemia
• Severe Electrolyte Abnormalities
• Significant Atelectasis on X-ray
• Diffuse Infiltrates on X-ray
Arterial Blood Gas Results
• Normal Values
– pH: 7.35 – 7.45
– PaCO2: 35 – 45 mmHg
– HCO3: 22 – 26 mEq/L
– BE: ± 2 mEq/L
– PaO2: 80 – 100 mmHg
– SaO2: 93% - 97%
Levels of Hypoxemia
• Mild: PaO2 of 60 – 79 mmHg
• Moderate: PaO2 of 40 – 59 mmHg
• Severe: PaO2 of < 40 mmHg
Alveolar-Arterial Oxygen
Difference
• P(A-a)O2 = PAO2 – PaO2
– Measures the Pressure Difference Between
Alveoli And Arterial Blood
– Normal Value: 10 – 15 mmHg
– Increase in P(A-a)O2 Caused by Defects in
Ability to Oxygenate
Mixed Venous Partial Pressure
of Oxygen (PvO2)
• Indicative of Tissue Oxygenation
• Normal Value: 38 – 42 mmHg
• Decrease Indicates Tissue Oxygenation
Less Than Optimal
• May Indicate Impairment of Circulation
Arteriovenous Oxygen Content
Difference C(a-v)O2
• Arterial and Mixed Venous Blood Sampled
Simultaneously
• Normal Value: 3.5 – 5.0 vol%
Arteriovenous Oxygen Content
Difference C(a-v)O2
• Increased in Patient With Stable Minute
Oxygenation, But Perfusion Decreasing
• Decreased in Patient With Stable Minute
Oxygenation, But With Excessive Perfusion
or Hypothermia
Carboxyhemoglobin (HbCO)
• Indicates Quantity of Carbon Monoxide
Bound to Hemoglobin
• Normal Value: 0.5%
Carboxyhemoglobin (HbCO)
• Mildly Elevated (5% - 10%) With Cigarette
Smoking
• Elevation of > 10% With Inhalation of Large
Quantities of Smoke, Exhaust, Etc
Determination of Acid-Base
State
• Acidemia
• Compensation
– Metabolic
– Partial Compensation
– Respiratory
– Full Compensation
• Alkalemia
– Metabolic
– Respiratory
Chest Radiograph
• Indications For Chest X-Ray
– Unexplained Dyspnea
– Cough, Sputum, And Fever
– Chest Trauma
– Aspiration of Foreign Object
– http://www.learningradiology.com/lectures/facultylectu
res/Basic%20Chest%20XRay%20Interpretation/player.html
Chest Radiograph
• Indications For Chest X-Ray
– History of COPD
– History of Pulmonary Fibrosis
– History of Inhalation of Dusts
Chest Radiograph
• Indications For Chest X-Ray
– Crackles or Wheezes on Auscultation
– Unilateral Decrease in Breath Sounds
– Pedal Edema
Chest Radiograph
• Indications For Chest X-Ray
– Severe Hypoxemia
– Acute Hypercarbia
– Post Intubation
Chest Radiograph
• Indications For Chest X-Ray
– Post CVP or PA Line Placement
– Post Chest Tube Placement
– Post Thoracic Surgery
Chest Radiograph
• Indications For Chest X-Ray
– Post CPR
– Sudden Increase in Peak Airway Pressure
During Mechanical Ventilation
– Routine Screening for Infectious Diseases
Chest Anatomy on The Film
Different tissues in our body absorb X-rays at different
extents:
•Bone- high absorption (white)
•Tissue- somewhere in the middle absorption (grey)
•Air- low absorption (black)
Be
systematic
:
1) Check the quality of the film
Film Quality
• First determine is the film a PA or AP view.
PA- the x-rays penetrate through the back of the patient
on to the film
AP-the x-rays penetrate through the front of the patient
on to the film.
All x-rays in the PICU are portable and are AP view
Film Quality (cont)
• Was film taken under full inspiration?
-10 posterior ribs should be visible.
Why do I say posterior here?
When X-ray beams pass through the anterior chest on to the film
Under the patient, the ribs closer to the film (posterior) are most
apparent.
A really good film will show anterior ribs too, there should
Be 6 to qualify as a good inspiratory film.
Quality (cont.)
• Is the film over or
under penetrated if
under penetrated you
will not be able to see
the thoracic
vertebrae.
Quality (cont)
• Check for rotation
– Does the thoracic
spine align in the
center of the
sternum and
between the
clavicles?
– Are the clavicles
level?
Verify Right and Left sides
• Gastric bubble should be on the left
Now you are ready
• Look at the diaphram:
for tenting
free air
abnormal elevation
• Margins should be
sharp
(the right hemidiaphram is
usually slightly higher than
the left)
Check the Heart
•
•
•
•
Size
Shape
Silhouette-margins should be sharp
Diameter (>1/2 thoracic diameter is
enlarged heart)
Remember: AP views make heart appear larger
than it actually is.
Cardiac Silhouette
1. R Atrium
4. Superior Vena
2. R Ventricle
Cava
3. Apex of L Ventricle
7. Pulmonary Valve
8. Pulmonary Trunk
Check the costophrenic angles
Margins should
be sharp
Loss of Sharp Costophrenic
Angles
Check the hilar region
• The hilar – the large
blood vessels going
to and from the lung
at the root of each
lung where it meets
the heart.
• Check for size and
shape of aorta,
nodes,enlarged
vessels
Finally, Check the Lung Fields
•
•
•
•
•
•
Infiltrates
Increased interstitial markings
Masses
Absence of normal margins
Air bronchograms
Increased vascularity
Hemothorax
Normal Chest Films
Emphysema
Chest Radiograph
• Views
• Posteroanterior (PA) View
– X-ray Beam Passes From Posterior of Patient
to Anterior
– Minimizes Cardiac Magnification
Views
• Lateral View
– Commonly Left Side Placed Against X-Ray
Plate
– Minimizes Cardiac Magnification
Views
• Lateral Decubitus View
– Patient Lying on Right or Left Side
– Able to Detect Presence of Fluid in The Chest
– May be Helpful in Detection of Pneumothorax
Views
• Oblique Views
– Patient Turned 45° to Right or Left With
Anterolateral Chest Against Film
– Helps to Delineate a Pulmonary or
Mediastinal Lesion
Views
• Anteroposterior (AP) View
• X-Ray Beam Passes From Anterior of
Patient to Posterior
• Common With Portable X-Rays
• Can Have Significant Magnification,
Rotation, or Exposure Issues
Pneumothorax
Tension Pneumothorax
Post Procedural X-Rays
• Tracheal Intubation
– Evaluate Position of Endotracheal Tube
– Inferior Tip Approximately 3 to 5 cm Above
The Carina
– If Tube is Repositioned, Repeat X-Ray May be
Done
Endotracheal Tube Placement
Post Procedural X-Rays
• Central Venous Line
– Catheter is Placed Into Right or Left
Subclavian or Jugular Vein
– Placed Just Above Juncture of Right Atrium
And Superior Vena Cava
Post Procedural X-Rays
• Pulmonary Artery Catheter
– Also Known as Swan-Ganz Catheter
– Checked Daily to Monitor Correct Position
– Placed in Pulmonary Artery And Sutured in
Place
Post Procedural X-Rays
• Chest Tube
– Placed to Provide Drainage of Fluid of
Removal of Free Air
– Checked to Ensure That Drainage is Being
Accomplished
Computed Tomography
Scanning (CT Scan)
• Very Accurate Three Dimensional Imaging
• Useful in Diagnosing Certain Clinical
Conditions
– Lung Tumors
– Chronic Interstitial Lung Disease
Computed Tomography
Scanning (CT Scan)
• Useful in Diagnosing Certain Clinical
Conditions
– Early Diagnosis of Pneumonias Associated
With Acquired Immunodeficiency Syndrome
(AIDS)
– Pneumoconiosis And Other Occupational
Diseases
Computed Tomography
Scanning (CT Scan)
• Useful in Diagnosing Certain Clinical
Conditions
– Pneumonia
– Bronchiectasis
– Chronic Obstructive Pulmonary Disease
(COPD)
Right Middle Lobe Pneumonia
Empyema
Magnetic Resonance Imaging
(MRI)
• Limited Role in Diagnosis of Intrathoracic
Lung Disease Due to Breathing Artifacts
• Useful in Diagnosis of Mediastinal And Hilar
Masses
• Used to Evaluate Chest Wall Invasion by
Lung Cancer
Radionuclide Lung Scanning
• Obtained by Measuring Gamma Radiation
Emitted From The Chest After Radiopharmaceuticals Are Injected Into The Blood
And Inhaled Into The Lungs
• Used to Evaluate Ventilation/Perfusion
States
Radionuclide Lung Scanning
• Separate Perfusion Scan is Compared to
Ventilation Scan
• Most Often Used in Diagnosis of Pulmonary
Embolism
Positron Emission Tomography
(PET)
• Radiopharmaceutical Sugar Water is
Injected; Patient Remains Still for One Hour;
Uptake is Evaluated
• Useful in Diagnosis of Tumors And Areas of
Infection (Increased Metabolic Activity
Results in Greater Uptake)
Electrocardiographic (ECG)
Assessment
• Indications For Obtaining an ECG
– Chest Pain
– Dyspnea on Exertion
– Palpitations
– Pedal Edema
– History of Heart Disease/Cardiac Surgery
Indications for Obtaining an
ECG
• Unexplained Tachycardia at Rest
• Hypotension
• Diaphoresis
• Jugular Venous Distension
• Cool, Cyanotic Extremities
Interpretation of Tracing
• Identification of Ventricular Response
– Evaluation of QRS Complex
– Strength of Pulse
– http://www.youtube.com/watch?v=ex1k_MPFw4
Interpretation of Tracing
• Determination of Origin of Impulse
Formation
– Atrial
– Junctional
– Ventricular
Interpretation of Tracing
• Electrophysiology (Pathway) of Conduction
Disturbance
– Ectopic Beats or Rhythms
– Escape Beats or Rhythms
– AV Blocks
– Bundle Branch Blocks
Systematic Approach to ECG
Interpretation
• Identify Rate
• Evaluate The Rhythm (Spacing Between
QRS Complexes ≤ 0.04 Seconds Normal)
• Determine Presence of Waves
• Measure The P-R Interval (Normal: 0.12 to
0.20 Seconds)
Systematic Approach to ECG
Interpretation
• Measure Width of QRS Complex (Normal: ≤
0.12 Seconds)
• Inspect The ST Segment
• Identify The Mean QRS Axis
Systematic Approach to ECG
Interpretation
• Assess The Waveform Morphology
• Evaluate The Q Wave
• Evaluate Chamber Enlargement
Systematic Approach to ECG
Interpretation
Variable
Normal
Interpretation
Rate
60 – 100 Beats/Minute Rate > 100 = Tachycardia
Rate < 60 = Bradycardia
PR Interval
0.12 – 0.20/Second
> 0.20 = Heart Block
QRS Interval < 0.12/Second
> 0.12 = Ectopic Foci
ST Segment
Isoelectric
Elevated or Depressed =
Myocardial Ischemia
T wave
Upright And Round
Inverted With Ischemia; Tall
And Peaked With
Electrolyte Disturbances
Common Dysrhythmias
• Sinus Bradycardia
– Originates in Sinus Node
– Rate Decreased Below 60 Beats/Min
Common Dysrhythmias
• Sinus Tachycardia
– Originates in Sinus Node
– Rate Increased Above 100 Beats/Min
Common Dysrhythmias
• Sinus Dysrhythmia
– Originates in Sinus Node
– Irregular Rhythm
Common Dysrhythmias
• Paroxysmal Atrial Tachycardia (PAT) (SVT)
– Originates in Ectopic Focus in Atrium, Rather
Than SA Node
– Usually Rate is 160 to 240 Beats/Min
– P Wave May be Obscured by T Wave in Very
Rapid Rates
Common Dysrhythmias
• Atrial Flutter
– Caused by Rapidly Firing Ectopic Site in Atria
– Characteristic Sawtooth Pattern
– Rates of 180 to 400 Beats/Min
– Diminished Filling Time for Atria; Minimal
Filling Assistance For Ventricle
Common Dysrhythmias
• Atrial Flutter
– Usually Leads to Atrial Fibrillation
– Stagnation of Blood in Atria Promotes
Formation of Thrombi (Mural Thrombi)
Leading to Increased Risk of Embolization
Common Dysrhythmias
• Atrial Fibrillation
– Chaotic Atrial Activity Arising From Multiple
Ectopic Sites
– Quivering of Atrial Myocardium; Complete
Loss of Atrial Pumping Ability
Common Dysrhythmias
• Atrial Fibrillation
– Decreased Ventricular Filling Leading to
Decrease in Cardiac Output
– Greater Risk of Mural Thrombi Than With
Flutter
– Rate High But Difficult to Determine
Common Dysrhythmias
• Premature Ventricular Contractions (PVCs)
– Ectopic Beats Originating in The Ventricles
– Occur in Both Normal And Diseased Heart
– Associated With Anxiety, Excessive Use of
Caffeine, Alcohol, And Tobacco
Premature Ventricular
Contractions (PVCs)
• Causes
– Myocardial Ischemia
– Acidosis
– Electrolyte Imbalance
Premature Ventricular
Contractions (PVCs)
• Causes
– Congestive Heart Failure
– Myocardial Infarction
– Hypoxia
Premature Ventricular
Contractions (PVCs)
• Single PVC is no Threat
• Warning Signs of Complications From PVCs
– Increase in Frequency (Multiple PVCs in One
Minute)
– Multifocal PVCs
Warning Signs of
Complications From PVCs
• Couplets – Paired PVCs (If Regular,
Bigeminy)
• Salvos – Three or More PVCs in a Row
• R-on-T Phenomenon – PVC Occurs on T
Wave; Can Lead to Ventricular Tachycardia
And/or Fibrillation
Common Dysrhythmias
• Ventricular Tachycardia
– Series of Broad QRS Complexes
– Rates of 140 to 300 Beats/Min
– No Identifiable P Wave
– Sustained Ventricular Tachycardia – Lasts
More Than 30 Seconds
Ventricular Tachycardia
• Non-Sustained Ventricular Tachycardia –
Terminates Spontaneously After a Short
Burst
• May Become Hypotensive And Lethargic
Ventricular Tachycardia
• If Significant Deterioration of Cardiac Output,
Patient Becomes Unresponsive
• Without Treatment, May Lead to Ventricular
Fibrillation
Ventricular Fibrillation
• Complete Chaotic Electrical Activity in
Ventricular Myocardial Fibers
• No Cardiac Output
• Life Threatening And Must be Treated
Immediately
Asystole
• Cardiac Standstill
• Invariably Fatal
• Complete Pulselessness And Loss of
Consciousness
Pulseless Electrical Activity
(PEA)
• Electromechanical Condition
• Dissociation of Electrical and Mechanical
Activity; Pattern Present on ECG, But no
Pulse Results
Pulseless Electrical Activity
(PEA)
• Causes
– Tension Pneumothorax
– Cardiac Trauma
– Hypothermia
– Severe Electrolyte or Acid-Base Disturbances
AV Heart Block
• Disturbance in Conduction of Impulses From
Atria to Ventricles Through The AV Node
• May be at The AV Node, The Bundle of His,
or The Bundle Branches
AV Heart Block
• 1st Degree AV Block
– Prolonged PR Interval (> 0.2 Seconds)
– Blocked at AV Node
1st Degree AV Block
• May or May Not Compromise Cardiac
Output
• Caused by Increased Vagal Tone,
Hyperkalemia, Myocarditis, Adverse Effects
of Medications Like Digitalis
2nd Degree AV Block, Type I
(Mobitz I)
• Also Known as Wenckebach
• PR Interval Becomes Progressively Longer
Until Atrial Stimulus is Blocked Completely
For a Single Cycle; Recovery Occurs And
The Cycle Begins Again
2nd Degree AV Block, Type I
(Mobitz I)
• Irregular Ventricular Rhythm
• May or May Not Compromise Cardiac Output
• Causes Similar to 1st Degree Block
2nd Degree AV Block, Type II
(Mobitz II)
• More Serious Than Type I Block
• Series of Non-Conducted P Waves Followed
by a Conducted P Wave
• When P Wave Conducted, PR Interval is
Always Fixed
2nd Degree AV Block, Type II
(Mobitz II)
• Causes
– Extensive Damage to Bundle Branches After
Acute Anteroseptal Myocardial Infarction
– Degenerative Disease
3rd Degree AV Block
• Caused by Disruption of Conduction Below
The AV Node
• If Block at Bundle of His, Then Narrow QRS
Complex
• If Block at Bundle Branches, Then Wide
QRS Complex
3rd Degree AV Block
• No Conduction of Stimuli From The Atria to
The Ventricles; Atria And Ventricles Beat
Independently
• May be Transient or Permanent
• Requires Immediate Intervention
3rd Degree AV Block
• Causes
– Inferior Myocardial Infarction
– Increase Vagal Tone
– Myocarditis
3rd Degree AV Block
• Causes
– Digitalis Toxicity
– Acute Anteroseptal Myocardial Infarction
– Degenerative Disease
Junctional Rhythm
• AV Junction Takes Over The Pace Making
Role
• Follows Normal Pathways of Conduction
• Normal QRS Complexes
• P wave May or May Not be Present
Junctional Rhythm
• Causes
– AV Node Damage
– Electrolyte Disturbances
– Digitalis Toxicity
– Heart Failure
Junctional Rhythm
• Causes
– Valvular Disease
– Rheumatic Fever
– Myocarditis
Nutritional Assessment
• Reciprocal Status Between Nutrition And
Respiratory Status
• Necessary For Energy Utilization And
Normal Organ Function
Components of a Comprehensive
Nutritional Assessment
• Anthropometrics
– Usual Height and Weight
– History of Weight Loss
– Actual vs. Ideal Body Weight
Components of a Comprehensive
Nutritional Assessment
• Anthropometrics
– Body Mass Index (BMI)
– Triceps Skinfold
– Arm Muscle Area
Components of a Comprehensive
Nutritional Assessment
• Clinical Laboratory Tests
– Visceral Proteins
– Creatinine-Height Index
– Immune-Related Tests
– Nitrogen Balance
Components of a Comprehensive
Nutritional Assessment
• Dietary Balance
– Usual Food Intake
– Food Likes and Dislikes
– Appetite
Components of a Comprehensive
Nutritional Assessment
• Total Caloric Requirements
– Resting Energy Expenditure Prediction x
Stress Factor
– Indirect Calorimetry
Components of a Comprehensive
Nutritional Assessment
• Access to Food
– Income
– Education
– Mobility
– Mechanical Impediments