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:– 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:

– 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)– 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=36zbMwxoM6g

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:– 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:

– 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=a-8H8e

mId-M&feature=related• Accessory muscle use/stridor• http://www.youtube.com/watch?v=Zkau4yH

sLLM&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_M0GEZrg

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 'Ninety-nine' 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&feature=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=cFHlEDwzcZk

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 ValuesRBCs Men Women

4.6 – 6.2 x 106/mm3

4.2 – 5.4 x 106/mm3

Hemoglobin Men Women

13.5 – 16.5 g/dl12 – 15 g/dl

Hematocrit Men Women

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=j7PJrUFciec

Normal ValuesWBCs – Differential

Segmented Neutrophils

Bands

Eosinophils

Basophils

Lymphocytes

Monocytes

40% - 75%

0% - 6%

0% - 6%

0% - 1%

20% - 45%

2% - 10%

Normal Values

WBCs–Absolute Value Neutrophils

Eosinophils

Basophils

Lymphocytes

Monocytes

1800 – 7500

0 – 600

0 – 100

90 – 1000

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 pink-orange 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 (K+)

• Major Cation Occurring Within Cells

• Normal Value: 3.5 – 4.8 mEq/L

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

• Extracellular to Intracellular Shift of

Potassium

– Alkalosis

– Increased Plasma Insulin

– Diuretic Use

Causes of Hypokalemia (Low K+)

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

• 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

Causes of Hyperkalemia (High K+)

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=1dhb6eB

EV8o

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

– Metabolic

– Respiratory

• Alkalemia

– Metabolic

– Respiratory

• Compensation

– Partial Compensation

– Full Compensation

Chest Radiograph

• Indications For Chest X-Ray

– Unexplained Dyspnea

– Cough, Sputum, And Fever

– Chest Trauma

– Aspiration of Foreign Object

– http://www.learningradiology.com/lectures/facultylectures/Basic%20Chest%20X-Ray%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 shouldBe 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 tentingfree airabnormal 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 Atrium2. R Ventricle3. Apex of L Ventricle

4. Superior Vena Cava

5. Inferior Vena Cava

6. Tricuspid Valve

7. Pulmonary Valve8. Pulmonary Trunk9. R PA 10. L PA

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 Radio-

pharmaceuticals 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_MPF-w4

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 = TachycardiaRate < 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