NBRC Study Guide (National Board of
Respiratory Care): Essential Exam Prep
Questions
The four steps for respiratory mgmt -
\1. tx *ventilation *first (should problem exist)
2. *oxygenation*
3. *circulation*
4. *perfusion*
problems at one step will adversely affect each process that follows it within sequence
External respiration
vs.
Internal respiration -
\External = exchange of O2 and CO2 across AC membrane
- depends on diffusion capacity of AC membrane & ventilation
Internal = exchange of O2 & CO2 across blood and tissue cells
- depends on circulation
Signs
vs.
Symptoms -
\*Signs = Objective information*; can be seen, measured, heard, or felt
- Color, pulse, edema
*Symptoms = Subjective information*
- Dyspnea, pain, nausea
Steps in Assessment: -
\1. *Visual examination*
- General appearance, sensorum, chest movement, posture, skin color
2. *Bedside exam*
- BS, VS, auscultate, percussion, PMH, cap refill
3. *Lab exam *
- ABG, CBC, CXR, lytes
4. *Specials*
- urinalysis, gram stain, MIP, VC
Skin Appearance
- color
,- condition -
\- *Normal:* Race specific
- *Decrease in color* = ashen, pallor → anemia, blood loss
- *Jaundice: *↑ bilirubin levels → liver failure
- *Erythema: *Redness of the skin → *hypercarbia, COHb, inflammation*
- *Cyanosis: *Bluish → Hypoxia (this is a poor assessment of hypoxia bc it shows up
late! Only appears after 5 gram% of Hb is desaturated...)
- *diaphroesis:* sweating
- *turgor*: slowed response shows dehydration → either through hypernatremia or/and
hypovolemia
Smoking history
- Calculating Pack-year
- Verifying if pt is compliant w/smoking cessation program -
\Pack Years = *(packs per day) x (# years smoked)*
Measure pt's COHb to see if they actually are quitting smoking
COHb be levels should ↓ from their baseline to non-smoking normals of < 1%
Terms for Describing Sensorium/Neuro (LOC)
- Conscious
- Confused
- Disoriented
- Lethargic
- Obtunded
- Stuporous
- Comatose -
\- *Conscious*: alert to time, place, and person; responds appropriately
-* Confused: *can't think clearly, responds inappropriately
-* Disoriented: *disoriented to time/place; starting loss of conscience
-* Lethargic: *sleepy, but will wake; still oriented (can be early sign of increased ICP)
-* Obtunded:*hard to wake; slowed response but appropriate
- *Stuporous: *doesn't awaken completely; only responds to painful stimuli
- *Comatose*: unconscious; doesn't respond to any stimuli
Glasgow Coma Scale (GCS) -
\To measure level of consciousness (LOC)
*Eye opening:* spontaneous 4, in response to voice 3, respond to pain 2, none 1
*Verbal response:* oriented 5, confused 4, inappropriate words 3, incomprehensible
words 2, none 1
*Motor response:* obeys commands 6, localizes 5, withdraws 4, flexes (decorticate) 3,
extends (decerebrate) 2, none 1
• > 13 minor impairment
,• 9-12 moderate impairment
• < 8 severe impairment
iatrogenic -
\of or relating to illness caused by medical examination or treatment
Jugular Vein Distension (JVD) -
\- Occurs with *CHF and pneumothorax*
- most commonly bc of right vent fail due to chronic hypoxemia and CHF
pleurodesis -
\pleural space is artificially obliterated
- requires a hemostat, and 3 way stop cock
macroglossia -
\swelling or enlargement of the tongue
- bc of trauma, or congenital (ie Down's Syndrome)
Orthopnea -
\Difficulty breathing except in the upright position
- can relate to CHF
tracheal shift
- causes -
\Toward abnormality:
- pneumonectomy (lung removal)
- atelectasis
- lung collapse
- unilateral diaphragmatic paralysis
Away from abnormality:
- pneumothorax
- hemothorax
- pleural effusion
- lung tumor
- neck tumor
- diaphragmatic hernia
Pulsus paradoxus
vs.
Pulsus alterans -
\*Pulsus paradoxus: *Significant reduction in pulse strength during inhalation by 10+
BPM
- could be bc status asthmaticus causing air trapping
*Pulsus alterans: *Succession of strong and weak pulses, but rate doesn't change
, - could be due to MI or CHF
Pectus carinatum
vs.
Pectus excavatum -
\*Pectus carinatum: *Anterior protrusion of the sternum "pigeon-chest"
*Pectus excavatum: *Depression of the sternum
Kyphosis
vs.
Scoliosis -
\*Kyphosis *= Convex of the spine (hunchback)
*Scoliosis *= lateral curve
What is considered an adverse rxn to neb tx? -
\∆RR > 20 b/m (call nurse)
Respiratory alternans / Paradoxical breathing
vs.
Asymmetrical chest movements -
\*Respiratory Alternans / paradoxical breathing:* alternating btwn use of diaphragm &
accessory muscles to breath
- chest moves inward during inhalation instead of moving outward; and abdomen moves
outward
- indicative of end-stage resp muscle fatigue
*Asymmetrical chest movements: *Uneven expansion of chest wall during inhalation
Cheyne Stokes
vs.
Biot's Respiration
vs.
Kussmaul's -
\*Cheyne Stokes:* Crescendo then decrescendo in rate and depth in a cycle with
periods of apnea
• typical of CHF, ↑ ICP , drug overdose, CNS disorders
*Biot's respiration:* ↑ RR & depth w/IRREGULAR periods of apnea
• typical of ↑ ICP and head trauma,CNS disorders
*Kussmaul's:* RR >20, increased depth, irregular rhythm, labored breathing
• associated w/DKA or severe metabolic acidosis bc renal failure
Two types of Normal Breath Sounds:
Respiratory Care): Essential Exam Prep
Questions
The four steps for respiratory mgmt -
\1. tx *ventilation *first (should problem exist)
2. *oxygenation*
3. *circulation*
4. *perfusion*
problems at one step will adversely affect each process that follows it within sequence
External respiration
vs.
Internal respiration -
\External = exchange of O2 and CO2 across AC membrane
- depends on diffusion capacity of AC membrane & ventilation
Internal = exchange of O2 & CO2 across blood and tissue cells
- depends on circulation
Signs
vs.
Symptoms -
\*Signs = Objective information*; can be seen, measured, heard, or felt
- Color, pulse, edema
*Symptoms = Subjective information*
- Dyspnea, pain, nausea
Steps in Assessment: -
\1. *Visual examination*
- General appearance, sensorum, chest movement, posture, skin color
2. *Bedside exam*
- BS, VS, auscultate, percussion, PMH, cap refill
3. *Lab exam *
- ABG, CBC, CXR, lytes
4. *Specials*
- urinalysis, gram stain, MIP, VC
Skin Appearance
- color
,- condition -
\- *Normal:* Race specific
- *Decrease in color* = ashen, pallor → anemia, blood loss
- *Jaundice: *↑ bilirubin levels → liver failure
- *Erythema: *Redness of the skin → *hypercarbia, COHb, inflammation*
- *Cyanosis: *Bluish → Hypoxia (this is a poor assessment of hypoxia bc it shows up
late! Only appears after 5 gram% of Hb is desaturated...)
- *diaphroesis:* sweating
- *turgor*: slowed response shows dehydration → either through hypernatremia or/and
hypovolemia
Smoking history
- Calculating Pack-year
- Verifying if pt is compliant w/smoking cessation program -
\Pack Years = *(packs per day) x (# years smoked)*
Measure pt's COHb to see if they actually are quitting smoking
COHb be levels should ↓ from their baseline to non-smoking normals of < 1%
Terms for Describing Sensorium/Neuro (LOC)
- Conscious
- Confused
- Disoriented
- Lethargic
- Obtunded
- Stuporous
- Comatose -
\- *Conscious*: alert to time, place, and person; responds appropriately
-* Confused: *can't think clearly, responds inappropriately
-* Disoriented: *disoriented to time/place; starting loss of conscience
-* Lethargic: *sleepy, but will wake; still oriented (can be early sign of increased ICP)
-* Obtunded:*hard to wake; slowed response but appropriate
- *Stuporous: *doesn't awaken completely; only responds to painful stimuli
- *Comatose*: unconscious; doesn't respond to any stimuli
Glasgow Coma Scale (GCS) -
\To measure level of consciousness (LOC)
*Eye opening:* spontaneous 4, in response to voice 3, respond to pain 2, none 1
*Verbal response:* oriented 5, confused 4, inappropriate words 3, incomprehensible
words 2, none 1
*Motor response:* obeys commands 6, localizes 5, withdraws 4, flexes (decorticate) 3,
extends (decerebrate) 2, none 1
• > 13 minor impairment
,• 9-12 moderate impairment
• < 8 severe impairment
iatrogenic -
\of or relating to illness caused by medical examination or treatment
Jugular Vein Distension (JVD) -
\- Occurs with *CHF and pneumothorax*
- most commonly bc of right vent fail due to chronic hypoxemia and CHF
pleurodesis -
\pleural space is artificially obliterated
- requires a hemostat, and 3 way stop cock
macroglossia -
\swelling or enlargement of the tongue
- bc of trauma, or congenital (ie Down's Syndrome)
Orthopnea -
\Difficulty breathing except in the upright position
- can relate to CHF
tracheal shift
- causes -
\Toward abnormality:
- pneumonectomy (lung removal)
- atelectasis
- lung collapse
- unilateral diaphragmatic paralysis
Away from abnormality:
- pneumothorax
- hemothorax
- pleural effusion
- lung tumor
- neck tumor
- diaphragmatic hernia
Pulsus paradoxus
vs.
Pulsus alterans -
\*Pulsus paradoxus: *Significant reduction in pulse strength during inhalation by 10+
BPM
- could be bc status asthmaticus causing air trapping
*Pulsus alterans: *Succession of strong and weak pulses, but rate doesn't change
, - could be due to MI or CHF
Pectus carinatum
vs.
Pectus excavatum -
\*Pectus carinatum: *Anterior protrusion of the sternum "pigeon-chest"
*Pectus excavatum: *Depression of the sternum
Kyphosis
vs.
Scoliosis -
\*Kyphosis *= Convex of the spine (hunchback)
*Scoliosis *= lateral curve
What is considered an adverse rxn to neb tx? -
\∆RR > 20 b/m (call nurse)
Respiratory alternans / Paradoxical breathing
vs.
Asymmetrical chest movements -
\*Respiratory Alternans / paradoxical breathing:* alternating btwn use of diaphragm &
accessory muscles to breath
- chest moves inward during inhalation instead of moving outward; and abdomen moves
outward
- indicative of end-stage resp muscle fatigue
*Asymmetrical chest movements: *Uneven expansion of chest wall during inhalation
Cheyne Stokes
vs.
Biot's Respiration
vs.
Kussmaul's -
\*Cheyne Stokes:* Crescendo then decrescendo in rate and depth in a cycle with
periods of apnea
• typical of CHF, ↑ ICP , drug overdose, CNS disorders
*Biot's respiration:* ↑ RR & depth w/IRREGULAR periods of apnea
• typical of ↑ ICP and head trauma,CNS disorders
*Kussmaul's:* RR >20, increased depth, irregular rhythm, labored breathing
• associated w/DKA or severe metabolic acidosis bc renal failure
Two types of Normal Breath Sounds:
