Flashcards in SC3 Deck (24):
Need to know the 5-6 different VO2 max tests, the basics of what each test is, who you would use it on and why, etc.
2) Why do we do VO2 max tests?
3) What is VO2 max?
GO REVIEW all my notes about VO2 and METS in the powerpoint I created.
o 6MWT, Cooper 1.5-mile run/walk test, 2MWT, 5MWT
o Advantages = easy to admin in large #s at one-time, little equipment
o Disadvantages = can be near max or max for some individuals
o Single stage treadmill walk or jog test
o Advantages = can accommodate to the least physically fit and most physically fit
o Disadvantages = treadmills are expensive, not transportable, make some things more difficult to measure, balance issues
o Advantages = lower expense, transportable, greater ease for measures
Good for patients with balance problems
o Disadvantages = less familiar mode of exercise leading to sooner fatigue (not replicatable to real life exercise)
o Advantages = little equipment, transportable, little practice, short duration, mass testing
o Disadvantages = excessive fatigue and inadequate compliance to step cadence
5 Meter walk test (not really used to calculate VO2 max, just used as an assessment of cardiorespiratory fitness).
2) We need to know where the patient is at. Whatever their VO2 max comes out as tells us about their cardiorespiratory fitness (CRF) health, and that will correlation with how much O2 their heart can pump / tissues can consume, and knowing this will let us know at what MET level they can do exercise at.
3) The max amount of O2 you can consume per unit of time. Usually mL / min. Basically it tells us how healthy the heart is and how able it is to pump blood (O2) to body tissues.
1) Review the external landmarks of each lobe of the R and L lung:
2) Be able to find and palpate:
- ALL Ribs (1-12)
- Suprasternal notch (jugular notch)
- Sternal angle
- Sternum (body)
- Xiphoid process
- Intercostal spaces
3) When doing observation of chest, thorax, ribs, what do you do and what are you looking for?
- ALL Ribs (1-12)
- Clavicle right above Rib 1, Rib 1 going into side of
manubrium. Rib 2 going into sternal angle between
manubrium and body.
- Suprasternal notch
- Sternal angle
- Sternum (body)
- Xiphoid process
- T7 area
- Intercostal spaces
- Umbilical (T10 area ... 10th rib)
- Look at anterior, lateral, and posterior
- Symmetry of movement on both sides
- Abnormal spinal curvature or movements
- Rib rotation
- Diaphragm vs. upper chest breather
- Thoracic cage expansion/compliance (or compensation or pain)
- Difficulty labored breathing (abnormal movements)
- Muscle weakness (tight intercostals ... associated with pain)
1) If you observe normal quiet breathing, you are observing what:
1A) Tidal volume is normally what type of breathing:
2) If you observe forced INSPIRATION, you are observing what:
3) If you observe forced EXPIRATION, you are observing what:
4) If you observe maximum breathing in and maximum out, you are observing what:
4A) Max breathing moves from diaphragmatic to ______ _______ breathing:
4B) Is upper chest or diaphragmatic breathing more commonly used and why?
5) If you observe breathing pattern, what in general are you looking for:
6) What do you document with breathing?
1) Tidal volume
2) Inspiratory reserve volume
3) Expiratory reserve volume
4) Vital capacity
4A) Upper chest
4B) Diaphragmatic is more natural and more EFFICIENT - it takes much less effort, energy, muscle contraction to breathe diaphragmatically.
- Breathing sequence: what moves first, second, third
- Primary movement pattern: diaphragmatic, lateral, upper chest, inconsistent, paradoxical
- Quality of breathing: smooth vs. forced, labored or easy, discontinuous, nasal flares
- Anything abnormal
- If auscultating: Intensity, pitch, duration, location
1) With auscultation of lungs, what is probably most important thing to remember
1A) What area do you typically hear lungs sounds best?
2) Review what the adventitious breath sounds are ... (and why you'd get them):
3) What does "consolidation" mean:
4) What is Atelectasis:
5) What are infiltrates
6) Where is the lingual region of the lung:
1) To auscultate on bare skin, and listen to sounds in MULTIPLE PLACES (all lobes), and compare bi-laterally.
1A) On the back
2) You have discontinuous or continuous adventitious (or abnormal) breath sounds:
- Discontinuous: crackling or rales (popping) during inspiration (get from air passing through moisture)
- Continuous: wheezing (high pitched) and rhonchi (low pitched) ... (get from swelling or asthma or secretions in air way).
- Stridor (like croop) . (caused from some obstruction or major respiratory distress, tumor, aspiration).
- Pleura rubbing together (grating sound).
3) Fluid gathering or consolidating in lung
4) Collapsed lung
5) Extra fluid
6) The area of the LEFT lung that protrudes out under mediastinum (where right middle lobe would be).
1) Explain the "99" test
1A) Abnormal result means:
2) Explain the "E" - "A" test
3) Words Test is:
3AA) What is whisper test
3A) T or F: Consolidated lung tissue transmits sounds more clearly?
4) What do you document?
1) Normal test: Use your stethescope and place it over a lobe of the lung to listen. Have the patient repeat the phrase "99" over and over. You listening in stethescope should hear that "99" sound MUFFLED.
1A) If you hear "99" clearly, it means there could be consolidation (fluid build up, pneumonia, mucus, aspired water, whatever) in lungs at that area you are auscultating.
2) This is egophony test ... Patient should repeat the "E" sound. Dr. should hear a muffled "E" sound. But if "E" sounds like "A", that is abnormal (maybe from consolidation). Document E to A change in sound.
3) Bronchophony test: If person says words and they are muffled, that is good. If they are clear, that is abnormal. If abnormal, probably means lung is filled with fluid (consolidation).
3AA) - Whispered pectoriloguy: Whisper words. If muffled/unclear = good. If clear = consolidation.
- Abnormal sounds
- Intensity, pitch, duration, location
1) What is fremitus
2) If you feel increased vibrations on one side, what does that mean?
2A) If you feel decreased vibrations on one side, what does that mean?
2B) If you feel no vibrations at all on one side, what does that mean?
3) Where should you NOT place hands when doing fremitus
4) What side of the body will naturally by a little less vibrations with fremitus, and why?
- Decreased fremitus (vibration) means:
- Increased fremitus (vibration) means:
- Absent fremitus means:
1) If you don't have stethoscope, you can still access lung sound quality, but using the ulnar surface of your hands. Place your hands symmetrically across a certain lobe, have patient talk or say "99" and see if you feel symmetrical vibrations. Fremitus refers to vibratory tremors that can be felt through the chest by palpation. To assess for tactile fremitus, ask the patient to say “99” or “blue moon”. While the patient is speaking, palpate the chest from one side to the other.
2) Consolidation on the side with more vibrations
2A) Probably some obstruction
2B) Possibly a collapsed lung
3) Scapula or over ribs (you won't feel fremitus that way) ... over breast obviously, and heart area.
4) The Patient's LEFT side - extra tissue of the heart in the way
- Decreased fremitus in areas where fremitus is normally expected indicates OBSTRUCTION, pnemothorax, or emphysema.
- Increased fremitus may indicate CONSOLIDATION of lung tissue, as occurs in PNEUMONIA.
- Absent = collapsed lung
1) What is aspiration
2) What lung will be most effected by aspiration. Why?
3) If someone aspirated, what would you do?
4) If aspiration happened in the right middle lobe, where would you auscultate ... and what would you expect to hear?
1) When something goes down the wrong tube ... something went down trachea and is in bronchi, lungs, etc.
2) RIGHT lung. Right main bronchial is more vertical, shorter and wider - so things go down that side easier/first.
3) Look for choking (hymlic if so), auscultate / fremitus, take vital, lie them down
4) right side (patient's right, Dr's left) below 4/5 rib above 6. If there was a peice of FOOD, you might hear CRACKLES. If you have FLUID build up / CONSOLIDATION / pneumonia then you might here wheezing or rhonchi.
1) Identify where you would auscultate for the 4 valves of the heart (and what are they):
2) Where would you auscultate for breath sounds
3) What is so important to remember when auscultating breath sounds?
- What areas are hard to hear breath sounds
- What areas are best to auscultate and hear breath sounds?
5) What are the 4 NORMAL breath sounds you'll hear, and describe each (what they sound like) and where:
6) What are the I/E (inspiratory/expiratory) ratios for those 4 normal sounds:
- Aortic (2nd intercostal space to pt's right of sternal angle)
- Pulmonary (2nd intercostal space to pt's left of sternal angle)
- Tricuspid (5th intercostal space just left of pt's sternum)
- Mitral (5th intercostal space, to left of sternum, but over at mid clavicular line)
- All lobes, both sides, all over. Remember your landmarks for each lobe, and then listen (have pt do a deep breath in and then out) ... listen at each lobe of the lung ... do it anteriorly, laterally, and posteriorly.
- Apex of lung: above clavicles
- Base anteriorly is about at T7, base laterally about T8, base posteriorly is at T10 (and parietal pleura goes 2 ribs lower on each side so lung can expand).
- You can do multiple spots for each lobe to get closer to bronchi and further out into bronchioles.
3) Auscultate bi-laterally to compare both sides, and ideally do it on bare skin. And do it in multiple spots (all lobes).
- Behind bones, and the left side where the heart is in the way and interferes with breath sounds.
- In the back
- Tracheal: Over trachea ... loud, harsh, high-pitched
- Bronchial: Just to right and left of manubrium / sternal angle. Loud high pitched.
- Bronchovesicular: 1st and 3rd intercostal spaces just out away from sternum, or posteriorly between scapula. This is a medium pitch and intensity.
- Vesicular: Out in peripheral lung. Soft pitch and low intensity.
- Tracheal: 1:1
- Bronchial: 2:3
- Bronchovesicular: 1:1
- Vesicular: 3:2
BELOW ARE FLASHCARDS ON LAB 7
1) You may need to palpate and FEEL for breathing patterns in a patient. Explain why and what you'd do
2) How would you palpate for testing breathing pattern
- What muscles play a role in normal breathing
- What muscle might compensate more during difficult breathing:
4) CWE means:
4A) What might limit CWE
5) If you had to use a tape measure to measure tidal volume and vital capacity, what would you do?
6) Typically the increase in measurement for the:
- 3rd rib / axilla area:
- Xiphoid site:
- 1/2 way between Xiphoid and umbilical:
- BASICALLY THE POINT IS ...
1) You want to see if there is proper ribcage expansion, or weakness, compensation, pain, or lack of symmetry.
2) Place hands on anterior, lateral, and posterior rib cage superiorly, middle, and inferiorly to feel and palpate for ribcage expansion.
- NORMAL: Diaphragm, Intercostals
- Abnormal: SCM, Scalenes, Peck major, rectus abdonmins, or other posterior m's to help compensate
4) Chest Wall Expansion or Excursion
4A) Compliance issues due to collapsed lung, alveoli not expanding, diaphragm issues, intercostal m's issues, nerve innervation issues, etc.
5) Measure patient in 3 different positions: upright to supine to side-lying. Use tape measure around 3rd rib/axilla, Xiphoid (7th rib), and 1/2 way between Xiphoid and naval (10th rib).
- 3rd rib and axilla: 2/8th an inch
- Xiphoid: 3/8th inch
- 1/2 way between Xiphoid and umbilical: 4/8th inch
- EXPANSION GETS LARGER AS YOU MOVE DOWN THE CHEST
1) Occassionally you may need to measure rib cage / thorax mobility. How would you do this:
2) If you measured lumbar, what are the landmarks:
3) Lumbar area measures length of what muscle
4) Would thorax or lumbar areas be more flexible?
1) Measure from axilla to the bottom of rib cage during side bending to see how much lateral flexion movement they can create. CHECK BOTH SIDES. Ideally mark with a marker bottom of rib cage so you can measure how much that skin moves.
2) Base of rib cage to greater trochanter (with stable end placed on trochanter)
3) Quadratus lumborum
1) Best way to measure pulmonary function or lung capacity is:
2) A PFT stands for:
3) What are a few non-formal PFT's (and explain each):
3A) Are counting syllables or holding a vowel sound formal PFT's?
3B) Vowel sound test measures what?
4) What is an incentive spirometer:
5) What does an incentive spirometer measure
6) Is an incentive spirometer a formal PFT?
7) What are 2 ways you can use an incentive spirometer .. or 2 things you can assess?
1) Incentive Spirometer
2) Pulmonary Function Test
- Syllables test
Count how many syllables in one breath (that probably
would measure tidal volume. You want 15 + syllables.
- Hold a vowel sound
Patient should maximally exhale, then maximally inhale,
and then hold a vowel sound as long as they can. You
want 15-25 seconds for healthy lungs.
- Incentive spirometer (see below)
3B) VITAL CAPACITY
4) A device used to test lung / respiratory health and function. An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. ... After surgery, it may be too painful to take deep breaths. You may also feel too weak to take deep breaths. It can either measure vital capacity, or help train pt therapeutically to use lungs more efficiently.
5) Vital capacity
- ASSESSMENT: To access Vital Capacity. So patient should max exhale, then inhale through incentive spirometer. This moves dial up and measure vital capacity.
- THERAPUTICALLY: Patient does a max exhale, but then a slow steady inhale trying to keep little ball in the desired range. This tests lung function by keeping airways open longer.
1) What are the 4 phases of a cough
2) What device do you use to measure effectiveness of a cough?
- Instruct how to use
- What is level you want them to be at:
- What can this be used for as well?
3) What are the 3 results or how you'd document what you can get from this test:
- Cough out
2) Peak flow meter
- You do big inhale and then cough as hard as you can into the peak flow meter.
- Above 162 is indication of a functional cough, lower is concern. But really you want it above 250, but min for functional is 162.
- Test for asthma patients
- Functional: adequate to clear secretions (cough) with no assistance
- Weak Functional: adequate to clear the throat and small amounts of secretions, but assistance to cough would be required to clear all mucous (assistance might be the therapist has to give instructions on how to cough better).
- Nonfunctional: unable to generate any cough force
1) First heart sound is:
2) Second heart sound is:
3) S1 on EKG (PQRST complex)
4) S1 is beginning of diastole or systole
5) S2 is end of diastole or systole
6) S2 is where on EKG (PQRST complex)
7) S3 is heard when:
8) S4 is heard when:
9) Rapid ventricular re-filling (ventricular gallop) is what heart sound:
10) Atrial gallop is what heart sound
11) Ken-tuc-ky is for:
12) Ten-nes-see is for:
13) Which heart sounds are normal, which are not
- Explain what is happening in S3:
- Explain what is happening in S4:
- S1 is heard BEST where:
- S2 is heard BEST where:
- S3 is heard BEST where:
- S4 is heard BEST where:
1) Lub, or S1, closing of atrioventricular valves (tricuspid and mitral)
2) Dub, or S2, closing of semilunar valves (aortic and pulmonary)
3) QRS complex
6) T wave
7) Right after S2, very beginning of Diastole
8) Late diastole (as atria are contracting)
13) S1 and S2 are normal, S3 and S4 are not
- S3: ventricular failure and refilling
- S4: pressure in ventricle is so high that atria have to contract harder to get blood into ventricle. Heard in HTN, MI, CAD, angina
- S1: Mitral area
- S2: Aorta
- S3: Apex
- S4: Apex
1) When doing BP with arm (normal), what must you remember to do
2) If a blood pressure cuff is too small, what will that result in?
3) If a blood pressure cuff is too large, what will that result in?
4) If you can't do a BP reading in the traditional brachial artery area, where else could you get a BP reading:
- What is a PICC line
- How would a PICC line impact taking BP?
6) What if you had an obese patient, how would this impact taking BP?
7) What if a patient had a cardiac arrythmia, how would this effect BP?
8) If someone had a masectomy due to breast cancer, how would this change taking BP?
9) Is BP lower or higher in 1st trimester of a pregnant woman?
10) What if you don't have a stethescope when doing a BP reading?
11) What if someone has a blood clot?
12) What should be included in BP documentation?
13) Will BP be higher or lower in forearm (compared to brachial artery). Why?
1) Put arm at level of heart
2) Too HIGH of a BP reading
3) Too LOW of a BP reading
- Radial artery
- Popliteal artery
- Periferal inserted central catheter to access pt's blood.
- Ideally, avoid the PICC line ... use other arm, or other area of body. Usually a picc line is over brachial artery, so you'd have to take BP in other area.
6) Just get a bigger cuff, but also ... you might want to take BP in forearm at radial artery if they have a LOT of extra fat in upper arm area.
7) You'll just get an irregular pulse (and you'll hear it) so be aware of that.
8) Avoid taking BP on the side of the masectomy.
9) Lower in 1st, higher in 3rd
10) Just use your fingers to check pulse
11) Do NOT take BP
- What type of cuff
- What arm/leg (right or left)
- Where was cuff placed (what artery)
- How was patient sitting
- What was the reading
- Anything abnormal
- What activity they were doing
13) HIGHER ... arteries are smaller, so higher BP
AREAS TO PRACTICE MORE:
1) Review the VOICE sounds you'll test and hear using stethoscope:
- With increased lung density, sound is heard more clear or less clear?
- Consolidated lung tissue transmits higher or lower frequency sounds more clearly or muffled
3) If you measure chest wall excursion (CWE) you are measuring what:
- What device do you use to measure the effectiveness of a cough?
- Explain how that device works?
- 4 stages of a cough
- Normal: Say "99" and it should be muffled or unclear in stethescope. If it is audible, then probably consolidation.
- Bronchophony: Say normal words. If it is muffled/unclear = normal. If it is clear = consolidation
- Whispered pectoriloguy: Whisper words. If muffled/unclear = good. If clear = consolidation.
- Egophony: Say "E" and it should sound like a muffled E. If it sounds like an "A" then = consolidation.
- More clear
- Higher - clearly
3) Both. You can measure tidal volume (normal) or vital capacity (forced ex/inhale).
- Peak Flow Meter
- PT instructs the patient on 4 steps of the cough, and then has the pt do it. As the patient coughs into the peak flow meter, the PT measures it. If the pt got over 162, that is good. Below is cause of concern.
- Big inhale, hold, tense/pressure, cough out
1) 3 muscles of normal triad breathing:
- If a pt is hypoventilating, would fremitus (feeling of vibrations on hands) be more or less?
- If mucus or junk in lungs is increased (more consolidation), will fremitus be more or less?
1) Diaphragm, intercostals, abdominal m's
Review the auscultating voice sounds
Repeat “99” or “1, 2, 3”
Should hear muffled non-distinct sounds
Normal = unintelligible words
Abnormal = clear words
Air filled lungs filled with fluid=pulmonary consolidation
Whispered series of word as you ascultate
Should be non-distinct/unintelligible
With increased lung density, sound is heard clearly .
despite being whispered
Consolidated lung tissue transmits higher frequency
sounds more clearly
Indicates pulmonary consolidation
Normal = muffled “E” or non-distinct sound
Abnormal = “E” sounding like “A”
Document “E to A changes”
Review normal vs. abnormal fremitus
Normal and Abnormal Fremitus
Tactile Fremitus or vocal Fremitus
Caused by vibration of the vocal cords on phonation
Vibration transmitted by bronchopulmonary system and
felt on chest wall
Palpable vibration on chest wall
Produced by turbulent air flow over thick secretions in
Indicates increased lung density (from
Pneumonia, edema, lung tumor, pulmonary fibrosis
Indicates decreased lung density (from
Emphysema, pleural effusion, COPD, asthma, bronchitis,
pneumothorax, thick chest wall
1) How would you measure CWE for tidal volume and vital capacity?
2) How would you measure thoracic mobility?
3rd rib / axilla
1/2 way from xiphoid process and naval
Use tape measure
2) Tape measure. Measure from axilla down to bottom of rib cage (for lumbar it is from bottom of rib cage to greater trochanter).
How would you measure vital capacity:
- Count syllables per breath after maximal expiration and inhalation
- Time length of a vowel sound after maximal expiration and inhalation
- Use incentive spirometer
Here are the cases for SC3. You need to determine which tests/measures you'd do, and what VO2 test you'd use on them:
A 75-year-old with COPD has been diagnosed with pneumonia and is being seen in an acute care hospital for an initial evaluation by a PT.
- I'd auscultate lungs, maybe CWE measures, incentive
spirometer for Vital Capacity and especially
for therapeutic reason, Peak Flow Meter, BP (place
depends on lines/tubes)
- Either 5 meter walk test (if after eval he is really SOB
and weak), or do 2 min walk test if after eval he is
An 82-year-old morbidly obese patient is being evaluated in home health by PT after being discharged from the acute care hospital with an exacerbation of CHF.
- AUSCULTATE HEART, PAR Q, BP, Incentive Spirometer
- No jogging/running. Might have access to a
treadmill. Either 5 meter walk test (if after eval he is
really SOB and weak), or do 2 min walk test if after
eval he is doing well).
- Do BP in forearm (because of excess skin over arm so
I'll get a bad reading)
A 38-year-old is being evaluated in acute rehab after being discharged from the acute care hospital with an acute CVA.
- For VO2, check cognition, test side for strength
- BP on side not effected
- Lung auscultate, peak flow meter
- Same concept as VO2 above
A 20-year-old with cystic fibrosis (MUCOUS BLOCKS AIRWAYS) is being evaluated in an outpatient clinic.
- Auscultate lungs, peak flow meter, incentive
- See how active they are, to see what they have done
... maybe do treadmill walk test.
- BP normal brachial artery.
What are s/s of:
- Cystic Fibrosis:
- SOB, wheezing, chronic cough, fatigue, difficulty
doing activity (exercise, house work)
- SOB, increased HR, chest pain, dizziness, fatigue,
difficulty doing activity (exercise, house work), swollen
legs (water retention), weight gain
- unilateral impairment, slurred speech, paralysis of
side of face / body, weak muscles, vertigo,
lightheaded, weakness, fatigue, blurred vision,
difficulty swallowing = aspiration / pneumonia
- bad cough, SOB, wheezing, fatigue, lung infection,
pulmonary HTN, weight loss