Respiratory Notes: Respiratory Therapist's Pocket Guide (Davis's Notes)

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untitledF. A. Davis Company • Philadelphia
Purchase additional copies of this book at your health science bookstore or directly from F. A. Davis by shopping online at or by calling 800-323-3555 (US) or 800-665-1148 (CAN)
A Davis’s Notes Book
Gary C. White, MEd, RRT, RPFT
Respiratory Notes
Respiratory Notes
00White (F)-FM 4/6/07 11:14 AM Page 3
F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103
Copyright © 2008 by F. A. Davis Company
Copyright © 2008 by F. A. Davis Company. All rights reserved. This prod- uct is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, elec- tronic, mechanical, photocopying, recording, or otherwise, without writ- ten permission from the publisher.
Printed in China by Imago
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As new scientific information becomes available through basic and clin- ical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted stan- dards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from appli- cation of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional stan- dards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product infor- mation (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1467/08 0 $.10.
00White (F)-FM 4/6/07 11:14 AM Page 4
Waterproof and Reusable
Notes with a ballpoint pen. Wipe old entries off
with an alcohol pad and reuse.
For a convenient and refillable note pad
HIPAA Compliant OSHA Compliant
00White (F)-FM 4/10/07 6:55 PM Page 5
Look for our other Davis’s Notes titles RNotes® Nurse’s Clinical Pocket Guide, 2nd edition
ISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5
Coding Notes Medical Insurance Pocket Guide ISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6
Derm Notes Dermatology Clinical Pocket Guide ISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6
ECG Notes Interpretation and Management Guide ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8
IV Therapy Notes Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1288-5 / ISBN-13: 978-0-8036-1288-4
LabNotes Guide to Lab and Diagnostic Tests ISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5
LPN Notes Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1132-3 / ISBN-13: 978-0-8036-1132-0
MedSurg Notes Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1115-3 / ISBN-13: 978-0-8036-1115-3
NutriNotes Nutrition & Diet Therapy Pocket Guide ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6
MA Notes Medical Assistant’s Pocket Guide ISBN-10: 0-8036-1281-8 / ISBN-13: 978-0-8036-1281-5
OB Peds Women’s Health Notes Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1466-7 / ISBN-13: 978-0-8036-1466-6
Ortho Notes Clinical Examination Pocket Guide ISBN-10: 0-8036-1350-4 / ISBN-13: 978-0-8036-1350-8
PsychNotes Clinical Pocket Guide ISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0
Screening Notes Rehabilitation Specialists Pocket Guide ISBN-10: 0-8036-1573-6 /ISBN-13: 978-0-8036-1573-1
Rehab Notes Evaluation and Intervention Pocket Guide ISBN-10: 0-8036-1398-9 /ISBN-13: 978-0-8036-1398-0
IV Med Notes IV Administration Pocket Guide ISBN-10: 0-8036-1446-2 / ISBN-13: 978-0-8036-1466-8
MedNotes: Nurse’s Pharmacology Pocket Guide, 2nd Edition ISBN-10: 0-8036-1531-0 / ISBN-13: 978-0-8036-1531-1
For a complete list of Davis’s Notes and other titles for health care providers, visit
00White (F)-FM 4/6/07 11:14 AM Page 6
the second patient has the same organism.
Private room (negative pressure with 6–12 air changes per hour). Cohorting is OK if the second patient has the same organism.
Private room. Cohorting is OK if the second patient has the same organism.
Always wear gloves and gown.
Always wear gloves and gown.
Wear gloves for any patient contact. Wear gown if you anticipate contact with patient, soiled equipment, or soiled environmental surfaces.
Surgical mask
HEPA mask
During transport the patient should wear a HEPA mask.
During transport ensure that any contact transmission by the patient is minimized.
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Group Anxieties Strategies Senses Skills Ability Considerations
Separation from parent(s).
Use concrete verbal com- munication strategies.
Loud noises may startle an infant.
Senses are acute.
Gross motor skills.
Can under- stand more than they can verbalize.
Never leave unattended; always use side rails on cribs. Support head and neck, protecting the airway.
Requires close supervision. Don’t leave small objects that may become a choking hazard.
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Group Anxieties Strategies Senses Skills Ability Considerations
Separation, death, disability, injury, pain.
Embarrass- ment, loss of control, loss of conscious- ness, changes in appear- ance/function, separation from peer group.
Use con- crete verbal strategies.
Be more thorough in expla- nations.
Senses are acute.
Senses are acute.
Good motor skills.
Good motor skills.
Can under- stand more, explain why a child will benefit from treatment or a procedure.
May be capable of abstract thought.
Don’t leave sharps or other poten- tially hazar- dous items at the bedside. Privacy be- comes more important.
Privacy is very important. Encourage verbalization and partic- ipation in health-care decisions.
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Group Anxieties Strategies Senses Skills Ability Considerations
Loss of control, changes in appearance/ function, separation from spouse, death.
Loss of control, changes in appearance/ function, separation from spouse (significant other), death.
Be more thorough in expla- nations. Involve the patient in health- care deci- sions.
Be more thorough in expla- nations. Involve the patient in health- care deci- sions.
Hearing, taste, and sight may decline.
Hearing, taste, sight (cataracts, macular degenera- tion, etc.) may decline.
Reflexes may be slower, balance and coor- dination may be dimin- ished.
Joints are stiffer and less mobile. Balance may be more dimin- ished.
Possesses abstract thought.
Possesses abstract thought. Dementia or other mental diminish- ment may be present.
Be aware of values effect on patient’s care. Endu- rance may be diminished. Independence and fostering self-care should be encouraged.
Patient’s skin is more fragile. Patient may have dysphasia. Patient should be involved in decision- making.
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Eye contact
Generally accept therapeutic touch. Establish trust first.
Responsibility for decision-making varies by educational level and socioeconomic status.
Belong to Baptist and other Protestant sects; Muslim.
Will refuse blood if a Jehovah’s Witness. Are reluctant to donate blood or organs.
General, no prohibitions unless prohibited by religious beliefs (pork not eaten by Muslims).
Reluctant to donate organs. Death is a universal experience transcending racial, religious, and socioeconomic barriers.
Silence may indicate lack of trust toward the caregiver.
Females may avoid eye contact with males and strangers.
Is generally acceptable within the same gender, but is not acceptable between genders.
Most decisions are made by men. Care for daily needs is delegated to women.
Muslim (generally Sunni branch), also Protestant, Greek Orthodox, or other Christian faiths.
Mutilation of the body (autopsy) or organ donation may be refused. Some may donate organs because it will benefit the community.
Most Muslims do not eat pork. Avoid icy drinks when sick or hot/cold drinks together.
Colostrum is believed to be harmful to infants.
Supportive family members may need to be encouraged to take breaks from caregiving.
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Eye contact
& birth
Looking straight into someone’s eyes during a conversation shows honesty and frankness.
Shaking hands is OK. Strict Muslims do not allow male nurses to examine women.
Traditionally, a patriarchal family structure.
Majority are Muslim or Christian, a few may be Jewish.
Organ donation and receiving blood products are acceptable.
Pork is prohibited by Muslims. Medications should not contain alcohol (also prohibited by Muslims).
Many visitors can be expected. No cremation is allowed. May only want females present during delivery of a child.
Permanent life support is unacceptable. Most consider it shameful to accept Medicaid.
It is important to maintain sustained eye contact during conversations.
Light touch handshake is OK. Maintain a respectful distance while interacting with the patient.
Varies from nation to nation.
May be traditional Native American belief or Christian.
Blood and organ donation is generally not desired, but may be open to discussion.
Restrictions will vary with religious/spiritual beliefs.
Full family involvement occurs throughout all stages of life. Circumcision may be refused.
Older adults may prefer the use of “American Indian” over Native American.
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Eye contact
May avoid direct eye contact with authority figures (health-care providers included).
Except for handshaking, touching may be considered disrespectful.
Entire family shares equally in decision-making.
Primary religion is Roman Catholic.
Will vary; may be against organ donation.
Catholics may refrain from eating meat on Fridays and during Lent.
Strong family support during labor. Most are very expressive during bereavement.
Silence may sometimes indicate a disagreement with the plan of care.
Direct eye contact is OK. Nodding signi- fies approval.
Touching is OK once familiarity or friend- ship has been established.
Typically, both men and women share in decision-making.
Primary religions are Jewish, Eastern Orthodox, and Christian. Many may not practice a faith due to past oppression.
May refuse organ donation based on belief that the body is sacred.
Drinks with ice should not be served.
Father may not attend birth, but the closest female family member usually does.
Interpreters should be used whenever possible.
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Lb Kg F C Cm Inches Feet and Inches
300 136.4 212 100 142 56 4′8′′ 275 125.0 108 42.2 145 57 4′9′′ 250 113.6 107 41.6 147 58 4′10′′ 225 102.3 106 41.1 150 59 4′11′′ 210 98.5 105 40.6 152 60 5′0′′ 200 90.9 104 40.0 155 61 5′1′′ 190 86.4 103 39.4 157 62 5′2′′ 180 81.8 102 38.9 160 63 5′3′′ 170 77.3 101 38.3 163 64 5′4′′ 160 72.7 100 37.8 165 65 5′5′′ 150 68.2 99 37.2 168 66 5′6′′ 140 63.6 98.6 37.0 170 67 5′7′′ 130 59.1 98 36.7 173 68 5′8′′ 120 54.5 97 36.7 175 69 5′9′′ 110 50.0 96 35.6 178 70 5′10′′ 100 45.5 95 35.0 180 71 5′11′′ 90 40.9 94 34.4 183 72 6′0′′ 80 36.4 93 34.0 185 73 6′1′′ 70 31.8 92 33.3 188 74 6′2′′ 60 27.3 91 32.8 191 75 6′3′′ 50 22.7 90 32.1 193 76 6′4′′ 40 18.2 89 31.7 196 77 6′5′′ 30 12.6 88 31.1 198 78 6′6′′ 20 9.1 87 30.6 201 79 6′7′′ 10 4.5 86 30.0 203 80 6′8′′
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Lb Kg F C Cm Inches Feet and Inches
5 2.3 85 29.4 206 81 6′9′′ 2.2 1 75 23.9 208 82 6′10′′ 2 0.9 74 23.3 1 0.45 73 22.8
72 22.2 71 21.7 70 21.1 69 20.6 68 19.9 32 0.0
Lb Kg 2.2 Lb/Kg Kg Lb 0.45 Kg/Lb
F C 9 5

Pressure Conversions (60F)
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01White (F)-01 4/6/07 11:22 AM Page 9
cmH2O mmHg KPa
40 29.41 3.92 45 33.09 4.41 50 36.76 4.90 55 40.44 5.39 60 44.11 5.88 65 47.79 6.37 70 51.47 6.86 75 55.15 7.35 80 58.82 7.84 85 62.5 8.33 90 66.17 8.82 95 69.85 9.31
100 73.53 9.80
BTPS ATPS STPD ATPS PB Barometric pressure PH2O Partial pressure of H2O at spirometer temperature
47 Partial pressure of H2O at body temperature and pressure saturated
310 Body temperature in Kelvin T Spirometer temperature (C)
273 273 T
PB PH2O 760
310 273 T
The patient interview facilitates the collection of subjective information regarding the patient’s present illness while establishing a professional rapport and trust with the patient.
Structure of the Interview
Project a genuine interest in the patient Be sensitive to the patient’s concerns Give undivided attention to the patient and his or her
responses Use eye contact effectively
Introduction Be professional (dress, mannerisms, respect, etc.) Introduce yourself to the patient using last names
(Mr. Smith, I am Mrs. Lanker from respiratory care.) Use eye contact
Professionalism Conduct the interview seated beside the patient facing him
or her The patient should be seated upright with his or her eyes at
an elevation higher than yours Maintain privacy
Respect the patient’s beliefs and attitudes Use open-ended questions (Tell me, how is your breathing
this morning?) Use reflection in your responses (So your chest feels
tight.) Be empathetic
Biographical Age, gender, occupation, race/culture
Chief complaint What resulted in the patient seeking medical attention? What are the symptoms that caused the patient to seek
medical attention? Are there any associated symptoms (sweats/chills, fever,
cough, etc.)? Onset, duration, severity?
History of present illness Detailed description of each symptom described in the chief
complaint P, Q, R, S, T
P (Provokes/Point): What causes it, what makes it better, where is it?
Q (Quality): Dull, achy, how much is involved, how does it look, how does it feel?
R (Region/Radiation): Where does it radiate or spread? What makes it better? What makes it worse?
S (Severity): Lichert scale 1 (no pain) to 10 (worst pain). T (Timing): When did it start? Is it constant? Is it sudden
or gradual? Past medical history
Childhood illnesses Hospitalizations (injuries, accidents, emergent conditions,
etc.) Surgeries (elective, emergency, etc.) Allergies, immunizations Current medications (prescribed and over-the-counter) Social history
Smoking: How long? What (cigarettes, cigars, pipe, etc.)? Have you quit? How long?
Alcohol: How long? What (liquor, wine, beer)? How often? How much? How long?
Drug use: What? How often? How long?
emphysema, bronchitis, cystic fibrosis)? Family history for heart disease? Family history for hypertension? Family history for renal disease? Family history for cancer?
Occupational/environmental history Work: Shipyard, mining, farming, foundry work, mill
work, insulation installation, welding, chemical exposure, textile work, etc.
Home: Air conditioning, evaporative cooling, humid- ifier, molds, insulation, plants, smoking, wood stove use
Geographical: Histoplasmosis, coccidioidomycosis, blastomycosis
Vital Signs
Vital Signs
Assess vital signs upon admission as ordered; on change in status, with chest pain or any abnormal sensation; before and after administration of blood products or medications that can cause cardiovascular or respiratory changes; before and after any intervention that can affect the cardiovascular or respira- tory system.
Vital signs should include temperature (T), heart rate (HR), respiratory rate (RR), blood pressure (BP), SpO2, and pain assessment.
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SS Normal Ranges
Age Preemie Term 6 mo 1 yr 3 yr 6 yr 9 yr 12 yr 15 yr Adult Elderly
T 36.8 36.8 37.7 37.7 37.7 37 37 37 37 37 36
HR 140 80–180 80–140 80–140 80–140 75–120 50–90 50–90 50–90 60–100 60–100
RR 40–60 30–80 30–60 20–40 20–40 15–25 15–25 15–24 15–20 12–20 15–20
BP 73/55 73/55 73/55 90/55 90/55 95/57 95/57 120/80 120/80 120/80 120/80
SpO2 95% 95% 95% 95% 95% 95% 95 % 95% 95% 95% 95%
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Head—Facial expressions, cyanosis, pursed lip breathing, nasal flaring, eyes (pupil size and reaction)?
Neck—Jugular venous distension, use of accessory muscles, tracheal position, lymph node palpation?
Physical Examination of the Chest
Stokes, Biot’s Chest conformation: A-P diameter, kyphosis, scoliosis,
lordosis, kyphoscoliosis, pectus? Digital clubbing?
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Tracheal position: Midline, deviated right or left? Areas of tenderness? Symmetry: Do the hands move uniformly? Tactile fremitus: Present or absent? Subcutaneous emphysema present?
Normal (Eupnea)
Vesicular: Low pitched and soft with inspiration longer than expiration. Normal over most of the lung fields.
Bronchial: Harsh, loud and higher pitched with expiration longer than inspiration. Normal over the manubrium.
Bronchovesicular: Moderate intensity and pitch with equal inspiratory and expiratory phases. Over sternum and lung apices.
Crackles: Discontinuous (starts and stops) fine, medium, or coarse (inspiratory or expiratory). Can be caused by alveoli opening (fine), fluid in bronchioles (medium), and fluid in large airways (coarse).
Wheezes: Continuous “musical” sound (inspiratory or expiratory). Caused by air flowing through narrowed airway lumen. A wheeze will have a higher pitch if the narrowed lumen is very small. Wheezing should be described as inspiratory, expiratory, monophonic (single pitch), or polyphonic (multiple pitches). Polyphonic wheezing occurs during the expiratory phase.
Rhonchi: Coarse, wet, low-pitched continuous sounds produced by large amounts of secretions in the airways. Rhonchi may clear if the patient is asked to cough.
Rub: Grating or creaking sound (like leather rubbing). Caused by inflamed pleural layers or pleural irritation.
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Cough—Duration (acute 3 weeks, chronic 3 weeks or recurrent), productive, nonproductive, time of occurrence?
Sputum—Amount (30 mL/day, 30 mL/day), color, consistency, odor, hemoptysis?
Ventilation Assessment
VE, VT, and Frequency Minute Volume (VE)—The volume exhaled or inhaled in
1 minute Normal: 5–7 L/min (adult)
Tidal Volume (VT)—The resting volume inhaled or exhaled during each breath Normal: 4–7 mL/kg
Frequency (rate)—The number of breaths per minute. Normals: Term infant: 30–80 6-month-old: 30–60 Pediatric: 20–40 Adolescent: 15–25 Adult: 12–20
Rapid Shallow Breathing Index (frequency/tidal volume [L]) Normal: 100
PaCO2 Normal: 35–45 mmHg
PEtCO2 Normal: 35–43 mmHg
Deadspace (VD ana, VD/VT) Anatomic: Normal 1 mL/Lb body weight
VD 1 mL Body Weight (Lb)
VD/VT: Normal 0.25–0.35
Note: Only calculate at FIO2 of 0.21 or 1.0
CaO2 SaO2(Hb 1.34) (PaO2 0.003) Normal: 15–24 mL/dL PaO2: 80–100 mmHg SpO2: 90%
DO2 QT (CaO2 10) Normal: 1000 mL/min SvO2(Hb 1.34) (PvO2 0.003) Normal: 12–15 mL/dL CaO2 – CvO2
Normal: 4–6 mL/dL PaO2/FIO2 Normal: 200
PaO2/PAO2 Normal: 0.8–0.9
Normal: 0.25
Inspection Palpation Percussion Auscultation VT f PaCO2 SpO2 CaO2 QS/QT
Pursed lip breathing
Pursed lip breathing
↑ A-P Dia
Wheezing, crackles