Test Thursday 1/11/18
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each of the black spaces below before clicking
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| Patient Related Factors | 1) Preexisting, age, risk factors 2)Rapidity of onset 3) Type, stage, severity 4) Presence/absence of coexisting complications or drugs
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| Technical Factors | 1) Improper setup/maintenance 2) Poor/inconsistent technique 3) Defects in monitor/cables 4) malposition or occlusion of catheter tip 5) artifacts 6) pt-related factors
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| Appropriateness of Monitor and Labs | If pt looks "bad" despite "good" numbers, pt physiologic status is bad. Pt can also look "good" and have "bad" numbers due to acute problem.
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| Reliability of Monitor Alarm systems | Depends on limits set by caregivers & whether alarms are activated and functioning
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| Pressures are equal / no airflow | end expiration
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| Pressure in alveoli fall below atmospheric pressure / airflow In | Inspiration
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| Pressure in alveoli rise above atmospheric pressure/ airflow out | Expiration
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| Negative intrathoracic pressure brings in / positive pressure sends out | spontaneous breathing
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| Positive Pressure sends air in | Mechanical breathing
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| Increased PaCO2 will increase Rate & depth of breathing Decreased PaCO2 will decrease rate & depth of breathing | CNS Control of Breathing
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| Hypoxemia causes an increased rate & depth of breathing | PNS Control of Breathing
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| Other Factors that affect Mechanics of Ventilation | 1) Stretch receptors and sensory nerves in lungs effect ventilation 2) Muscle and joint movement, pain, strong emotions, fever & sepsis
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| Abnormalities in Ventilatory Control | Hypoxic ventilatory drive may become primary stimulus, esp in pts with COPD
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| CNS Disorders -- vascular | A stroke may cause damage to brainstem & cause chronic resp depression ie: cerebral vascular disease
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| CNS Disorders -- Brain | Acute increases in intracranial pressures cause alterations in rate & pattern of breathing ie: brain injury
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| Distribution | Delivery of fresh air from upper airway to alveoli
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| Upper airways | Nose, pharynx, and larynx
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| Lower airways | trachea, bronchi, bronchioles, and terminal bronchioles
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| Alveoli | Tiny air sacs
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| Anatomic Dead Space | Air that doesn't reach the alveoli
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| Alveolar Dead Space | Ventilation without perfusion
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| Physiologic Dead Space | total of anatomic and Alveolar dead space
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| Factors that interfere with Adequate gas distribution and WOB | 1) Decreased lung compliance (stiff) 2) Increased lung compliance (flabby) 3) Decreased chest wall compliance (rigid) 4) Increased RAW 5) Artificial airways
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| Diffusion | Transfer of O2 and CO2 between alveoli, plasma, and tissue
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| Factors that determine rate of gaseous diffusion | 1) Diffusion coefficient 2)Membrane surface area 3) Membrane thickness 4) Diffusion of resp gases in lungs & tissue level
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| Perfusion and Transport | Means by which venous blood is brought to the AC membrane for oxygenation, CO2 removal, sustenance of lung tissue, & dlvy to left side of heart for transport to body cells
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| Increased PVR (pulmonary vascular resistance) | Pulmonary arterial pressures & ventricular systolic work increases
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| Decreased PVR (pulmonary vascular resistance) | Right ventricular systolic work & O2 demand decreases
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| Pulmonary Vasoactive Agents | A. Vasoconstrictors = 1) Epinephrine & 2) Norepinephrine
B. Vasodilators = 1) Isoproterenol 2) Diltiazem
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| PVR means | Pulmonary Vascular Resistance
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| Causes of V/Q Mismatch | 1) Shunting (absolute & relative) 2) Hypoventilation 3) Alveolar Dead Space 4) Silent Units
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| Silent Units | No ventilation or perfusion
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| How the body compensates for V/Q mismatches | 1) Poorly ventilated alveoli tend to be under perfused
2) Poorly perfused alveoli tend to be under ventilated
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| Two ways Oxygenated blood is transported to body tissue | 1) Dissolved in plasma or 2) bound to Hb
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| Factors that affect the affinity of Hb to O2 | PO2, Body Temperature, Quantity of 2,3 DPG, ph & PCO2
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| If PaO2 is elevated, Hb has a(n) ____________ affinity for O2 | Increased
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| If PaO2 is low, Hb has a (n) ____________ affinity for O2 | Decreased
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| Hypercarbia | High CO2
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| Hypocarbia | Low CO2
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| Acidemia and hypercarbia do what to Hb affinity for O2? | Decrease
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| Alkalemia and hypocarbia do what to Hb affinity for O2? | Increase
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| Monitors are only _____________ to patient evaluation | adjuncts
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| _____________ conditions for accurate physical assessment | Optimize
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| Assessment ________________ and specific assessment ____________ are to be determined by the pts known or suspected problems | Frequency -- with which assessment needs to be done
Techniques -- those that are key and those that aren't
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| ______________ of certain assessment findings are patient dependent | Characteristics
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| General considerations under physical assessment | Transcultural considerations
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| Evaluation of symptoms of pulmonary disease | Cough, Dyspnea, and chest pain
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| Signs of pulmonary disease | 1) pt mentation 2) abnormalities in RR 3) abnormal breathing patterns 4) characteristics of breathing 5)Entirely thoracic breathing 6) Entirely abdominal breathing 7) Abnormal resp cycles 8) Stridor
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| Abnormalities in Respiratory Rate | 1) Tachypnea &
2) Bradypnea
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| Abnormalities in Characteristics of Breathing | 1) asymmetry of movement between both sides of chest
2) asymmetry of movement between chest & abdomen
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| Entirely thoracic breathing | Indicates that diaphragmatic movement is restricted
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| Entirely abdominal breathing | Indicates paralysis of intercostal muscles
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| Abnormalities relative to phases of respiratory cycle | 1) Labored inspiration (retractions & nasal flaring)
2) Labored expiration (using accessory muscles, prolonged, purse lip breathing, or grunting)
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| Other signs of Pulmonary Disease | 1) Cyanosis 2) pitting & edema 3) Subcutaneous emphysema 4) Pt posture 5) Pleural friction rub
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| Types of Cyanosis | 1) Central 2) Peripheral 3) Mixed 4) Differential
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| Central Cyanosis | Around the core, lips & tongue
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| Peripheral Cyanosis | Extremities and fingers; hypothermia
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| Mixed Cyanosis | Combination of central and peripheral cyanosis.
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| Differential Cyanosis | Coloration of lower but not upper part of head.
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| Specific Techniques of physical assessment | A. Tracheal position; 1)Tension pneumothorax, 2)atelectasis, 3)percussion
B. 1)Resonance, 2)Hyperresonance, 3)Tympany, 4)Dullness
C. Auscultation
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| Structures of Heart Wall | Pericardium, Myocardium, Endocardium
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| Cardiac Chambers | 1) Atria; upper right and left 2) Ventricles; lower right and left
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| Cardiac Valves | 1) Semilunar -- aortic & pulmonary
2) Atrioventricular -- Mitral & Tricuspid
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| Preload -- determines CO | Amount of stretch on myocardial muscle fibers at end diastole; determined by volume of blood in ventricles at that time
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| Afterload -- determines CO | Sum of forces against which the ventricular muscle fibers must shorten to eject blood into arterial circulation.
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| Left Ventricular Afterload | Imposed by aortic diastolic pressure and SVR
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| Right Ventricular Afterload | Imposed by pulmonary artery diastolic pressure and SVR
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| SVR | Systemic Vascular Resistance
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| Contractility -- determines CO | Force and velocity of myocardial fiber shortening independent of preload & afterload. Inotropic stimuli will increase or decrease strength of contraction.
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| Muscular Synergy - determines CO | Pattern of ventricular contractile dynamics.
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| Coronary Circulation | Supplies blood in the sinus node, AV node, and initial portion of Bundle of HIS
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| Left Main Coronary Artery (2) | 1) LAD (Left Anterior Descending branch)
2) Circumflex branch
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| Physical factors that determine coronary blood flow | 1) Coronary perfusion pressure
2) coronary vascular resistance
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| Factors that may globally or locally decrease coronary blood flow | 1) physical obstruction/narrowing of lumen
2) decrease in aortic diastolic pressure or significant increase in right atrial pressure
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| Ventricular Wall _____________ will proportionately affect myocardial work | Tension = determined by afterload and ventricular size
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| Myocardial ______________ will proportionately affect myocardial work | Contractility = determined by inotropic stimuli
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| ___________ rate will proportionately affect myocardial work | Heart
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| Normal systemic circulation pressure gradient | 90 mm Hg to drive systemic blood flow
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| Normal Pulmonary circulation pressure gradient | 8 mm Hg to drive pulmonary blood flow
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| Vascular System rate and volume of blood flow is determined by | 1) Inflow vs. outflow pressure difference (gradient)
2) The resistance to blood flow
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| Components of Vascular system | 1) Systemic Vessels 2) pressure by blood on arterial walls 3) blood pressure 4) Arterial Pressure 5) anything influencing systolic and diastolic pressures
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| 3 types of systemic vessels | Systemic arteries, systemic capillaries, systemic veins
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| 3 controllers of blood pressure | Arterial baroreceptors, chemoreceptors, strong emotional stimuli
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| 2 components of arterial pressure | 1) systolic pressure 2) diastolic pressure
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| Systolic pressure | The higher pressure that relates to contraction of ventricles and ejection of a bolus of blood into arterial system
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| Diastolic pressure | The lower pressure that relates to relaxation and runoff of blood through the vascular system
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| Factors influencing systolic and diastolic pressures | 1) Stroke volume 2) Vascular resistance 3)Heart rate 4) Intravascular volume
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| Symptoms of Cardiovascular disease | Chest pain, Dyspnea, Weakness, and fatigue
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| Signs of Cardiovascular disease | 1) Changes in mentation 2) Changes in skin color and temp 3) Cyanosis 4) Urine output
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| Specific Techniques of Physical Assessment | 1) Evaluate HR and rhythm (repeatability & regularity)
2) Evaluate arterial pressure (time doman & frequency)
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| O2 Consumption | `VO2 = `QT [C(a-v)O2 x 10]
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| Total O2 Delivery (amount of O2 transported to tissues) | DO2 = `QT x (CaO2 x 10)
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| O2 Content Arterial | CaO2 = (Hb x 1.34 x SaO2) + (PaO2 x .003)
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| O2 Content Mixed Venous | CvO2 = (Hb x 1.34 x SvO2) + (PvO2 x .003)
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| O2 Content Pulmonary Capillary | CcO2 = (Hb x 1.34) + (PAO2 x .003)
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| A-a gradient or Ideal Alveolar Air Equation | PAO2 = [PB - PH2O] FiO2 - PaCO2 (1.25) If all is normal
PAO2 = (713 x FiO2) - (PaCO2 x 1.25)
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| Cardiac Output | CO = SV x HR
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| Blood pressure | BP = CO x SVR (Systemic Vascular Resistance)
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| Vascular Resistance | SVR = BP/CO
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| O2 Bound to Hb | 1.34 x Hb x SaO2
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| Dissolved O2 | PaO2 x 0.003
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| Arterial - Venous O2 Content Difference | C (a-v)O2 = CaO2 - CvO2
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| O2 Extraction Ratio | O2ER = CaO2 - CvO2 / CaO2
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| Shunt Equation | Qs/Qt = CcO2 - CaO2 / CcO2 - CvO2
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| Semilunar Heart Valves | Aortic & Pulmonary
Systole = open ; Diastole = closed
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| Atrioventricular Heart Valves | Mitral & Tricuspid
Systole = closed ; Diastole = open
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| Vasoconstrictors (drugs) | Epinephrine and Norepinephrine
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| Vasodilators (drugs) | Isoproterenol and Diltiazem
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| Hypoxia (PVR) | Stimulates vasoconstriction and increases PVR
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| Acidemia (PVR) | Stimulates vasoconstriction and increases PVR
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| Atelectasis (PVR) | May increase PVR
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| Increased pulmonary blood flow (PVR) | decreases PVR (unless it's a great amt of blood flow)
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| Increased pulmonary venous & left atrial pressures | PVR response varies; depends on complications & underlying condition(s)
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| Vascular Obstruction | Massive blockage will increase PVR ie. PE/Tumor
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| Common Therapeutic Interventions for Hypothermia | Remove wet clothing, provide dry clothing, place pt in warm area, cover pt with warm blankets, apply warming pads, keep pts limbs close to body, cover pts head with a cap or towel, supply warm oral or iv fluids
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| Cyanosis is a result of | decreased V/Q ratio, pulmonary shunting, venous admixture, and hypoxemia
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