2014 wilkins clinical assessment in respiratory care 7e with MCQ

Contents PREPARING FOR THE PATIENT ENCOUNTER, THE MEDICAL HISTORY AND THE INTERVIEW, 15 CARDIOPULMONARY SYMPTOMS, 32 VITAL SIGNS, 56 FUNDAMENTALS OF PHYSICAL EXAMINATION, 73 NEUROLOGIC ASSESSMENT, 102 CLINICAL LABORATORY STUDIES, 126 INTERPRETATION OF BLOOD GASES, 152 PULMONARY FUNCTION TESTING, 178 10 CHEST IMAGING, 207 11 INTERPRETATION OF ELECTROCARDIOGRAM TRACINGS, 234 12 NEONATAL AND PEDIATRIC ASSESSMENT, 263 13 OLDER PATIENT ASSESSMENT, 296 14 RESPIRATORY MONITORING IN CRITICAL CARE, 314 15 VASCULAR PRESSURE MONITORING, 348 16 CARDIAC OUTPUT MEASUREMENT, 373 17 BRONCHOSCOPY, 396 18 NUTRITION ASSESSMENT, 410 19 SLEEP AND BREATHING ASSESSMENT, 436 20 HOME CARE PATIENT ASSESSMENT, 453 21 DOCUMENTATION, 468 GLOSSARY, 486 Albert J Heuer, PhD, MBA, RRT, RPFT Program Director, Masters in Health Care Management & Associate Professor, Respiratory Care Program-North School of Health Related Professions University of Medicine and Dentistry of New Jersey Newark, New Jersey Craig L Scanlan, EdD, RRT, FAARC Professor Emeritus School of Health Related Professions University of Medicine and Dentistry of New Jersey Newark, New Jersey 3251 Riverport Lane Maryland Heights, Missouri 63043 WILKINS’ CLINICAL ASSESSMENT IN RESPIRATORY CARE ISBN: 978-0-323-10029-8 Copyright © 2014 by Mosby, an imprint of Elsevier Inc Copyright © 2010, 2005, 2000, 1995, 1990, 1985 by Mosby Inc., an affiliate of Elsevier Inc All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Notice Knowledge and best practice in this field are constantly changing As new research and experience broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or appropriate Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of the practitioners, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the Editors/Authors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book The Publisher Library of Congress Cataloging-in-Publication Data Wilkins’ clinical assessment in respiratory care / [edited by] Albert J Heuer, Craig L Scanlan – 7th ed p ; cm Clinical assessment in respiratory care Rev ed of: Clinical assessment in respiratory care / Robert L Wilkins, James R Dexter ; consulting editor, Albert J Heuer 6th ed c2010 Includes bibliographical references and index ISBN 978-0-323-10029-8 (pbk : alk paper) I Heuer, Albert J II Scanlan, Craig L., 1947- III Wilkins, Robert L Clinical assessment in respiratory care IV Title: Clinical assessment in respiratory care [DNLM: Diagnostic Techniques, Respiratory System Physical Examination Respiratory Therapy–methods WF 141] 617’.075—dc23 2012045666 Content Strategy Director: Jeanne Olson Content Manager: Billi Sharp Senior Content Development Specialist: Kathleen Sartori Publishing Services Manager: Gayle May Project Manager: Deepthi Unni Design Direction: Maggie Reid Printed in the United States of America Last digit is the print number:  9  8  7  6  5  4  3  2  Through the leadership and scholarly commitment of Dr. ­Robert  L Wilkins, PhD, RRT, this text has become a cornerstone resource in respiratory patient assessment and is used by a majority of respiratory programs worldwide This accomplishment can be attributed directly to the significant and sustained efforts of Dr Wilkins, through the many editions of this text for which he has been senior editor Simply stated, this book is current, thorough, concise, and clearly written As a result of his untimely death, Dr Wilkins’ presence in preparing this edition was greatly missed, and maintaining his high standard was a challenge However, both editors for this seventh edition, Dr Craig Scanlan and I, had worked with Bob on other projects, including prior editions of this and other texts In addition, we assembled a team of returning and new contributors These factors, coupled with the appropriate retention of content written by Dr Wilkins for prior editions, have resulted in what we believe is worthy of the standard and style set by Dr Wilkins In recognition and appreciation of his contributions to this text and to respiratory therapy education, this text has been renamed Wilkins’ Clinical Assessment in Respiratory Care Dr Wilkins is deeply missed by me on a personal and professional level, and his absence from our profession will be felt for some time However, his legacy will live on in the memory of his family, friends, and colleagues, as well as the pages of this text Warmly, Al Heuer To Dr Robert L Wilkins and Dr Craig L Scanlan for their unwavering mentorship, to my lovely wife Laurel for her patience and support, and to the students, faculty, and my fellow respiratory therapists, who are constant sources of inspiration AJH To Mom and Dad who believed in me; to Barrie and Craig Patrick, in whom I believe CLS Sixth Edition Editors/Contributors Douglas D Deming, MD Professor of Pediatrics Loma Linda University Medical Director of Neonatal Respiratory Care Medical Director of ECMO Loma Linda University Children’s Hospital Loma Linda, California James A Peters, MD, DrPH, MPH, RD, RRT, FACPM Attending Physician, Preventive Medicine Department of Internal Medicine and Center for Health St Helena Hospital and Health Center; Physician and Owner Nutrition and Lifestyle Medical Clinic St Helena, California De De Gardner, MSHP, RRT, FAARC Associate Professor and Chair Department of Respiratory Care School of Health Professions University of Texas Health Science Center at San Antonio San Antonio, Texas Helen M Sorenson, MA, RRT, FAARC Assistant Professor Department of Respiratory Care School of Health Professions University of Texas Health Science Center at San Antonio San Antonio, Texas Susan L McInturff, RCP, RRT Clinical Director Farrell’s Home Health Bremerton, Washington Cheryl Thomas Peters, DCN, RD Clinical Manager St Helena Center for Health St Helena, California S Gregory Marshall, PhD, RRT, RPSGT, RST Associate Professor/Chair Department of Respiratory Care College of Health Professions Texas State University—San Marcos San Marcos, Texas vi Richard Wettstein, BS, RRT Assistant Professor Department of Respiratory Care School of Health Professions University of Texas Health Science Center at San Antonio San Antonio, Texas Contributors Robert F Allen, III, MA, RPSGT Manager, Sleep Wake Disorder Lab St Mary’s Medical Center Langhorne, Pennsylvania Zaza Cohen, MD, FCCP Assistant Professor Fellowship Program Director Division of Pulmonary and Critical Care Medicine University of Medicine and Dentistry of New Jersey Newark, New Jersey Cara DeNunzio, MPH, RRT, CTTS Adjunct Assistant Professor Respiratory Care Program—North School of Health Related Professions University of Medicine and Dentistry of New Jersey Newark, New Jersey Nadine A Fydryszewski, PhD, MLS Associate Professor School of Health Related Professions University of Medicine and Dentistry of New Jersey Newark, New Jersey David A Gourley, RRT, MHA, FAARC Executive Director of Regulatory Affairs Chilton Hospital Pompton Plains, New Jersey Elaine M Keohane, PhD, MLS Professor and Chairman Department of Clinical Laboratory Sciences University of Medicine and Dentistry of New Jersey Newark, New Jersey Kenneth Miller, MEd, RRT-NPS, AE-C Educational Coordinator, Dean of Wellness Respiratory Care Services Lehigh Valley Health Network Allentown, Pennsylvania Ruben D Restrepo, MD, RRT, FAARC Professor Director, Bachelor’s Completion Program School of Health Professions Department of Respiratory Care University of Texas Health Science Center San Antonio, Texas Narciso Rodriguez, BS, RRT-NPS, RPFT, AE-C Assistant Professor and Program Director Respiratory Care Program University of Medicine and Dentistry of New Jersey School of Health Related Professions Newark, New Jersey David L Vines, MHS, RRT, FAARC Chair and Program Director Department of Respiratory Care Rush University Chicago, Illinois Jane E Ziegler, MD, DCN, RD, LDN Assistant Professor Graduate Programs in Clinical Nutrition School of Health Related Professions University of Medicine and Dentistry of New Jersey Newark, New Jersey vii Reviewers Georgine Bills, MBA/HAS, RRT Program Director, Respiratory Therapy Dixie State College of Utah St George, Utah Craig P Black, PhD, RRT-NPS, FAARC Director, Respiratory Care Program The University of Toledo Toledo, Ohio Helen Schaar Corning, AS, RCP, RRT Shands Jacksonville Medical Center Jacksonville, Florida Erin Ellis Davis, MS, MEd, RRT-NPS, CPFT Director of Clinical Education-Clinical Coordinator Our Lady of Holy Cross College/Ochsner Health System New Orleans, Louisiana Dale Bruce Dearing, RCP, RRT, MSc Respiratory Therapy Program Assessment Coordinator San Joaquin Valley College Visalia, California Lindsay Fox, MEd, RRRT-NPS Respiratory Care Program Coordinator Southwestern Illinois College/St Elizabeth Hospital Belleville, Illinois Laurie A Freshwater, MA, RCP, RRT, RPFT Health Sciences Division Director Carteret Community College Morehead City, North Carolina Christine A Hamilton, DHSc, RRT, AE-C Assistant Professor, Director of Clinical Education Cardio-Respiratory Care Sciences Program Tennessee State University Nashville, Tennessee Sharon L Hatfield, PhD, RRT, RPFT, AE-C, COPD-C Chair of Community Health Sciences, Associate Professor of Respiratory Therapy and Healthcare Management Jefferson College of Health Sciences Roanoke, Virginia viii Robert L Joyner, PhD, RRT, FAARC Associate Dean and Director, Respiratory Therapy Program Henson School of Science & Technology Salisbury University Salisbury, Maryland Chris Kallus, MEd, RRT Professor and Program Director Victoria College Respiratory Care Program Victoria, Texas Kevin Shane Keene, DHSc, RRT-NPS, CPFT, RPSGT Program Director Respiratory Care University of Cincinnati Cincinnati, OH Tammy Kurszewski, MEd, RRT Director of Clinical Education, Respiratory Care Midwestern State University Wichita Falls, Texas J Kenneth LeJeune, MS, RRT, CPFT Program Director Respiratory Education University of Arkansas Community College at Hope Hope, Arkansas Stacy Lewis-Sells, EdM, RRT-NPS, CPFT, AE-C Program Director for Respiratory Care Southeastern Community College West Burlington, Iowa Cory E Martin, EdS, RRT Program Director, Associate Professor Volunteer State Community College Gallatin, Tennessee Michael McLeland, MEd, RPSGT, RST Program Director Sanford-Brown College Fenton, Missouri Harley R Metcalfe, BS, RRT Adjunct Professor Respiratory Care Program Johnson County Community College; Vice President PM Sleep Lab LLC Overland Park, Kansas REVIEWERS ix Michell Oki, MPAcc, RRT RPFT, RPSGT Assistant Professor Weber State University Respiratory Therapy Ogden, Utah Shawna L Strickland, PhD, RRT-NPS, AE-C, FAARC Clinical Associate Professor University of Missouri Columbia, Missouri Timothy Op’t Holt, EdD, RRT, AE-C, FAARC Professor University of South Alabama Mobile, Alabama Cam Twarog, RRT-NPS, BSRT, MBA Director of Clinical Education Respiratory Care Practitioner Program Wheeling Jesuit University Wheeling, West Virginia Sara Parker, BHS-RT, RRT-NPS, AE-C Clinical Instructor University of Missouri School of Health Professions Columbia, Missouri José D Rojas, PhD, RRT Associate Professor University of Texas Medical Branch Galveston, Texas Paula Denise Silver, BS Biology, PharmD Medical Instructor ECPI University Newport News, Virginia Helen M Sorenson, MA, RRT, FAARC Associate Professor Department of Respiratory Care UT Health Science Center San Antonio, Texas Michael D Werner, MS, RRT, CPFT Respiratory Therapy Program Director Concorde Career College North Hollywood Los Angeles, California Ancillary Authors Craig P Black, PhD, RRT-NPS, FAARC Director, Respiratory Care Program The University of Toledo Toledo, Ohio Jill H Sand, MEd, RRT Program Chair Respiratory Care Southeast Community College Lincoln, Nebraska 518 Index Pediatric assessment (Continued) auscultation in, 275 blood gases in, 279–281 arterial, 279–280, 280t capillary, 280, 280b for fetal hemoglobin, 279, 279f noninvasive monitors for, 281, 281b venous, 280 clinical laboratory data in, 275–279 blood chemistry in, 278–279, 278t hematology in, 276–278, 276t–278t, 277b microbiology in, 279 fetal assessment in, 267–268, 267f, 268t for growth and gestational age, 268–270, 269f history in, 264–267 family, 265 labor and delivery, 265–267, 266b–267b, 266t maternity, 264–265, 265t postnatal, 267 pregnancy, 265 inspection in, 272–274 for body position, 272, 273f of breathing effort and pattern, 273 for grunting, 274, 274f for nasal flaring, 273–274, 273b for polycythemia, 272–273 of precordium, 274 for retractions, 273, 273b, 273f lung topography in, 272, 272f morphometric measurements in, 272 palpation in, 274–275, 274b physical examination in, 268–272 pulmonary function testing in, 265 for chemoreceptor response, 283 for mechanics, 282–283, 283f for volumes, 281–282 radiographs in, 277t, 283–285, 284b of meconium aspiration syndrome, 284, 285f of respiratory distress syndrome, 284, 284f of transient tachypnea of the ­newborn, 284, 285f techniques of examination in, 272–275 transillumination in, 275, 276f for vital signs, 270–272 blood pressure as, 272, 272t body temperature as, 270, 270b, 270f, 270t pulse as, 270–271, 271f respiratory rate as, 271–272 of older infant and child, 287–292 blood gases in, 290 bronchoscopy in, 290 clinical laboratory data in, 289–290 history in, 287–288 physical examination in, 288–289, 289t pulmonary function testing in, 290, 290f radiographs in, 290–292, 291f PEEP See Positive end-expiratory pressure (PEEP) PEF (peak expiratory flow), 182, 182f, 182t PEM (protein-energy malnutrition), 416 Percussion to assess resonance, 85–86, 85f clinical implications of, 86, 86b defined, 85 of diaphragmatic excursion, 86, 86f mediate or indirect, 85, 85f over lung fields, 85–86, 86b Perfusion scan, 228, 228f Pericardial pain, 45t–46t Pericardiophrenic vein, 224f Periodic acid-Schiff (PAS) stain, of lung tissue, 144–145 Periodic breathing in newborn, 271 in older patients, 304 Peripheral chemoreceptors, in control of breathing, 118, 119f Peripheral edema, 48–49 causes of, 48 definition of, 48 descriptions of, 48–49, 49t questions to ask about, 49b Peripheral nervous system, 103–104 functional organization of, 103–104, 105f spinal nerve roots in, 104, 106, 107b, 107f spinal nerves in, 104–105, 106f, 107 Peripheral resistance, 381 Peripheral skin temperature, 97 PERRLA, 76, 116–117, 117b Persistent vegetative state, 110 Personal space, 3, 5f Personality change, 51–52, 52b Pertinent negatives, in review of systems, 19 Pertinent positives, in review of systems, 19 PET (positron emission tomography), 229, 229f Petco2 (partial pressure of end-tidal carbon dioxide), 158 in critically ill patients, 331, 332f P/F ratio (partial pressure of oxygen-to-­ fraction of inspired oxygen ratio), in critically ill patients, 336 pH, 153t, 162 in newborn arterial, 280t capillary, 280 in nutritional assessment, 430 and ventilatory response to carbon dioxide, 118, 120f PHI (Protected Health Information), 4–5 Phlebostatic axis, 356, 356f Phlegm, 35 Phosgene, exposure to, 26t–27t Phosphorus (PO4-), 137 in newborn, 279 Phosphorus (PO4-) deficiency, 412 Phrenic nerves, 107, 107b Physical examination, 73-101 of abdomen, 96, 96f defined, 75 of extremities, 96–99 for capillary refill, 97 for clubbing, 96–97, 97b, 97f for cyanosis, 97, 97b for hydration (skin turgor), 98–99, 98f for pedal edema, 97, 97b for peripheral skin temperature, 97 of head and neck, 76–78 eyes in, 76–77 head and face in, 76 Physical examination (Continued) neck in, 77–78, 77f, 78b for home care, 459 of lung topography, 78–80 diaphragm in, 80, 80f imaginary lines in, 78f–79f, 80 lung borders in, 80 lung fissures in, 79–80, 80f of newborn, 272, 272f thoracic cage landmarks in, 78–79, 79f tracheal bifurcation in, 80 of newborn and infant, 268–272 auscultation in, 275 for growth and gestational age, 268–270, 269f inspection in, 272–274 for body position, 272, 273f of breathing effort and pattern, 273 for grunting, 274, 274f for nasal flaring, 273–274, 273b for polycythemia, 272–273 of precordium, 274 for retractions, 273, 273b, 273f lung topography in, 272, 272f morphometric measurements in, 272 palpation in, 274–275, 274b techniques of, 272–275 transillumination in, 275, 276f for vital signs, 270–272 blood pressure as, 272, 272t body temperature as, 270, 270b, 270f, 270t pulse as, 270–271, 271f respiratory rate as, 271–272 in nutritional assessment, 425–426, 427f of older infant and child, 288–289, 289t of precordium, 93–96 auscultation of heart sounds in, 94–96, 94f–95f, 95b inspection and palpation in, 94, 94f of newborn, 274 review of heart topography for, 94, 94f purpose of, 75 of thorax, 80–93 auscultation of lungs in, 86–93 defined, 86 mechanisms and significance of lung sounds in, 90–93, 90b, 91f–92f, 93b, 93t stethoscope for, 86–87, 87f technique for, 87, 88f, 89t terminology for, 87–90, 88b–89b, 89f, 90t voice sounds in, 93 inspection in, 80–83 of breathing pattern and effort, 81–83, 82b, 82t for central cyanosis, 83, 83b of thoracic configuration, 80–81, 81f palpation in, 83–85 defined, 83 for skin and subcutaneous tissues, 85 for thoracic expansion, 83–84, 85f for vocal fremitus, 83, 84f percussion in to assess resonance, 85–86, 85f clinical implications of, 86, 86b defined, 85 of diaphragmatic excursion, 86, 86f Index Physical examination (Continued) mediate or indirect, 85, 85f over lung fields, 85–86, 86b typical format for, 76, 76b Physical limitations, in home care assessment, 459–460, 461b Physician orders, 28 verbal or telephone, 470 Physiologic dead space, in critically ill patients, 316 Physiologic depressants, and myocardial ­contractility, 382 Phytochemicals, requirements for, 423 PiCCO (pulse-induced contour cardiac output), 387–388, 388f PIE (pulmonary interstitial emphysema), in newborns, 265, 282 chest radiographs of, 286t PImax (maximum inspiratory pressure), in critically ill patients, 316t, 321–322, 322b Pineal gland, 106f PIo2 (partial pressure of inspired oxygen), hypoxemia due to low, 159t PIP (peak inspiratory pressure), in critically ill patients, 319–320, 320b, 320f PIP (problem, intervention, and plan) ­charting, 476 Pitting edema, 48, 49t, 97 Plan, in SOAP charting, 474–475, 475b Plan of care, for home care, 464, 464b, 464t Plantar reflex, 115, 115b, 117f Plant-based protein, 421 Plasma, 128 Plateau pressure, in critically ill patients, 320, 321f Platelet count, 129t, 134 in infants, 276–278, 276t Platypnea, 41–42, 42t Plethysmography body, 190–191, 191f in newborns, 282 Pleural effusion, on chest radiograph, 220–222, 220f–221f Pleural fluid examination, 144, 144t Pleural friction rub, 93 Pleurisy, 93 pain due to, 45t–46t Pleuritic pain, 44, 45t–46t Pleuritis, pain due to, 44, 45t–46t PMI (point of maximal impulse), 94 PN (parenteral nutrition), 416, 424 PND (paroxysmal nocturnal dyspnea), 41 Pneumonia atelectasis with, 216f bronchoscopy of, 401 CT scan of, 227 in newborns, 286t in older patients, 301–302 silhouette sign with, 215f Pneumoperitoneum, in infant, 274–275 Pneumothorax chest radiograph of, 210, 216–217, 216f, 217b pain due to, 45t–46t shortness of breath due to, 43t tension, 216–217, 216f, 217b transillumination of, 275, 276f PO4- (phosphorus), 137 in newborn, 279 PO4- (phosphorus) deficiency, 412 Point of maximal impulse (PMI), 94 Poisoning, combined respiratory and ­metabolic acidosis due to, 167 Polycythemia, 134 infants with, 272–273 primary, 134 secondary, 134, 134b spurious, 134 vera, 132 Polymorphonuclear leukocytes See Segmented neutrophils Polysomnogram (PSG), 442–445, 443b defined, 437 leads for, 442–443, 444f montage in, 442–443, 444f of sleep apnea central, 448, 448f mixed, 449, 449f obstructive, 445, 446f Polysynaptic reflex, 106f Polyunsaturated fat, 422 Pons, 104, 105f–106f Pontine respiratory group, 119f Portable chest image, 211–212 Positive end-expiratory pressure (PEEP) auto-, in critically ill patients, 322 preload and venous return with, 379–380 pulmonary artery wedge pressure with, 366–367 titration with pressure-volume curve of, 328–330, 330f Positive inotropic effect, 382 Positive-pressure ventilation, preload and venous return with, 379 Positron emission tomography (PET), 229, 229f Post-analytic errors, in blood gas ­measurement, 168–169 external validity checks for, 169, 169b internal validity checks for, 169 Post-analytic phase, of laboratory testing, 127–128 Posterior axillary line, 78, 79f Posteroanterior (PA) view, on chest ­radiograph, 210, 212f Postnatal history, in newborn assessment, 267 Postterm infants, 264 Postural changes, and blood pressure, 67 Posture decerebrate, 114, 115f decorticate, 114, 115f Potassium (K+), 136 excess, 137, 137b low, 136, 136b in newborn, 278t nutritional requirement for, 424 reference range for, 136t PPD (purified protein derivative) test, 145, 146b PQRST mnemonic, 22, 22b PR interval, 241f, 242 interpretation of, 248, 248t PR segment, 241f Prealbumin, 428, 428t Pre-analytic errors, in blood gas measurement, 168, 169t Pre-analytic phase, of laboratory testing, 127–128 Precordial leads, 245, 245b, 245f 519 Precordium defined, 93–94 examination of, 93–96 auscultation of heart sounds in, 94–96, 94f–95f, 95b inspection and palpation in, 94, 94f review of heart topography for, 94, 94f of newborn, 274 hyperdynamic, 274 Pregnancy, radiation safety during, 231 Pregnancy history, in newborn assessment, 265 Prehypertensive blood pressure, 67t Preload, 377–380 and clinical applications of ventricular function curves, 379, 380f conditions associated with alterations in, 384t–385t defined, 377 effects of mechanical ventilation on, 379–380, 380b factors affecting, 378–379 and ventricular compliance, 378, 378f and ventricular function curves, 377–378, 377f Premature ventricular contractions (PVCs), 252 couplets of, 252 frequent, 252, 252f multifocal, 252, 252f R-on-T phenomenon with, 252, 253f salvos of, 252 single, 252, 252f, 252t Presbycusis, 298 Presbyopia, 299 Present health status or illness, 19, 21–22, 22b Present illness, history of, 21–22, 21b Pressure monitoring, in ICU, 323–326 Pressure-time scalar, 320f Pressure-time waveforms, in critically ill ­patients, 323–325, 324f–326f Pressure-volume curves in critically ill patients, 328, 329f–330f, 330b dynamic, 328, 329f–330f quasi-static, 330, 330f static, 328–329, 330f titrating PEEP and tidal volume with, 328–330, 330f Pressure-volume loop, 323 Preterm infants, 264 Privacy, 3–5 HIPAA on, 4–5, 5t intimate space in, 3, 5f personal space in, 3, 5f social space in, 3, 4b, 5f territoriality in, The Joint Commission on, 470 Problem, intervention, and plan (PIP) ­charting, 476 Problems/needs list, development of, 473, 474b–475b Procedure history, 22, 24f Progress notes, 28 Proprioception, 111 Protected Health Information (PHI), 4–5 Protein(s), 136t, 139–140 in newborn, 278, 278t plant-based, 421 quality of, 421 soy, 421 520 Index Protein deficiency, 412 Protein requirements, 421–422, 422b of cardiovascular system, 417 Protein-calorie malnutrition (PCM), 416 Protein-energy malnutrition (PEM), 416 Proteolytic enzymes, exposure to, 26t–27t Prothrombin time (PT), 135, 135b in infants, 278, 278t Provider collaboration, 9–13 coordinating patient care in, 10–11 enhancing interprofessional ­communication in, 10, 10b sharing responsibility in, 11, 12f Provocation testing, 196, 196b, 197t Pseudohypertension, in older patients, 304 Pseudoneutropenia, 131 Pseudoneutrophilia, 131 PSG See Polysomnogram (PSG) Psychosocial evaluation, for home care, 460–461, 461b PT (prothrombin time), 135, 135b in infants, 278, 278t Ptcco2 (transcutaneous carbon dioxide ­pressure), 154t, 157–158 in newborn, 281 Ptco2 (transcutaneous oxygen tension), 154t, 157–158 Ptosis, 76–77 Pulmonary angiography, 230, 230b Pulmonary artery (PA) on chest radiograph, 212f pulmonary artery catheter placement in, 361f, 362 Pulmonary artery catheter (PAC), 360–361, 360f complications of, 367 indications for, 359–360, 359b placement of, 361–362, 361f in pulmonary artery, 361f, 362 radiographic evaluation of, 224, 224f in right atrium, 361–362, 361f in right ventricle, 361f, 362 in wedge position, 361f, 362, 363f Pulmonary artery diastolic pressure (PADP), 363, 363b Pulmonary artery occlusion pressure (PAOP) See Pulmonary artery wedge ­pressure (PAWP) Pulmonary artery pressure (PAP), 359, 359b, 362–367 diastolic, 363, 363b mean, 350t reference range for, 350t systolic, 362–363 wedge, 363–367, 364b Pulmonary artery pressure (PAP) monitoring, 358–367 catheter placement for, 361–362, 361f in pulmonary artery, 361f, 362 in right atrium, 361–362, 361f in right ventricle, 361f, 362 in wedge position, 361f, 362, 363f catheters for, 360–361, 360f complications of, 367 indications for, 359–360, 359b interpretation of measurements in, 359, 359b, 362–367 diastolic, 363, 363b systolic, 362–363 wedge, 363–367, 364b Pulmonary artery pressure (Continued) wedge catheter placement for, 361f, 362, 363f interpretation of, 363–367, 364b obtaining, 364–366, 365f, 365t transmural pressure and, 366–367, 366t wedging of balloon in, 366 Pulmonary artery systolic pressure, 362–363 Pulmonary artery thermodilution cardiac output, 385–386, 386b, 386f Pulmonary artery thermodilution cardiac output monitoring, continuous, 387 Pulmonary artery wedge pressure (PAWP) catheter placement for, 361f, 362, 363f increase in, 364, 364b interpretation of, 363–367, 364b left ventricular preload measurement via, 359 obtaining accurate, 364–366, 365f, 365t optimal values for, 364 with PEEP, 366–367 and preload, 378 reduction in, 364 reference range for, 350t, 363 transmural pressure and, 366–367, 366t uses of, 363–364, 374b wedging of balloon in, 366 Pulmonary auscultation, 86–93 defined, 86 mechanisms and significance of lung sounds in, 90–93, 90b, 91f–92f, 93b, 93t in older patients, b0050, 305–306, 306b stethoscope for, 86–87, 87f technique for, 87, 88f, 89t terminology for, 87–90, 88b–89b, 89f, 90t voice sounds in, 93 Pulmonary capillary wedge pressure (PCWP) See Pulmonary artery wedge ­pressure (PAWP) Pulmonary clearance delay (PCD), in ­newborns, 282 Pulmonary defense mechanisms, in older patients, 301 and immunity, 301 Pulmonary edema, shortness of breath due to, 43t Pulmonary embolism (PE) CT scan of, 226–227, 226f pain due to, 45t–46t shortness of breath due to, 43t Pulmonary fibrosis, 210, 218f Pulmonary function testing, 178-206 case studies on, 202b–203b diffusing capacity of lung in, 192–194 equipment and quality assurance for, 192–193, 193f indications for, 192 interpretation of, 193–194, 194b, 194t test procedure and calculations for, 193 infection control with, 200–203 lung volumes and capacities in, 179–181, 180b, 180f, 181t in newborns, 265 for chemoreceptor response, 283 for mechanics, 282–283, 283f for volumes, 281–282 of older infant and child, 290, 290f in older patients, 307–308, 308b Pulmonary function testing (Continued) specialized tests in, 194–200 of airway hyperresponsiveness and inflammation, 195–198 bronchoprovocation testing for, 196, 196b, 197t exhaled nitric oxide (FENO) ­analysis for, 196–198, 197b–198b, 197f, 198t of airway resistance, 194–195, 195b exercise tests as, 198–200 cardiopulmonary, 199–200, 199b, 200t 6-Minute Walk Test as, 198–199, 199b of lung and chest wall compliance, 195, 195b, 196f spirometry for, 181–188 flow-volume loops in, 183, 183f forced vital capacity in, 181–183, 182b–183b, 182f, 182t indications and contraindications for, 181 interpretation of test results of, 185–188 algorithm for, 185–187, 186f flow-volume loop in, 187, 188f forced vital capacity curves in, 187, 187f with obstructive ventilatory impairment, 187, 187b, 187t pre- and post-bronchodilator test in, 188, 188b with restrictive ventilatory ­impairment, 187 upper and lower limits of normal in, 185, 186f maximal voluntary ventilation in, 181, 183–184, 184b quality assurance of, 184–185 equipment calibration in, 184, 184t technique validation in, 184–185, 185b, 186f static lung volume measurements in, 188–191 indications and contraindications for, 188 interpretation of, 191, 192f methods of, 188–191 body plethysmography as, 190–191, 191f closed-circuit helium dilution as, 189, 189f open-circuit nitrogen washout as, 189–190, 190f Pulmonary hypertension causes of, 381, 382t chest pain due to, 45t–46t Pulmonary infarction, pain due to, 45t–46t Pulmonary interstitial emphysema (PIE), in newborns, 265, 282 chest radiographs of, 286t Pulmonary pain, 44, 45t–46t Pulmonary secretions, examination of, 142–144, 143t sputum collection for, 142–143 sputum examination in, 143–144, 143b Pulmonary shunting, hypoxemia due to, 159t Pulmonary system, age-related changes in, 300–301 Index Pulmonary vascular resistance (PVR) calculation of, 381–382 reference range and formula for, 376t, 376t Pulmonary vascular resistance index (PVRI), reference range and formula for, 376t, 376t Pulmonary veins, on chest radiograph, 212f Pulmonic area, 94f palpation of, 94 Pulse paradoxical, 70 rhythm and pattern of, 64–65 strength of, 64–65 Pulse intensity, effects of respiratory cycle on, 70–71 Pulse oximetry, 154t, 156–157, 157t in children, 290 in critically ill patients, 336–337 in home care, 456 indications for, 153, 154t in newborn, 281, 281b in older patients, 307, 307b Pulse pressure, 66, 354, 354b for periodic measurement of cardiac ­performance, 390 Pulse rate, 64–65 and cardiac output, 64 fast (tachycardia), 64 measurement of, 64, 64f, 65b in newborn, 271, 271f in older patients, 303 of newborn, 270–271, 271f, 274 measurement of, 271, 271f questions to ask about, 65b radial, 64, 64f referred to age, 64, 64t slow (bradycardia), 64 PulseCO, 387–388 Pulse-induced contour cardiac output (PiCCO), 387–388, 388f Pulseless electrical activity (PEA), 254 Pulsus paradoxus, 70 Pump function determinants of, 377–383, 377f afterload as, 380–382 calculation of systemic and ­pulmonary vascular resistance for, 378f, 381–382, 381b conditions associated with ­alterations in, 384t–385t decreased, 381 defined, 380 increased, 381 peripheral resistance in, 381 ventricular wall stress in, 380–381 contractility as, 382–383 conditions associated with ­alterations in, 384t–385t defined, 382 factors related to, 382–383, 383b variables used to assess, 383 heart rate as, 377 preload as, 377–380 and clinical applications of ­ventricular function curves, 379, 380f conditions associated with ­alterations in, 384t–385t effects of mechanical ventilation on, 379–380, 380b Pump function (Continued) factors affecting, 378–379 and ventricular compliance, 378, 378f and ventricular function curves, 377–378, 377f venous return as, 375, 375, 375b effects of mechanical ventilation on, 379–380, 380b factors affecting, 378–379 measures of, 375–377 cardiac index as, 375–376 advantages of, 376b defined, 374b formula for, 376t obtaining, 375, 375f reference range for, 374b, 376t cardiac work as, 376 ejection fraction as, 376–377 ventricular stroke work as, 376 ventricular volume as, 376 Pupillary reflex, 76, 116–117, 117b, 117f Purified protein derivative (PPD) test, 145, 146b Purkinje fibers, 237-239, 238f Purkinje network, 238f Pursed-lip breathing, 76 PVCs See Premature ventricular contractions (PVCs) PVo2 (mixed venous oxygen tension), in ­critically ill patients, 334b, 338–339 PVR (pulmonary vascular resistance) calculation of, 381–382 reference range and formula for, 376t, 376t PVRI (pulmonary vascular resistance index), reference range and formula for, 376t, 376t Pyopneumothorax, 221 Pyothorax, 221 Pyramidal tract, 104 Pyrexia, 49t See also Fever Pyridoxine deficiency, 412 Q Q wave, 241, 242f interpretation of, 248 QRS axis, mean, 245–247, 246f, 246t, 247b deviation of, 246–247, 246f, 246t, 247b causes of, 248b interpretation of, 234, 248b QRS complexes, 240, 241b, 241f components of, 241, 242f interpretation of, 248 QRS interval, 242–243 interpretation of, 248t Qs/Qt (intrapulmonary shunt), in critically ill patients, 336 QT interval, 241f, 243 Questions closed, 17 direct, 17 to facilitate interview, 17–18 indirect, 17 neutral, 17 open-ended, 17 R R See Resistance (R) R waves, 241–242, 242f R’ (R prime) waves, 241, 242f 521 Radial artery catheter, 349 Radial artery sampling, 155, 155f Radial pulse, 64, 64f Radiography evaluation of, 212–214, 212f for inspiratory effort, 213, 213b review of clinical findings in, 212 for rotation, 213, 213f systematic approach to, 212–213, 213b, 213f findings in, 214–222 atelectasis as, 215–217, 216f congestive heart failure as, 219–220, 219f, 220b hyperinflation as, 217–218, 217f, 218b interstitial lung disease as, 218–219, 218f, 219b lung consolidation as, 222 pleural effusion as, 220–222, 220f–221f pneumothorax as, 210, 216–217, 216f, 217b indications for, 210, 210b interpretation of, 213–214 air bronchogram in, 214 densities in, 210, 213 lung shadow in, 214 normal lung architecture in, 214 silhouette sign in, 214, 214b, 215f limitations of, 214 in newborns, 277t, 283–285, 284b of meconium aspiration syndrome, 284, 285f of respiratory distress syndrome, 284, 284f of transient tachypnea of the newborn, 284, 285f of older infant and child, 290–292, 291f portable, 211–212, 212b postprocedural, 222–225, 225b of additional procedures, 225, 225b of central venous pressure line, 222–224, 223f–224f of chest tubes, 225, 225f of nasogastric feeding tubes, 224 of pulmonary artery catheter, 224, 224f of tracheal intubation, 222, 222f–223f production of, 208–210, 209f, 210b safety with, 230–231 views on, 210–212 portable (anteroposterior), 211–212, 212b standard and special, 210–211, 212b Radiolucent areas, 209 Radionuclide cardiac imaging to assess contractility, 383 for periodic measurement of cardiac ­performance, 390 Radionuclide lung scanning, 228–229, 228f Radiopaque areas, 209 Rales, 88–89 RAP See Right atrial pressure (RAP) Rapid eye movement (REM) sleep, 437–440, 438f, 439b Rapid response teams, 476–477 Rapid-shallow breathing index (RSBI), 316t, 318 RASS (Richmond Agitation Sedation Scale), 111, 111t Rate-pressure product (RPP), 376t, 383 Raw (airway resistance), 194–195, 195b 522 Index Raw (airway resistance) (Continued) in critically ill patients, 317, 323 in newborns, 282 RBP (retinol-binding protein), 428, 428t RCWI (right cardiac work index), 376, 376t RDS See Respiratory distress syndrome (RDS) Reason for visit, 19 Recommended dietary allowance (RDA), of protein, 421 Rectal temperature, 63 Red blood cell(s) (RBCs), 132–134, 132b abnormalities of, 133–134, 133b–134b hematocrit for, 129t, 132, 133f hemoglobin in, 129t, 132–133 reticulocyte count for, 129t, 134 Red blood cell (RBC) count, 129t in infants, 277, 277t Red blood cell (RBC) indices, 129t, 133 REE (resting energy expenditure), 412–413, 416 Reference ranges, 128 for lung volumes and capacities, 179–180 Reference value, 128 Reflecting, 17 Reflection spectrophotometry, 339, 339f Reflex(es), 114–117 brainstem, 115–117 corneal, 117, 118f gag, 115–116, 116b oculocephalic and oculovestibular, 117 pupillary, 116–117, 117b, 117f deep tendon, 114, 116f, 116t superficial, 115, 115b, 117f Reflex irritability, in Apgar score, 266t Reflux, 53–54 Regional tissue oxygenation (Sto2, Sro2), in critically ill patients, 340–343, 341f Religious considerations, for home care, 461–462 REM (rapid eye movement) sleep, 437–440, 438f, 439b Renal panel, 136t, 139 glomerular filtration rate in, 136t, 139 urinalysis in, 136t, 139 Reoxygenation rate (Reo2), 341 Repeatability, of forced vital capacity ­maneuver, 184, 185b Repolarization, 240, 241f RERA (respiratory effort–related arousal), 445, 446f Reservoir, in indwelling catheter, 156, 156t Residual volume (RV), 180, 180b, 180f, 181t Resistance (R) airway, 194–195, 195b in critically ill patients, 317, 323 in newborns, 282 peripheral, 381 vascular decreased, 381 increased, 381 pulmonary calculation of, 381–382 reference range and formula for, 376t, 376t reference ranges and formulas for, 376t, 376t systemic calculation of, 381–382 reference range and formula for, 376t, 376t use of cardiac output to determine, 374b Respiration See Breathing Respirators, safety precautions with, 9b Respiratory acidosis, 164–165, 166t acute (uncompensated), 164 chronic, 164 compensation for, 164, 166t defined, 163, 165b fully compensated, 164 and metabolic acidosis, 167 metabolic alkalosis and, 168 Respiratory alkalosis, 163, 165, 166t metabolic acidosis and, 168 metabolic alkalosis and, 167 Respiratory alternans, 82–83 Respiratory centers, nutritional needs of, 417 Respiratory cycle, effects on blood pressure and pulse intensity of, 70–71 Respiratory distress syndrome (RDS), in newborns chest radiographs of, 284, 284f family history of, 265 prematurity and, 265 Respiratory drive, carbon dioxide and, 118, 120f Respiratory effort in Apgar score, 266t in newborns and infants, 273 Respiratory effort–related arousal (RERA), 445, 446f Respiratory home care defined, 454 evolution and importance of, 454 indications for, 454–455, 455b Respiratory monitoring, 314-347 defined, 315 evaluation of oxygenation in, 319b, 333–337 evaluation of oxygen transport in, 322b, 333–335 cardiac output in, 334 oxygen reserves in, 333–334, 334b oxyhemoglobin dissociation curve in, 334–335 monitoring adequacy of arterial ­oxygenation in, 335–337 alveolar-to-arterial oxygen tension difference in, 335 intrapulmonary shunt in, 336 oxygenation index in, 336, 336b partial pressure of arterial oxygen in, 335 pulse oximetry for, 336–337 ratio of Pao2 to FIo2 in, 336 ratio of Pao2 to PAo2 in, 335–336 monitoring tissue oxygen delivery and utilization in, 337–343, 340b arterial-to-mixed venous oxygen content difference in, 340 blood lactate in, 340 mixed venous oxygen saturation in, 339–340, 339f, 339t mixed venous oxygen tension in, 338-339, 338–339 oxygen consumption in, 337–338, 338b, 338f oxygen delivery and availability in, 337 oxygen extraction ratio in, 340 regional tissue oxygenation (near infrared spectroscopy) in, 340–343, 341f Respiratory monitoring (Continued) ventilatory assessment in, 315–333 of airway pressures, 319–323 auto-PEEP as, 322 maximum inspiratory, 316t, 321–322, 322b mean, 320–321 peak inspiratory, 319–320, 320b, 320f plateau, 320, 321f of airway resistance, 317, 323 of compliance, 322–323 fractional gas concentrations in, 330–333 exhaled carbon dioxide as, 331–333, 331b, 331f–332f fraction of inspired oxygen ­concentration as, 330–331 integrating pressure, flow, and volume in, 323–330 to evaluate patient-ventilator ­interface, 323 flow-time waveforms in, 326–330, 327b, 327f–328f to monitor pressure, flow, and volume, 323–326 pressure-time waveforms in, 323–325, 324f–326f pressure/volume curves in, 328, 329f–330f, 330b volume-time waveforms in, 326, 326f of lung volumes and flows, 315–319 dead space-to-tidal volume ratio as, 316t FEV1/FVC ratio as, 319 frequency as, 316t functional residual capacity as, 316, 319 indications for, 316 measurements in, 316–319 minute volume as, 316t, 318 Paco2 as, 318 rapid-shallow breathing index as, 316t, 318 rationale for, 316 spontaneous breathing trial for, 318, 318b tidal volume as, 316, 316b–317b, 316t vital capacity as, 316t, 318 parameters for, 315, 316t Respiratory muscles in control of breathing, 119f nutritional needs of, 417 Respiratory quotient (RQ), 414, 418–420 Respiratory rate, 65–66 above normal (tachypnea), 65 causes of abnormal, 66b measurement of, 66, 66b in newborn, 271–272 in older patients, 304 of newborn, 271–272 measurement of, 271–272 questions to ask about, 66b referred to age, 64t, 65 slow (bradypnea), 65 terms used to describe, 65, 65t Respiratory system compliance, 322 Respiratory system impedance (Zrs), 195 Index Respiratory variations in aortic pressure waveform, 352 in central venous pressure waveforms, 356–357, 357b Respirometer, 180–181 Resting energy expenditure (REE), 412–413, 416 Resting metabolic rate (RMR), 412–413 Restrictive ventilatory impairment, 187 changes in lung volumes and capacities with, 192f flow volume loops for, 187, 188f Resuscitation, safety precautions with, 9b Reticulocyte, 134 Reticulocyte count, 129t, 134 in infants, 277t, 278 Reticulospinal tract, in control of breathing, 119f Retinol-binding protein (RBP), 428, 428t Retractions, during breathing, 82 by newborns and infants, 273, 273b, 273f Retrognathia, 445 Return demonstration, Review of systems (ROS), 19, 20f Rhonchi defined, 88–89, 89b, 90t mechanisms and significance of, 93t Rib identification, 78–79 Richmond Agitation Sedation Scale (RASS), 111, 111t Right atrial pressure (RAP) reference range for, 350t uses of, 374b Right atrial pressure (RAP) waveforms, 356–357, 357f respiratory variations in, 356–357, 357b Right atrium, 94f, 236, 237f–238f pulmonary artery catheter placement in, 361–362, 361f Right bundle branch, 238f Right cardiac work index (RCWI), 376, 376t Right ventricle, 94f, 236, 237f–238f pulmonary artery catheter placement in, 361f, 362 Right ventricular end-diastolic pressure (RVEDP), reference range for, 350t Right ventricular pressure (RVP), 350t Right ventricular stroke work index (RVSWI), 376, 376t Right-sided heart failure, in older patients, 300b RMR (resting metabolic rate), 412–413 Roentgen, Wilhelm, 208–209 Roentgen radiation, 208–209 R-on-T phenomenon, 252, 253f ROS (review of systems), 19, 20f RPP (rate-pressure product), 376t, 383 RQ (respiratory quotient), 414, 418–420 RR interval, 243 RSBI (rapid-shallow breathing index), 316t, 318 RV (residual volume), 180, 180b, 180f, 181t RVEDP (right ventricular end-diastolic ­pressure), reference range for, 350t RVP (right ventricular pressure), 350t RVSWI (right ventricular stroke work index), 376, 376t S S wave, 241, 242f S’ (S prime) wave, 241, 242f S1, 94 loudness of, 95 splitting of, 95 timing of, 95, 95f S2, 94 loudness of, 95 splitting of, 95 in older patients, 306 timing of, 95, 95f S3, 94–95 in older patients, 306 timing of, 95, 95f S4, 94–95 in older patients, 306 timing of, 95, 95f SA (sinoatrial) node, 236–237, 238f, 239b Safety patient and family participation in, 8–9, 8b–9b radiation, 230–231 Salvos, of premature ventricular contractions, 252 Sao2 See Hemoglobin (Hb) saturation (Sao2, Spo2) Saturated fat, 422 Sawtooth waves, 438f SBAR (situation, background, assessment, and recommendation) charting, 476–480 SBAR format, 10 SBT (spontaneous breathing trial), 318, 318b Scalars, 323 flow-time, 326–330, 327b, 327f–328f pressure-time, 320f, 323–325, 324f–326f volume-time, 326, 326f Scalene muscles, as accessory muscles of breathing, 82 Scapula, 79f Scapular borders, of vertebrae, 79 Scatter radiation, exposure to, 231 Scoliosis, 80, 81f Scope of duty, 471 Scope of practice, 471 Screening information, in health history, 18 SDB See Sleep-disorders breathing (SDB) Second-degree AV block type I, 254, 255f, 255t type II, 256, 255f, 255t Sedation, moderate, for bronchoscopy, 397, 404–405, 405b Segment, on electrocardiogram, 242 Segmented neutrophils in differential count, 129t functions of, 130 Selenium, and lung function, 423 Self-awareness, in culturally competent ­communication, Sensitivity, 128 of specimens, 142 Sensorium, 61, 61b Glasgow Coma Scale for, 61 questions to ask about, 61b Sensory cortex, in control of breathing, 119f Sensory deficit, age-related, 298–299 hearing impairment as, 298–299 assessing for, 298 compensating for, 298–299 vision impairment as, 299 assessing for, 299 compensating for, 299, 299b 523 Sensory dissociation, 112 Sensory division, of peripheral nervous ­system, 103–104, 105f Sensory examination, 112–113 Sensory nerve roots, 104–105 Sensory neuron, 106f Sensory receptor, 106f Sepsis, fever due to, 50t Serum, 128 SGA (small for gestational age), 268 Sharps, safety precautions with, 9b Shortness of breath (SOB), 38–42 acute, 41, 41b, 43t case study on, 53b causes of, 39–41, 40t, 43t chronic, 41, 41b, 43t clinical presentation of, 39–41 clinical types of, 39–41, 40t descriptions of, 41–42, 42t–43t questions to ask about, 42b scoring systems for, 39, 39t subjectiveness of, 38–39 SI (stroke index), 376t Sick-building syndrome, 25–27 SIDS (sudden infant death syndrome), 283, 449 Sigh(s), in critically ill patients, 316 Sighing respiration, 65t Signs, 19 Silhouette sign, 214, 214b, 215f Silica, crystalline-free, exposure to, 26t–27t SIMV (synchronous intermittent ­mandatory ventilation), lung volume ­measurement with, 318 Single-breath technique, for diffusing capacity of lung, 193, 193f Sinoatrial (SA) node, 236–237, 238f, 239b Sinus bradycardia, 242f, 249, 249t in newborn, 271 Sinus dysrhythmia, 249, 249t Sinus rhythm, normal, 248 Sinus tachycardia, 249, 250f, 250t Situation, background, assessment, and recommendation (SBAR) charting, 476–480 Situational awareness, in culturally competent communication, 6-Minute Walk distance (6MWD), 198 6-Minute Walk Test, 198–199, 199b Skin of newborn inspection of, 272–273 palpation of, 274, 274b thoracic examination of, 85 Skin antigen testing, in nutritional ­assessment, 428, 428t Skin perfusion, of newborn, 274 Skin temperature of newborn, 274 peripheral, 97 Skin testing, 145–146 Skin turgor, 98–99, 98f in older patients, 305, 305b Skinfold thickness, 426 Sleep apnea, 445 assessment for, 440–445, 440b apnea-hypopnea index for, 443, 445, 445b Berlin Questionnaire for, 440–441, 442f 524 Index Sleep apnea (Continued) Epworth Sleepiness Scale for, 440, 441f polysomnogram for, 442–445, 443b, 444f STOP-BANG, 441–442, 442b–443b central, 448–449 children with, 449 defined, 445 differential diagnosis of, 449 etiology of, 448, 448b polysomnogram of, 448, 448f signs and symptoms of, 448 defined, 440 epidemiology of, 437 excessive daytime sleepiness/somnolence due to, 440 management of, 443 mild, 443 mixed, 449–451, 449b defined, 445 differential diagnosis of, 449 polysomnogram of, 449, 449f moderate, 443 obstructive, 440, 445–448 children and infants with, 448, 448b differential diagnosis of, 449 etiology of, 445, 445b hypopnea due to, 445, 446f Mallampati score for, 446–447, 446b, 446f physical assessment for, 447–448 polysomnogram of, 445, 446f respiratory effort–related arousal due to, 445, 446f risk factors for, 447, 447b signs, symptoms, and additional health consequences of, 447, 447b snoring due to, 52, 53b, 440 treatment of, 449 severe, 443 snoring due to, 52, 53b, 440 Sleep architecture, 439, 439b, 439f Sleep arousal, 445 Sleep physician, 443 Sleep spindles, 437, 438f Sleep stages, 437–440, 438f non–rapid eye movement, 437–438, 438b, 438f rapid eye movement, 437–440, 438f, 439b slow-wave (delta), 437, 438f Sleep studies, qualifications to perform, 437 Sleep-disordered breathing (SDB), 445–451 assessment of, 440–445, 440b apnea-hypopnea index for, 443, 445, 445b Berlin Questionnaire for, 440–441, 442f Epworth Sleepiness Scale for, 440, 441f polysomnogram for, 442–445, 443b, 444f STOP-BANG, 441–442, 442b–443b case studies on, 449b–451b definitions for, 445 epidemiology of, 437 hypopnea as, 445 respiratory effort–related arousal due to, 445 sleep apnea as, 445 central, 448–449 children with, 449 Sleep-disordered breathing (Continued) defined, 445 differential diagnosis of, 449 etiology of, 448, 448b polysomnogram of, 448f signs and symptoms of, 448 defined, 440 excessive daytime sleepiness/­ somnolence due to, 440 mixed, 449–451, 449b defined, 445 differential diagnosis of, 449 polysomnogram of, 449, 449f obstructive, 440, 445–448 children and infants with, 448, 448b differential diagnosis of, 449 etiology of, 445, 445b hypopnea due to, 445, 446f Mallampati score for, 446–447, 446b, 446f physical assessment for, 447–448 polysomnogram of, 445, 446f respiratory effort–related arousal due to, 445, 446f risk factors for, 447, 447b signs, symptoms, and additional health consequences of, 447, 447b snoring due to, 52, 53b, 440 sleep arousal due to, 445 snoring due to, 52 Sleepiness, excessive daytime See Excessive daytime sleepiness/somnolence (EDS) Slope of the tracings, 328 Slow vital capacity (SVC), 181 in critically ill patients, 318 Slow-wave sleep, 437, 438f Small for gestational age (SGA), 268 Smoking history, 22–25, 24b, 24f Snares, with bronchoscope, 399, 399f Snoring, 52–53 causes of, 52, 53b clinical presentation of, 52–53 definitions for, 52, 440 habitual, 52 incidence of, 52 inspiratory, 52 occasional, 52 SOAP charting See Subjective, objective, assessment and plan (SOAP) ­charting SOB See Shortness of breath (SOB) Social space, 3, 4b, 5f Sodium (Na+), 136 excessive intake of, 424, 424b in newborn, 278t nutritional requirement for, 424 reference range for, 136t Soiled patient care equipment, 9b Somatic motor division, of peripheral nervous system, 105f Somatic sensory division, of peripheral ­nervous system, 105f Somatosensory pathways, 112 Somnolence, excessive daytime See Excessive daytime sleepiness/somnolence (EDS) Soy protein, 421 Space intimate, 3, 5f personal, 3, 5f social, 3, 4b, 5f “Speak Up” initiative, 8, 8b Specific conductance (Gaw/TGV), 195 Specific gravity, of urine, 139 Specificity, 128 Specimen(s) culture and sensitivity of, 142 integrity of, 128 microscopic examination of, 142 in outpatient bronchoscopy, 406, 406b selection, collection, and transport of, 142 Spectrophotometry, reflection, 339, 339f Sphygmomanometer cuff, 67–68, 67f, 68t, 69b Spinal accessory nerve, 112f, 113t Spinal cord, anatomy of, 104, 104f, 106f Spinal cord injury, outcome after, 107b, 107f Spinal nerve(s), 104–105, 106f, 107 Spinal nerve roots anatomy of, 104 dorsal, 104–105 motor, 104–105 pathology of, 106, 107b, 107f sensory, 104–105 ventral, 104–105 Spinal respiratory muscles, in control of breathing, 119f Spinothalamic (ST) system, 112 Spinous processes, of vertebrae, 79, 79f Spirogram, 179–180 Spirometry, 181–188 flow-volume loops in, 183, 183f indications and contraindications for, 181 interpretation of test results of, 185–188 algorithm for, 185–187, 186f flow-volume loop in, 187, 188f forced vital capacity curves in, 187, 187f with obstructive ventilatory ­impairment, 187, 187b, 187t pre- and post-bronchodilator test in, 188, 188b with restrictive ventilatory impairment, 187 upper and lower limits of normal in, 185, 186f maximal voluntary ventilation in, 181, 183–184, 184b parameters measured during, 181–182, 182t FEV1/FVC ratio as, 182, 182t forced expiratory flow as, 182, 182f, 182t forced expiratory volume as, 181–182, 182f, 182t forced vital capacity as, 181–183, 182b, 182f, 182t peak expiratory flow as, 182, 182f, 182t quality assurance for, 184–185 equipment calibration in, 184, 184t technique validation in, 184–185, 185b, 186f Spleen, of infant, 275 Splenomegaly, in infant, 274–275 Spo2 See Hemoglobin (Hb) saturation (Sao2, Spo2) Spontaneous breathing, preload and venous return with, 379 Index Spontaneous breathing trial (SBT), 318, 318b Spurious polycythemia, 134 Sputum collection, transport, and storage of, 142–143, 143t color of, 36, 36t consistency of, 36, 36t defined, 35 descriptions of, 35–36, 36t examination of, 143–144 macroscopic, 143 microscopic, 143–144, 143b fetid, 36 frothy, 36 mucoid, 36t mucopurulent, 36t of newborn, 279 purulent, 36t tenacious, 36 Sputum production, 35–36 causes of, 35–36, 36b defined, 35 descriptions of, 35–36, 36t questions to ask about, 36b Sro2 (regional tissue oxygenation), in critically ill patients, 340–343, 341f ST segment, 241f, 243, 243b, 243f depression of, 243, 243f, 257–258, 257f, 258b elevation of, 243, 243f, 258, 258b, 258f interpretation of, 248, 248t ST (spinothalamic) system, 112 Staining methods, 142 Standard precautions, 9, 9b Starling curves, 374b, 377–378, 377f Starling’s law of the heart, 377 Statements, to facilitate interview, 17–18 Static compliance, in critically ill patients, 322 Static lung volume measurements, 188–191 indications and contraindications for, 188 interpretation of, 191, 192f methods of, 188–191 body plethysmography as, 190–191, 191f closed-circuit helium dilution as, 189, 189f open-circuit nitrogen washout as, 189–190, 190f Static pressure, in critically ill patients, 320, 321f Steeple sign, in croup, 288–289 ST-elevation myocardial infarction (STEMI), 258, 258f Sternal angle, 78–79 Sternal retraction, in croup, 289t Sternocleidomastoid muscle as accessory muscle of breathing, 82 contraction of, 78 Sternum body of, 79f manubrium of, 79f Stethoscope, for auscultation of lungs, 86–87, 87f Sthenic body type, 60b Sto2 (regional tissue oxygenation), in critically ill patients, 340–343, 341f STOP-BANG assessment, 441–442, 442b–443b Stress test, ECG, 199 Stretch, dysrhythmia due to, 239 Stretch receptor, 106f Stridor, 90 in croup, 288–289, 289t inspiratory, 35t mechanisms and significance of, 92, 93t Stroke index (SI), 376t Stroke volume (SV), 374b and contractility, 383 defined, 239, 374, 374b reference range and formula for, 376t Stroke volume index (SVI), 376 Stupor, 110b Subclavian vein, 224f central venous catheter in, 355 Subcostal retractions, 82 Subcutaneous emphysema, 85 Subcutaneous tissues, thoracic examination of, 85 Subjective, objective, assessment, and plan (SOAP) charting, 473, 476 assessment in, 473–474, 474b–475b data collection in, 473, 473b evaluation of results in, 476, 476b implementation in, 475 plan in, 474–475, 475b Subjective data, 19 in SOAP charting, 473 Suctioning, for outpatient bronchoscopy, 404 Sudden infant death syndrome (SIDS), 283, 449 Sulcus, 105f Sulfur dioxide, exposure to, 26t–27t Superficial reflexes, 115, 115b, 117f Superior vena cava, 224f, 238f on chest radiograph, 212f Supplementary motor area, in control of breathing, 119f Supraclavicular retractions, 82 Suprasternal notch, 78–79 Surface area-to-mass ratio, in newborn, 270, 270b, 270t Surfactant, nutrition effect on, 412, 417–418 SV See Stroke volume (SV) SVC (slow vital capacity), 181 in critically ill patients, 318 SVI (stroke volume index), 376 SVo2 (mixed venous oxygen saturation), in critically ill patients, 339–340, 339f, 339t SVR (systemic vascular resistance) calculation of, 381–382 reference range and formula for, 376t, 376t SVRI (systemic vascular resistance index), 376t, 376t Swan-Ganz catheter See Pulmonary artery catheter (PAC) Sweat chloride test, 137 in children, 289–290 Sweat electrolytes, 137 Sweating, excessive, 76 Swelling, of ankles, 48–49 causes of, 48 definition of, 48 descriptions of, 48–49, 49t questions to ask about, 49b Switch-in errors, 189 Sympathetic nerve stimulation dysrhythmia due to, 239 and myocardial contractility, 382 525 Symptom(s), 39t chest pain as, 42–47 case study on, 54b causes of, 42–44, 45t–46t characteristics of, 44, 45t–46t descriptions of, 44–47 location of, 44b questions to ask about, 46b constitutional, 21 cough as, 33–35 causes of, 34, 34t clinical presentation of, 34 descriptions of, 34–35, 35t questions to ask about, 34b–35b defined, 19, 33 description of, 21–22, 22b dizziness and fainting (syncope) as, 47–48 causes of, 47–48, 47b definition of, 47 descriptions of, 48 questions to ask about, 48b fever, chills, and night sweats as, 49–51 causes of, 49–50, 50t definitions of, 49 with pulmonary disorders, 50–51, 51b questions to ask about, 51b terms used to describe, 49t gastroesophageal reflux as, 53–54 headache, altered mental status, and ­personality change as, 51–52, 51b–52b in health history, 19–21, 21b hemoptysis as, 36–38 causes of, 36–37, 37b definition of, 36 descriptions of, 37 vs hematemesis, 37–38, 37t questions to ask about, 38b importance of, 33b shortness of breath (dyspnea) as, 38–42 acute, 41, 41b case study on, 53b causes of, 39–41, 40t, 43t chronic, 41, 41b clinical presentation of, 39–41 clinical types of, 39–41, 40t definition of, 38 descriptions of, 41–42, 42t–43t questions to ask about, 42b scoring systems for, 39, 39t subjectiveness of, 38–39 snoring and daytime somnolence ­(sleepiness) as, 52–53 case study on, 54b causes of, 52, 53b clinical presentation of, 52–53 definitions for, 52 incidence of, 52 sputum production as, 35–36 causes of, 35–36, 36b defined, 35 descriptions of, 35–36, 36t questions to ask about, 36b swelling of ankles (dependent edema) as, 48–49 causes of, 48 definition of, 48 descriptions of, 48–49, 49t questions to ask about, 49b 526 Index Synchronous intermittent mandatory ­ventilation (SIMV), lung volume measurement with, 318 Syncope, 47–48 carotid sinus, 47 causes of, 47–48, 47b cough (tussive), 47–48 definition of, 47 descriptions of, 48 questions to ask about, 48b vasovagal, 47 Systemic vascular resistance (SVR) calculation of, 381–382 reference range and formula for, 376t, 376t Systemic vascular resistance index (SVRI), 376t, 376t Systolic pressure, 66 pulmonary artery, 362–363 reference range for, 350t, 352 Systolic thrust, 94 T T cells, functions of, 130 T (tracheostomy) tube, bronchoscopy with, 407 T wave, 240, 241f interpretation of, 248t Tachycardia, 64, 243–244, 247 and cardiac output, 377 in newborn, 271 paroxysmal atrial, 249–250, 250f, 250t sinus, 249, 250f, 250t ventricular, 252–253, 253f, 253t nonsustained, 252–253 short run of, 252 sustained, 252–253 Tachypnea, 42t, 65, 65t, 82t in newborn, 271 transient chest radiographs of, 284, 285f delivery history and, 266 in older patients, 304 Tactile fremitus, 83, 84f Target, in radiography, 208, 209f TB (tuberculosis) fever due to, 50t skin testing for, 145, 146b TBB (transbronchial biopsy), 401–402 TBPA (thyroxin-binding prealbumin), 428, 428t TCA (tricarboxylic acid) cycle, 418, 419f tcPco2 (transcutaneous carbon dioxide ­pressure), 154t, 157–158 in newborn, 281 tcPo2 (transcutaneous oxygen pressure), 281 TDCO (thermodilution cardiac output), 385–386, 386b, 386f TDCO (thermodilution cardiac output) ­monitoring, continuous, 387 TDI (toluene diisocyanate), exposure to, 26t–27t Teach-back method, Teasdale, Graham, 110 Telemetry, 58 Telemonitoring, in home care, 465 Telephone orders, 470 Temperature body See Body temperature skin of newborn, 274 peripheral, 97 Temporal lobe, 105f, 109f, 109t Tenacious sputum, 36 Tension pneumothorax, 216–217, 216f, 217b Term infants, 264 Territoriality, Test results, 472 Tetralogy of Fallot, chest radiographs of, 286t TGV (thoracic gas volume), 191, 191f in newborns, 282 The Joint Commission (TJC), 456 and legal aspects of medical record, 469–472 Thermodilution cardiac output (TDCO), 385–386, 386b, 386f Thermodilution cardiac output (TDCO) monitoring, continuous, 387 Thermogenesis, diet-induced, 413 Theta waves, 438f Third-degree AV block, 256, 256f, 256t Thoracentesis, 230 Thoracic cage landmarks, 78–79, 79f Thoracic configuration, 80–81, 81f Thoracic examination, 80–93 auscultation of lungs in, 86–93 defined, 86 mechanisms and significance of lung sounds in, 90–93, 90b, 91f–92f, 93b, 93t stethoscope for, 86–87, 87f technique for, 87, 88f, 89t terminology for, 87–90, 88b–89b, 89f, 90t voice sounds in, 93 inspection in, 80–83 of breathing pattern and effort, 81–83, 82b, 82t for central cyanosis, 83, 83b of thoracic configuration, 80–81, 81f palpation in, 83–85 defined, 83 for skin and subcutaneous tissues, 85 for thoracic expansion, 83–84, 85f for vocal fremitus, 83, 84f percussion in to assess resonance, 85–86, 85f clinical implications of, 86, 86b defined, 85 of diaphragmatic excursion, 86, 86f mediate or indirect, 85, 85f over lung fields, 85–86, 86b Thoracic expansion, 83–84, 85f Thoracic gas volume (TGV), 191, 191f in newborns, 282 Three-way stopcock, in indwelling catheter, 155, 156f, 156t Thrombocythemia, essential, 132 Thrombocytopenia, 134 in infants, 277–278 Thrombocytosis, 134 in infants, 277–278 Thumb sign, in epiglottitis, 289 Thyroxin-binding prealbumin (TBPA), 428, 428t TIBC (total iron-binding capacity), 428, 429t Tidal volume (VT), 180, 180f, 181t in critically ill patients, 316, 316b–317b, 316t in newborns, 282 titration with pressure-volume curve of, 328–330, 330f Tight-building syndrome, 25–27 Tin, exposure to, 26t–27t Tinnitus, 298 Tissue oxygen delivery and utilization ­monitoring, 337–343, 340b arterial-to-mixed venous oxygen content difference in, 340 blood lactate in, 340 mixed venous oxygen saturation in, 339–340, 339f, 339t mixed venous oxygen tension in, 338-339, 338–339 oxygen consumption in, 337–338, 338b, 338f oxygen delivery and availability in, 337 oxygen extraction ratio in, 340 regional tissue oxygenation (near infrared spectroscopy) in, 340–343, 341f TJC (The Joint Commission), 456 and legal aspects of medical record, 469–472 TLC (total lung capacity), 180, 180f, 181t TN (true negative), 128 Toluene diisocyanate (TDI), exposure to, 26t–27t Tone, in biophysical profile, 268t Total cholesterol, 136t, 140, 140t Total CO2, 136t, 137 in newborn, 278t Total compliance, 195 Total iron-binding capacity (TIBC), 428, 429t Total lung capacity (TLC), 180, 180f, 181t Total lymphocyte count, in nutritional ­assessment, 428, 428t Total protein, 139–140 in newborn, 278, 278t TP (true positive), 128 Trace elements, 422–423 Trachea on chest radiograph, 212f shift of, 77 Tracheal breath sounds, 87, 89t Tracheal tube See Endotracheal (ET) tube Tracheobronchitis, pain due to, 45t–46t Tracheostomy, in infant or child, 287 Tracheostomy (T) tube, bronchoscopy with, 407 Transbronchial biopsy (TBB), 401–402 Transcutaneous blood gas analysis, 154t, 157–158 Transcutaneous carbon dioxide pressure (tcPco2 Ptcco2), 154t, 157–158 in newborn, 281 Transcutaneous oxygen pressure (tcPo2), 281 Transcutaneous oxygen tension (Ptco2), 154t, 157–158 Transesophageal Doppler monitoring, of cardiac output, 388–389 Transfer factor See Diffusing capacity of lung (DLCO) Transferrin, serum, 428, 428t Transient tachypnea of the newborn (TTN) chest radiographs of, 284, 285f delivery history and, 266 Transillumination, of newborn, 275, 276f Transmural pressure, and wedge pressure, 366–367, 366t Transposition of the great vessels, chest ­radiographs of, 286t Index Transpulmonary indicator-dilution cardiac output, 386–387, 387f Transpulmonary pressure, in newborns, 282 Transthoracic echocardiography (TTE), for periodic measurement of cardiac performance, 389–390 Transthoracic electrical bioimpedance, ­continuous measurement of ­cardiac performance using, 389 Transtracheal Doppler monitoring, of cardiac output, 388–389 Transudate, 220–221 Treatment, in clinical encounter, 4t Treatment records, 472 Trepopnea, 41, 42t Tricarboxylic acid (TCA) cycle, 418, 419f Triceps reflex, 116t Triceps skinfold thickness, 426 Tricuspid area, 94f Tricuspid valve, 238f Trigeminal nerve, 112f, 113t Trigeminy, 64 Triglycerides, 136t, 140 Trochlear nerve, 112f, 113t Troponin I (cTnI), 136t, 141, 141b, 141f True negative (TN), 128 True positive (TP), 128 TTE (transthoracic echocardiography), for periodic measurement of cardiac performance, 389–390 TTN (transient tachypnea of the newborn) chest radiographs of, 284, 285f delivery history and, 266 Tube feeding, 424 Tuberculin skin test, 145, 146b Tuberculosis (TB) fever due to, 50t skin testing for, 145, 146b Tumors, chest pain due to, 45t–46t Turgor, of skin, 98–99, 98f Tussive syncope, 47–48 Tympanic infrared thermometry, 63–64 Tympanic temperature, 63–64 U U wave, 240–241, 241f UIP (upper inflection point), of pressurevolume curve, 328–329, 330f ULN (upper limit of normal) for diffusing capacity of lung, 193–194 for spirometry test results, 185, 186f Ulnar artery catheter, 349 Ultrasound, 230 endobronchial, 400 Umbilical artery and vein, cannulation of, 287, 288f UMN (upper motor neuron), 114 UMN (upper motor neuron) lesion, 114, 114b, 115t Unconjugated bilirubin, 140 Unsaturated fat, 422 Unusual presentation of illness, in older patients, 301–302 for asthma, 302, 302b for myocardial infarction and congestive heart failure, 302 for pneumonia, 301–302 Upper inflection point (UIP), of pressurevolume curve, 328–329, 330f Upper limit of normal (ULN) for diffusing capacity of lung, 193–194 for spirometry test results, 185, 186f Upper motor neuron (UMN), 114 Upper motor neuron (UMN) lesion, 114, 114b, 115t Upper respiratory infection (URI), fever due to, 50t Urinalysis, 136t, 139 Urinary tract infection, fever due to, 50t Urinary urea nitrogen (UUN), 421 Urobilinogen, 139 V v wave, in central venous pressure, 356, 357f VA (alveolar volume), in critically ill patients, 316 Vagus nerve, 112f, 113t in control of breathing, 119f Validation, of spirometry technique, 184–185, 185b, 186f Validity checks, for blood gas measurement external, 169, 169b internal, 169 Vascular occlusion test (VOT), 341 Vascular pressure monitoring, 348 arterial, 349–354 arterial pressure waveforms in, 351–352, 352f–353f to estimate cardiac output, 352 respiratory variations in, 352 catheter insertion for procedure for, 351, 351b sites for, 349 complications of, 354, 354b hemorrhage as, 354 infection as, 354 ischemia as, 354 equipment set-up for, 350–351, 351f indications for, 349 interpretation of measurements in, 352–354, 354b case studies on, 369b with central line bundle, 367–370, 368b central venous, 354–358 catheter insertion for procedure for, 355–356, 356f sites for, 355, 355f catheters for, 355, 355f central venous and atrial pressure waveforms in, 356–357, 357f respiratory variations in, 356–357, 357b complications of, 358 indications for, 354 interpretation of measurements in, 357–358, 358b as reflection of left ventricular ­function, 358, 358b of critically ill infant, 287, 288f overview of hemodynamic pressure ­relationships for, 350b pulmonary artery, 358–367 catheter placement for, 361–362, 361f in pulmonary artery, 361f, 362 in right atrium, 361–362, 361f in right ventricle, 361f, 362 in wedge position, 361f, 362, 363f catheters for, 360–361, 360f complications of, 367 527 Vascular pressure monitoring (Continued) indications for, 359–360, 359b interpretation of measurements in, 359, 359b, 362–367 diastolic, 363, 363b systolic, 362–363 wedge, 363–367, 364b wedge catheter placement for, 361f, 362, 363f interpretation of, 363–367, 364b obtaining, 364–366, 365f, 365t transmural pressure and, 366–367, 366t wedging of balloon in, 366 reference ranges for hemodynamic ­pressures in, 350t reference rates for heart rate and blood pressure in children in, 350t Vascular resistance(s) decreased, 381 increased, 381 pulmonary calculation of, 381–382 reference range and formula for, 376t, 376t reference ranges and formulas for, 376t, 376t systemic calculation of, 381–382 reference range and formula for, 376t, 376t use of cardiac output to determine, 374b Vasodilators, arterial pressure monitoring with, 352 VC See Vital capacity (VC) Vco2 (carbon dioxide production), in critically ill patients, 331 VD (dead space volume), in critically ill ­patients, 316 VD/VT (dead space–to–tidal volume ratio), in critically ill patients, 316t, 332–333 VE (minute volume), 180 in critically ill patients, 316t, 318 nutrition and, 417 Venous admixture, in arterial blood gas sample, 169t Venous anatomy, of neck, 223–224, 224f Venous blood, in arterial blood gas sample, 169t Venous blood gases, in newborn, 280 Venous oxygen saturation, in critically ill patients, 339–340, 339f, 339t Venous return, 378-379, 375, 375b effects of mechanical ventilation on, 379–380, 380b factors affecting, 378–379 Venous tone, and cardiac output, 379 Ventilation dead space, 163 maximal voluntary, 181, 183–184, 184b minute, 180 in critically ill patients, 316t, 318 nutrition and, 417 Ventilation problems, in SOAP charting, 474 Ventilation scan, 228–229, 228f Ventilation/perfusion (V/Q) mismatch, 118–119 hypoxemia due to, 159, 159t in older patients, 306 528 Index Ventilation/perfusion (V/Q) scan, 228, 228f Ventilator asynchrony, in critically ill infant, 286 Ventilator-induced alkalosis, 167 Ventilatory assessment, 315–333, 316t of airway pressures, 319–323 auto-PEEP as, 322 maximum inspiratory, 316t, 321–322, 322b mean, 320–321 peak inspiratory, 319–320, 320b, 320f plateau, 320, 321f of airway resistance, 317, 323 of compliance, 322–323 of fractional gas concentrations, 330–333 exhaled carbon dioxide as, 331–333, 331b, 331f–332f fraction of inspired oxygen ­concentration as, 330–331 integrating pressure, flow, and volume in, 323–330 to evaluate patient-ventilator interface, 323 flow-time waveforms in, 326–330, 327b, 327f–328f to monitor pressure, flow, and volume, 323–326 pressure-time waveforms in, 323–325, 324f–326f pressure/volume curves in, 328, 329f–330f, 330b volume-time waveforms in, 326, 326f of lung volumes and flows, 315–319 dead space–to–tidal volume ratio as, 316t, 332–333 FEV1/FVC ratio as, 319 frequency as, 316t functional residual capacity as, 316, 319 indications for, 316 measurements in, 316–319 minute volume as, 316t, 318 Paco2 as, 318 rapid-shallow breathing index as, 316t, 318 rationale for, 316 spontaneous breathing trial for, 318, 318b tidal volume as, 316, 316b–317b, 316t vital capacity as, 316t, 318 parameters for, 315, 316t Ventilatory failure, chronic, 164 Ventilatory impairment obstructive, 187, 187b, 187t changes in lung volumes and capacities with, 192f flow volume loops for, 187, 188f restrictive, 187 changes in lung volumes and capacities with, 192f flow volume loops for, 187, 188f Ventilatory response, to carbon dioxide, 118, 120f–121f Ventral nerve root, 104–105 Ventral respiratory group, 119f Ventricles, 236, 237f Ventricular compliance, 378, 378f Ventricular contractions, premature, 252 couplets of, 252 frequent, 252, 252f Ventricular contractions (Continued) multifocal, 252, 252f R-on-T phenomenon with, 252, 253f salvos of, 252 single, 252, 252f, 252t Ventricular fibrillation, 253, 254f, 254t Ventricular filling volume, 374b Ventricular function curves, 374b, 377–378, 377f clinical applications of, 379, 380f Ventricular stroke work, 376 Ventricular tachycardia, 252–253, 253f, 253t nonsustained, 252–253 short run of, 252 sustained, 252–253 Ventricular volume, 376 Ventricular wall stress, 380–381 Verbal orders, 470 Vertebral disk herniation, nerve root ­pathology due to, 106, 107b Vertebral vein, 224f Very low birthweight (VLBW), 268 Vesicular breath sounds, 88b characteristics of, 87, 89t defined, 87 diagram of, 87, 88f location of, 87, 89f mechanisms of, 90, 90b Vestibulocochlear nerve, 112f, 113t Visceral sensory division, of peripheral ­nervous system, 105f Vision impairment, in older patients, 299 assessing for, 299 compensating for, 299, 299b Vital capacity (VC), 180f, 181, 181t in body plethysmography, 191 in critically ill patients, 316t, 318 crying, 282 Vital organ function, 118–122 control of breathing as, 118–122 apneustic breathing in, 121f ataxic breathing in, 120, 121f Biot breathing in, 120, 121f with brainstem lesions, 118, 121f central neurogenic hyperventilation (Kussmaul breathing) in, 121f Cheyne-Stokes respiration in, 120, 120b, 121f–122f cluster breathing in, 121f hypercapnic drive in, 118–119, 122f hypoxia and, 118, 121f hypoxic drive in, 118–119 Paco2 in, 118–119, 122f receptors that influence, 118, 120f schematic representation of, 118, 119f control of cardiovascular system in, 122 Vital sign(s), 56 blood pressure as, 66–71 arterial, 66 changes in posture and, 67 effects of respiratory cycle on, 70–71 high (hypertension), 66, 67t low (hypotension), 67, 71b measurement of, 67–69 auscultatory, 68–69, 68t, 69b errors in, 69, 70f sphygmomanometer cuff for, 67–68, 67f, 68t, 69b in newborn, 272, 272t normal values for, 66, 66t Vital sign(s) (Continued) in older patients, 303–304, 304b pulse, 66 questions to ask about, 70b body types in, 60b comparing information on, 58–59 general clinical presentation as, 59–61 questions to ask about, 60b height and weight as, 59 key to expert assessment of, 59, 59b level of consciousness (sensorium) as, 61, 61b Glasgow Coma Scale for, 61 questions to ask about, 61b measurement of baseline, 58 frequency of, 58, 58b signs of hypoxemia assessed during, 59t in newborn, 270–272 blood pressure as, 272, 272t body temperature as, 270, 270b, 270f, 270t pulse as, 270–271, 271f respiratory rate as, 271–272 obtaining, 57–58, 57b in older patients, 303–304 blood pressure as, 303–304, 304b pulse as, 303 respiratory rate as, 304 temperature as, 303 pain level and type as, 60–61, 61b questions to ask about, 61b pulse as, 64–65 measurement of, 64, 64f, 65b in newborn, 270–271, 271f in older patients, 303 questions to ask about, 65b referred to age, 64, 64t rhythm and pattern of, 64–65 respiratory rate and pattern as, 65–66 above normal (tachypnea), 65 causes of abnormal, 66b measurement of, 66, 66b in newborn, 271–272 in older patients, 304 questions to ask about, 66b referred to age, 64t, 65 slow (bradypnea), 65 terms used to describe, 65, 65t temperature as, 61–64 elevated (fever), 62, 64b measurement of, 62–64 axillary, 63 oral, 63 rectal, 63 tympanic (ear), 63–64 in newborn, 270, 270b, 270f, 270t normal, 61–62, 61t below normal (hypothermia), 62 in older patients, 303 questions to ask about, 63b trends in, 58, 58b uses of, 57 Vitamin(s) fat-soluble, 422–423 water-soluble, 422–423 Vitamin A, and respiratory function, 423 Vitamin A deficiency, 412 Vitamin C, and lung function, 423 Index Vitamin C deficiency, 412 Vitamin D, and lung function, 423 Vitamin deficiencies, 412 Vitamin E, and lung function, 423 Vitamin E deficiency, 412 Vitamin requirements, 422–423 of cardiovascular system, 417 VLBW (very low birthweight), 268 Vo2 See Oxygen consumption (Vo2) Vo2max (maximal oxygen consumption), 199, 200t Vocal fremitus, 83, 84f Vocal resonance, 93 Voice sounds, 93 Volume calibration, of spirometry equipment, 184, 184t Volume linearity, of spirometry equipment, 184, 184t Volume monitoring, in ICU, 323–326 Volume-time waveforms, in critically ill ­patients, 326, 326f Volumetric device, 195 Volutrauma, in critically ill patients, 317 VOT (vascular occlusion test), 341 V/Q See Ventilation/perfusion (V/Q) VT See Tidal volume (VT) W Waist circumference, in nutritional ­assessment, 426 Water, on radiographs, 210 Water requirements, 423–424 of cardiovascular system, 417 Water-soluble vitamins, 422–423 Waxing and waning pattern, in central sleep apnea, 448 WBCs See White blood cell(s) (WBCs) Wedge pressure See Pulmonary artery wedge pressure (PAWP) Weight, 59 ideal, 427 of newborn, 272 in nutritional assessment, 426 Wenckebach block, 254, 255f, 255t Wheezes defined, 91, 89b, 90t mechanisms and significance of, 91–92, 91f, 93t in nutritional assessment, 429–430 polyphonic vs monophonic, 92 time-expanded waveforms of, 89f Whispering pectoriloquy, 93 White blood cell(s) (WBCs), 129–132 abnormalities of malignant, 132 nonmalignant, 130–131 basophilia as, 131 eosinophilia as, 131 leukocytosis as, 130 leukopenia as, 130 lymphocytopenia as, 131 lymphocytosis as, 131 monocytosis as, 131 neutropenia as, 130, 131b neutrophilia as, 130, 130b–131b pseudoneutropenia as, 131 pseudoneutrophilia as, 131 functions of, 129–130, 130b 529 White blood cell (WBC) count, 129t differential, 129, 129t in nutritional assessment, 428t in infants, 276–277, 276t in older patients, 309 White matter, 106f Work of breathing (WOB), 81–83 in newborns, 282 in SOAP charting, 474 Wright stain, of sputum, 143–144 X Xiphoid, 79f X-rays, 208, 209f Z Ziehl-Neelsen stain, of lung tissue, 144–145 Zinc, exposure to, 26t–27t Zinc deficiency, 412 Zrs (respiratory system impedance), 195 This page intentionally left blank       Abbreviations ∆ µg µm AARC A-ao2 ABG(s) A/C P(a-et)co2 ALI APRV ARDS ARF ASV ATPD ATPDS ATS auto PEEP BAL bilevel PAP BiPAP BP BPD BTPS Cao2 C(a – v)o2 CHF Cl− Cl CLD CMV CO CO2 COHb COLD COPD CPAP CPG CPPB CPPV CPR CPT Cs CSV Cvo2 Cv o2 CVP D DIC Dlco Dlcosb DPAP Dm EDV EE change in microgram micrometer American Association for Respiratory Care Partial pressure of oxygen between alveoli (A) and arterial blood (a) arterial blood gas(es) assist/control arterial -to-end tidal partial pressure of carbon dioxide acute lung injury airway pressure release ventilation acute (or adult) respiratory distress syndrome acute respiratory failure adaptive support ventilation ambient temperature and pressure, dry ambient temperature and pressure saturated with water vapor American Thoracic Society unintended positive end-expiratory pressure bronchoalveolar lavage bilevel positive airway pressure registered trade name for a bilevel PAP device blood pressure bronchopulmonary dysplasia body temperature and pressure, saturated with water vapor arterial content of oxygen arterial-to-mixed venous oxygen content difference congestive heart failure chlorides lung compliance (also Clung) chronic lung disease controlled (continuous) mandatory or mechanical ventilation carbon monoxide carbon dioxide carboxyhemoglobin chronic obstructive lung disease chronic obstructive pulmonary disease continuous positive airway pressure Clinical Practice Guideline continuous positive pressure breathing continuous positive pressure ventilation cardiopulmonary resuscitation chest physical therapy static compliance continuous spontaneous ventilation venous oxygen content mixed venous oxygen content central venous pressure diffusing capacity disseminated intravascular coagulation diffusing capacity Single-breath method for diffusing capacity demand positive airway pressure diffusing capacity of the alveolar capillary membrane end-diastolic volume energy expenditure EEP EIB eNO EPAP ERV ETco2 or etco2 fb FEF FEFmax FEFX FEco2 FEo2 FENO FETX FEVt FEV1 FEV1/VC FIco2 FIF FIo2 FIVC Fo2 Fco2 FRC f/VT FVC g/dL HbO2 HCO3− H2CO3 HFA HFJV HFO HFOV HFNC HFPV HFPPV HFV HRmax HRmax% IC I:E IgE ILD IMV IPAP IPPB IPPV IRDS IVC MDI mEq/L MEP metHb MIP end-expiratory pressure exercise-induced bronchospasm exhaled nitric oxide (end-)expiratory positive airway pressure expiratory reserve volume end-tidal CO2 Respiratory rate per minute/frequency of breathing forced expiratory flow maximal forced expiratory flow achieved during an FVC forced expiratory flow, related to some portion of the FVC curve fraction of CO2 in mixed expired gas fraction of O2 in mixed expired gas fraction of nitric oxide in mixed expired gas forced expiratory time for a specified portion of the FVC forced expiratory volume (timed) forced expiratory volume at second or FEV1/SVC – Forced expiratory volume in second over slow vital capacity fractional inspired carbon dioxide forced inspiratory flow fractional inspired oxygen forced inspiratory vital capacity fraction of oxygen fraction of carbon dioxide functional residual capacity rapid shallow breathing index (frequency divided by tidal volume) forced vital capacity grams per deciliter oxygenated hemoglobin bicarbonate carbonic acid hydrofluoroalkane high-frequency jet ventilation high-frequency oscillation high-frequency oscillatory ventilation high-flow nasal cannula high-frequency percussive ventilation high-frequency positive pressure ventilation high-frequency ventilation maximal heart rate maximal heart rate percentage inspiratory capacity inspiratory-to-expiratory ratio Immunoglobulin E interstitial lung disease intermittent mandatory ventilation inspiratory positive airway pressure breathing intermittent positive pressure breathing intermittent positive pressure ventilation infant respiratory distress syndrome inspiratory vital capacity metered dose inhaler milliequivalents/liter maximum expiratory pressure methemoglobin maximum inspiratory pressure mm Hg MMV mPaw - Paw MV MVV NAVA NBRC NEEP NIF NIV NPPV NPPV NPV nSIMV OSA ∆P P50 P100 Pa PA PAC PA Catheter P(A-a)o2 PAco2 Paco2 PAo2 Pao2 Pao2/FIo2 Pao2/PAo2 PAOP PAP PAP P(a-et)co2 PAV Paw Paw PAWP PC20 Pco2 PCV PCWP PE PEmax PEA PE co2 PEEP Petco2 PFT PEmax PImax PIo2 PIP PL pMDI Pmus millimeters of mercury mandatory minute ventilation mean airway pressure mechanical ventilation maximum voluntary ventilation neurally adjusted ventilatory assist National Board of Respiratory Care negative end-expiratory pressure negative inspiratory force (also see MIP and MIF) non-invasive mechanical ventilation (formerly NIMV) non-invasive positive pressure ventilation (also NPPV) noninvasive positive pressure ventilation negative pressure ventilation nasal synchronized intermittent mandatory ventilation obstructive sleep apnea change in pressure Po2 at which 50% saturation of hemoglobin occurs pressure on inspiration measured at 100 milliseconds arterial pressure pulmonary artery premature atrial contraction Pulmonary artery catheter alveolar-to-arterial partial pressure of oxygen partial pressure of carbon dioxide in the alveoli partial pressure of carbon dioxide in the arteries partial pressure of oxygen in the alveoli partial pressure of oxygen in the arteries ratio of arterial Po2 to FIo2 ratio of arterial Po2 to alveolar Po2 pulmonary artery occlusion pressure pulmonary artery pressure mean pulmonary artery pressure arterial-to-end-tidal partial pressure of carbon dioxide (also a-et Pco2) proportional assist ventilation airway pressure mean airway pressure pulmonary artery wedge pressure Provocative concentration of a drug at which a specified variable changes by exactly 20% partial pressure of carbon dioxide pressure control ventilation pulmonary capillary wedge pressure pulmonary embolism maximal expiratory pressure pulseless electrical activity partial pressure of mixed expired carbon dioxide positive end-expiratory pressure partial pressure of end-tidal carbon dioxide pulmonary function test(ing) maximal expiratory pressure maximum inspiratory pressure (also MIP, MIF, NIF) partial pressure of inspired oxygen peak inspiratory pressure (also Ppeak) transpulmonary pressure pressurized metered dose inhaler muscle pressure Po2 Ppl Pplateau PPV PRVC PS PSmax PSV Ptcco2 Ptco2 P-V PV PVC(s) Pv o2 PVR ˙ Q ˙ c′ Q ˙T Q ˙t ˙ Qs /Q R Raw RDS REE RM RQ RSV RT RV Sao2 SGaw SIMV Spo2 Sv o2 SVN SVR TCT TE TI TLC torr v V˙ V˙ E V˙ A VA VC VD/VT V˙ E V˙ V˙ o2 V˙ max V˙ max25/50/75 VS VT ˙ ˙ Q V/ VSV WOB ZEEP partial pressure of oxygen intrapleural pressure plateau pressure positive pressure ventilation pressure regulated volume control pressure support maximum pressure support pressure support ventilation transcutaneous Pco2 transcutaneous Po2 pressure-volume pressure ventilation premature ventricular contraction(s) partial pressure of oxygen in mixed venous blood pulmonary vascular resistance blood flow pulmonary capillary blood flow cardiac output shunt resistance (ie, pressure per unit flow) airway resistance respiratory distress syndrome resting energy expenditure lung recruitment maneuver respiratory quotient Respiratory Syncytial Virus respiratory therapist residual volume arterial oxygen saturation Specific airway conductance synchronized intermittent mandatory ventilation oxygen saturation measured by pulse oximeter mixed venous oxygen saturation small volume nebulizer systemic vascular resistance total cycle time expiratory time inspiratory time total lung capacity measurement of pressure equivalent to mm Hg mixed venous flow expired minute ventilation alveolar ventilation per minute alveolar gas volume vital capacity dead space-to-tidal volume ratio expired volume per minute inspired volume per minute oxygen consumption per minute maximal flow maximal flow at 25%, 50% or 75% of the FVC volume support tidal volume ventilation/perfusion ratio volume support ventilation work of breathing zero end-expiratory pressure ... ed p ; cm Clinical assessment in respiratory care Rev ed of: Clinical assessment in respiratory care / Robert L Wilkins, James R Dexter ; consulting editor, Albert J Heuer 6th ed c2010 Includes... and index ISBN 978-0-323-10029-8 (pbk : alk paper) I Heuer, Albert J II Scanlan, Craig L., 1947- III Wilkins, Robert L Clinical assessment in respiratory care IV Title: Clinical assessment in respiratory. .. property arising out of or related to any use of the material contained in this book The Publisher Library of Congress Cataloging -in- Publication Data Wilkins clinical assessment in respiratory care