(Test Bank) Paramedic Care: Principles & Practice, Vols. 2

Bledsoe,Porter,Cherry, 5

Nursing

Test Bank

5th Edition

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Test Bank for Paramedic Care: Principles & Practice, Vols. 2, The downloadable file consists of 387 pages, and the total size of the file is 5.59 MB. Purchase now only for highly discounted price.

Author(s): Bledsoe, Porter, Cherry

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©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 1 Detailed Lesson Plan Chapter 1 Pulmonology 170–180 Minutes Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes 5 I. Case Study Teaching Tips Have a student read the scenario. Tell students that the case will be reviewed after the lecture. 5 II. Introduction A. The respiratory system is a v ital body system responsible for providing oxygen to the tissues and removing metabolic waste . B. Respiratory emergencies are among the most common emergencies EMS personnel are called upon to treat . C. Several risk factors increase the likelihood of developing respiratory disease . 1. Intrinsic risk factors are those that are influenced from within the patient . The most important intrinsic risk factor is genetic predisposition . 2. Extrinsic risk factors are those that are external to the patient . The most important ext rinsic risk factor is cigarette smoking . Teaching Tip s Respiratory emergencies are some of the most common responses for the EMS provider. It is important for students to understand the importance of managing respiratory emergencies . 10 III. Review of Respir atory System Anatomy and Physiology A. Upper Airway Anatomy 1. The upper airway is responsible for warming and humidifying incoming air. 2. The nasal cavity includes turbinates , which cause turbulence that facilitat es the entrapment and removal of inhaled foreign p articles . 3. The pharynx is a funnel -shaped structure that connects the nose and mouth to the larynx . 4. In addition to its role in speech, t he larynx serves as a filtering device for the Teaching Tip s This is a review of material previously discussed. Revisit the previous topics concerning the anatomy of the respiratory system. Class Activities Because this is review material, MASTER TEACHING NOTES  Teaching Tips  Discussion Topics  Class Activities  Points to Emphasize  Knowledge Application ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 2 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes digestive and respiratory tracts. a. The opening between the vestibule and th e vocal cords is the glottic opening . b. The epiglottis closes during swallowing to divert food/liquids into the esophagus . B. Lower Airway Anatomy 1. The lower airway begins at the trachea and continues into the lungs. 2. The trachea is composed of a series of C-shap ed cartilaginous rings and is lined with the same type of cells that line the nares . 3. At the carina, the trachea divides into the right and left bronchi . a. The right mainstem bronchus is almost a straight continuation of the trachea , whereas the left mainstem bronchus angles more acutely to the left . b. The mainstem bronchi divide into the secondary (lobar) bronchi . c. Secondary bronchi divide into tertiary bronchi , which ultimately divide into bronchioles or small airways. d. The bronchioles are approximately 1 mm thi ck and contain smooth muscle that can contract, thus reducing the diameter of the airway . 4. The respiratory bronchioles divide into alveolar ducts , although limited gas exchange may occur in the alveolar sacs . a. The alveolar wall consists of a thin layer of ce lls that lines the surface of the lung. b. In close proximity to the alveoli are the pulmonary capillaries, which carry carbon dioxide –rich blood from the lungs for return to the heart. c. The alveol ar lining, supportive tissue, and capillaries make up the respi ratory membrane. d. The alveoli are moistened and kept open because of the presence of surfactant . 5. The lungs are the main organs of respiration . a. The right lung contains three major divisions or lobes ; the left lung has only two. b. The lungs are covered by conne ctive tissue called pleura . have students split into groups , and have each group present a portion of the respiratory system to the rest of the class. Then you can gauge which content students most need to review . ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 3 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes 6. Blood is supplied to the lungs through the pulmonary and bronchial vessels . a. Pulmonary arteries transport deoxygenated blood , rich in carbon dioxide , from the heart to the lungs . b. The pulmonary veins transport the newly oxygenated blood from the lungs back to the heart . c. The bronchial arteries branching from the aorta provide blood supply to the lungs and the bronchial veins return it to the superior vena cava . C. Physiologic Processes 1. The major function of the respiratory system is to exchange gases with the environment. 2. Oxygen is taken in while carbon dioxide is eliminated, a process known as gas exchange. 3. Ventilation is the mechanical process of moving air in to and out of the lungs . a. For ventilation to occur, several body structures m ust be intact, including the chest wall, nerve pathways, diaphragm, pleural cavity, and brainstem. b. During inspiration, air is drawn into the lungs, the diaphragm flattens , and the intercostal muscles contract , which expands the chest and decreases air pres sure within the chest cavity , drawing air into the respiratory system . c. During expiration, air leaves the lungs by the chest wall and diaphragm recoiling to the resting state , driving air out of the lungs . d. Airway resistance and lung compliance also play a r ole in the amount of airflow into and out of the lungs . i. More airway resistance means less airflow into the chest cavity . a)Asthma results in bronchospasm , which reduces the diameter of the airways . ii. Lung compliance refers to the ease with which the chest expa nds. a)The more the chest wall expands, the greater the volume of air entering the chest cavity . ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 4 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes b)Loss of elasticity in the muscles of the chest wall with age decreases lung compliance . e. The volume of air entering the lungs varies on the basis of the metabolic needs of the patient f. Ventilation is controlled by the lower portion of the brainstem, specifically the medulla 4. Diffusion is the process by which gases move between the alveoli and the pulmonary capillaries . a. Gases flow from areas with high concentration to areas of low concentration . b. In the alveoli, oxygen flows from areas of high concentration to areas of low concentration in the pulmonary capillaries ; conversely , carbon dioxide flows from the capillaries into the alveoli . c. High concentrations of oxygen ca n help to address problems with diffusion by increasing the amount available . 5. Perfusion is the circulation of blood through the lungs —specifically , through the pulmonary capillaries —and is dependent on three conditions . a. Adequate blood volume because of the concentration of hemoglobin in the blood b. Intact pulmonary capillaries where the gas exchange takes place c. Efficient pumping of blood by the heart for delivery of oxygen and elimination of carbon dioxide 15 IV. Pathophysiology A. Disruption in Ventilation 1. Disruption of ventilation can occur when the normal conducting pathways are obstructed, the normal chest wall function is impaired, or t here is an abnormality with the nervous system’s control 2. Disease states that affect the upper respiratory tract will result in obstruction of airflow to the lower structures . a. Upper airway trauma, infections, foreign bodies , and other structures (such as th e tongue) are causes of obstruction . 3. The chest wall and diaphragm are essential components in ventilation , and Class Activities Map a molecule of oxygen moving through the body , beginning with inhalation and ending with a target organ. Briefly discuss different areas where respiratory emergencies may affect its travel through the body . Knowledge Application ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 5 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes traumatic injuries to these areas disrupt normal mechanics . a. Pneumothorax, hemothorax, flail chest , and diaphragmatic rupture are examples of trau matic injuries to these areas . 4. Any disease process that impairs the nervous system’s regulation of breathing may also alter ventilation . a. CNS depressants such as alcohol or barbiturates can alter the brain’s response . b. Certain abnormal respiratory patterns a re produced by specific brain injury. i. Cheyne -Stokes respirations – seen in older patients with terminal illness or brain injury ii. Kussmaul’s respirations – result as a corrective measure against conditions such as diabetic ketoacidosis that produce metabolic acidosis iii. Central neurogenic hyperventilation – caused by strokes or injury to the brainstem iv. Ataxic (Biot’s) respirations – seen in patients with increased intracranial pressure v. Apneustic respirations – a result of stroke or severe central nervous system d isease B. Disruption of Diffusion 1. Disruption of diffusion can be caused by many disease processes and situations, causing hypoxia 2. Changes in oxygen concentration affect diffusion . 3. Any disease that alters the structure or patency of the alveoli will limit diffusion. 4. Disease states that alter the thickness of the respiratory membrane will limit diffusion of gases. (The most common cause of this alteration is accumulation of fluid and inflammatory cells in the interstitial space. ) 5. Changes in permeability of the pulmonary capillaries affect diffusion . C. Disruption in Perfusion 1. Disruption in perfusion is caused by alteration of blood flow through the Respiratory physiology is fundamental in the management of respiratory emergencies. It is important to be able to tie the concepts of respiratory emergencies to the functions and structures within the body they affect. For example, correlate the pulmonary circulation with the disorders that affect it. ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 6 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes pulmonary capillaries. 2. Any disease state that reduces the normal circulating blood volume will limit perfusion in the lungs. 3. If a portion of lung is without blood flow, it becomes unavailable for perfusion regardless of oxygenation . 10 V. Assessment of the Respiratory System A. Scene Size -Up 1. When you first approach the scene, conside r two major questions : a. Is the scene safe to approach the patient? b. Are there visual clues that might provide information regarding the patient’s medical complaint? B. Primary Impression 1. Take the following considerations and steps to help form your initial gene ral impression of the patient’s respiratory status : a. Position of the patient b. Color c. Mental status d. Ability to speak e. Respiratory effort 2. Signs of respiratory distress include: a. Nasal flaring b. Intercostal muscle retraction c. Cyanosis d. Pursed lips e. Tracheal tugging 3. Airway assessment should be done immediately . a. Note whether the airway is open and patent and whether there are abnormal noises . b. If the airway is compromised, it must be corrected before you move on. 4. Breathing is the next step in respiratory assessment 5. The fol lowing signs suggest a possible life -threatening respiratory problem Discussion Topics How does the assessment of a respiratory patient differ from that of other patients? What is important to consider when assessing respiratory patients? Class Activities If possible, demonstrate the use of a pulse oximeter, capnogram , or other tools used to assess respiratory illnesses. Take some time for the class to become comfortable using them on one another. ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 7 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes in adults: a. Alterations in mental status b. Severe central cyanosis c. Absent breath sounds d. Audible stridor e. One-to two-word dyspnea f. Tachycardia ≥130 beats per minute g. Pallor and diaphoresis h. Prese nce of intercostal and sternocleidomastoid retractions i. Use of accessory muscles C. Secondary Assessment 1. History should be directed at problem areas determined by the chief complaint or primary problem . a. Obtain a SAMPLE history . b. Ask the OPQRST questions , includ ing questions about current symptoms. c. Ask whether the patient has had similar symptoms in the past . d. Ask whether the patient has a known respiratory disease. e. A good history of m edication use is essential and may provide useful clues to the diagnosis. 2. The ph ysical examination should focus on the respiratory system and address the patient’s head and neck and include the following: a. Inspection b. Palpation c. Percussion of the chest wall d. Auscultation i. Normal breath sounds are described as bronchial, bronchiovesicular, or vesicular . ii. Abnormal breath sounds include: a)Snoring b)Stridor c) Wheezing ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 8 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes d)Rhonc hi e)Crackles f) Pleural friction rub 3. The patient’s vital signs may also provide information regarding the severity of the respiratory complaints . 4. Three diagnostic measurements are of v alue in assessing the patient’s respiratory status: pulse oximetry, peak flow, and capnography. 5. Pulse oximetry offers a rapid and accurate means of assessing oxygen saturation . a. Most p ulse oximeters cannot discern between hemoglobin saturated with oxygen and carbon monoxide . 6. Peak flow is used to determine a patient’s peak expiratory flow rate (PEFR). a. This requires a cooperative patient who understands the use of the device to get an accurate reading. 7. Capnography measures levels of carbon dioxide in the exhal ed breath. a. Decreased carbon dioxide levels can be found in shock, cardiac arrest, pulmonary embolism, bronchospasm , and with incomplete airway obstruction . b. Increased carbon dioxide is found with hypoventilation, respiratory depression , and hyperthermia . 10 VI. Management of Respiratory Disorders A. Management Principles 1. The airway always has the first priority . 2. Any patient with hypoxi a should receive oxygen . 3. Any patient whose illness or injury suggests the possibility of hypoxia should receive oxygen until pulse oximetry is available . 4. If there is a question whether oxygen should be given, as in COPD, administer enough oxygen to maintain an adequate SpO 2 level (typically ≥96 %). Strive for normoxia in your patient to avoid both hypoxia and hyperoxia if possible. 5. Supplemental oxygen administration is the mainstay of respiratory emergency management. Teaching Tips Don’t forget to focus on th e importance of good basic skills of airway and breathing management , including ventilation. Points to Emphasize Oxygen should be treated like any other drug. You must be careful to provide just enough to treat hypoxia without causing hyperoxia. ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 9 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes 90 VII. Spec ific Respiratory Diseases A. Upper Airway Obstruction 1. The most common cause of upper airway obstruction is the relaxed tongue . 2. Assessment of the patient with an upper airway obstruction varies depending on the cause of the obstruction and the history of the event. 3. Management of the obstructed airway i s based on the nature of the obstruction . a. In a conscious adult, ask the patient whether he is choking ; if the patient can speak , encourage him to cough the foreign body out . b. If obstruction is severe or the patient has poor air exchange , perform rapid abdominal thrusts . c. In the unconscious adult, open the airway using the head - tilt/chin-lift or jaw -thrust without head extension maneuver in an attempt to open the airway. i. Begin CPR. ii. Each time you open the airway during CPR, l ook an object in the victim’s mouth and remove it. iii. If the obstruction persists and ventilation cannot be provided , visualize the airway with a lary ngoscope . If you can see the foreign body, grasp it with the Magill forceps and remove it. iv. Once the ob struction has been removed, begin ventilation and administer supplemental oxygen. v. In cases of airway obstruction caused by laryngeal edema, supplemental oxygen and rapid airway management are necessary . B. Noncardiogenic Pulmonary Edema/Adult Respiratory Dist ress Syndrome (ARDS) 1. ARDS is a life -threatening condition that adversely affects gas Teaching Tips Specific respiratory dis eases are treated on the basis of the underlying cause. It is more important to stress the priorities of care for airway and breathing rather than attempting to diagnose the respiratory problem. Discussion Topics This chapter covers several different path ophysiologies. Assign groups to cover different topics and find unique ways to discuss them with the class. Perhaps students can build case studies around a patient and have the other students try to determine the cause of illness and treatment of each. Class Activities Each respiratory complaint has different components of the history, physical exam , and treatment. Have students attempt to figure out the matching respiratory disease when given clues in pathophysiology, assessment , or management. ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 10 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes exchange in the lungs . 2. It is a form of pulmonary edema that is caused by fluid accumulation in the interstitial spaces within the lungs . 3. It occurs in response to a wide va riety of lung insults , including sepsis, aspiration, pneumonia, pulmonary injury, burns , inhalation injury, oxygen toxicity, drugs such as aspirin or opiates, high altitude, hypothermia, near drowning , head injury, emboli , tumor destruction, pancreatitis, procedures such as cardiopulmonary bypass or hemodialysis, and other insults such as hypoxia, hypotension, or cardiac arrest. 4. Increase s in pulmonary capillary permeability, destruction of the capillary lining , and increase s in osmotic force draw fluid into the interstitial space and contribute to interstitial edema . 5. Specific clinical symptoms are related to the underlying cause of ARDS . 6. Specific management of the underlying cause is the hallmark of treatment for ARDS . a. Use p ositive pressure ventilation to su pport any ARDS patient who demonstrates signs of respiratory failure. b. PEEP and CPAP will help to maintain patency of the alveoli . C. Obstructive Lung Disease 1. The most common lung diseases that are encountered in prehospital care are asthma, emphysema, and chr onic bronchitis D. Emphysema 1. Emphysema results from destruction of the alveolar walls distal to the terminal bronchioles . 2. The major factor contributing to emphysema in our society is cigarette smoking. Significant exposure to environmental toxins is another c ontributing factor. a. Pathophysiology i. Continued exposure to noxious substances result s in the gradual destruction of the walls of the alveoli , ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 11 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes lessening the area available for gas exchange . ii. Pulmonary capillaries decrease in number , which leads to pulmonary h ypertension and right heart failure . iii. Emphysema weakens the walls of the small bronchioles . b. Assessment i. The emphysema patient may report a history of recent weight loss, increased dyspnea on exertion , and progressive limitation of physical activity . ii. Physical exam ination usually reveals a barrel chest and a pink hue to the skin resulting from polycythemia . iii. Emphysema patients often involuntarily purse their lips to create continuous positive airway pressure . iv. Clubbing of the fingers is common . c. Management i. The pri mary goal of management is relief of hypoxia and reversal of bronchoconstriction . E. Chronic Bronchitis 1. Chronic bronchitis results from an increase in the number of goblet cells in the respiratory tree . a. Pathophysiology i. Unlike emphysema, the alveoli are not se verely affected , and diffusion remains normal . ii. Gas exchange is decreased because of lowered alveolar ventilation secondary to chronic inflammation of the airways . iii. Increased PaCO 2 causes pulmonary vasoconstriction , resulting in pulmonary hypertension , and e ventually, cor pulmonale. b. Assessment ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 12 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes i. Patients will often have a history of heavy cigarette use, but the disease may also occur in nonsmokers . ii. There may also be a history of respiratory infections. iii. Patients tend to be overweight and cyanotic , leading to the ir being termed “blue-bloaters .” iv. ECG changes reflect increased right ventricular size . c. Management i. The primary goal is to relieve hypoxia and reverse any bronchoconstriction that might be present . ii. Fluid administration is suggested with signs of dehydration . iii. If ordered by medical direction, administer bronchodilators via small-volume nebulizer. 2. Asthma is a chronic inflammatory disorder of the airways . a. Pathophysiology i. Asthma may be induced by one of many different factors or triggers that vary from one individ ual to the next. ii. Within minutes of exposure to an offending trigger, a two-phase reaction occurs . a)The first phase is characterized by the release of chemical mediators such as histamine , resulting in bronchoconstriction and bronchial edema . b)The second phas e begins 6–8 hours after exposure to the trigger and is characterized by inflammation of the bronchioles as cells of the immune system invade the mucosa of the respiratory tract . b. Assessment i. The most common presenting symptoms are dyspnea, wheezing , and cou gh. ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 13 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes ii. Other symptoms include a)One- to two -word dyspnea b)Pulsus paradoxus (a drop of systolic BP of 10 mmHg or more with inspiration) and tachycardia c) Decreased oxygen saturation on pulse oximetry iii. Determine whether this has happened previously, when the symptoms started , and what steps the patient has taken to correct symptoms already . iv. Note abnormal breath sounds such as wheezing . v. Patients will have low peak flow rates . vi. Capnogram will show a “shark fin” pattern , indicating bronchoconstriction . c. Management i. Treatmen t is designed to correct hypoxia, reverse any bronchospasm , and treat inflammatory changes associated with the disease . ii. Administer supplemental oxygen to correct hypoxia. iii. Establish intravenous access , and place the patient on an ECG monitor. iv. Administer b eta-agonist preparations such as albuterol or levabuterol in conjunction with ipratropium bromide . v. Be prepared for the patient to fatigue and require aggressive airway management and ventilation d. Special Cases i. Status asthmaticus is a severe, prolonged asthma attack that cannot be broken with repeated doses of bronchodilators . a)Recognize that respiratory arrest is imminent , and be prepare d for endotracheal ©2017 Pearson Education , Inc. Paramedic Care: Principles & Practice, Volume 3, 5th Ed. 14 Chapter 1 objectives can be found on text p. 1. These objectives, which form the basis of each chapter, were developed from the current National EMS Education Standards and the accompanying Paramedic Instructional Guidelines . Minutes Content Outline Master Teaching Notes intubation . ii. Asthma in children is common , and the pathophysiology and treatment are the same as in adults, with altered medication dosages. iii. Several additional medications are used in the treatment of childhood asthma (discussed in greater detail in “Pediatrics” : Volume 5, Chapter 4). F. Upper Respiratory Infection (URI) 1. Infections involving the upper airway and res piratory tract are among the most common infections for which patients seek medical attention. a. Pathophysiology i. Viruses cause the vast majority of URIs . ii. Most are self -limiting illnesses and resolve after several days of symptoms . b. Assessment i. The major sympto ms of URI are determined by the portion of the upper respiratory tract that is predominantly affected . ii. Patients with URIs will often have accompanying symptoms such as fever, chills, myalgias , and fatigue . c. Management i. In most cases, diagnosis and treatment is based on history and physical findings . ii. Focus on the patient’s airway and ventilation . iii. Most URIs are treated symptomatically . G. Pneumonia 1. Pneumonia is an infection of the lungs and a common medical problem , especially in the aged and those infected with H IV. a. Pathophysiology i. Bacterial and viral pneumonias are the most