Identify the three key areas of respiratory care patient assessment.
- a. History
- b. Physical Examination
- c. Diagnostic testing (laboratory testing/ imaging studies)
Explain each of the main drivers of the healthcare system (quality, access, and cost).
- a. Cost:
- i. In 2010, the US spent $2.6 trillion, or about 17% of its gross domestic product, on healthcare, and it is expected to nearly double by 2020.
- ii. The united states is again, and older patients are responsible for higher healthcare costs. Over half the patients who are 65 or older have three or more chronic conditions and patients with multiple chronic conditions cost up to seven times as much as patients with only one chronic condition.
- iii. Inpatient hospital costs represent the largest portion of healthcare expenditures in the US and average $2,000 per patient day. In 2005, coronary artery bypass surgery to treat narrowed obstructed arteries cost over $20,670 per patient in the US and a single hospital stay for pneumonia cost up to $15,829. A great deal of RC is provided in the hospital setting, often in the ICU, mean ICU cost per patient in 2005 was about $32,000 for patients requiring mechanical ventilation and those not requiring mechanical ventilation is was $13,000.
- b. Access:
- i. Not everyone has access to high-quality healthcare, and many people have little to no access to basic or preventative care.
- ii. The Agency for Healthcare Research and Quality describes differences in health outcomes based on race/ethnicity, socioeconomic status, insurance status, sex, sexual orientation, health literacy and language.
- c. Quality:
- i. High healthcare expenditures does not mean the results are better.
- ii. A study found that patients in higher spending areas reciefed 60% more care, and that the increase in care could not attributed to levels of illness or socioeconomic status.
- iii. A major factor associated with increased cost was higher concentration of medical specialists in high-cost regions.
Explain the key elements (6) of the scientific method for critical diagnostic thinking in respiratory care.
- a. Identify the problem: The first step in making a diagnosis is to identify the patients problem/ chief complaint (“why are you here?”)
- i. For respiratory patients, common complaints include: acute/chronic cough, sputum production, shortness of breath, wheezing, whistling, chest tightness, chest pain/ discomfort, hemoptysis (blood tinged sputum), hoarseness, fever, and night sweats.
- b. Gather additional information to identify the problem: Following a review of the patients existing medical record, the clinician should perform a detailed patients history and physical examination to further identify and clarify the patients problem(s).
- i. Existing medical record: Should include, patient demographics, previous physicians’ orders, results of previous history and physical examination, laboratory and/or imaging reports, and progress reports and reports of procedures.
- ii. Patient interview should include: History of patients illness, past medical history, family history, current medications, smoking history, environmental data, and occupational history.
- iii. Physical examination should assess: Patients general appearance, mental state (anxiety, restlessness, distress), level of consciousness (alert, awake, sleepy, somnolent), vital signs, skin color, mucosa characteristics, nail beds (cyanosis), perfusion and capillary refill, and presence of pursed lips.
- 1. Chest examination: Inspection, auscultation, palpation, and percussion.
- a. Inspection: RR, depth, and pattern; retractions, accessory muscle use, or paradoxical motion of the chest and abdomen; AP (anteroposterior) diameter, and presence of deformity.
- b. Palpation: Assess for tracheal deviation, chest expansion, vocal fremitus, chest wall tenderness, amd subcutaneous emphysema.
- c. Percussion: Note resonance, hyperresonance, or dullness.
- d. Auscultation: Assess for normal or adventitious breath sounds including, crackles, gurgles, wheezes, rubs, stridor, and bronchial breath sounds over the periphery.
- c. Formulate and explanation: Following identification and clarification of the patients problems, the next step is to formulate a possible explanation as to the cause of the problem. Each symptom and sign identified during the history and physical examination is listed, along with more common and less common explanations for this sign and symptom.
- d. Test possible explanation: After each common and less common sign and symptom is identified and the cause for each is reviewed, additional testing via laboratory and imaging studies is conducted.
- i. These studies may include: oximetry, ABG analysis, PFT, sputum analysis, blood tests including hematology and blood chemistry, other microbial studies, skin tests, and various stains, swabs, and molecular medicine techniques.
- ii. An ECG may be performed, and imaging studies may include chest radiograph, CT scan, MRI, and/or ultrasound imaging.
- e. Formulate and implement solutions: Based of the finding from the patient history, physical examination, laboratory and imaging studies, and medical records, the patients diagnosis is confirmed and the respiratory care plan is designed and implemented.
- i. Care can include: oxygen and/or humidity therapy, aerosol medications administration, lung expansion therapy, chest physiotherapy, and other techniques for secretion management, airway care, and.or mechanical ventilatory support.
- ii. Medical treatment may include: administration of anti-infective agent, anti-inflammatory agent, diuretics, cardiovascular medications, and other pharmacologic agents.
- iii. Procedures include: PT, rehabilitation technique such as diet and exercise, and in some cases, surgical intervention.
- f. Monitor and reevaluate: Following the establishment of a care plan, the patient is continually monitored and reevaluated. The clinician will assess the patients improvement and/or deterioration in his/her condition and the development of new problems that may occur that may require further evaluation and treatment.
Explain evidence-based practice and provide examples of the best to least sources of evidence (Figure 1-3).
- a. Evidence based practice integrates finding with clinical expertise and patient values to provide a structured approach to clinical decision making. By integrating the best scientific evidence into decision making, EBP has the potential to improve patient outcomes and reduce cost.
- i. Weak evidence:
- 1. Case series:
- a. Single case report
- b. Editorials
- c. animal studies
- d. in-vitro (test tube) research
- ii. Moderate evidence:
- 1. Cohort studies:
- a. Follow a large group with a treatment or disease over time, determine etiology or harm
- 2. Case control studies:
- a. Compare patients with the disease to those without it
- iii. Best evidence:
- 1. Randomized controlled trial (RCT):
- a. Multicenter RCT
- b. Meta-analysis of multiple RCTs
- c. Single RCT
- d. Best evidence for therapy
Identify the factors that determine individual health and provide examples of each (Table 1-1).
- a. Genetic makeup
- b. Natural physical environment
- i. Climate
- ii. Housing
- iii. Neigborhood
- iv. Work
- v. School
- c. Healthcare services
- i. Quality, access, cost
- ii. Acute care
- iii. Preventative care
- iv. Rehabilitation
- v. Chronic disease management
Compare and contrast restrictive and obstructive lung disease.
- a. Obstructive lung disease:
- i. Associated with a decrease in PFT expiratory flow rates (FEV1, FEV25-75%, PEF) and include asthma, chronic bronchitis, emphysema, combined/COPD, bronchiectasis and cystic fibrosis. These patients have trouble getting air out of the lungs therefor FEV1/FVC ratio is reduced!
- b. Restrictive lung disease:
- i. Associated with a decreased ability to take a deep breath in, as indicated by a reduced inspiratory capacity (IC), vital capacity (VC) and total lung capacity (TLC) as assessed by PFT.