EVALUATE DATA IN THE PATIENT RECORD Shawna Strickland, PhD, RRT-NPS, AE-C, FAARC Objectives At the end of this module, the learner will be able to identify the pertinent data from the patient chart for the following: 6MWT (Six-minute walk test) Cardiopulmonary Stress Test Chest Tube Drainage system Metabolic Study Intracranial Pressure Trends 1
6MWT Purpose: assess functional exercise level for daily physical activities Data gathered: Dyspnea level Distance walked (6MWD) SpO 2 Blood pressure Heart rate Usually performed before and after intervention Supplemental oxygen Bronchodilator Inhaled corticosteroid Lung volume reduction surgery (COPD) 6MWT Dyspnea level assessed with Borg dyspnea scale 0-10 scale 0=no dyspnea 10=very, very severe Low 6MWD is non-specific and non-diagnostic When noted, look for underlying cause Further cardiac, pulmonary, nutrition, or muscle function test may be warranted Improved 6MWD may show intervention was helpful Positive change from pre-intervention distance walked to postintervention distance walked 2
Cardiopulmonary Stress Test Primary indication: coronary artery disease Patient exercises on treadmill or cycle ergometer Values measured Blood pressure Heart rate Electrocardiogram (ECG) Terminate test when: Protocol is complete Sustained ventricular tachycardia with a pulse Signs of ischemia Test results: Presence and severity of CAD Chest Tube Drainage Physiologic concern: Air or fluid in pleural space put pressure on lung tissue è lung tissue is unable to completely inflate è patients experience dyspnea, increased P(A-a)O 2, hypercapnia Purpose of chest tube: drain air or fluid from the pleural or mediastinal space Pneumothorax (air) Pleural effusion (fluid): hemothorax (blood), chylothorax (chyle from thoracic duct trauma), empyema (pus from infection), hydrothorax (thin fluid from CHF or pulmonary neoplasm) Mediastinal fluid: typically placed post cardiac surgery to drain bleeding that occurs during and after surgery 3
Chest Tube Drainage: Pneumothorax Spontaneous Primary (no underlying lung disease) Secondary Underlying lung disease (COPD, asthma, cystic fibrosis, etc) Trauma Blunt chest trauma Penetrating chest trauma Iatrogenic Complication of procedures (needle aspiration lung biopsy, thoracentesis, central venous catheter placement) Chest Tube Drainage: Pleural Effusions Transudate Very low in protein and blood cells Accumulation of fluid Examples: CHF Cirrhosis Nephrotic syndrome Lymphatic obstruction Hypoalbuminemia Atelectasis Exudate High in protein and blood cells Typical of inflammation Examples: Bacterial infection Neoplastic disease (carcinoma, lymphoma, mesothelioma) Tuberculosis Fungal infection 4
Chest Tube System Findings Assessment Cause Action Bubbling in water seal chamber when chest tube is in the pleural space Bubbling in water seal chamber when chest tube is in mediastinal space Pneumothorax (air is being removed from pleural space) Disconnection/air leak Pneumomediastinum (air is being removed from mediastinal space) None-normal function Tighten connections Replace broken drainage unit None if the mediastinal space was recently opened Unexpected absence of bubbling or drainage Drainage <100ml for 8 hours; no air leak Drainage tube kinked/occluded Malposition of chest tube Closure of bronchopleural fistula or evacuation of pleural effusion Milk tube to displace clots Remove kinking of tube Reposition tube after CXR Consider d/c chest tube after CXR confirmation Metabolic Study Indirect Calorimetry: the estimation of energy expenditure (caloric needs) by measurement of oxygen consumption and carbon dioxide production Assess metabolic status Plan nutritional support Indications: Morbid obesity Difficulty liberating from mechanical ventilation Uncertain weight estimates Severe malnutrition High stress level Extreme weight and/or age Failing to respond to nutritional support 5
Energy Expenditure BMR = basal metabolic rate Measure of energy expenditure Macronutrients supplying body s energy requirements Protein, carbohydrates, fat REE = resting energy expenditure BMR + specific dynamic action of food after eating Use Harris-Benedict equation Male REE: 66.47 + 13.75(weight) + 5 (height) - 6.76(age) Female REE: 655.1 + 9.56(weight) + 1.7(height) 4.7(age) TEE = total energy expenditure Uses REE and factors stress and activity factors TEE = (REE x activity factor) x stress factor Metabolic Study Results Respiratory Quotient (RQ): ratio of CO 2 produced to O 2 consumed CO 2 produced = VCO 2 Normal: 200 ml/min O 2 consumed = VO 2 Normal: 250 ml/min More oxygen consumed when BMR is high (hyperthermia, pain, anxiety, exercise) Normal = 0.8 >1.0 = overfeeding 0.9-1.0 = carbohydrate oxidation 0.8-0.9 = fat, protein, and carbohydrate oxidation 0.7-0.8 = fat and protein oxidation; starvation 6
Metabolic Study Results Can also use abbreviated Weir equation to determine REE: REE = (3.9 x VO 2 ) + (1.1 x VCO 2 ) x 1.44 Inadequate protein intake = malnutrition, wasting of lean body mass, reduced function of diaphragm Can result in mechanical ventilation weaning difficulty and poor pulmonary function test results High protein diet =stimulate ventilatory drive and minute ventilation Can cause increased WOB and dyspnea in COPD patients Intracranial Pressure Trends Cranial space is a fixed, closed space with constant volume Increased volume è increased intracranial pressure (ICP) è reduced cerebral perfusion pressure (CPP) è interrupted cerebral blood flow Normal ICP: 5-15 mm Hg Treat levels above 20 mm Hg by resolving the underlying issue and with hyperventilation (short term) and medications CPP should be above 70-80 mm Hg Difference between the mean arterial blood pressure and the ICP Maintain by raising MABP or lowering ICP 7
References ATS Statement: Guidelines for the six-minute walk test. Am J Respir Crit Care Med, 2002;166:111-117. Damjanov I. Pathology for the health professions. 2012. St. Louis, MO: Elsevier. Kacmarek RM, Dimas S, Mack CW. The essentials of respiratory care, 4 th Ed. 2005. St. Louis, MO: Elsevier Mosby. Siobal MS, Baltz JE. A guide to the nutritional assessment and treatment of the critically ill patient. 2013, American Association for Respiratory Care. Wilkins RL, Stoller JK, Kacmarek, RM. Egan s fundamentals of respiratory care, 9 th Ed. St. Louis, MO: Elsevier. 8