ACCS-Patient Assessment

*What is normal range for VD/VT ratio?

(Paco2-Peco2/ Paco2) x 100 normal: 20-40% (MAX 60%)

Describe the following heart sounds and when they would occur in the cardiac cycle. First sound (S1) Second sound (S2)

(S1) - closure ofthe mitral and tricuspid valves at the beginning of ventricular contraction. (S2) - occurs when systole ends ventricles relax and pulmonic and aortic valves closes. *S1 and S2 are NORMAL closure of the heart valves.

Describe what this abnormal heart sound may indicate: Third sound (S3) Fourth sound (S4)

(S3) = CHF (S4) = myocardial infarct or cardiomegaly

What is the formula used to calculate deadspace ventilation (VD)?

(VD/VT) x VT = VD

*Describe the different types of deadspace listed below: *Anatomic Alveolar Physiologic *Mechanical

*Anatomic: amount of inspired tidal volume, but does NOT enter the alveoli. 1mL per lb of IBW => approximate alveolar ventilation Alveolar: amount of alveolar ventiation with no blood perfusion, especially with pulmonary embolism. Physiologic: the sum of anatomic and alveolar deadspace and is estimated by the deadspace to tidal volume (VD/VT) ratio. *Mechanical: amount of circuit tubing between the patient and the wye adaption in the ventilation circuit. (Approx. 10mL per inch of flex tubing.... so 5" equates to 50mL VD, which can be adjusted to correct Paco2 levels)

Describe the Glasgow Coma Scale score values:

*Eye - opening response E Spontaneous opening - 4 Y To verbal Stimuli - 3 E To Pain - 2 S None - 1 *Most appropriate verbal response M Oriented - 5 O Confused - 4 U Inappropriate words - 3 T Incoherent - 2 H None - 1 *Most integrated motor reponse (arm) M Obeys commands - 6 O Localizes Pain - 5 V Withdraws from pain - 4 I Flexion to pain - 3 N Extension to pain - 2 G None - 1

*HINT: Nasal flaring is a sign of respiratory distress

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*HINT: A dry non productive cough may indicate a tumor in the lungs or signs of asthma or/ allergy reaction to Lisinopril.

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*HINT: Oximeters will read higher saturation if carbon monoxide poisoning is present.

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*Hint He might dynamics refers to the second two life functions - circulation and perfusion.

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*Hint: Formula for Cvo2 and Cao2 are the same except change whether the Spo2 is via venous or arterial.

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*Hint: RETRACTIONS are due to blocked/ obstructed airway. SEVERE distress in ADULTS

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*NOTE: PFT labs are not on the exam. Patient lab reports may include: - abg - imaging reports - basic lab assessments (hematology)

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HINT: If patient c/o pain, DO NOT select drug screen (no one in the NBRC is a druggee).

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Hint: For pulmonary patients: - diet is high in FAT & PROTEINS, because carbs increases CO2

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Hint: If a case of syncope is unidentified, it is described as FUO (fever of unknown origin) Think to r/o Sepsis if unknown

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List the four face/and or neck pathologies that would present difficult ventilation or intubation.

1) short receding mandible (no chin) 2) enlarged tongue (microglossia) 3) bull neck 4) limited range ofmotion of the neck *all these are qualities someone with down syndrome may have

Stata normal values for systolic, diastolic, mean

120, 80, 93

What is normal CVP pressures?

2-6 mmhg via Swan Ganz 4-12 cmh20 via central line

*Calculate the VD/VT ratio for a patient with a PaO2 of 85 torr, Paco2 of 50 torr, pH of 7.35 and PECO2 of 40 torr.

20% [(50-40)/50] x 100

Calculate the alveolar oxygen tension for a patient receiving 45% oxygen with a PaCo2 of 50 torr when the barometric pressure is 760 torr.

255 Alveolar Air equation Pa02 = (7xFio2) - (PaCo2 + 10)

What is normal shunt?

3-5%

Calculate the alveolar to arterial gradient for a patient receiving oxygen therapy with a Paco2 of 60 torr and a Pao2 of 105 torr when the barometric pressure is 760 torr and PAO2 is 405 torr.

300 (shunting) 25-65 is normal >65-300 is V/Q mismatch >300 is shunting

What is the normal value for urine output?

40 mL/hr = 1 liter per day

If the arterial oxygen saturation is between 70-90% the PaO2 can be estimated between what values...

40-60%

What is a normal pulse?

60-100 bpm

Changes in patient's CVP reading can indicate hypovolemia.

< CVP = hypovolemia > CVP = hypervolemia

Define bradycardia

<60 bpm

Define Tachycardia

>100 bpm

How do you treat a patient with the following A-a gradient? >300 >65-300 25-65

>300 (Shunting) Oxygen and pressure >65-300 (V/Q Mismatch) give o2 25-65 is NORMAL

Defined the classification of severity complete the following table. ATS\ERS criteria versus Berlin criteria (old vs. new)

ATS\ERS criteria - old school Acute lung injury <300 ARDS <200 Berlin criteria - new school < 300 mild ARDS <200 Moderate ARDS <100 severe ARDS

Describe the causes of tracheal deviation: PUSHED to NORMAL side

AWAY from pathology - outside the lungs massive pleural effusion tension pneumothorax neck or/thyroid tumor large mediastinal mass

*What is the A-a gradient?

Alveolar Air oxygen gradient A-aDo2 = PAo2- Pao2

The normal range for end tidal co2 is?

Between 3-5%

Sao2 is calculated by what device?

Blood gas analyzer

Hemodynamics is simply the monitoring of what?

Blood pressure

What breath sounds would be expected in a patient with pneumonia?

Bronchophony

Calculate Cao2 for a patient with: Pao2 50 torr Sao2 85% Hb 10g/100 mL of blood

Cao2 = (Hb x 1.34 x Sao2) OR Cao2 = Hb x 1.34 Normal is 17-20%

Describe/ Define this formula: ^P x ^V

Change in PRESSURE x Change in Volume Calculates the patient's WOB

What changes would indicate that a patient may not have adequate perfusion?

Check blood pressure, sensorium, temperature, urine output, and hemodynamics.

How would the ACCS determine if a patient has a problem with oxygenation?

Check heart rate, color, sensorium, pao2, sao2 HINT: This is the most common problem

What information would help the ACCS determine if a patient's circulation is adequate?

Check pulse and heart rate, heart strength, cardiac output

Define the following hemodynamic terms: Contractility, preload, afterload

Contractility - the ability of Eddy myocardial vipers do you shorten during systole.*Contractility and stroke volume are directly proportional. Preload - a measure or\estimate a ventricular volume at the end of diastole. *How much of the heart fills. Afterload - The emptying of the heart from the ventricle from systole

Calculate the mixed venous content for a patient with a: Pvo2: 50 torr Svo2: 75% Hb: 12g/ 100mL of blood

Cvo2 = (Hb x 1.34 x Svo2) OR Cvo2 = (Hb x 1.34) Normal: 12-16% Answer: 1.34 x 12 = 16% (this is normal)

What would an increase in Peco2 indicate?

Decrease in ventilation

List and describe the four types of advance directives: DNR DNI Living Will DPO

Do Not Resuscitate Do Not Intubate Living Will describes treatment plan would want if he becomes terminally ill (<6 months to live) Durable power of attorney - makes health care decisions effective when patient is unable to make decisions.

Define obtunded

Drowsy state, many have decreased cough or/ gag reflex.

What is the arterial Oxygen Content? Cao2

Estimates the amount of oxygen carried by the hemoglobin and dissolved in the plasma. Normal is 17-20%

List four items that would be important to identify in the patient's past medical history.

Heart disease Diabetes Cancer Pulmonary Disease *Family history: focus on blood relative and immediate family.

List the three factors that control blood pressure

Heart, blood, and vessels

Define hemo, define dynamics

Hemo - blood, dynamics - movement = movement of blood or circulation\perfusion of blood.

What causes hypertrophy of the accessory muscles?

Hypertrophy is the increase in muscle size. EX: COPD

"Eight or less" Hint: Glasgow Coma Scale

INTUBATE Note: Dead body is a 3

What would a decrease in P2Co2 indicate?

Increase in ventilation or/ decreased perfusion due to deadspace disease, pulmonary embolism, or hypovolemia

Immediately following intubation, the PetCo2 remains at a low level. How should the adult critical care specialist interpret this information?

Increase ventialtion (aka hyperventilation or Increased wob) or/ decreased perfusion due to deadspace disease, pulmonary embolism, or/ hypovolemia.

A patient with a pulmonary disease would be expected to have a/an _______ wob.

Increased

Describe the following breath sounds and the recommended treatment. Pleural friction rub

Inflamed surface of visceral and parietal picture rubbing together. Ex: TB*, PNA, Cancer*, pulmonary infarct. = corticosteroids = give antibiotics if WBC are low

What are the accessory muscles used to increase ventilation?

Intercostals, scaline, sternocleidomastoids, pectoralis major abdominal muslces (oblique, rectus abdominas, etc.)

How does the PetCo2 compare to the arterial Pco2?

It will read lower

When assessing a patient's orientation to time, place and person, what are four factors that could affect the patient's ability to cooperate?

Language difficulty influence to medication hearing loss fear, apprehension, depression, etc. *Euphoria - drug overdose (ex: morphine overdose)

Describe the following breath sounds and the recommended treatment. Coarse rales/ rhonchi

Large airway secretions = suction

Describe the following breath sounds and the recommended treatment. Medium rales

Middle airway secretions = CPT

Describe what this abnormal heart sound may indicate: Murmur Bruits

Murmur: caused by tubulent flow; caused by heart valve defects or/ congenital abnormalities. Bruits: occurs in artery or/ venin when blood flow becomes turbulent or/ flows at an abnormal speed - can be heard over the carotid artery.

Define and identify. Eupnea

NORMAL respiratory rate, depth, and rhythm. 12-20bpm

Describe Resonant sound

Normal air filled lungs with a hollow sound. (Little air)

Define the following symptoms: Orthopnea General Malaise Dyspnea Dysphagia

Orthopnea: difficulty breathing except in the upright position (CHF*, heart problem) (+diabetes) General Malaise: feeling run down, nausea, weakness, fatigue, headache (usually irritated) - electrolyte imbalance Dyspnea: sob or difficulty breathing. *Grade V - dyspnea @ rest, shaving, dessing, etc. Dypshagia: difficulty swalling. *age will play a factor. (Ex: 70y.o. at risk for aspiration vs a 25 y.o. with myasthenia gravis)

*What is the Alveolar Air Equation (aka alveolar oxygen tension)

Pao2 = (7xFio2) - (Paco2 +10)

What are the two indicators of oxygenation and state the normal value for each?

Pao2: 80-100 Sao2: 93-98%

What device can be used to estimate Sao2?

Pulse oximeter

Which two sounds have little air.

Resonant and flat

What assessments would determine how well a patient is ventilating?

Respiratory Rate, tidal volume, chest movement, breath sounds, etco2, paco2 HINT: Always choose "turn up the flow" if it's an option.

Define Stuporous/ Confused

Responds inappropriately, drug overdose, or/ intoxication

Define semicomatose

Responds only to painful stimuli lethargic somnolent sleepy Consider drug overdose *protect patient's airway

What is meant by tenderness?

Sensitive skin or muscle which may be tender around sutures, chest tubes, bruises, fractured bones, and burns.

Define an advance directive.

Set of instructions documenting what treatment a patient would want if he/she was unable to make medical decisions.

What is the formula for the Arterial - Venous Oxygen Content Difference C(a-v) o2

Shortcut formula: C(a-v)o2 = (Sao2 - Svo2) x 0.2 **HINT: Don't do the math. If the Cao2 and the Cvo2 are within normal rangem then the C(a-v)o2 is going to be normal. Normal: 4-5%

What is the formula for the arterial oxygen content (Cao2)?

Shortcut formulas: Cao2 = (Hb x 1.34 x Sao2) OR Cao2 = (Hb x 1.34) Normal: 17-20% (mL/dL)

Shunt Equation (Qs/Qt) Calculate the percent shunt of a patient with an A-a gradient of 200 torr and a C(a-v)o2 of 3.0 vol%

Shortcut: 1) look at A-a gradient 2) for each 100, add 5% to it + another 5% for normal shunt Normal shunt is 5% Ex: 300 = 5+5+5+5 = 20% shunt

What is the formula for Cvo2?

Shortcut: Cvo2 = (Hb x 1.34 x Svo2) OR Cvo2 = (Hb x 1.34) Normal: 12-16%

Describe the difference between "signs" and "symptoms" and list an example of each.

Sings: objective information - things that you can see or/ measure. Example: Color, pulse, edema, blood pressure Symptoms: subjective information - those things that the patient must tell you. Example: dyspnea, nausea, pain, muscle weakness, etc.

Describe Tympanic sound

Sound heard over air filled stomach. IT's lika drum-like sound and when heard over lungs, it indicates an increase in volume.

Describe Flat sound

Sound heard over the sternum, muscles or/ areas of atelectasis. (Little air).

Define Dull

Sounds heard over fluid filled organs such as the heart and the liver. Ex: pleural effusion or/ pneumonia will give a thudding sound.

What condition is crepitus associated with?

Subcutaneous emphysema (extrapulmonary air): bubbles of air under the skin.

Describe the causes of tracheal deviation: PULLED toward the ABNORMAL side

TOWARDS the pathology - it's inside the lung atelectasis pulmonary fibrosis pneumonectomy diaphragmatic paralysis

Define and identify. Cheyne-Stokes

The gradual increase and decrease of the rate and depth in a cycle lasting from 30-180 seconds with periods of apnea up to 60 seconds. = increased ICP, meningitis, *drug overdose (opoid use), head trauma

Describe how egophony is identified and what it would indicate?

This is when a patient says 'e,' but sounds like an 'a.' This indicates consolidation w/ a pneumonia like condition.

What is Mixed Venous Oxygen Content? Cvo2

Total amount of oxygen carried i nthe mixed venous blood from pulmonary artery via Swan Ganz catheter.

Which two lung sounds have too much air.

Tympanic and hyperresonant.

A properly written order for respiratory care should include what four factors?

Type of therapy Frequency Medication dosage and dilution Physician signature

*What is the formula used to calculate alveolar minute ventilation (VA?

Va= (VT-VD) x F

Name four different types of syncope

Vasovagal syncope Orthostatic hypotension Corotid sinus syncope Cough (tussive) syncope

Which of the four life function is the FIRST priority?

Ventilation HINT: Do not pick STAT ABG on the exam

List he four critical life functions

Ventilation - moving air in and out of the lungs Oxygen - getting oxygen into the blood Circulation - moving the blood through the body Perfusion - getting blood and oxygen into the tissue

Describe the difference between 'vesicular' and 'adventitious' breath sounds.

Vesicular is normal sounds Adventitious is abnormal sounds (rales, wheezes, stridor, pleural friction rub)

What findings might indicate that the patient's fluid intake has exceeded their urine output?

Weight gain Electrolyte imbalance Increased hemodynamic pressures Decreased lung compliance

Describe how to perform chest motion symmetry.

You put two fingers on the center of the chest and observe movement of fingers. If chest rise is not equal, then it is assymetrical.

If the partial pressure of arterial oxygen is between 40-60 torr, the arterial oxygen saturation can be estimated by...

adding 30

Define Corotid Sinus syncope

associated with hypersensitive corotid sinus (more common in elderly patients)

Define and identify. Kussmaul's

breathing deep and fast = metabolic imbalance (ex: diabetic ketoacidosis)

Describe the following breath sounds and the recommended treatment. Wheeze

bronchospasms bilateral = bronchodilator unilateral = foreign object

What is another name for an exhaled co2 detection device?

colorimetric detection device

Define Vasovagal syncope

common dizziness and fainting caused by loss of peripheral venous tone.

What are the normal muscles of ventilation?

diaphragm external intercostals exhalation is normally passive

Define Orthostatic hypotension

extensive drop in BP when assuming a standing position.

*What is the formula to calculate minute ventilation (VE)?

f x vt = VE

Define and identify. Biots

increased respiratory rate and depth with irregular periods of apnea. Each breath has the same breath. = CNS problem, opoid use

Define Atrophy

loss of muscle tone and occurs in paralysis

What is the normal value for WOB?

measured with a manometer and a spirometer 0.5-0.7 J/L (0.05-0.07 kg - m/L)

What does the P/F ratio measure?

measures the efficienty of oxygen transfer across the lungs. Used in the determination of acute lung injury (ALI) or respiratory distress (ARDS).

Describe the following breath sounds and the recommended treatment. Fine rales/ crackles

moist/ crepitant - alveoli fluid ex: CHF/ pulmonary edema *positive presure/ inotropic = CPAP, heart drugs: digitalis or/ digoxin, diuretics (lasix or/ furosemide), oxygen.

Define Cachectic

muscle wasting

The relationship of Pao2 and Sao2 is describe by using the...

oxyhemoglobin dissasociation curve

Define and identify. Apneustic

prolonged gasping inspiration followed by extremely short, insufficient expiration. = problem with respiratory center, trauma, or/ tumors Fish/ guppy breathing

Define Tactile Fremitus

rattling fo the chest (vibration) Ex: Pleural rub - a grating sensation due to roughened pleural surfaces rubbing together.

Describe hyperresonant sound

sounds heard in areas of lung w/ a pneumothorax (unilateral) or/ emphysema (bilateral) is present. Like a booming sound.

Define paradoxical pulse/ pulsus paradoxus indicate?

the pulse or blood pressure varies with respiration *May indicate air trapping (Ex: status asthmaticus or/ cardiac tamponade.

What is one indication for the use of an exhaled co2 detection device?

to confirm tracheal intubation

What is an exhaled Co2 detection device used for?

to detect esophageal intubation

Define Cough (tussive) syncope

transient loss of consciousness following a severe cough. Ex: Laughing so hard

Describe the following breath sounds and the recommended treatment. Stridor

upper airway obsruction such as CROUP/ epiglotittis (thumb sign) = humidified o2 = racemic epinephrine for swelling&edema =corticosteroid =intubation if marked/ severe