a. Patient history

Review the complete initial patient history and note the following:

It is important that the respiratory therapist obtain a brief history before beginning therapeutic procedures. Determine how the patient has been doing since the last treatment. Has there been a change in dyspnea, cough and secretions, chest pain, and so on? This will help guide therapy as effectively as possible.

b. Admission notes

The attending physician writes up his or her key findings and how they are related to the reason the patient was admitted to the hospital.

c. Progress notes

Review the physician’s, nurse’s, and respiratory therapist’s patient progress notes before seeing the patient and beginning the therapeutic procedure. Look for any cardiopulmonary or other organ-system changes that will have an impact on the patient’s ability to take the treatment. You may need to revise the therapy, get different equipment, or seek help. Check for new patient care orders if the physician notes a change in the patient’s care plan.

d. Diagnoses

After the medical history, physical exam, and laboratory tests are completed, the patient will be placed into one of the following four diagnostic categories. Refer to Table 1-1 for examples of each category:

TABLE 1-1 Patient Illness Categories

e. Current respiratory care orders

Physician orders must have the patient’s name, date, time, complete and proper orders for each therapeutic procedure, and the physician’s signature. Verbal orders from the physician to the nurse or respiratory therapist must follow hospital guidelines and include the preceding information. Incomplete, improper, or questionable orders must be confirmed by calling the physician for clarification or correction.

f. Medication history

Note the respiratory medications that the patient is currently taking. In addition, note any medications used to help manage cardiovascular, renal, or neurological problems that may also affect the patient’s respiratory status.

g. Do not resuscitate (DNR) status

The physician, patient, and family should determine the patient’s cardiopulmonary resuscitation status. A patient with a terminal condition, such as end-stage chronic obstructive pulmonary disease (COPD), often will choose not to be resuscitated. If it has been determined that the patient does not want to be resuscitated, his or her DNR status should be clearly posted in the chart and in the patient’s room. All members of the health care team should be aware of the patient’s decision.

h. Previous patient education

If the patient has asthma or COPD and has been admitted before, check for any record of a respiratory therapist teaching the patient about the disease and how it can be better managed.

a. Current vital signs

Review the current vital signs in the patient’s chart. Compare them with the admission vital signs and what you observe in the patient now. Look for a change in pattern that suggests either worsening or improvement in the patient.

b. Temperature

The textbook “normal” oral body temperature is 98.6° F (37° C). However, some range from 96.5° F to 99.5° F (35.8° C to 37.4° C) is normal. Make sure the patient has not eaten any hot or cold foods recently and has not been smoking before taking an oral temperature.

A rectal or core temperature is commonly taken in very sick patients, because it is more accurate and reliable. The normal rectal temperature is 97.5° F to 100.4° F (36.4° C to 38° C). Some variance is normal, but less so than with oral temperatures. Axillary temperatures are used as a last resort in stable patients. These run 1° F lower than oral temperatures and are less accurate and reliable.

The variations in temperature noted depend on the time of day, activity level and, in women, stage of the menstrual cycle. For example, a lower body temperature is normal when a person is in a deep sleep. An oral temperature higher than 99.4° F (37.4° C) in a patient with a history of respiratory disease indicates a fever. Typically, it can be caused by atelectasis or a pulmonary or systemic infection. Patients commonly are treated to keep their temperature below 103° F, if possible. In general, a rectal temperature below 97° F (36° C) is considered hypothermic. In some procedures, such as open-heart surgery, a patient’s temperature is lowered to reduce metabolism and oxygen needs. The rectal temperature must be kept above 90° F (32° C) to prevent cardiac dysrhythmias caused by the cold.

c. Respiratory rate

The respiratory rate (f for frequency) is the number of breaths the patient takes in 1 minute. The number is counted by looking at or feeling the chest or abdominal movements, or both. The normal rate varies with age (Table 1-2). It is assumed that the patient is resting but awake and has a normal temperature and metabolic rate. A respiratory rate above or below normal is cause for alarm.

TABLE 1-2 Normal Resting Respiratory Rates

Hyperthermia (fever), acidemia, hypoxemia, fear, anxiety, and pain cause a patient to breathe more rapidly. Hypothermia, alkalemia, and hyperoxia in a patient breathing on hypoxic drive, sedation, and coma cause a patient to breathe more slowly.

Remember that even in healthy people, considerable variation is found in the respiratory rate. It is best to consider the respiratory rate and the patient’s tidal volume and minute volume to get a more complete impression of how the patient is breathing. Carefully measure the respiratory rate of any patient with cardiopulmonary disease or with a respiratory rate outside the normal range. The rate should be checked as often as needed to monitor the patient’s condition.

d. Blood pressure

The blood pressure (BP) is the result of the pumping ability of the left ventricle (made up of the heart rate and stroke volume), arterial resistance, and blood volume. Normal BP results when all three factors are in balance with each other. If one factor is abnormal, the other two have some ability to compensate. For example, if the patient has lost a lot of blood, the body attempts to maintain BP by increasing both arterial resistance and the heart rate.

As with the other vital signs, some variation in BP is noted among individuals. It is important to know the patient’s normal BP to compare it with the current value. Carefully measure the BP in any patient who has cardiopulmonary disease or a history of hypotension or hypertension.

Hypotension in the adult is a systolic BP of less than 80 mm Hg. Recommend a BP measurement for any patient who has a history of hypotension, appears to be in shock, has lost a lot of blood, has a weak pulse, shows mental confusion, is unconscious, or has low urine output.

Hypertension in the adult is a systolic BP of 140 mm Hg or greater or a diastolic BP of 90 mm Hg or greater, or both. Carefully measure the BP of any patient with a history of hypertension, bounding pulse, or symptoms of a stroke (mental confusion, headache, and sudden weakness or partial paralysis). Fear, anxiety, and pain also cause the patient’s BP to increase temporarily.

e. Heart/pulse rate

The heart/pulse rate (HR) is the number of heartbeats per minute. It can be counted by listening to the heart tones with a stethoscope or by feeling any of the common sites where an artery is easy to locate. Table 1-3 shows the normal pulse rates based on age. It is assumed that the patient is alert but resting when the pulse is counted. Carefully measure the heart/pulse rate in any patient with cardiopulmonary disease or any of the aforementioned conditions for hypotension or hypertension.

TABLE 1-3 Normal Pulse Rates According to Age

a. Review the results of the patient’s serum electrolyte levels and other blood chemistries (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

b. Recommend blood tests, such as the potassium level, to obtain additional data (WRE code: IC1) [Difficulty: WRE: R, Ap, An]

The serum (blood) electrolytes are measured in most patients when they are admitted to the hospital and as needed thereafter. This is to determine whether the values are within the normal ranges listed in Table 1-4. Any abnormality should be promptly corrected so that the patient’s nervous system, muscle function, and cellular processes can be optimized. Diet and a number of medications can affect the various electrolytes. Most abnormalities can be corrected by dietary adjustments or, if necessary, by oral or intravenous supplementation.

TABLE 1-4 Normal Serum Electrolyte and Glucose Levels

* These values may vary somewhat among references.

a. Review the results of the patient’s complete blood count (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

b. Recommend a complete blood count for additional data. (Code: IC1) [Difficulty: WRE: R, Ap, An]

A complete blood count (CBC) is routinely done for all hospitalized patients, as well as for patients seen for a variety of illnesses and for routine physical examinations. The red blood cell (RBC, or erythrocyte) count, white blood cell (WBC, or leukocyte) count, and differential (Diff) provide a great deal of information about the hematologic system and many other organ systems.

The key normal values for the RBC count are listed in Table 1-5. The hemoglobin and hematocrit values also are important, because they directly relate to the patient’s oxygen-carrying capacity. Decreased hemoglobin and hematocrit values indicate that the patient is anemic. An anemic patient has less oxygen-carrying capacity, and as a result, more stress is placed on the heart during exercise. Hypoxemia resulting from a cardiopulmonary abnormality places this patient at great risk. A transfusion is indicated if the hematocrit is below the level the physician considers clinically safe.

TABLE 1-5 Normal Hemoglobin, Hematocrit, and Red Blood Cell Counts for Adults and Children ^*

An increased number of circulating erythrocytes indicates that the patient has polycythemia. When this is seen as a response to chronic hypoxemia from COPD, cyanotic congenital heart disease, or another disorder, it is labeled secondary polycythemia. This patient is at added risk because the thickened blood causes an increased afterload against which the heart must pump. These patients also are more prone to blood clots. With supplemental oxygen or other clinical treatment to increase the arterial partial pressure of oxygen (Pao₂) to at least 55 to 60 torr, the erythrocyte and hematocrit levels, over time, return to normal.

The key normal leukocyte count and differential are listed in Table 1-6. A normal leukocyte count and a normal differential reveal two things about the patient. First, no active bacterial infection is present. Second, the patient’s body is able to produce the normal number and variety of WBCs to combat an infection.

TABLE 1-6 White Blood Cell and Differential Counts^*

* These values may vary somewhat among references.

A mild to moderate increase in the leukocyte count is called leukocytosis. It is seen as a WBC count of 11,000 to 17,000 per cubic millimeter (mm³). Usually, the higher the count, the more severe the infection. A WBC count above 17,000/mm³ is seen in patients with severe sepsis, miliary tuberculosis, and other overwhelming infections. When a patient has an acute, severe bacterial infection, the WBC differential count shows an increased number of neutrophils. Exceptions to this are patients who are elderly, those who have acquired immunodeficiency syndrome (AIDS), and those with other immunodeficiencies. These patients may have an infection but show only a mildly elevated WBC count.

Leukopenia is a low absolute WBC count of 3,000 to 5,000/mm³ or less. An acute viral infection can cause a mild to moderate decrease in the neutrophil count. A patient with a low WBC count is at great risk of bacterial or other infections.

a. Review the patient’s Gram stain results, culture results, and antibiotic sensitivity results (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

The first step in the microbial analysis of sputum, mucus, or other body fluids or tissues is a Gram stain. Gram staining is a special process for colorizing bacteria that divides them into two groups. Gram-positive (g⁺) bacteria are stained violet. These are the most common types of bacteria that cause bronchitis and pneumonia. In general, penicillin or related drugs and sulfa-type antibiotics kill gram-positive bacteria. Gram-negative (g⁻) bacteria are stained pink. These organisms, unfortunately, are found in many of the sickest and weakest patients. Often the only way to kill gram-negative bacteria is with a specific antibiotic to which they have been proven sensitive. So-called broad-spectrum antibiotics, such as tetracycline, also may be used.

After Gram staining of the sample of fluid or tissue, a culture and sensitivity (C & S) study is performed. Culturing involves actively growing the organism or organisms to determine what they are. In a sensitivity test, the cultured organism is exposed to a variety of antimicrobial drugs. The goal is to determine which drug or drugs kill the pathogen most effectively. The patient then is treated with that antibiotic. It may take 1 to 3 days to get back the C & S results.

Gram staining cannot be used to identify Mycobacterium tuberculosis (TB) bacteria. Instead, the Ziehl-Neelson stain must be used. This is an acid-fast stain, and it gives the TB bacteria a red coloration. Other pathogens, such as viruses, protozoa, and fungi, cannot be identified by Gram staining. Protozoa and fungi must be identified with specialized stains. Fungi and M. tuberculosis may take 6 to 8 weeks to culture.

b. Recommend a Gram stain and C & S study for additional data (Code: IC4) [Difficulty: ELE: R, Ap; WRE: An]

Whenever an infection is suspected, it is important to obtain a sample of fluid or tissue from the site in question. This patient material is tested for possible bacterial infection by Gram staining and C & S study. Whenever bronchitis or pneumonia is suspected, it is important to obtain a mucus or sputum sample for evaluation. A sample of mucus suctioned from the lungs should show only pulmonary organisms. Sputum is the mix of mucus from the lungs and saliva from the mouth; therefore the organisms found in it may have come from either place. If the patient has pleural fluid, that also must be sampled. Often a blood sample also is taken to look for evidence of septicemia.

Note: The following two items have been listed as testable on the previous NBRC Content Outlines. They are included here in case they are tested again.

a. Chest radiograph

A chest radiograph should be recommended in the following situations:

b. Upper airway radiograph

An upper airway radiograph (anterior or lateral or both) should be recommended for a patient who presents with indications of upper airway obstruction. This can include:

c. CT scan

A CT scan provides a more detailed image than a conventional radiograph. It is able to depict abnormalities of the lungs and mediastinum. Indications include, but are not limited to, the following:

d. MRI scan

An MRI scan provides images of body organs without the use of radioactive materials. The images are created when the powerful magnet of the MRI machine is turned on and off, affecting the way hydrogen atoms align within the body. A limitation of MRI is that the patient cannot have any metallic implants. In addition, most mechanical ventilators cannot be used during an MRI scan because the magnetic field will interfere with the unit. Indications for an MRI scan include, but are not limited to, the following:

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