Intro to Resp 121 Egan's Chapter 15

Fetid

Sputum that is foul-smelling.

Shock

The inadequate delivery of O2 and nutrients to the vital organs relative to their metabolic demand. -Vital body organs are in imminent danger of receiving inadequate blood flow (underperfusion) and impaired O2 delivery to the tissues (tissue hypoxia). -Usually treated aggresively with fluids, blood products, or vasoactive drugs, or in combination of these, depending on the severity.

Obtunded

-Awakens only with difficulty. -Responds appropriately when aroused.

Vital Signs

-Body temperature -Pulse rate -Respiratory rate -Blood pressure -Easy to obtain and provide useful information about the patients clinical condition. -Oximiter is not a vital sign it is an assessment.

Hypodynamic

-Category of hypotension and shock. -Includes left ventricle failure (cardiogenic) and reduced blood volume (hypovolemia or hypovolemic) caused by either hemorrhage or severe fluid loss.

Hyperdynamic

-Category of hypotension and shock. -Occur with profound systemic vasodilation (peripheral vascular failure) associated with overwhelming infection (septic shock), systemic allergic reaction (anaphylaxis), or sever liver failure.

Comatose

-Unconscious. -Does not respond to stimuli. -Does not move voluntarily. -Exhibits possible signs of upper motor neuron dysfunction, such as Babinski reflex or hyperreflexia. -Loses reflexes with deep or prolonged coma.

Factors that Affect Communication between the RT and the Patient

- Sensory and emotional factors. -Environmental factors. -Verbal and nonverbal components of the communication process. -Cultural and other internal values, beliefs, feelings, habits, and preoccupations of both the healthcare professional and the patient.

Tripodding

- Sitting upright while bracing his or her elbows on a table. - This position helps the accessory muscles gain a mechanical advantage for breathing.

Diaphoresis

- Sweating. - Can indicate fever, pain, severe stress, increased metabolism, or acute anxiety.

General Appearance

- The first few seconds of an encounter with the patient usually helps reveal the severity of the current problem. - Several indicators are important in assessing the patients overall appearance, including the patients level of consciousness, facial expression, level of anxiety or distress, positioning, and personal hygiene. -Does the patient appear well nourished or emaciated? -Is the patient sweating?

Dyspnea

-A general term describing the sensation of breathing discomfort. -The most important symptom and RT will asses and treat. -Subjective experience and should not be inferred from observing the patients breathing pattern. -Dyspnea also is used specifically to describe difficulty in the mechanical act of breathing. -Patient tells us they are short of breath **perceived by patient**

Angina

-A pressure sensation exertion or stress and results from coronary artery occlusion.

Language of dyspnea

-A subjective experience, and patients possess a nuanced language to describe their sensations. -RT's should ask specific questions about the quality and characteristics of the patients dyspnea. -The RT should categorize each according to a particular aspect of breathing such as insperation, expiration, respiratory drive, or lung volume.

Orthopnea

-Dyspnea presented only when the patient assumes the reclining position. -Common in patients with cogestive heart failure (CHF); it apparently is caused by sudden increase in venous return that occurs with reclining.

Pulsus Alternans

-An alternating succession of strong and weak pulses. -Suggests left-sided heart failure and usually is not related to respiratory disease.

Fever

-An elevated body temperature secondary to disease. -A common complaint of patients with an infection of the airways or lungs. -May occur with a viral infection of the upper airway or bacterial pneumonia or tuberculosis. -All patients with a fever need further assessment to determine the cause. -Consume more oxygen with fever, increases metabolic rate, increases CO2 -When infection causes fever, the magnitude of temperature elevation may indicate the type and virulence of the infection. -Low grade fever typically acoompanies common upper respiratory tract infections. whereas a high fever occurs with viral influenza infection. -Fever that occurs with a cough suggests a respiratory infection. -An infection is even more likely to be the cause of the fever if the patient is producing purulent sputum.

Hypertension

-Arterial blood pressure persistently greater than 140/90 mmHg. -Common medical problem in adults, and in approximately 90% of cases the cause is unknown (primary hypertension).

Level of Consciousness

-Assess the patients orientation to time, place, person, and situation. (sensorium) -An alert patient who can correctly tell the interviewer the current date, location, his or her name, and his or her situation is said to be oriented X4 and the patients sensorium is considered normal. -If the patient is not alert the level of concsiousness is assessed by confused, delirious, lethargic, obtunded, stuporous, or comatose.

Body Temperature

-Average for adults is approximately 37 degrees C or 98.6 degrees F with daily variations of approximately 0.5 degrees C or 1 degree F -An elevated body temperature (hyperthermia or hyperpyrexia) can result from disease or from normal activities such as excercise. -Most often measured by mouth, axilla, ear (tympanic membrane) or rectum. -Oral temperature is the most common for adults but can not be used in infants, comatose patients, or orally intubated patients. -Oral temperature cannot be taken if a patient ingests hot or cold liquid or has been smoking, will have to wait 10-15 minutes. -The tympanic membrane is acceptable for infants. - Rectal temperature is the closest to actual core temperature.

Tachycardia

-Condition in which the pulse rate exceeds 100 beats per minute. -Common causes are excercise, fear, anxiety, low blood pressure, anemia, fever, reduced arterial blood O2 levels and certain medications.

Bradycardia

-Condition in which the pulse rate is less than 60 beats per minute. -Less common than tachycardia. -Can occur with hypothermia, as a side effect of medications, with certain cardiac arrhythmias, and with traumatic brain injuries.

Hemoptysis

-Coughing up blood-streaked sputum from the lungs. -Common in patients with pulmonary disease. -Characterized as massive when more than 300ml of blood is expectorated over 24 hours and represents a medical emergency. -Non-massive hemotysis is most often cause by an infection of the airways but also is seen in lung cancer, tuberculosis, blunt and penetrating chest trauma, and pulmonary embolism. -Associated with infection usually seen as blood-streaked purulent sputum. -Commonly found in patients with bacterial pneumonia.

Past Medical History

-Describes all past major illnesses, injuries, surgeries, hospitizations, allergies, and health-related habits. -Should be reviewed second.

Review of Systems

-Designed to uncover problem areas the patient forgot to mention or omitted. -Usually reviewed in a head-to-toe review of all body systems.

Stuporous

-Does not awaken completely. -Has decreased mental and physical activity. -Responds to pain and exhibits deep tendon reflexes. -Responds slowly to verbal stimuli.

Platypnea

-Dyspnea in the upright position. -May accompany arteriovenous malformations in the lung, such as occur in chronic liver disease (hepatopulmonary syndrome), and some hereditary conditions. -May be accompanied by orthodeoxia.

Delirious

-Easily agitated. -Irritable. -Exhibits hallucinations.

Physical Examination

-Essential for evaluating the patients problem and determining the effects of therapy. 1.) Inspection- Visually examining. 2.) Palpation- Touching. 3.) Percussion- Tapping. 4.) Auscultation- Listening with a stethoscope.

Confused

-Exhibits slight decrease of consciousness. -Has slow mental responses. -Has decreased or dulled perception. -Has incoherent thoughts.

Family and Social/Environmental History

-Focuses on potential genetic or occupational links to disease and the patients current life situation. -Should be reviewed third.

Pedal Edema

-Swelling of the lower extremeties. -Occurs most often with heart failure, which causes an increase in the hydrostatic pressure of the blood vessels in the lower extremeties. The increase hydrostatic pressure causes fluid to leak into the interstitial spaces. The degree depends on the level of heart failure.

Chief Complaint and History of Present Illness

-The RT should begin reviewing the patient's chart by reading about the patient's current medical problems. -Should be reviewed first.

Structure for Patient Interview

-Ideal interview is one where the patient feels secure and free to talk about important personal matters. -Introduce yourself to the patient stating the purpose of the visit. - The introduction is done in the social space, approximately 4 to 12 feet from the patient. It begins the process of establishing repport with the patient and helps them feel comfortable. -Pulling the curtain between beds of a semiprivate room also may be helpful in making the patient feel more at ease. -Next the RT moves into the personal space (2 to 4 feet from the patient) to begin the interview. - RT should assume physical position at the same level as the patient (e.g., sitting in a chair) before beginning the formal interview. Standing over the patient should be avoided. -Approprate eye contact with the patient is essential. Eye contact gives the patient more confidence. -Use open-ended questions such as When did it start? How severe is it? Where on the body is it? What seems to make it better or worse?

Charateristics of the patients cough

-Identify whether the cough is dry or loose, productive or nonproductive, and acute or chronic. -Identify if the cough occurs more frequently at particular times (i.e. day or night) -Document time of cough

Advance Directive

-Information indicating any limits on the extent of care to be provided in the event of cardiac or respiratory arrest.

Nonpleuritic Chest Pain

-Located typically in the center of the anterior chest and may radiate to the shoulder or back. -Not affected by breathing , and it is described as a dull ache or pressure type of pain. -Common cause of nonpleuritic chest pain is angina. -Other common causes include gastroesophageal reflux (usually burning sensation), esophageal spasm, chest wall pain, (e.g. costochondritis), and gallbladder disease.

Two Key Sources of Patient Data

-Medical History -Physical Examination

Loose productive cough

-More often associated with inflammatory obstructive diseases such as bronchitis and asthma. -Loose cough has rattling sound

Acute self-limited cough

-Most common in viral infection of the upper airway

Sputum

-Mucus that comes from the lung but passes through the mouth as it is expectorated. -Changes in color, viscosity, or quantity of sputum produced are often signs of infection and must be documented and reported to the physican.

Blood Pressure

-The arterial blood pressure is the force exerted against the wall of the arteries as the blood moves through them. -Normal is 120/80 mmHg

Pulse Pressure

-The difference between the systolic and diastolic pressures. -Normal is 30 to 40 mmHg. When less than 30 mmHg the peripheral pulse is difficult to detect.

Respiratory Rate

-Normal 12-18 bpm -Meassure for full minute

Pulse Rate

-Normal is 60-100 -Messure for 1 full minute -Evaluated for rate, rhythm, and strength. -Radial artery is most common site used to palpate pulse. -Second and third finger are used to palpate the pulse. Never use the thumb.

Psychogenic Hyperventilation Syndrome

-Perplexing situations in which the patients with normal cardiopulmonary function complain of intense dyspnea or suffocation. -Associated with panic disorders. -The RT should always approach any situation involving hyperventilation or dyspnea as if it had a pathophysiologic basis.

Diastolic Pressure

-The force in the major arteries remaining after relaxation of the ventricles. -Normal range is 60-90mmHg

Cough

-The most common, yet nonspecific symptom seen in patients with pulmonary disease. -A forceful expiratory maneuver that expels mucus and foreign material from the airways. -Usually occurs when the cough receptors are stimulated by inflammation, mucus, foreign materials, or noxious gases. -Cough receptors are located primarily in the larynx, trachea, and larger bronchi.

Medical History

Familiarizes clinicians with the signs and symptoms the patient exhibited on admission and the reason the therapy is being administered

Lethargic

-Sleepy. -Arouses easily. -Responds appropriately when aroused.

Pack-Years

-Smoking history is often recorded by this. -Determined by multiplying the number of packs smoked per day by the number of years smoked.

Purulent

-Sputum that contains pus cells suggesting a bacterial infection. -Appears thick, colored, and sticky.

Mucoid

-Sputum that is clear and thick. -Commonly seen in patients with airway disease (i.e. asthma). -Changes in color, viscosity, or quantity of sputum produced are often signs of infection, and must be documented and reported to the physician. (Note: smell/no smell, color, amount, and thickness)

Systolic Pressure

-The peak force exerted in the major arteries during contraction of the left ventricle. -Normal range is 90-140mmHg

Bedside assessment

-The process of interviewing and examining a patient for signs and symptoms of disease and the effects of treatment. -A cost effective way of obtaining pertinent information about the patients health status. -In many cases , bedside assessment provides the initial evidence that something is wrong and often helps establish the severity of the problem. - Are of little risk to the patient. - Patient initially assessed to identify the correct diagnosis.

Breathlessness

-The specific sensation of an unpleasant urge to breathe. -Breathlessness can be triggered by acute hypercapnia and acidosis and by hypoxemia. -Hyperventilating is most common.

Dry nonproductive cough

-Typical for restrictive lung disease such as CHF or pulmonary fibrosis. -Dry cough has no rattle

Pleuritic Chest Pain

-Usually located laterally or posteriorly. -Worsens when patient takes a deep breath, and is described as sharp, stabbing type of pain. -Associated with diseases of the chest that cause the pleural lining of the lung to become inflammed, such as pneumonia or pulmonary embolism.

Hematemesis

-Vomiting blood from the gastrointestinal tract. -May be mixed with food particles and occurs most often in patients with a history of gastrointestinal disease.

Cachexia

-Weakness and emaciation. -Signs of general ill health and malnutrition.

Assessing Dyspnea in the Interview

-When conducting an interview the RT should pay particular attention to whether the patient can speak in full sentences. -Questions should be brief and limited to the quality and intensity of dyspnea and the circumstances of symptom onset. -The assessment of dyspnea should occur simultaneously with gross examination of the patients breathing pattern.

Hypotension

A Systolic arterial blood pressure less than 90 mmHg or a mean arterial pressure less than 60 mmHg.

Pulsus Paradoxus or Paradoxical Pulse

A significant decrease in pulse strength (>10 mmHg) during spontaneous inhalation.

Interviewing a Patient

A way of "connecting" with the patient.

Acute Hypertensive Crisis

Acute, severe elevation of blood pressure can cause acute neurologic, cardiac, and renal failure.

Hypothermia

Body temperature below normal. -The most common cause is prolonged exposure to cold to which the hypothalamus responds by shivering (to generate heat) and vasoconstriction (to conserve heat).

Open-ended Questions

Encourage patients to describe events and priorities as they see them, helping to bring out concerns and attitudes and to promote understanding.

Three factors for a persons perception of breathing

Complex balance of three factors: -The neural drive to breath. -The tension developed in the respiratory muscles. -The corresponding displacement of the lungs and chest wall.

Hypercapnia

High level of CO2

Phlegm

Mucus from the tracheobronchial tree that has not been contaiminated by oral secretions.

Orthodeoxia

Oxygen desaturation assuming an upright position.

Febrile

Patient is called to be this when temperature elevation is caused by disease.

Asthma

Patients often complain of chest pain.

Tachypnea

Respiratory rate greater than 20 bpm

Bradypnea

Respiratory rate less than 10 bpm

Paresthesia

The sensation of tingling and numbness in the extremities that often accompanies respiratory alkalosis. -May be sporadic or chronic and often is self-perpetuating.

Weeping Edema

When a small fluid leak occurs at the point where pressure is applied.

Pitting Edema

When pressure is applied with a finger on a swollen extremity an indentation mark is left on the skin.