Acute Care - Assessment 1 Study Notes PDF

STUDY NOTES GUIDE Acute Care – Assessment 1 Study Summary Table of Contents Key Lung volumes E.g., Vt, VC, ect.......................................................................................................2 Mechanics and Distribution of ventilation............................................

STUDY NOTES GUIDE Acute Care – Assessment 1 Study Summary Table of Contents Key Lung volumes E.g., Vt, VC, ect.......................................................................................................2 Mechanics and Distribution of ventilation...........................................................................................2 Lung clearance mechanisms (mucociliary clearance, collateral ventilation, cough).............................4 Ventilation & Perfusion (V/Q mismatch: shunt and dead space)...........................................................4 Heart and Lung structure and function................................................................................................5 Physiology and implications of cardiorespiratory impairments (O2, CO2, Secretion movement & mobility impairments).........................................................................................................................6 Hypoxia and Oxygen saturation (measurement, normative values, pathology).....................................6 ABGs – what they measure and how to interpret..................................................................................7 Determination of Respiratory Failure (ARDS).......................................................................................8 Calculate and interpret respiratory reserve (P/F ratio).........................................................................8 Common symptoms of cardiorespiratory disease (e.g., dyspnoea, sputum (volume, colour), cough, etc).....................................................................................................................................................8 Vital Signs – norms and ranges for basic pathology (e.g., hypertension, orthostatic hypotension, Spo2)......................................................................................................................................................... 11 Spirometry interpretation (including GOLD classification if provided)................................................ 12 Signs, symptoms, and basic pathology of CAD and Heart Failure....................................................... 12 Aetiology of COPD and Restrictive lung disease................................................................................. 13 Know the differences between Obstructive vs Restrictive lung disease.............................................. 16 Mobility assessment (Weight bearing status and level of assistance)................................................. 16 Chest X-rays (no visual interpretation required in this exam).............................................................. 16 STUDY NOTES GUIDE Key Lung volumes E.g., Vt, VC, ect. Know description and normal ranges Volume Description Normal Range Total lung capacity Maximum volume of air your lungs Depends on age, sex and height can hold after a full inhalation 5-6L Tidal Volume Volume of air you breathe in and out 500mL during a normal breath Vital Capacity Maximum amount of air you can 4L exhale after a deep inhalation Residual Volume Volume of air remaining in your 1L lungs after a forceful exhalation Functional Residual Volume of air left in your lungs after 2.5L Capacity a normal exhalation Expiratory Reserve Additional air you can forcefully 1000 mL Volume exhale after a normal exhalation Inspiratory Reserve Extra air you can inhale after a 2.4-3000 ml Volume normal inhalation Mechanics and Distribution of ventilation Control of breathing Respiratory canter is located in the brain stem (ventilation) Receptors indicate pressures changes and changes in the blood levels which helps control the rate of breathing Respiration Lungs facilitate gas exchange between the circulatory system and the external environment Ability of the lungs to stretch → compliance Lungs are composed of branching airways that terminate in respiratory bronchioles and alveoli, which participate in gas exchange Gas exchange occurs in the lungs between alveolar air and the blood of the pulmonary capillaries via diffusion The alveoli are surrounded by capillaries in which O2 from the lungs will diffuse into the blood and CO2 from the blood will enter the lungs to be expelled For effective gas exchange to occur, alveoli must be ventilated and perfused Ventilation (V) refers the flow of air into the alveoli Prefusion (Q) refers to the flow of blood to the alveolar capillaries Alveoli will have different degrees of ventilation and perfusion: alveoli at the base of the lung have a greater capacity that the apex of the lung. V/Q ratio Changes in ventilation and perfusion in the lungs are measured using the ration of ventilation to perfusion (V/Q) Reduced ventilation: blood but no air → shunt STUDY NOTES GUIDE Reduced perfusion: air but no blood → dead space Pleura and the pleural The lungs sit int the plural cavity. The visceral pleura covers the lungs and space the parietal pleura covers the internal lining of the thoracic cage Inside the pleural cavity there is pleural fluid which allows the two layers to slide past each other during respiration This fluid helps maintain mechanical coupling between the lungs and the chest wall-preventing the two surfaces from separating during respiration → maintains pressure to keep the lungs inflated There can be acute presentations that impact the pleura and pleural space Pleuritis: inflammation of the parietal pleura, mainly due to infection Pleural effusion: accumulation of fluid in the pleural space, usually as a result if inflammation of the pleura Pneumothorax: accumulation of air in the plural space. Can occur spontaneously or due ti trauma and open chest wounds Tension pneumothorax: overaccumulation of air in the pleural space, usually as a result of a valve mechanism. Air enters but doesn’t exit during expiration causing an increase in pleural pressure Thorax Thoracic cage Protects the heart, lungs and great vessels Ribs: all attach posteriorly to the thoracic vertebrae 1-7 → true ribs: attach to the sternum by costal cartilage 8-10 → false ribs: attach the sternum by indirectly joining the costal cartilage above it 11-12 → floating ribs: have no anterior attachment The dimensions of the thorax need to change for respiration to occur Pump handle: increases AP diameter of the thorax during inspiration Bucket handle movement increases lateral diameter of the thorax during inspiration Respiration Muscles Diaphragm Large dome shaped muscle, innervated by the phrenic nerve. During contraction, the diaphragm descends and increases the vertical diameter of the thorax. Intercostals 11 pairs of intercostals which pass between adjacent ribs 3 layers: external (inspiration) , internal (expiration) and innermost (stabilise the chest wall) Accessory muscles Assist with deep respiration or during respiratory distress Scalenes, sternocleidomastoid, pectoralis major and minor STUDY NOTES GUIDE Lung clearance mechanisms (mucociliary clearance, collateral ventilation, cough) Secretion clearance impairment  secretion impairment → Secretion retention: o Consolidation/collapse → V/Q mismatch →  O2 and CO2 o  airway resistance →  respiratory load →  alveolar ventilation →  O2 and CO2  cough effectiveness o To clear secretions, need a strong cough and big breath o Weak and ineffective cough from: ▪ Poor technique ▪ Pain – post op- not taking a big breath in ▪ Weakness – weak inspiratory muscles/abs ▪ Thick/viscous secretions o Characteristics of a cough ▪ Moist or dry? ▪ Productive or Non-productive (NP) ▪ Effective or ineffective? ▪ Paroxysmal? ▪ Assess sputum quantity and quality (colour, consistency, purulence)  mucociliary clearance → cilia issue, secretion issue o Cilia → they ‘beat’ to sweep mucous along → the beating can be affected by smoking, general anesthetic, cold air. Can also  no. of cilia (smoking) or damage cilia (burns) o Aqueous layer → lubricates cilia to enhance efficiency → impaired by  periciliary fluid (pulmonary oedema) or  levels (dehydration) o Viscous layer → Ciliary movement can be impaired with hypersecretory conditions (CF, bronchiectasis) due to increased volume of mucus layer or depletion of sol layer  vol of mucous and  thickness of mucous → smoking, respiratory infections, CF Ventilation & Perfusion (V/Q mismatch: shunt and dead space) V/Q ratio → ventilation (flow of air into and out of the alveoli)/perfusion (flow of blood to alveolar capillaries) → mismatch =  ability to provide O2 or blood.  ventilation = blood but no air (shunt).  perfusion = air but no blood (dead space) STUDY NOTES GUIDE Heart and Lung structure and function Heart Lungs - Function: is a pump to circulate blood - Spongy organs located in the thoracic cavity, throughout the body one on each side of the heart - Chambers - Function: gas exchange, bringing oxygen into o Four chambers; two atria and two the blood stream and removing carbon ventricles dioxide o Right atrium – receives deoxygenated - Lobes blood and pumps it into the right o Right lung has 3 lobes (superior, ventricle middle and inferior) o Right ventricle – pumps blood to lungs o Left lung has 2 lobes (superior and to be oxygenated inferior) to accommodate the heart o Left atrium – receives oxygenated - Bronchi and alveoli blood from the lungs and pumps to o The trachea divides into two main left ventricle bronchi, each entering a lung and o Left ventricle – pumps blood around further branching into smaller the body bronchioles - Valves o These end in tiny air sacs called o Tricuspid valve alveoli, where gas exchange occurs o Pulmonary valve - Pleura o Mitral valve o Each lung is enclosed by a double- o Aortic valve layered membrane called the pleura, - Circulation which provides lubrication and o The pulmonary loop – right side of the reduces friction during breathing heart to the lungs and back o The systemic loop – left side of the heart to the rest of the body and back Relationship - Ensure oxygenation of blood and removal of carbon dioxide - Right side of heart pumps deoxygenated blood to lungs - Where it picks up oxygen and releases carbon dioxide - Oxygenated blood then returns to the left side of the heart and pumps it to the rest of the body STUDY NOTES GUIDE Physiology and implications of cardiorespiratory impairments (O2, CO2, Secretion movement & mobility impairments) O2 movement CO2 movement Low O2 readings on ABGs or O2 saturation (vital signs, Struggle to get air out of chest (obstructive) pulse oximetry) Elevated CO2 readings on ABGs Low lung volumes on chest xray – underinflated Diagnosis of obstructive conditions Cyanosis – blue lips, fingertips Hyperinflated on chest Xray Reports of dizziness Accessory muscle use Confusion Pursed lipped breathing to try and blow off excess Fatigue / Shortness of breath CO2 Auscultation- reduced breath sounds, fine crackles Fatigue (atelectasis- popping open) Reduced exercise capacity & independence in ADL Reduced exercise capacity & independence in ADL Secretion clearance impairment Mobility impairment Ineffective cough- weak, non-productive OR Moist cough, Reduction in mobility from baseline non-productive Limitations due to weight bearing status Diagnosis- CF, bronchiectasis, pneumonia Increased periods of bed rest- & risk of Could be coughing up phlegm (increased from normal) or deconditioning report difficulty clearing Requiring assistance for ADLs Current smoker/ history of smoking- could increase risk Reduced exercise tolerance Changes on Xray- consolidation Potentially low gas readings (O2 saturation- vital signs, pulse oximetry) Fatigue / Shortness of breath / Increased work of breathing Auscultation- course crackles Reduced exercise capacity & independence in ADL Hypoxia and Oxygen saturation (measurement, normative values, pathology) STUDY NOTES GUIDE ABGs – what they measure and how to interpret. - Measures partial pressure oxygen - Oxygen content in arterial blood - Normal: 80-100 mmHg - Low (hypoxemia): 1 symptom Long term, feature Accessory muscle (wheeze, SOB, progressive s use cough, chest obstructive lung  breath sounds on tightness) disease – auscultation Symptoms worse causes SOB O2 desaturation at night or in early due to over- Hyperinflation on morning inflation of chest radiograph Symptoms vary alveoli and over time and in destruction of intensity alveolar walls Symptoms are Noxious thing – triggered by viral inflammatory infections (colds), immune cells exercise, allergen respond – exposure, changes destruction of STUDY NOTES GUIDE  Functional in weather, lungs epithelial exercise capacity – laughter, irritants barrier e.g. car exhaust, Abnormal fumes, smoke, permanent strong smells enlargement of air spaces Destruction of alveolar walls and without 6MWT obvious fibrosis Gold 1-4 MRC scale CAT ax Therefore, ABCD Ax Tool Manage Controller ment (preventer) medications →  airway inflammation, control symptoms,  future risk of exacerbations and reduction in lung function Reliver (rescue) medication → Ventolin, salbutamol (bronchodilators or steroids) Add on therapies → for severe asthma – other meds, non-drug therapies (breathing exercises) STUDY NOTES GUIDE Know the differences between Obstructive vs Restrictive lung disease. Mobility assessment (Weight bearing status and level of assistance). We good right? YEAH SURELY Chest X-rays (no visual interpretation required in this exam) DRS ABCDE DRS ABCDE Approach D = Details Patient details → name, DOB, MRN Date and time film was taken Previous imaging (useful for comparison) R = RIPE = Rotation Rotation, → are they standing straight on? Inspiration, Look for medial aspect of each clavicle – should be equidistant Projection, Look for spinous processes – should be vertically orientated against Exposure vertebral bodies Inspiration STUDY NOTES GUIDE → to determine if lung inflation is sufficient, we count no. of ribs that dissect midclavicular line 5-6 anterior ribs, lung apices, both costophrenic angles and lateral rib edges should be visible Posterior ribs 9-10 normally If number is less than above, lungs = hypoinflated/underinflated If number is greater than above, lungs = hyperinflated/over inflated Projection Portable film (ICU) = generally AP If no label, assume it’s a PA If the scapulae are not projected, its PA Exposure → Brightness or darkness of the chest L hemidiaphragm should be visible to the spine and vertebrae should be visible behind the heart S = Soft tissues Neck, thoracic wall, breasts, clavicles, ribs, previous injuries → look for and bones asymmetries If a patient has very thick, soft tissue due to obesity, lung markings may be obscured A = Airway E.g. trachea, carina, bronchi, hilar structures Trachea → looking for deviation – push or pulling of the trachea Carina and bronchi → R main bronchus is generally wider, shorter and more vertical than L main → therefore, more likely for inhaled objects to become lodged in R main bronchus Hilar structures → each hilar has a collection of lymph nodes which aren’t usually visible in healthy individuals. L hilum often slightly higher than R (cuz of heart). Usually same size. It is also where the descending pulmonary artery intersects the superior pulmonary vein – when lost, possible lesion B = Breathing E.g. lungs and pleura Lungs → 3 zones → Upper zone (T1-T6), Middle zone (T6-T10), Lower zone (T10 – end) Compare, noting any asymmetry/or symmetry (pulmonary oedema), increased airspace shadowing (consolidation, malignant lesion), lung borders (absence = pneumothorax) Pleura are not usually visible in healthy individuals – if visible = indicate pleural thickening = mesothelioma Fluid (hydrothorax) or blood (haemothorax) can accumulate in pleural space -  opacity. A combination of air and fluid can accumulate in pleural space (hydropneumothorax) = mixed pattern of both  and  opacity within pleural cavity Tension pneumothorax → life threatening condition → ing amount of air being trapped within pleural cavity displacing mediastinal structures (trachea) and impairing cardiac function o If suspected clinically (SOB and tracheal deviation) - Immediate intervention should be performed without waiting for imaging as this condition will result in death if left untreated C = Cardiac Assess heart size STUDY NOTES GUIDE o In healthy pop, heart should occupy no more than 50% of thoracic width – generally 1/3 of heart is on R and 2/3 on L o * this rule only applies to PA chest xrays (as AP films exaggerate heart size) o Cardiomegaly (enlarged heart) → heart > 50% of thoracic width on PA chest xray → can develop from valvular heart disease, cardiomyopathy, pulmonary hypertension and pericardial effusion D = Diaphragm Including assessment of costophrenic angles R hemidiaphragm o Typically, higher than L (d/t liver) – stomach under L side – identify by gastric bubble Costophrenic angles o Formed from the dome of each hemidiaphragm and lateral chest wall o In healthy, costophrenic angles should be clearly visible – ACUTE angle o Loss of acute angle = costophrenic blunting → may indicate fluid or consolidation in the area, lung hyperinflation (diaphragmatic flattening) (COPD), pleural effusion E = Everything E.g. Mediastinal contours, bones, soft tissues, tubes, valves, pacemakers, else review areas ETT, CVP line, NG tube, PA catheters, ECG electrodes, PICC line, chest tube, pacemakers, metal work